Recommended Citation

II. The Laws and Regulations

III.  Applying Ethical Principles in Practice

  The importance of ethics in society is clear. Take the example of going to a mechanic…an evil, unethical mechanic. My wife took her car to one such person. Her car was making an unflattering noise. The mechanic told her he would need to replace the catalytic converter for close to $1000. She took the car to another mechanic and he fixed it for under $100. He just needed to replace a small part. Another, more recent example, is the issues we has with a plumber. We had a small leak in our home. The first plumber wanted over $1000 to repair the leak and all it entailed. We were referred to a different handyman who only charged $65.

Now, you could argue that most auto mechanics and plumbers are ethical and try to do the best they can and stand behind their work. However, one bad mechanic’s or plumber’s reputation can tarnish the reputation of all of them. When you practice your profession, you are not only representing yourself, but all licensed professionals in your field. What will clients tell their friends and family about their experience in therapy?  What happens when a bad story hits the news?  People who really need help will be reluctant to do so because of what they have heard.

A. The following is a list of some behaviors that
weaken boundaries:

• Physical contact
                   
• Inappropriate dress
                   
• Horseplay
                    
• Divulging too much personal information like your own marriage problems, dating life, use of alcohol, etc.
                    
• Language
                    
• Allowing clients to break client therapist agreement
                   
• Selling or buying items to or from clients
                    
• Seeing each other outside of counseling sessions /socially
                    
• Dating
                    
• Extending individual sessions longer than agreed upon
                    
• Longer term therapy than necessary
                    
• Flirting
                    
• Dual relationship: Serving client you know outside of the therapeutic relationship.

B. Behaviors which strengthen therapeutic boundaries include:

• Maintain appropriate space
                   
• Appropriate dress
                    
• Professional consultation
                    
• Keep time and number of session to agreed upon amount.
                    
• Setting limits
                    
• Consistency
                    
• Role model appropriate behavior
                    
• No personal favors
                    
• Reinforce definition of relationship.

C. The use of appropriate boundaries to enhance therapeutic outcomes

People come to counseling for various reasons: usually as a result of some type of dissatisfaction with themselves, their lives and/or their relationships. It is important for them to have a safe environment to share thoughts feelings and emotions. Clients offer a high level of vulnerability in sharing with therapists intimate personal details of their lives. When the client can feel that there is positive regard and respect for their feelings, and this is maintained through appropriate boundaries, then the relationship becomes a significant part of the therapy itself. If those boundaries are broken, then the client enters an environment that only repeats, but at a more intense level, the issues that are the cause of them coming to therapy.  

Levels of self-disclosure play a large part in the therapeutic relationship that can damage or help the relationship depending on the motivation, timing and content of the disclosure. When not sure about what to disclose, it is probably best to follow the rule: less is more. Therapy is not about the therapist. Talking too much about yourself can weaken boundaries and redefine the relationship as something more social than therapeutic. 

“Maintain a professional helping relationship. Do not use your client to satisfy the needs that should be satisfied by your friends, spouses, and relatives. A warm, caring relationship with a client does not involve romantic love or sexual involvement.” (Mehr, p.297, 1986)

D. Risks of poor boundaries – How did that happen?

Illustration of How Boundaries may be Weakened

Jeff is a handsome 25 year-old man who is going through a divorce. The separation was initiated by his wife who was seeing a previous boyfriend. He does not have any children and Jeff describes his marriage as having been seemingly happy for them both, and says he still loves his wife. He wants to develop a meaningful relationship with another woman, but is somewhat insecure about going through the dating scene again.   

The divorce dealt a major blow to his confidence and his willingness to trust someone to be close. That is the dilemma he presents:  On the one hand he is lonely and would like to have a marital relationship again, on the other, he is insecure about initiating such a relationship and fearful what might occur if he does.

The therapist, a Licensed Clinical Social Worker named Anne, is a 32 year-old happily married woman with two children. She has been practicing for five years with a focus on couples therapy and families. She has counseled many individuals in relationships including males and has not had a problem with boundaries or inappropriate behaviors.  

