EPISODE 02

[INTRODUCTION]

[00:00:12] ANNOUNCER: Welcome to Season One. All Things Ethics, a podcast series presented by SpeechTherapyPD.com. The SLP Learning Series explores various topics of speech-language pathology. Each season dives deeper into a topic with a different host, and guest who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on SpeechTherapyPD.com and is available for 0.1 ASHA CEU. Now come along with us as we look closer into the many topics of speech-language pathology.

[INTERVIEW]

[00:01:04] EDM: Welcome to ethics is essential. Most of America's Speech-Language Pathologist practice in our public schools. They have diverse practices and often provide services for children with complicated medical conditions and histories. They treat children of all ages, from very young children and child development programs to high school seniors. School Speech-Language Pathologists are often involved in many aspects of a child's education. Everything from one-on-one communication therapy, to group therapy, to in-class intervention to help children build communication skills, reading instruction, even accompanying a child to the cafeteria to help with social language interaction, as well as being on the playground monitoring carryover of language therapy goals and programming augmentative communication devices. 

There are also assessments and evaluations to be done and lots of report writing. Consultations and in-service presentations for teachers and school staff not to mention IEP meetings, consultations with parents, and program advocacy, because the schoolÕs Speech-Language Pathologist job is complex, and caseloads are often too large, especially in urban schools. There can be opportunities for errors or ethical lapses. We're going to be talking about potential ethical violations that can impede good practice and put Speech-Language Pathologists at risk for sanctions and perhaps even suspension or revocation of their certification. 

Today, our guest is Theresa Rodgers. She's ASHA's President-elect. She's also an ASHA fellow, and a former government employee and officer, a Speech-Language Pathologist, and Special Education Consultant with more than 30 years experience in public schools. She has also served as president of two national associations. She has served as ASHAÕs Vice President for Government Relations and Public Policy and chair of the Council for Clinical Certification. She also served on ASHAÕs Board of Ethics, and the Louisiana State Licensure Board. Theresa has provided the National Council of State Boards with training on an ethical resolution for more than a decade. She co-presented ASHAÕs 2016 Ethics Seminar and is presented on the topic at numerous national and state conventions. Theresa, welcome to All Things Ethics. 

We're going to get right into our discussion of ethical practice in this place, where most of our Speech-Language Pathologist practice and that is in our schools. You've had a lot of experience with school practice, as a Speech-Language Pathologist, a supervisor, a consultant, and you've made many presentations on the topic of ethics in school practice. You've given me some great scenarios that illustrate some of the ethical principles that we're going to be talking about. So let's get started. 

Let's start out by talking about Sarah. She's a school Speech-Language Pathologist who has difficulty mastering the record-keeping systems required by her district. She has received training on the technology systems utilized by the school system and requests more individualized instruction from the district Special Education Office when she experienced problems completing progress reports after the first nine weeks, as the school year progresses, and there are more deadlines, Sarah lapses into a pattern of being even more sporadic about collecting data, and documenting therapy sessions. 

She is quite popular with the school administration, faculty, parents and students. She has a gift for establishing rapport and engaging students. Her therapy sessions are fun, she enjoys focusing her creative talents on therapy activities, rather than on detailed paperwork. However, because her therapy logs are not completed on a regular basis, documentation is inaccurate, including incorrect dates of service provision. She submits Medicaid billing based on her therapy logs and audit findings indicate billing was submitted for staff development days, and for dates when students were absent from school. Other issues were discovered by the school system during follow-up to an audit. Theresa, what do you think? 

[00:05:55] TR: Thank you so much, Elise, for the opportunity to engage in this important discussion about our school-based practices and how to be successful as we face dilemmas. Let's think about Sarah and the scenario that you read. I want to first focus on thinking about competencies. So certainly we know that we all exhibit certain competencies by the time we complete graduate school, but here are additional knowledge and skill sets that are required as we engage in professional practice. Many of the skill sets that I am referring to are directly related to our work setting, schools, hospitals, skilled nursing facilities, home health, University, etc. but the skill sets are even more specifically tied to our direct employment setting. 

In this case, it would be the school district, the school system for which Sarah works. In this scenario, the Speech-Language Pathologist has difficulty mastering the record-keeping systems that are required by the school system. In every school system, there are going to be requirements relative to certain data systems and ensuring that should the system be questioned for any reason that there is appropriate documentation that regulations are being adhered to that student's IEPs are being implemented, that services are being delivered as prescribed on the IEP. There are many, many, many more facets relative to implementing services in the schools, but those are just a few, but because the school system has such accountability, there are always systems that are delineated for its employees to follow. 

