Standards Of Care & Ethical Issues

Louise Stanger Ed.D, LCSW ▪ Director All About

Interventions ▪ Faculty SDSU ▪ Member NII, AIS ▪ MINT Trainer ▪ Author, Falling Up-A

Memoir of Renewal ▪ & Learn to Thrive

Objectives

▪ Describe and Define Standard of Care & Ethics

▪ Describe and Define Laws ▪ Identify Top Ethical Issues visa vie Snowball

Sample ▪ Recommend Ethical Decision Making Models ▪ CARE Challenge Providers to Develop

Mission, and Ethics Statements for Behavioral Health Care Centers

Getting to Know You

▪ What brings you here today?

▪ What groups do you represent?

Standards of Care

Definitions

▪ Tort Law- The level at which the average provider in a given community would practice

▪ A diagnostic and treatment process that a clinician would follow for a certain type of patient, illness or clinical circumstance -New England Journal of Medicine 2004

Benefits Of JACHO

▪ Organize ad Strengthen patient safety efforts ▪ Strengthens community confidence in quality of

care ▪ Provides Competitive Edge in Marketplace ▪ Improves Risk Management and risk reduction ▪ May reduce Liability Insurance Costs ▪ Provides education to improve business operations ▪ Provides professional advice and counsel ▪ Provides customized and intensive review

▪ Enhances staff review and recruitment ▪ Provides deeming authority for medicare ▪ Provides a framework for organizational

structure and management ▪ May fulfill regulatory requirements ▪ Provides practical tool to strengthen ▪ Aligns health care organizations 603-792-5000

Money, Ethics & Behavioral Health Care

What are Ethics ??????

▪ Ethics are the beliefs an individual or group maintains about what constitutes correct or proper behavior

▪ Standards of conduct an individual uses to make decisions.

LAWS What do you stand for ?

▪ Folks that do not understand the laws

▪ Folks that understand the laws they do not have a strong sense of ethics

Ethical Issues

▪ Individual

▪ Group

▪ Organizational

▪ Societal

How do Ethical Problems Occur ?▪ People are human they make mistakes ▪ Clients misreport ▪ Inexperience ▪ Ignorance ▪ Unpredictable /Unforeseen situations ▪ Inadequate Agency Policies ▪ Guidelines not adequate for situation ▪ Ethics in conflict with law

How do Ethical Problems Occur?

▪ Greed ▪ Need to Fill Beds ▪ Quotas ▪ Job Security ▪ Inadequate

Guidelines

What’s Your Codes of Ethics

▪ American Association of Advertising Agencies

▪ Direct Marketing Association ▪ Public Relations Society of America ▪ American Marketing Association ▪ Foundation for Public Affairs ▪ American Hospital Association ▪ NATAP

Code Of Ethics

▪ NAADAC ▪ NASW- Social Workers ▪ MFT ▪ NATAP ▪ CARF ▪ Psychologists ▪ Nurses –Doctors ▪ Lawyers ▪ Interventionists ▪ Insurance Company ▪ Treatment Center ▪ Web Developer

Code of Ethics

▪ Association of Intervention Specialists ( AIS)

▪ Network of Independent Interventionists (NII)

▪ Recovery Coaches ▪ Certified Rehabilitation

Counselors ▪ Hayes-Davidson Ethics

Pledge

What are your top 3 Ethical Concerns

Snowball Sample

▪ Qualitative Research ▪ Set Up Open Ended

Question ▪ Ask the question and

then ask who else might I talk to

▪ Collapse and collate Data

▪ Asked in different areas

Areas Covered

▪ CEOS ▪ Marketers ▪ Admissions ▪ Web Designers ▪ Clinicians ▪ Interventionists ▪ Thought Leaders

David Skonezny-CADC-II ICAD CEO-Simple Recovery

Ethics Chair-CCAPP Board of Directors

▪ Paying For Referrals ▪ Improper UA Billings-

Facilities owning labs ▪ Incorrect Billing ▪ Having Non

Credentialed Staff facilitate Clinical Events

Denise Klein-Milestones Ranch

▪ Lack of Standardized and Best Practice Training

▪ Exploitation of Insurance Companies

▪ Over Promising -Under delivering of Services

▪ Unlawful Kickbacks

Marsha Stone BRC Recovery

▪ Competence ▪ Misrepresentation

of Services ▪ Lack of

Compassion ▪ Folks do Not

Understand Laws

David Lisonbee CEO Twin Town

▪ Waiving Deductibles-Kickbacks

▪ General Public Distrust of Treatment Industry

▪ Treatment perceived as a scam

Paul Alexander CEO Northbound

▪ Accreditation and Standardization of Care

▪ “CURES” Promised as opposed to Solution

▪ Mission and Code of Ethics

Incredible Marketing :Wes Jones CEO

▪ Misrepresenting treatment modalities in website content

▪ Accepting Clients that are not a fit

▪ Misrepresenting Culture

More About The Web▪ Misrepresenting Location ▪ Adding Fake locations ▪ Using high end photos ▪ Misrepresenting amenities ▪ Fake Positive reviews ▪ Buying Competitions Keywords ▪ Referrals based on ▪ Kickbacks ▪ Reciprocation