Anne notices that Jeff is not bad looking. She expresses empathic concern for his heartbreak and troubles. She feels for Jeff’s sadness and he is very distraught. At the end of the first session, she thinks giving him a hug would be the natural thing to do to offer comfort. It is what she would do with a child, or even a woman who seemed to need such comfort. She chooses not to because at the moment she decides it would be a weakening of the boundaries.  

In a later session, however, she justifies to herself that it would be okay to give Jeff hugs to comfort him. She finds herself being more aware of her personal appearance on the days that Jeff is scheduled to be seen. They are developing a rapport and Jeff seems to be getting happier as he adjusts to the separation from his wife. In helping Jeff with his insecurity of initiating relationships, Anne roll plays as a date partner in phone and date conversations. Jeff thanks Anne for her assistance but states he is still very worried about how things will go on a date. He asks her if they could have a practice date---just out to dinner or lunch. She is hesitant, but agrees as Jeff expresses his need for the help.  

The Poor Choices

First, Anne found Jeff to be handsome. Depending on Anne’s internal response to this, it may or may not be a problem in itself; however, it would at least put up a red flag for her to be careful with her own thoughts, behaviors and emotions and to keep them in check. There are different rules of thought in regards to hugging clients, regardless of their age or gender. In this case, Anne did show some awareness by not hugging him at the first session, but then justified it later. Decisions such as these when justified through the foggy lens of human emotion often end up being poor decisions.     

It is next noted that she is becoming more aware of wanting to look attractive to Jeff. Being aware of one’s personal appearance would be a positive thing (and one more therapists should pay attention to!), but the fact that she was paying extra attention in regards to how she would look to Jeff was a sure sign that her boundaries and feelings were going beyond the therapeutic relationship. Anne’s self-awareness as a therapist should have been a warning bell, but she ignored it. It is doubtful that she was not aware of what she was doing, but she was ignoring the potential consequences. With the proper response, she may have referred Jeff to another therapist, or at least at this point, if she had not from the beginning, sought consultation.  

The roll playing could have been a positive therapeutic technique, except that Anne had weakened the boundaries to the point where the roll play wasn’t just a roll play, and obviously the practice date was not going to be just practice. Anne has then created a dual relationship under the guise of therapy, and the path, if she continued on it, becomes obviously difficult.  

Fortunately, Anne suddenly got a hold of herself, realized what she was doing and where it was leading.  She sought consultation and, instead of the practice date, asked Jeff to see her in the office for an appointment.  In that appointment, as discussed in her consultation session, she stated to Mark that it was out of the scope of their therapy for her to go on a “practice date” with him, and that she should not have set such an appointment to do so.They discussed the progress that he had made thus far in his counseling and suggested to him that if he still felt a need to see a therapist that she could refer him to another very qualified therapist.      

To her credit, Anne eventually stopped the relationship from moving further in the direction it was. It was unfortunate that she let it go as far as it did, having potentially harmed the client, depending on his response to it. This vignette illustrates the need for the provider to have vigilant self-awareness in order to maintain appropriate boundaries. The harm that comes from the failure to do so can be severe.

A. Child Abuse & Neglect

B. Elder Abuse

“15630.  (a) Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent  adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent  adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter.  
(b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse,  as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report sent within two working days, as follows:
(A) If the abuse has occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the report shall be made to the local ombudsperson or the local law enforcement agency.”

C. Domestic Violence

  The clients of healthcare practitioners may be victims of domestic/family violence. These may not be child abuse or Elder abuse, but between a husband and wife or another type of adult on adult violence. The safety of the client is the primary concern. It is important for the healthcare practitioners to discuss with the victim of domestic violence the resources available and to assist them to obtain those resources. This includes medical attention if needed, the involvement of law enforcement and shelters. There should also be an awareness of children in the home and their emotional health under such a situation, which can be abusive in itself.   

There are many complex biopsychosocial issues surrounding abuse and violence. The purpose of this section has been to clarify the legal and ethical responsibilities of the licensed healthcare professional surrounding abuse.  

D. Confidentiality vs. Need to Report: Tarasoff

The case of Tarasoff vs. Regents of the University of California established the duty of therapists to warn the public if the client or another identifiable person is in clear or imminent danger. The Tarasoff case concerns a University of California student, ProsenjitPoddar who was seeing a psychiatrist at the student healthcare center. Tatiana Tarasoff was a young woman who Mr. Poddar had feelings for, but she did not have the same for him.   