Sarah has been trained on the technology systems utilized by the school district. We did not describe Sarah as a newly hired individual, but let's talk about that briefly. I want to emphasize how important it is for new employees to receive training from school districts. The district's accountability really rests with the ability of the staff to be in compliance. Well-written policies and procedures, as well as training, are essential not only for the district but for the new school-based Speech-Language Pathologist. In this scenario, Sarah requested additional training on the district's technology systems. Her request was made at the time of the first nine weeks of progress reports were due. The provision of progress reports to parents, which is a mechanism for informing the parents about their child's progress toward achieving IEP goals and objectives. 

Progress Reports are mandated under the Individuals with Disabilities Education Act, and the progress report is typically created using the web-based IEP system or the software that the district employs to develop each student's Individualized Education Program document. Utilizing the goals and objectives from the IEP document, a progress report document can then be created. The school-based Speech-Language Pathologist should be utilizing the data from the student's therapy logs and tally sheets to determine the performance level to be recorded on the progress report for each goal. 

Sarah receives additional training from the school system. She sounds like a fantastic Speech-Language Pathologist. She has a great rapport with students. She's popular with administrators and parents. Sarah's therapy sessions are fun. She utilizes her creative abilities to focus on therapy activities. However, as the school year progresses, there are more deadlines. Sarah lapses into a pattern of being even more sporadic than she was at the beginning of the year relative to collecting data and documenting therapy sessions, because Medicaid billing is based on those therapy records, if the therapy records are not accurate or do not exist, there are going to be significant issues. Sarah does not complete her therapy logs on a regular basis. 

Therefore, the therapy records are inaccurate. Medicaid billing is required for Medicaid-eligible students, but Sarah does not seem to base her Medicaid billing on what services were provided on specific dates. Sarah's errors are discovered during a Medicaid audit. The audit findings indicate billing was submitted for days on which students could not have been receiving services because students were absent on those days or they were staff development days. 

Obviously, given the Medicaid audit results, the school system takes up a review of Sarah's other record keeping and practices in the school. It raises red flags to be sure. So let's talk about some of the principles and rules of ethics that are contained in ASHAÕs Code of Ethics, which have likely been violated by Sarah. There are a number of them, but let's start with under Principle I, Rule K. It states, ÒIndividuals shall evaluate the effectiveness of services provided.Ó That would have to be discussed further, but if Sarah does not collect data on a regular basis, and or if her data collection is not accurate, how then can she make appropriate decisions about the effectiveness of her therapy with each student? 

This is really a significant rule of ethics to be considered in this situation. That's also under Principle I, Rule Q. It explicitly states that ÒIndividuals shall maintain timely records and accurately record and bill for services provided.Ó Certainly, we have seen in this scenario that Sarah is in violation of that rule of ethics. Another rule of ethics that we would need to discuss if we were sitting on ASHAÕs Board of Ethics would be that, under Principle IV, Rule E, ÒIndividuals shall not engage in dishonesty, negligence, fraud, deceit or misrepresentations.Ó Now, one may say, ÒWell, Sarah didn't mean to defraud and utilize inaccurate documentation and submit that on Medicaid billing.Ó Whether there was intent or not, inappropriate Medicaid billing is considered fraud, submitting false. I'm going to refer to it that way, false claims for Medicaid are considered fraud. 

I've had this discussion with others. We could go both ways on whether this is negligence, whether Sarah just doesn't treat her paperwork, Medicaid billing, documentation of therapy and as deliberate away as important away as it needs to be handled, or if this is intentional, we did not write into the scenario any poor attitude on the poor part of Sarah, but I have had individuals tell me that given the fact that the individual was trained, including specifically on the systems, technology systems used for Medicaid billing, that then this then must be intentional. We could go both ways on that and certainly gives us food for thought relative to weighing intent versus negligence. The bottom line is that improper records exist, inaccurate records exist, there has been Medicaid fraud by virtue of the faults billing that occurred, and the system is going to suffer some significant repercussions. 

Those are not all of the rules of ethics under ASHAs Code of Ethics, which I personally feel Sarah has violated, but given our time constraints, I'm going to move on to a discussion that would occur next. If you and I were engaged in an ASHA Board of Ethics meeting, after delineating the violations that Sarah has, unfortunately, engaged in the Board of Ethics would then need to consider what sanction is appropriate given the violations. One of the first sanctions that would be considered would be a reprimand. That is something that is private. No one ever knows about a reprimand, other than the complainant, who is the person that files the complaint. In this case, it's likely that it's a school system administrator. So only the complainant and Sarah would know about a reprimand if that was the sanction determined to be appropriate by the Board of Ethics. 