Where does your name go ?▪ Search your Center ▪ Independent Review Sites ▪ Trademark Rules ▪ Come ons- ▪ Flights paid ▪ Deductibles Paid ▪ Come and Go

Questionable Practices ▪ Internet marketing

scams ▪ Using Brain scans

with other unproven treatments and billing the patient

▪ AP, March 2013

Questionable Practices▪ Call Centers share

Patient Prospect info between treatment Providers

▪ Call Centers run through 5013C Non Profits

▪ Landlords -Drug Companies and Sober Living Homes

▪ Insurance Companies Dictate Treatment

Paying Kickbacks▪ To Interventionists ▪ Paying bounties to for

referrals ▪ Claiming to take a

patient’s insurance when reimbursement

is low ▪ To Labs

Kickbacks-Federal Laws

Anti-Kick Back Statue Criminal offense for anyone to give a kickback with the Intent of influencing referral of patients

Stark Law Physicians Self referral law Kickback occurs when a physician refers a patient to a facility he owns or family has financial interest

Trips , hotels, gifts

Whistleblower –False Claim Act

▪ False Claims Act

▪ Unlawful for anyone knowingly or willingly submit or cause a fraudulent claim to the government for payment

Questionable Practices

▪ Promising a cure

▪ Using nutrient supplements that are proprietary and billing the patient

Historical Context

▪ In Nazi Germany 1945-1946 and 1935 American Public Health research African American men

▪ 1966 Public Health Services established ethical regulation

▪ 1979 Belmont Report

(Protection of Human Subjects)

▪ 1970s bio ethics emerged

▪ 1980s Watergate

▪ 1996 Revised Codes

▪ As professions grow code of ethics are formed

Do not confuse Ethics and Morality !!!!!

▪ The word Morality comes from Latin word MORES which translates into custom or values

▪ Morality involves the judgment or evaluation of an ethical system, decision, or action based on socialcultural or religious norm

Ethical Principles

▪ Autonomy

▪ Beneficence- To do Good-To Do No Harm

▪ Confidentiality

▪ Fidelity _To keep ones promise or word, Duty to report , honesty, trustworthiness

▪ Gratitude

▪ Justice ( treat all fairly)

▪ Nonmalefience :The duty to cause no harm

▪ Reparation –duty to make up for a wrong

Competence

Integrity

Importance Of Human Relationships

Dignity of Individual

Social Justice

Service

VALUES

Ethical Principles

▪ Respect for Others

▪ Universality

▪ Utility- the duty to provide the greatest good or least harm to greatest number of people

▪ Ordering

Ethical Considerations■ Fiduciary

Relationships with Providers

■ Call Centers ■ Pay per click ■ Truth in advertising ■ Gifts & Kickbacks ■ Internet Marketing

scams

Ethical Principles

▪ Veracity –To tell the Truth

▪ Herein lies dilemmas ▪ Between self, IP,

agency and outside world

Ethical Responsibilities

▪ To Clients ▪ To Colleagues ▪ To Practice Settings ▪ As Professionals ▪ To Professional

Affiliations ▪ To Broader Society

8 Step Model for Ethical Decision Making

▪ 1. Identify the Problem or Issue

- Clinical - Legal - System (polices etc) - Cultural - Ethical -

counselors own issues

Steps 2-4

▪ Apply a code of ethics

▪ Determine Nature and Dimensions of Dilemena

▪ Pros and Cons

Steps 5-8▪ Choose Course of

Action ▪ Implement a

Course of Action ▪ Evaluate the

Outcome ▪ Evaluate the

implications

Congress Ethic Model

▪ Examine ▪ Think ▪ Hypothesize ▪ Identify ▪ Consult

CONFIDENTIALITY

▪ Hallmark of Therapeutic Relationship

▪ Consent Forms ▪ Mandated Reporting-

Duty to Warn ▪ Exceptions ( Drug

Court, federally assisted treatment programs

Confidentiality and Minors ▪ Age of Consent

▪ Being Familiar with state laws

▪ Can Clara or parents know everything if they are under 18?

Informed Consent Description of any reasonable foreseeable risks or discomforts Description of any benefits to the subject or others Disclosure of alternative treatments & medications Statement describing extent to which confidentiality of records

identifying client will be maintained Explanation on limits of confidentiality Explanation on who to contact in emergency Costs to client Consequences of early withdrawal

Record Keeping

▪ Client prior hx of services ▪ Present reason for call ▪ Dx of bio-psycho-social ▪ Documentation of any changes

since assessment ▪ Treatment plan goals & objectives

(changes in Tx) ▪ Duration & frequency of service ▪ Progress notes ▪ Rec for further treatment-

discharge plans ▪ Doc. Of fees charged and paid ▪ HIPPA Forms

Competence

▪ Competence? ▪ How do you

achieve and maintain

▪ Cultural competence

▪ Is it ok to practice outside of ones competence?

Advertising

▪ Truthful

▪ “Number 1 , Unique, Cure “

Wireless Devices

■ How are these used to protect confidentiality ???