Tarasoff had expressed his intention to the psychiatrist to buy a gun and as a result of their sessions together the psychiatrist felt that Mr. Poddar meant to do Ms. Tarasoff harm and informed the police. The police questioned Mr. Poddar, felt that he would not harm Ms. Tarasoff and made him commit to staying away from her.A couple of months later, Mr. Poddar killed MsTarasoff.   

As a result of the killing, the parents of MsTarasoff sued the University, the healthcare center staff and the police, but the courts dismissed the case. In a later appeal to the California State Supreme Court it was ruled that the psychiatrist had responsibility to inform Ms. Tarasoff of the imminent danger she was in. As a result of this case, it is the legal duty of healthcare practitioners to breach confidentiality if a client or an identifiable person is in danger. If it is another identifiable person that is in danger, the practitioner must warn them directly of the threat. Just calling the police does not fulfill the obligation of the “duty to warn.”

A. Exercises in Confidentiality

For each situation consider the following:
1. How can you best discharge your ethical responsibilities in the situation?
2. Do you experience conflicting pulls regarding possible courses of action?
3. In situations that involve legal ramification, how would you handle it with the client in the event your planned action would be contrary to the client’s request?

Situation 1. A male client confided in an individual marital therapy session several weeks ago that he is a practicing homosexual, although his wife does not know this. The client’s wife, who you have also seen conjointly with him, calls you today, troubled over the lack of progress in solving marital problems, and asks you point-blank whither you think her husband could be homosexual.

Situation 2. A client with whom you have had several sessions in a family agency confides to you that he is wanted by legal authorities for repeatedly ignoring court orders to pay child support to his wives from two previous marriages. The client, who has eluded authorities by assuming a false name and changing addresses frequently, also indicates that he has been warned he will be incarcerated if he is apprehended. With respect to such situations, you were recently advised by legal counsel in a staff meeting that withholding information regarding fugitives from the law also makes you culpable.

Situation 3. You are forming a group for youth in a state correctional facility. You know from the past experience that youth sometimes make references in the group to previous offenses that they have committed without being apprehended. You also know that they may talk about plans to run form the institution or about indiscretions or misdemeanors they (or others) may have committed or plan to commit within the institution, such as smoking marijuana or stealing institutional supplies or property from peers or staff.

Situation 4. In conducting an intake interview with a client in a family agency, you observe that both of her young children are withdrawn. Further, one of the children is badly bruised, and the other, an infant, also appears malnourished. Throughout the interview, the client seems defensive and suspicious and also ambivalent about having come for the interview. At one point, the client states that she feels overwhelmed with her parenting responsibilities and is having some difficulty in coping with her children. She also alludes to her fear that she may hurt them but then abruptly changes the subject. As you encourage her to return to the discussion of her problems with the children, your client says she had changed her mind about wanting help, takes her children in hand, and leaves the office.

Situation 5. You have seen a husband and wife and their adolescent daughter twice regarding relationship problems between the parents and the girl. The parents are united in their approach to the problem—both extremely negative and blaming in their attitude toward their daughter, feeling that their troubles would be over if she would just “shape up.”Today, during an individual interview with the girl, she breaks into tears and tells you that she is pregnant and plans to “go somewhere” with her boyfriend this weekend to get an abortion. She pleads with you not to tell her parents, who she feels would be extremely angry if they knew.

Situation 6. In a mental health agency, you have been working with a male client who has a past history, when angered, of becoming violent and physically abusive. He has been under extreme psychological pressure lately because of problems relating to a recent separation from his wife. In an interview today, he is extremely angry, clenching his fists as he tells you that he has heard that his wife has initiated divorce proceedings and plans to move to another state. “If this is true,” he loudly protests, “she is doing it to take the kids away from me, and I’ll kill her rather than let her do that.”

Situation 7. A colleague and close friend sees you at a casual event and remarks that she knows you are seeing a friend in therapy. She begins to talk about problems she knows your client is experiencing and then asks you whether it is true that the client has been hospitalized previously for depression.