Let's jump to the Sanction of Censure. Censure is basically a public reprimand. It is published in the ASHA leader. It is on the ASHA website. It appears anytime someone does a search history on ethics violations on the ASHA website. The decision would be shared with the State Department of [inaudible 00:16:39] and the state licensure board. So that's how censure becomes a public reprimand. I have a feeling that given the nature of what Sarah was doing, and the number of violations and by the way, I have at least eight violations delineated on my list. 

Let's talk about the suspension of certification and membership. So personally, in my opinion, Sarah's actions warrant suspension of certification and membership. When there is a suspension, the Board of Ethics must also decide upon the length of time that suspension should be imposed. One of the things the Board of Ethics considers, if known is the damage, so to speak to the school district. What was the total dollar loss in Medicaid funding to that school district? That is money designated for special education services, which the school district cannot recoup. If we were functioning as members of the ASHA Board of Ethics, in deciding upon the appropriate length of time for a suspension, we would likely deliberate at length, but perhaps propose something like a two-year period of time. 

I just want to mention here, although I personally think it's not appropriate, given the scenario we described Sarah and the violations in which she engaged. I just want to mention the four Sanctions that the Board of Ethics has for certified individuals and members, and that is revocation. The difference between suspension and revocation has to do with the fact that if certification and membership have revoked the individual then at the end of the period of time, let's say it would be for 10 years, they would have to go back to the Board of Ethics for permission to reinstate their certification. Know that the Board of Ethics does not engage in awarding certification, that is the job of ASHAÕs certification department and the Council for clinical certification. 

In order for an individual who has been revoked to obtain their certification again, they first must go to the Board of Ethics to ask for permission to do that. Typically, the Board of Ethics is looking for some evidence of remediation, for example, in Sarah's case, if she would have been revoked, and as I said, I don't think that would be appropriate in this case, they would be looking for some new mechanisms for her to ensure that she is engaging in timely and accurate recording of services, not misrepresenting those services, timely billing, etc. I believe that's going to wrap up my discussion of Sarah, Elise. Thank you. 

[00:19:52] EDM: Well, I think that you've given us a really comprehensive and in-depth look at the consequences that can occur if in fact a school SLPs are not as careful and doing everything that they should be doing. Documentation is so important. The work that we do with children in the schools certainly does have to be documented. We have to be able to show what we've done, and the extent to which we're getting results. Thanks a lot for that. I think that that scenario is one that I think yields a lot of information. I thank you so much for what you've given us on that.

[MESSAGE]

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[INTERVIEW CONTINUED]

[00:21:05] EDM: Let's move on to something that's a little bit different. Let me give you a different scenario. Jim is a Speech-Language Pathologist who's disgruntled with his current job. He's been hearing about Telepractice, and he decides he would like to engage in this exciting form of service delivery. He leaves his employment setting and begins delivering services from his home, utilizing his already existing equipment, and the free version of Skype loaded on his home computer. Using his contacts in the state, he signs contractual agreements with several schools to provide therapy to an in-state pediatric client population. Within three months, he loses a Telepractice contract with one school system due to complaints about the lack of reliability of his equipmentÕs connectivity, and other technical issues. Theresa, what is Jim facing here? 

[00:22:03] TR: Well, Jim is struggling with some issues relative to implementing services via Telepractice. It sounds like Jim made some assumptions about leaping into that mechanism for delivering therapy as well as assessment without really being trained or well versed in all aspects that must be taken into account. I want to mention here, well, let's talk about some things relative to delivering service via Telepractice. Let's talk about what's going on, given this specific example with Jim. 

Number one, it sounds like he thinks the grass is greener in terms of leaving whatever his job was and then jumping into Telepractice using the equipment that already exists in his home. A lot of us may have equipment in our home that is sufficient for delivering services via Telepractice, but we really cannot assume that, we need to look at what hardware is required, what software is required, and ensure that we have encrypted web platforms for engaging in this type of service. In this scenario, Jim is using the free version of Skype that was loaded on his home computer, that's a major issue. Not that he already has the software or that it was free, the fact is that Skype is not considered to be a HIPAA-compliant mechanism for delivering Telepractice services. 