■ Laptops, Ipads, Phones, Earpieces,

&other devices

Visual Wrong doing

▪ Web Sites that are misleading

▪ Fake addresses ▪ Toll free numbers ▪ Posting of photos

on misleading websites

▪ Certificates

Social Media

■ Written Materials ■ Business Cards ■ Letterhead etc ■ Website ■ Mailings ■ Texting ■ Facebook, Twitter and

Linked In

BOUNDARIES

▪ Length of counseling, self disclosure by counselor, confidentiality, giving of gifts, touch or personal communication between counselor and client and client, counselor and supervisor’

▪ Intimate relationships ▪ Personal benefit ( monetary goods , services) ▪ Emotional dependency needs of counselor ▪ Altruistic gestures which can be misinterpreted ▪ Unexpected situations such as meeting sisters new

boyfriend who turns out to be a client

DUAL RELATIONSHIPS

▪ Friendships between client and counselor, supervisor and supervisee

▪ Sexual Relationships ▪ Professional –where client and counselor are

professional colleagues ▪ Business dual relationships where counselor and

client are business partners or have an employee/employer relationship

▪ Communal –where both belong to same community (AA, NA, Alanon, SA etc.)

Hiring Practices

▪ Former counselor calls to ask if she or he can hire a former client of hers and mine from a different treatment center that has less then a year recovery

Employer Relationships

▪ A handsome admissions person is your subordinate. He is also in a 12 step program. You invite him for coffee after the meeting.

▪ ?? Ethical Considerations

Business Temptations

Money for Admits

▪ An admissions officer offers you money for referrals

Consent and HIPPA

▪ Mother wants to know what daughter is saying about their relationship

▪ 19 yo daughter has not signed consent form for mother

Other Considerations

▪ You are a substance abuse/mental business professional and are attending the same 12 step meeting as your client do you need to share, what do you do??

▪ Organizations referral practices ▪ Organizations billing practices

▪ Other Examples

Gifts

▪ A $100.00 Starbucks card

▪ Court side Laker Tickets

▪ Boxes From Tiffany ▪ A Rolex Watch ▪ A center offers you

referral fees ▪ ??What do you do

Standard of Care Challenge

▪ Develop Mission Statement for your Organizations

▪ Articulate the Organizations Values ▪ Revisit or Develop Organizations Ethical

Code ▪ Obtain Appropriate Licensure ▪ The World Know-Mission, Values and

Ethical Statement

Standard of CARE

▪ Review Your Professional Code of Ethics ▪ Engage in Appropriate Continuing

Education ▪ Sign Hayes-Davidson Pledge ▪ Work tirelessly to elevate Behavioral

Health Care Field

Let Me Know

▪ Meet me Oct 13 & 14 ▪ Admissions and Marketing Seminar ▪ Tell the world what you are doing ▪ Send me ( drstanger@me.com) your

Mission, Values and Organizational Ethics and I will share on my www.allaboutinterventions.com and on my blog

It Takes A Village

Questions

Resources▪ The Ethics of an Addiction Counselor ▪ The Ethics of an Addiction Counselor , The Association of

Addiction Professionals ▪ NASW Code Of Ethics ▪ NII Code of Ethics ▪ AIS Code of Ethics ▪ Ethics Updates http://ethics.sandiego.edu ▪ The Elements of Ethics for Professionals-Brad Johnson ▪ Center for the Study of Ethics in the Professions ▪ National Board for Certified Counselors; The Practice of

Internet Counseling http://www.nbcc.org/assest/ethics/internetcounseling.pdf

▪ http://www.mentalhealthlaw.us/10/Practice_Dilemmas.html

Resources

▪ Hayes- Davidson Ethics Hayes -http://www.hayes-davidson-ethicspledge.org

▪ Northbound Code Of http://www.livingsober.com/about-us/northbound-code-of-ethics/

▪ Dreamscape Marketing Code of https://www.dreamscapemarketing.com/about-dreamscape-marketing/code-of-ethics/

▪ Twin Town http://twintowntreatmentcenters.com/about-twin-town-tc/our-mission/

▪ Cinga http://www.cigna.com/about-us/corporate-governance/code-of-ethics

Resources

▪ Joint Commission on Accreditation of Rehabilitation Facilities ▪ JACHO Accreditation http://www.jointcomission.org ▪ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088386/The

Standard ▪ http//:www.carf.org./home/ for Commission on Accreditation of

Rehabilitation Facilities ▪ National Council for Recovery Residences http://narronline.org

▪ Trauma -Informed Care in Behavioral Health Services TIP 57 ▪ The ASAM National Practice Guideline for Use of Medications in

The Treatment of Addiction Opioid USE ▪ http://www.jcrinc.com/2016-cambhc-behavioral-heath

Dr. Louise Stanger Ed.D, LCSW, BRI II, CIP

▪ Faculty SDSU Interwork Institute ▪ Member NII ▪ Member AIS ▪ MINT Trainer of Trainers ▪ Director All About Interventions ▪ http://www.allaboutinterventions.com ▪ Falling Up-A Memoir of Renewal -Amazon ▪ 619-507-1699 ▪ DrStanger@allaboutinterventions.com ▪ 619-507-1699