Situation 8. In the last several interviews, a 15-year-old girl has seemed troubled, but despite repeated inquiries and expressions of concern, she did not confide in you. In the course of today’s interview, however, she blurts out that her brother-in-law has been making sexual advances and pressuring her to have intercourse with him. Your client, who has been living in the home of her brother-in-law and her sister, indicates that she has resisted the man’s sexual attempts thus far, but it is evident that she is frightened and perplexed. Although embarrassed and guarded about disclosing details of the situation, she indicates strongly that she does not want her sister to know about this problem. After exploring the problem to the extent your client is willing and able, you discuss and role-play approaches she can take to confront her brother-in-law and quell his advances. But in view of her fright and the difficulty she has in rehearsing assertive behavior, you are worried that she may be unable to manage the situation if the brother-in-law were to intensify his pressure. ( pp72-73)

Each of these scenarios creates a type of dilemma regarding confidentiality, without being absolutely clear cut. The framework already provided from Reamer, and a solid knowledge of your professions code of ethics would be helpful in making decisions for each of these scenarios. Another resource to be seriously considered is that which has also already been discussed—a consultant.

B. HIPAA Regulations

No doubt either you or your agency had to make some significant changes in regards to how you gather and maintain clients’ information. I have noticed as a patient/consumer such things as how sign-in sheets are handled differently at both doctors’ offices and pharmacies. Somebody is making good money on those little adhesive strips that cover patients’ names after signing in. I have to admit that I had never given it a second thought before then that my name would be on a sign-in sheet. In fact if someone had presented the idea of it I would have told them that it was ridiculous and another instance of the government becoming over regulatory, and in some ways I probably still feel that way about a lot of regulations. However, if I were to go to have a procedure done, or go to counseling, that I would prefer others not know about, it would become more important to me that my name is not our there for all to see.

The regulations were primarily intended to provide patients with greater access and control of their records, which makes a lot of sense. We should have the freedom to transfer care providers and expect that if we desire our records would follow in a timely manner.Being able to send these records electronically provides the convenience and timeliness we would all like. It also cuts down on office work, having to make copies of large files, and then finding ways to physically transport them. With electronic means it is as easy as sending an email. So easy, in fact, that such information could be sent nearly anywhere and everywhere—probably not something that we would prefer as patients or consumers. As a result, regulations were put in place to ensure steps were taken for the private and secure transfer of this information. The caution is with reason: just look at the news on some of the private information, such as social security numbers and credit card information and that has accidentally been sent out to locations unintended. No doubt there will be mistakes made and we will be hearing about them, and lawsuits will be occurring as a result. Some will be because of the evil intentions of some; others will be caused by human error. Thus, it is important to implement the safeguards provided and to be able to show due diligence in complying with the regulations.

Whether we like them or not, it doesn’t really matter. The fact is that we are now governed by the Health Insurance Portability and Accountability Act (HIPAA) and we need to comply in our practice as professionals. The following is from the US department of Health and Human Services website. It contains information and FAQs that are helpful in our effort to understand and comply with the regulations. The following information is provided by the United States Department of Health and Human Services (HHS). It provides an overview of the regulations and the process by which privacy statutes became a part of the regulations. The link to this and further information is provided here. I have attempted to provide that which is most pertinent: http://www.hhs.gov/ocr/hipaa.

PROTECTING THE PRIVACY OF PATIENTS' HEALTH INFORMATION

Overview: The first-ever federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country. State laws providing additional protections to consumers are not affected by this new rule.

Congress called on HHS to issue patient privacy protections as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA included provisions designed to encourage electronic transactions and also required new safeguards to protect the security and confidentiality of health information. The final regulation covers health plans, health care clearinghouses, and those health care providers who conduct certain financial and administrative transactions (e.g., enrollment, billing and eligibility verification) electronically. Most health insurers, pharmacies, doctors and other health care providers were required to comply with these federal standards beginning April 14, 2003. As provided by Congress, certain small health plans have an additional year to comply. HHS has conducted extensive outreach and provided guidance and technical assistant to these providers and businesses to make it as easy as possible for them to implement the new privacy protections. These efforts include answers to hundreds of common questions about the rule, as well as explanations and deblockedions about key elements of the rule.
These materials are available at http://www.hhs.gov/ocr/hipaa.