There are a number of web platforms that individuals can purchase if you want to engage in Telepractice. Typically, the free version of any of those platforms does not have the appropriate level of encryption to ensure that confidentiality is being maintained. I don't need to, I think mentioned specific brands, but there are a number of them. I've also been told that there is a business platform for Skype that has additional encryption. I have not personally checked that out. I'm not saying that Skype in and of itself isn't necessarily a bad thing. I'm just saying the free version that is loaded on many of our computers is not going to be HIPAA compliant for delivering these services. Right there, what I've described is a confidentiality violation. 

If we looked at the ASHA Code of Ethics under Principle I, what we would see is that under Rule of Ethics O, ÒIndividual shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is necessary to protect the welfare of the person.Ó Then certainly the next rule of ethics is quite applicable in the scenario. That is under Principle I, Rule P as in Paul, ÒIndividual shall protect the confidentiality of any professional or personal information about person served professionally.Ó The rule goes on to talk about participants in research. 

Certainly here in this scenario, if Jim is using the free version of Skype to deliver therapy, confidentiality is not being protected as it should be. I want to mention here, in attending training about delivering services via Telepractice, one of the things that has always been emphasized besides having appropriate hardware, software, encryptions, etc. you can still breach confidentiality based on how all of those mechanisms are utilized or misused. I have everything's established as it should be on my computer, on the web platform, with my clients, so to speak. 

Well, who am I allowing to walk by my practice room? I'm at home, but who is coming into the room, where I am performing those services? Who is in the client's home, when the client is receiving those services? Or in whatever facility the client is at. Not just the hardware and the software, but the environment has to be carefully controlled so that confidentiality is not breached. While you may feel that you cannot control what goes on at a client's in if you are going to serve clients via Telepractice that is an important conversation that you need to have. Anyone that is Òinvading their spaceÓ physically on their in, it's okay if it's without their permission, but you need to have a discussion with a client so that they are well aware of what individuals are going to be seeing as they come into and out of a physical environment. 

All right, let's talk about the fact that Jim engaged in contracts, he agreed to contracts with several schools to provide therapy, but he loses these contracts because there are complaints about the lack of reliability with his equipmentÕs connectivity and other issues. So you might be thinking, well, aren't there going to be glitches relative to use of the Internet, these platforms may be weather interference, who knows what troubles can go on both on the clients and the SLPs in. Sure, there can be glitches from time to time, but the problem here is that on Jim's part, there are so many issues with the connectivity that he's not considered a reliable provider of the service, and he loses the contract. 

Certainly as hardware and software is analyzed the needs assessment, and then the implementation of both parameters need to be examined, so that connectivity issues are quickly resolved, both for the client and for you as the provider. One other piece of this has to do with competency, and we could have a long discussion about this, but one does not deliver necessarily the same type of therapy activity for pediatric clients using a computer service using Telepractice. It is really important that dynamic activities are planned for children. 

If an SLP is utilizing a lot of static activities for children, they are going to quickly lose interest. Delivering services via Telepractice has to be considered in a really different and dynamic way when planning for those activities. I've identified the confidentiality violation that GM engaged in, so we could have a discussion then also about Principle of Ethics I, Rule A, which states that ÒIndividuals shall provide all clinical services and scientific activities competently.Ó I do want to talk here, not only is this related to being competent, but it has to do with understanding the need for training, specifically in Telepractice. One of the things that made me aware of this was studying various states, codes of ethics, and regulations, specifically related to Telepractice. 

Many of us hold not only a department of education credential to work in the schools, but we may also hold a state license from our State Department of Health, or Department of Public Instruction, or wherever your state licensure board is housed within a state government organization. So in my state, it's the State Department of Health. I hold a credential from the Department of Education, and I hold a state license. So I must abide by the standards for both of those credentials. I must know inside and out all the regulations relative to my Department of Health license, including the Code of Ethics. I certainly have to know federal laws, state laws, local policies, everything that goes into being a school-based practitioner on the local level. I just want to plant the seed about some of the things that we need to consider when we're engaging in Telepractice. I'm looking at one state-specific regulation, but there is a commonality with these aspects. 

One is that Telepractice services delivered via telecommunication technology must be equivalent to the quality, scope, and nature of services delivered face-to-face. What this says is, the service has got to be equivalent, whether it's face-to-face or via Telepractice. Another is that the individual delivering the service must have the knowledge and skills to competently deliver services via telecommunication technology, by virtue of education, training, and experience. Providers are responsible for assessing the client's candidacy for Telepractice, including behavioral, physical, and cognitive abilities to participate in services provided via telecommunication. 

