As a seasoned speech-language pathologist working in a skilled nursing facility or other health care setting, you're accustomed to recommending appropriate levels of treatment for your patients and having those recommendations stick. But what do you do if your supervisor—in many cases not an SLP—insists on more sessions for the people in your care? What if the supervisor recommends far more treatment than you believe is advisable, or even safe?
SLPs find themselves in this prickly situation all too often, a fact borne out by the recently unsealed Department of Justice complaint against Life Care ("Federal Case Alleges Company Committed Medicare Fraud," The ASHA Leader, January 2013), as well as the 2005 and 2009 ASHA Health Care Surveys. The surveys suggest an increasing pattern of inappropriate employer demands, a problem even more pronounced in skilled nursing facilities.
It remains the SLP's responsibility to maintain ASHA ethical standards, even under intense pressure from an employer. But if you find yourself stuck in a similar predicament, what can you do? Granted, every ethical violation case is unique, making any blanket statements of advice less useful than targeted consultation. But here are some pointers on where to start:
Contact ASHA. Specific advice tailored to your situation is key to navigating it successfully. ASHA Director of Ethics Heather Bupp, an attorney, offers confidential ethics counseling and guidance for ASHA members and certificate holders (firstname.lastname@example.org).
See the sidebar of this column for links to relevant ASHA resources. More ASHA guidance on ethical issues in health care settings is available in The ASHA Leader ("Ethics and Patient Management," Jan. 20, 2009; "Nine Upsetting Dilemmas, Nov. 20, 2012) and the ASHA website.
Seek recourse within your institution. Whether you tap a corporate compliance process or simply request written documentation of policies that contradict your clinical judgment, you can sometimes stem unethical demands by using an already-established process. These situations are seldom as blatant as Life Care's published corporate policies, which were exposed in the DOJ complaint. More often, members report that administrators or supervisors imply that their bosses are held accountable for how much revenue the therapy departments generate. When the expectations are communicated orally, fraud may be more difficult to prove.
Keep records. Maintain a detailed, written record of your actions, and your employer's actions, related to the situation. These records can be in the form of e-mail correspondence, or a personal journal with dated entries. Both may be useful if you must explain—or defend—your actions and decisions.
Call Medicare. When clear documentation of fraud exists—as in the case of Life Care, where corporate documentation clearly demonstrated intentions to meet "UltraHigh" therapy targets (as defined by Medicare) regardless of the patients' needs—contact Medicare's Fraud and Abuse hotline (1-800-MEDICARE).
Contact your state. ASHA provides a state-by-state overview of regulatory and licensing entities' requirements and conduct standards.
Consider your last resort. Seek legal counsel in your state.
It's important to recognize circumstances that may present fraud, or unethical behavior that falls short of fraud but likely violates the ASHA Code of Ethics and the state's code of conduct. But you don't need to suffer in silence, compromise your ethics or resign your position. First, take action to address the problem. With inappropriate—and sometimes fraudulent—employer demands on the rise, it's critical to be prepared for situations in which your professional ethics may be threatened.