PATIENT PROTECTIONS

The new privacy regulations ensure a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use patients' personal medical information. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in computers or communicated orally. Key provisions of these new standards include:

• Access To Medical Records. Patients generally should be able to see and obtain copies of their medical records and request corrections if they identify errors and mistakes. Health plans, doctors, hospitals, clinics, nursing homes and other covered entities generally should provide access these records within 30 days and may charge patients for the cost of copying and sending the records.
• Notice of Privacy Practices. Covered health plans, doctors and other health care providers must provide a notice to their patients how they may use personal medical information and their rights under the new privacy regulation. Doctors, hospitals and other direct-care providers generally will provide the notice on the patient's first visit following the April 14, 2003, compliance date and upon request. Patients generally will be asked to sign, initial or otherwise acknowledge that they received this notice. Health plans generally must mail the notice to their enrollees by April 14 and again if the notice changes significantly. Patients also may ask covered entities to restrict the use or disclosure of their information beyond the practices included in the notice, but the covered entities would not have to agree to the changes.
• Limits on Use of Personal Medical Information. The privacy rule sets limits on how health plans and covered providers may use individually identifiable health information. To promote the best quality care for patients, the rule does not restrict the ability of doctors, nurses and other providers to share information needed to treat their patients. In other situations, though, personal health information generally may not be used for purposes not related to health care, and covered entities may use or share only the minimum amount of protected information needed for a particular purpose. In addition, patients would have to sign a specific authorization before a covered entity could release their medical information to a life insurer, a bank, a marketing firm or another outside business for purposes not related to their health care.
• Prohibition on Marketing. The final privacy rule sets new restrictions and limits on the use of patient information for marketing purposes. Pharmacies, health plans and other covered entities must first obtain an individual's specific authorization before disclosing their patient information for marketing. At the same time, the rule permits doctors and other covered entities to communicate freely with patients about treatment options and other health-related information, including disease-management programs.
• Stronger State Laws. The new federal privacy standards do not affect state laws that provide additional privacy protections for patients. The confidentiality protections are cumulative; the privacy rule will set a national "floor" of privacy standards that protect all Americans, and any state law providing additional protections would continue to apply. When a state law requires a certain disclosure -- such as reporting an infectious disease outbreak to the public health authorities -- the federal privacy regulations would not preempt the state law.
• Confidential communications. Under the privacy rule, patients can request that their doctors, health plans and other covered entities take reasonable steps to ensure that their communications with the patient are confidential. For example, a patient could ask a doctor to call his or her office rather than home, and the doctor's office should comply with that request if it can be reasonably accommodated.
• Complaints. Consumers may file a formal complaint regarding the privacy practices of a covered health plan or provider. Such complaints can be made directly to the covered provider or health plan or to HHS' Office for Civil Rights (OCR), which is charged with investigating complaints and enforcing the privacy regulation. Information about filing complaints should be included in each covered entity's notice of privacy practices. Consumers can find out more information about filing a complaint at http://www.hhs.gov/ocr/hipaa or by calling (866) 627-7748.

HEALTH PLANS AND PROVIDERS

The privacy rule requires health plans, pharmacies, doctors and other covered entities to establish policies and procedures to protect the confidentiality of protected health information about their patients. These requirements are flexible and scalable to allow different covered entities to implement them as appropriate for their businesses or practices. Covered entities must provide all the protections for patients cited above, such as providing a notice of their privacy practices and limiting the use and disclosure of information as required under the rule. In addition, covered entities must take some additional steps to protect patient privacy:

• Written Privacy Procedures.The rule requires covered entities to have written privacy procedures, including a deblockedion of staff that has access to protected information, how it will be used and when it may be disclosed. Covered entities generally must take steps to ensure that any business associates who have access to protected information agree to the same limitations on the use and disclosure of that information.
• Employee Training and Privacy Officer.Covered entities must train their employees in their privacy procedures and must designate an individual to be responsible for ensuring the procedures are followed. If covered entities learn an employee failed to follow these procedures, they must take appropriate disciplinary action.
• Public Responsibilities. In limited circumstances, the final rule permits -- but does not require --covered entities to continue certain existing disclosures of health information for specific public responsibilities. These permitted disclosures include: emergency circumstances; identification of the body of a deceased person, or the cause of death; public health needs; research that involves limited data or has been independently approved by an Institutional Review Board or privacy board; oversight of the health care system; judicial and administrative proceedings; limited law enforcement activities; and activities related to national defense and security. The privacy rule generally establishes new safeguards and limits on these disclosures. Where no other law requires disclosures in these situations, covered entities may continue to use their professional judgment to decide whether to make such disclosures based on their own policies and ethical principles.
• Equivalent Requirements For Government. The provisions of the final rule generally apply equally to private sector and public sector covered entities. For example, private hospitals and government-run hospitals covered by the rule have to comply with the full range of requirements.

OUTREACH AND ENFORCEMENT

HHS' Office for Civil Rights (OCR) oversees and enforces the new federal privacy regulations. Led by OCR, HHS has issued extensive guidance and technical assistance materials to make it as easy as possible for covered entities to comply with the new requirements. Key elements of OCR's outreach and enforcement efforts include:

• Guidance and technical assistance materials. HHS has issued extensive guidance and technical materials to explain the privacy rule, including an extensive, searchable collection of frequently asked questions that address major aspects of the rule. HHS will continue to expand and update these materials to further assist covered entities in complying. These materials are available at http://www.hhs.gov/ocr/hipaa/assist.html.
• Conferences and seminars. HHS has participated in hundreds of conferences, trade association meetings and conference calls to explain and clarify the provisions of the privacy regulation. These included a series of regional conferences sponsored by HHS, as well as many held by professional associations and trade groups. HHS will continue these outreach efforts to encourage compliance with the privacy requirements.
• Information line. To help covered entities find out information about the privacy regulation and other administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, OCR and HHS' Centers for Medicare & Medicaid Services have established a toll-free information line. The number is (866) 627-7748.
• Complaint investigations. Enforcement will be primarily complaint-driven. OCR will investigate complaints and work to make sure that consumers receive the privacy rights and protections required under the new regulations. When appropriate, OCR can impose civil monetary penalties for violations of the privacy rule provisions. Potential criminal violations of the law would be referred to the U.S. Department of Justice for further investigation and appropriate action.
• Civil and Criminal Penalties.Congress provided civil and criminal penalties for covered entities that misuse personal health information. For civil violations of the standards, OCR may impose monetary penalties up to $100 per violation, up to $25,000 per year, for each requirement or prohibition violated. Criminal penalties apply for certain actions such as knowingly obtaining protected health information in violation of the law. Criminal penalties can range up to $50,000 and one year in prison for certain offenses; up to $100,000 and up to five years in prison if the offenses are committed under "false pretenses"; and up to $250,000 and up to 10 years in prison if the offenses are committed with the intent to sell, transfer or use protected health information for commercial advantage, personal gain or malicious harm.

COMMON HIPAA QUESTIONS AND THEIR ANSWERS

Question: Generally, what does the HIPAA Privacy Rule require the average provider or health plan to do?

Answer:
For the average health care provider or health plan, the Privacy Rule requires activities, such as:
- Notifying patients about their privacy rights and how their information can be used.
- Adopting and implementing privacy procedures for its practice, hospital or plan.
- Training employees so that they understand the privacy procedures.
- Designating an individual to be responsible for seeing that the privacy procedures are adopted and followed.
- Securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them.

Responsible health care providers and businesses already take many of the kinds of steps required by the Rule to protect patients’ privacy. Covered entities of all types and sizes are required to comply with the Privacy Rule. To ease the burden of complying with the new requirements, the Privacy Rule gives needed flexibility for providers and plans to create their own privacy procedures, tailored to fit their size and needs. The scalability of the Rule provides a more efficient and appropriate means of safeguarding protected health information than would any single standard.
For example,
- The privacy official at a small physician practice may be the office manager, who will have other non-privacy related duties; the privacy official at a large health plan may be a full-time position, and may have the regular support and advice of a privacy staff or board.

- The training requirement may be satisfied by a small physician practice’s providing each new member of the workforce with a copy of its privacy policies and documenting that new members have reviewed the policies; whereas a large health plan may provide training through live instruction, video presentations, or interactive software programs.