Not all children are going to be good candidates for Telepractice. I can tell you that almost many, many, many students will be, but there needs to be a determination about their candidacy for engaging in services delivered via Telepractice. Certainly, a provider must also be sensitive to cultural and linguistic variables that affect identification, assessment, treatment and management of the clients receiving services via Telepractice. We've talked about the equipment, but it is the responsibility of the practitioner that the equipment is maintained in appropriate operational status, so that there is appropriate quality of services. 

Pertaining to liability and malpractice issues, the practitioner is held to the same standards of practice, just as if the services were being provided in person. Certainly, Telepractice providers have to comply with all laws, rules, and regulations governing the maintenance of those records and confidentiality requirements, regardless of the state that the patient is in. Then it is very important that the client, the patient-client, the family, and perhaps the multidisciplinary team if that's a factor are notified of the right to refuse Telepractice services and options for other methods of service delivery. So thank you, Elise. I think that's going to wrap up my discussion of Jim and his use of Telepractice. 

[00:34:35] EDM: Well, I think you've really brought to our listener's attention the fact that it may not be so easy to jump from in-school therapy to Telepractice, because there are so many things that need to be considered. We may feel that since we're in the privacy of our own home, that confidentiality is ensured, but that certainly is not necessarily the case. The reliability of the provider of service is really important, whether or not the potential client is a good candidate for Telepractice, as well as the cultural issues that are involved in all of the work that we do as Speech-Language Pathologists, but certainly cannot be neglected in terms of Telepractice. Thank you for that very comprehensive Ð

[00:35:23] TR: I'm so sorry.

[00:35:24] EDM: Go ahead.

[00:35:24] TR: I didn't mention one important thing relative to ASHAÕs Code of Ethics and what may apply here. I mentioned it in the discussion, but I just want to ensure that the listeners know that there are a couple of rules of ethics specifically about the use of technology. One is under Principle II, Rule G, ÒIndividuals shall make use of technology and instrumentation consistent with accepted professional guidelines in their areas of practice.Ó Under Principle II, also Rule H, ÒIndividuals shall ensure that all technology and instrumentation used to provide services or to conduct research and scholarly activities are in proper working order and are properly calibrated.Ó Excuse my interruption, Elise. I just want to make sure we didn't overlook those two important Rules of Ethics. 

[00:36:22] EDM: I think, those are very important. Obviously, anyone who is considering developing a Telepractice certainly does need to be aware of those ethics rules as well as others that you mentioned. So thank you. Let's go on. I have another scenario for you, Theresa. Janie Smith is an enthusiastic Speech-Language Pathologist, who has established her own private practice. She enjoys communicating with clients and their families at her office and outside of work. She has friended several of the older students with hearing impairment, as well as their families on Facebook. Janie posts information about how much progress the cochlear implant students made recently. She also posts defamatory comments about another local private practice and the Speech-Language Pathologist who works there. Wow, can you respond to that for us?

[00:37:24] TR: ÒWowÓ is the right word, I think. Okay, so we are in a technological age. There is so much going on relative to social media. Well, it's a great tool. Not all that is going on is a good thing, unfortunately. In this scenario, Janie, and friending her older students with hearing impairment even if she hadn't friended the students, she sprinted the families on Facebook. That is a slippery slope. At the point in time that she posts information about the progress that the cochlear implant students made. She's probably violated Principle I, Rule P, relative to confidentiality. 

It sounds as though that is a breach of confidentiality. So by virtue of the fact that if the studentsÕ names are appearing, say on a list of likes or comments in response to Janie's post on Facebook, their names are there, readily identifiable. Depending on the detail of the information she posed, they may even be named. She may not be making general statements, ÒOh, all of my cochlear implant students made such a wonderful progress in the last two weeks.Ó That's a very general statement, but in this scenario, we said that she had friended the older students. If you're on Facebook you know that when friends start liking or responding to your post, you can touch that button and it'll list all of the persons. That's a breach of confidentiality. 

If only the families were friended on Facebook, you've still got an issue. I've had this question asked of me, where a parent posts a comment on your Facebook page, they use your name and they say, ÒWe love the progress that Johnny has made. You have worked wonders with him. We are so appreciative of your speech therapy services.Ó Okay, so how should you respond? My recommendation and it may sound harsh, my recommendation is not to respond on Facebook. If you respond to that specific comment on Facebook, you have just identified yourself as being a client clinician relationship with whomever this child is. Obviously, that's a breach of confidentiality. 

You say, ÒWell, that was such a nice comment.Ó Absolutely. Yes, it was. So how can we resolve that? Well, we can pick up the phone and call the mother and say thank you so much. I just want you to know how grateful I am not only for your support of our therapy, but I so appreciate what you said about me publicly. Just know that I can't respond to that via social media. So you explain it to the parent. You could also email if you didn't want to pick up the phone, but what I just described goes beyond the scenario we utilized about Janie Smith, who's established her own private practice and has friended students as well as parents. I've described a situation where you friended a parent, and they've said something glowing about you on Facebook. How do you handle it? 

Okay, well, that is obviously an ethical dilemma. So how do we know how to respond to these ethical dilemmas? It is critical that we know how to engage in solid decision-making. It's unfortunate, but ethical dilemmas are a common part of the practice of Speech-Language Pathology, as well as audiology. We are going to be confronted with dilemmas. Some of them will be rather minor, but others can be very, very significant. What do we do when we're faced with an ethical dilemma? How do we even approach that? Well, I want to talk just a little bit about a decision-making model that I find is pretty easy to engage in and it's easy, yet it's comprehensive. 

What you're thinking about is you're applying the ethics codes, as a construct, rather than thinking of the Code of Ethics as a cookbook that you can look in and immediately find an answer. The Code of Ethics is not going to be like that. It's not a cookbook. Certainly, there's guidance in the Code of Ethics, but it's not a cookbook. We need to think about our proposed course of action, given this ethical dilemma and look at it in relation to the personal interest involve, the social roles, the expectations, and the obligations that accompany these roles. If we're utilizing a model that considers professional norms, and ethical principles, as well as the clients, and the clinician's cultural Heritage's, and the influence of diverse values, we can utilize a framework to address ethical questions where we can obtain confident resolutions and really good professional practice. 

As we work through a process where we are considering possible courses of action and analyzing, now what potential conflict can those various courses of action lead to? Let's examine all of the factors, cultural linguistic, societal, cultural, certainly codes of ethics, laws, and regulations that may apply. What will be the result of those various possible courses of action? Do they lead to consensus? Will there be a consensus among the parties that are involved? If consensus has been achieved, then your deliberation about the dilemma may be complete, but if consensus is not achieved, the information that's influenced your decision needs to be reassessed and you need to come up with some alternative solutions or interpretations that you may propose. 

This is an ethical decision-making model that I have engaged in frequently, particularly as a special education supervisor. It's fairly easy to come up with one potential course of action when there's an ethical dilemma, but analyzing the totality of the situation, what may be appropriate for the site-based administrator, the principal of the school may not be the best course of action for the special education department or those two parties may be on the same page relative to what they want to occur, but who or the service is about? It is always the student, the client that has to be paramount when we're engaging in this decision-making. 

Ultimately, all parties have to be taken into consideration in examining the situation, all the factors, and what's the best outcome for that child. Elise, I think that's going to exhaust my discussion about Janie Smith. Just one more thing I want to mention is that ASHA recently launched what is called a social civility toolkit. It is called the ASHA Civility Digital Toolkit and it's easily accessible on the ASHA website, someone can go to the ASHA homepage and type in Social Civility in the toolbox in the search box and the toolkit will appear. It has a background section, guiding principles, scenarios, tools for us to utilize guidelines and it's great that it also includes references and resources. 

I forgot one more thing. I did want to talk about defamation just a little bit, because in that scenario, we stated that Janie posted comments, defamatory comments about another local private practice and the Speech-Language Pathologist who work there. Depending on what that comment is, while it may be horrendous and certainly in poor taste, that comment in and of itself may not be an ethical violation. That would have to be considered. Defamation is really a legal term. Those laws vary from state to state. The defamation laws are generally intended to protect individuals and organizations from faults, factual statements that could harm their reputations. The term defamation can include both verbal and written statements that are factually false, but those elements I just described are what it takes to establish defamation legally, we would all need to look at our state laws about that. 

[00:47:06] EDM: All right, well, thank you so much for that guidance, and in particular, the decision-making model as well as the information on the Civility kit. I think both of those can be very, very useful for our listeners.

[MESSAGE]

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[INTERVIEW CONTINUED]

[00:47:44] EDM: Let's go on to a different scenario. Constance, who is completing her clinical fellowship experience, as well as the postgraduate professional experience required by the state licensure board, has an office adjacent to a clinical fellow mentor supervisor, her therapy room. Although the supervisor stated that she did not want to be anyone's supervisor. The two of them have a very good working relationship. They spend a lot of time together, developing materials, writing reports, doing team teaching, delivering presentations and programming augmentative communication devices. 