- The policies and procedures of small providers may be more limited under the Rule than those of a large hospital or health plan, based on the volume of health information maintained and the number of interactions with those within and outside of the health care system.

Conclusion for Part 1

As mentioned at the beginning of this course, Laws and Ethics are necessary to providing quality services to the consumer.  Maybe nowhere is this more important than in the healthcare field. This course has covered many of the Laws, Regulations and Ethics pertaining to the professional conduct of LCSWs, MFTs and Nurses. It is your challenge as a licensed professional to implement the information in this course for the betterment of yourself as a clinician in helping the most vulnerable among us.

  Well, it appears you have survived Part 1 of the course, now on to Part 2, which probably isn’t as good as Part 1, but now we have you hooked so you have to stay to see how it ends!

Bibliography for Part 1

Banks, S. (2001), Ethics and Values in Social Work, London: McMillan Press, as found in McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas forSocial Workers in Direct Practice,” in Journal of Social Work Values and Ethics, Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17// (2005).

California Board of Behavioral Sciences at http://www.bbs.ca.gov/pdf/publications/lawsregs.pdf  (2013)

Congress, E. (1999), Social Work Values and Ethics: Identifying and Resolving Professional Dilemmas, Chicago: Nelson Hall, as found in McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas for Social Workers in Direct Practice,” in Journal of Social Work Values and Ethics, Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17//

Hawkins, P. and Shotet, R. (1989), Supervision in the Helping Professions, Philadelphia: Open University Press, as found in McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas for Social Workers in Direct Practice,” in Journal of Social Work Values and Ethics, Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17//

Hepworth and Larsen, Direct Social Work Practice: Theory and Skills (Chicago: The Dorsey Press, 1986)

Loewenberg, F.M., Dolgoff, R. and Harrington, D. (2001), Ethical Decisions for Social Work Practice, Itasca: F.E. Peacock Publishers, as found in McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas for Social Workers in Direct Practice,” in Journal of Social Work Values and Ethics,Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17// (2005)..

McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas forSocial Workers in Direct Practice,” in Journal of Social Work Values and Ethics, Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17//

Reamer, F.G., “Ethical Dilemmas in Social Services” (New York: Columbia University Press, 1982) as found in Hepworth and Larsen, Direct Social Work Practice: Theory and Skills (Chicago: The Dorsey Press, 1986)

Reamer, F.G. (1983), “Ethical Dilemmas in Social Work Practice”, Social Work, January-February, 31-35, as found in McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas forSocial Workers in Direct Practice,” Journal of Social Work Values and Ethics, Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17// (2005).

Rothman, J. (1998), From the Front Lines – Student Cases in Social Work Ethics, Boston: Allyn and Bacon, as found in McAuliffe, Donna (Ph.D.) “I’m Still Standing: Impacts and Consequences of Ethical Dilemmas forSocial Workers in Direct Practice,” Journal of Social Work Values and Ethics, Spring 2005: Vol. 2, No.1 at http://www.socialworker.com/jswve/content/view/17// (2005).  

The Author of Part 1

  Lance Parks, LCSW has a rich and diverse history of educational, clinical, training and administrative experience. Mr. Parks is a certified Group Home Administrator in the state of California and serves as an Associate Director and Licensed Clinical Social Worker at a residential placement facility for adolescents ages 13-18.  Mr. Parks' counseling experience includes the following populations and settings: HIV positive inmates at CIM in Chino, California, outpatient Spanish speaking clinic, private psychiatric hospital, skilled nursing facilities (nursing homes), private family counseling clinic, and adolescent residential placement.  

In addition, Mr. Parks has helped plan, develop and/or present training programs and conferences for the following personnel: group home staff, state certified group home administrators, probation officers, social workers, mental health personnel, LCSWs and MFTs. Since 1999 Mr. Parks has served on the continuing education committee, residential care committee and juvenile justice committee for a statewide association of private nonprofit child and family serving agencies.  

Mr. Parks received his Bachelor of Science in Family Sciences with a minor in Spanish from Brigham Young University, and his Master of Social Work from the University of Southern California.