The supervisor is frequently in ConstanceÕs office using her software. At the end of the school year, the supervisor cannot produce documentation of supervision and she refuses to complete the required forms. When questioned about the provision of supervision and mentorship. She states that she always maintained that she didn't want to supervise or mentor anyone, but really supervised almost 100% of the time, because she spent so much time with the clinical fellow. The supervisor then accepts the job in another region of the country and leaves without providing any supervision documentation. Theresa, what about that situation?

[00:49:10] TR: Oh, my. I feel for that clinical fellow because she is going to have to complete that clinical fellowship experience fortunately or unfortunately, depending on your perspective. It really sounds as though there wasn't much direct mentorship going on in conferences' clinical fellowship experience. It sounds like both the mentor and the mentee, well traditionally we call that a supervisor, but it's really a CF mentor that the CF mentor shared physical space at the worksite with the clinical fellow who in this case is Constance. So they did a lot of activities together, they did team teaching. Certainly, some of that team teaching could have been utilized for direct observation, but it doesn't sound like the mentor really engaged in supervision or mentorship as a distinct clinical activity. 

It sounds like for whatever reason, she just thought that, because they were sharing a lot of physical space and doing a lot of activities together, that this was going to, I don't know, satisfy clinical fellowship requirements. I have to say that what we described in no way even approximates what should go on during a clinical fellowship experience. This isn't even 1/3 of the CF requirement was completed or 2/3. It sounds like the CF has no documentation. I have to question why the CF when the first 1/3 of the clinical fellowship experience have been completed, didn't ask her mentor when they would be conferencing so that Constance could receive her first set of ratings, so that she would better know what to work on during the remainder of the clinical fellowship experience. 

The whole purpose of the CF is to help the new practitioner make the transition from being in graduate school, to being an independent professional. That is the purpose of the clinical fellowship. So in this case, it would have been wonderful if Constance had had a frank discussion with her mentor, after the first 1/3, when that conference did not take place where you would typically sit and rate all of the skills on the CF rating inventory. 

One of the things that should have preceded that, theoretically, is that the mentor and the mentee in this case, Constance should have had a frank conversation about what was expected of each other throughout the CF experience, what the goals were etc. Let's just bring this back, though for a minute to the ethics of the situation. What has potentially been violated here? A few things, I would say under Principle of Ethics IV, Rule D as in Danny, ÒIndividual shall not engage in any form of conduct that adversely reflects on the professions or on the individualÕs fitness to serve persons professionally.Ó 

Another one is under Principle of Ethics IV, Rule E, ÒIndividuals shall not engage in dishonesty, negligence, fraud, deceit, or misrepresentation.Ó If we were functioning as members of the Board of Ethics, we would engage in a lengthy discussion about other factors associated with this case, so is it that the mentor, the CF mentor, misrepresented that she was actually going to function as ConstanceÕs mentor for the CF experience? Was she being deceitful and taking on that role, yet not fulfilling it? Was she just negligent? Was she just someone that just said, tomorrow's another day, we will get to that. Then although the CF mentorship would not have been implemented appropriately, certainly, at the end of the experience when the mentor takes a job in another region of the country and leaves without any documentation, that's quite dishonest, really. 

We could make some judgments about that, but certainly there are elements of Principle of Ethics IV, Rule E that have been violated. I would also say that, depending on the credentials held by both of the individuals. Let's say that they are in a state like mine, and that they both hold a license under which they must comply with the state Practice Act and rules and regulations. There would be a violation of Principle IV, Rule R, ÒIndividual shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.Ó In my state, and in most states, the CFs have a level of licensure, not all states, I think we're down to about five that do not license at that level. 

If you're in a state that does license the CF, the new graduate during the CF mentorship, there is supervision required under state law and state regulations. By virtue of that there would be a violation of ASHAÕs Principle of Ethics IV, Rule R in addition to the state regulations, and the state Code of Ethics that has been violated. There may also be other sections of the state law that have been violated based on this situation. That's one reason you have to always know the standards under which you are governed. As we said earlier, they are multiple standards, frequently, they might be from the ASHA Code of Ethics, they might be from your state licensure law, as well as the regulations that go with that. 

There may also be a code of conduct that is implemented by your Department of Education. I know, for example, the state of Mississippi has one. Always know the ethical standards, all of the applicable laws, regulations and policies that come into play in any given situation. Elise, I thank you so much for allowing me to engage and this discussion today about topics which are very, very important to me. As a school-based practitioner for 33 years I always feel that individuals should arm themselves with information. I hope we've helped to do that today. 

[00:56:40] EDM: I think we have, but before I let you go, I have one more question for you. It's related to school strikes and missed sessions. This is something that I'm particularly interested in, because during my tenure as ASHA president, during that year, there were four school strikes or school strikes in four states. I signed the letters to the Speech-Language Pathology coordinators of those schools in those states, informing them about Speech-Language Pathologist responsibilities for the students that they served, and their requirement to communicate with those studentsÕ parents. What do our listeners need to know about school strikes, about missed therapy sessions during that time, and the information that parents need while their children are out of school?

[00:57:33] TR: Well, this is an important question, as you know, Elise. If someone is considering going on a strike, if the district is considering, the union is considering going on a strike, it is imperative on the part of the audiologist and Speech-Language Pathologist employed by that district to make contact with their Special Education Office. This is why you need to make contact. There may come about depending on the length of the strike and the nature that it's dealt with, the need to communicate with all the parents of the children that are on the caseloads. Why do you need to contact the Special Ed Office about that? Then you need to know what the special ed districts office is planning, if there are missed sessions and how that is going to be handled. 

Let's say a district goes on strike for a week. If the school system completely shuts down for that week, meaning there is no school, therefore, the school is not open for anybody to come and receive any services, we're not there to provide the service, the school system is closed for a week. Then we don't have an issue relative to someone saying that our students have been abandoned, because there was no school. Let's say that the district decided not to close the school during the strike, but you went on strike, there could be an issue relative to client abandonment. 

Someone could say, Johnny has an IEP, it dictates three sessions a week, Mrs. Smith was not there to deliver those services. Not only was she not there, she didn't inform me that she wasn't going to be there to deliver the services. It's important that the parents know that the services are not going to be offered. Now, it is not the school SLPs decision to make as to how the sessions might be made up. Let's talk about that some more. When we talk about missed sessions there is guidance under IDEA from the US Department of Education. There is an issue brief on ASHAÕs website, you could just type in IDEA issue brief missed sessions, you could probably type in missed sessions and it would come up. 

What the Department of Education has said obviously, this is a FAPE issue. Free Appropriate Public Education FAPE. It has by virtue of not delivering those services, and in this case, we said a week for that individual child has fate been denied, what is the effect on that child's progress or lack thereof, because there weren't services provided during the strike? That's how the situation has to be initially evaluated. If there are repercussions for Johnny's progress relative to not receiving services during the strike, then you would probably make a decision that FAPE, Free Appropriate Public Education has been denied. Therefore, Johnny and his parents are entitled to those missed sessions being made up. 

Before I talk about missed sessions just any more, let me say, though, if Johnny's individual progress showed that there was no harm in missing that one week of services, then FAPE that determination, the Individual Determination is that FAPE has been provided. It's fine. The progress is not impeded by the strike, and you move on, just like there was not the strike lasting a week. Let's go back to the scenario where progress was impacted. Now we need to do something, we've made a decision. Missed sessions impacted FAPE. FAPE was denied, because of the missed sessions. It is going to be up to the school districts, Special Ed Office to decide how those sessions will be made up. 

Will it be after school, before school, during the summer? Who's going to do it? Will it be you? Will it be contracted providers etc.? Those kinds of parameters are why that initial contact with the district office is essential, so that you know how those things may be handled. Should you be promising anything to the parents prior to a strike? Absolutely not. You would never ever, ever make a commitment as to something that may not even come about, but you need to know and tell the parent, the district office understands that a strike may commence, I am not going to be here, if there is a strike, whether the school district continues or not. 

If the school is open and Johnny misses sessions, we will make some decisions. When I return from the strike, we will review every child's progress and make some decisions about what needs to happen. Then you would find out from your district office, how they want you to handle any situation where the child has been denied bait, where progress is effective, and there needs to be sessions made up. 

[01:03:21] EDM: Well, that certainly gives our listeners some great information and guidance in the occasion that they're faced with a strike and what you should do and what the Speech-Language Pathologists role is and responsibility is there. I think this ends our time together, Theresa. I want to thank you so much for being with me today. You really provided us with a lot of information and ideas. You've given us a lot to think about. I know our listeners will benefit from what you have given us on the topic of ethics and ethical practice in school practice because ethics is essential. Thank you so much.

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