Scenario

“The company I work for assigns caseloads of 12-14 patients per BCBA. 14 would be for BCBAs that have a masters level student working under them in a mentorship program. My ethical dilemma is that I do not feel I am able to give my patients the full service that I have prescribed, and they require to make meaningful changes in their behavior reduction and skill acquisition. I am not able to see them for the full authorization of consultation hours nor am I able to keep up with updating their behavior plans as often as I see necessary. On top of that I am required to mentor a student- the company thinks having a student should help but this student is just starting to collect unrestricted hours and requires me to shadow her and provide feedback more frequently than a student who has collected most of their hours. I feel I am not meeting her needs as a up and coming BCBA and not doing a just service to my patients. Also, I have over 20 supervisees under my name under the board. I cannot effectively supervise that many RBTs during the month and maintain my patients programming.

Myself and colleagues have brought this to the attention of our supervisors both clinical and management and feel our concerns have been dismissed as other BCBAs in the organization are managing a caseload this large so we are expected to as well. I hate that my next solution is to leave and find a company that doesn’t push billable hours so hard and allows room to spend in unbillable supervision meetings and have a smaller caseload so I can provide meaningful supervision to my RBTs.”

Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions):

In accordance with Ethics Codes 2.01, 2.09b, 5.02, and 5.04 the committee recommends that the author continue to advocate for a client and supervisory caseload that is commensurate for the time required to perform the duties of behavior analysts successfully and ethically. The committee would encourage the author to explore the following steps as option, noting this should not be considered legal employment advice.

1. Write a formal letter to your supervisor and to the executive administration, including HR, educating them on and outlining our ethical codes of conduct surrounding supervision, caseload size, etc. Provide suggestions to them on ways in which they can support BCBAs in your agency that are more conducive to best practices in supervision and quality care for clients. 
   1. Documentation of concerns can provide protection against wrongful termination and provides a clear statement for follow-up. 
2. If meaningful change is not made to satisfy the ethical code of conduct, the BCBA could send their letter to the ethics committee at the BACB for further feedback.
   1. If administration/leadership are not behavior analysts, the correction process can be more difficult because they are not held to our standard. For this reason, we recommend seeking out leadership with a BCBA credential to minimize this challenge in the previous step. 

Ethics Codes (specific standards that could apply to support/oppose):

• 1.02 Boundaries of Competence 
• 2.01 Accepting Clients 
• 2.15 Interrupting or Discontinuing Services (subpart d) 
• 2.15 Interrupting or Discontinuing Services (subpart e) 
• 3.01 Behavior-Analytic Assessment

Scenario

“BCBA recently had clinic administration call parents of early learner to pick up during a tantrum and discharged child with a referral to get a “mental health evaluation”. No behavior data was taken and no assessment of the tantrum behaviors. Behaviors were typical of an early learner starting ABA services.” 

Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions):

In accordance with Ethics Code 7.02, we would encourage the submitter to foremost review if addressing the concern/individual directly would correct the issue.  The BACB recommends that all persons suspected of an ethics violation be contacted directly wherever possible.  You can find further information on the steps for reporting an ethics violation on the BACB website under the Ethics tab. If the person submitting this is a BCBA and felt that their colleague was performing outside of their scope during assessment or the behavioral incidents (before/after), we encourage you to reflect on what your immediate actions could have been during this process. In review of the submission, the committee is recommending that parties involved explore the following codes in relation to this issue.  The committee would recommend additional training and mentorship for all BCBAs to practice within their scope of competence in all areas including (1) accepting clients within the scope, (2) seeking supervision, (3) interrupting and discontinuing services, and (4) proper assessment methodology. Additionally, we recommend that the submitter consider their company’s internal grievance policy/process to ensure that the BCBA in question receives adequate supervision moving forward.  Finally, if a board complaint is found to be warranted after review of the Ethics Toolkit for decision-making and continuity of care, the submitter should also file concerns/reports to the board of licensure (AZBoPE). 

Ethics Codes (specific standards that could apply to support/oppose):

• 1.02 Boundaries of Competence 
• 2.01 Accepting Clients 
• 2.15 Interrupting or Discontinuing Services (subpart d) 
• 2.15 Interrupting or Discontinuing Services (subpart e) 
• 3.01 Behavior-Analytic Assessment

Scenario

Work space sharing is becoming an efficient way to share resources among hospitals and other business models. Do we have any ethical guidelines regarding shared work spaces among two companies that provide similar ABA services in a private property? We can address the confidentiality issues but we wanted to make sure we did our due diligence in preparation for a possible space sharing situation.

Response

• Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions): 
• • The committee input is provided based on the assumption that the shared workspace being referred to, is an outpatient treatment facility. 
  • • Additional privacy measures such as computer privacy screens, using abbreviations during phone calls and keeping files securely, considering schedule rotations/shifts to minimize client overlap 
    • Additional consents to consumers 
    • Posted disclosures to consumers 
    • Ongoing environmental audits to ensure compliance with privacy/confidentiality measures 
• Ethics Codes (specific standards that could apply to support/oppose): 
• • 06 maintaining confidentiality. 
  • 07 maintaining records- ensuring files are locked etc.

Scenario

You obtained your Board Certified Assistant Behavior Analyst (BCaBA) certification 3-months ago. You went from working as a Registered Behavior Technician (RBT), as you accumulated your required supervised fieldwork hours, to a position as a BCaBA with the same company. Suddenly, you had more authority to make decisions regarding your clients’ treatment programs, as well as an increased case load.

Shortly after you took on your new role as a BCaBA, you met with the Board Certified Behavior Analyst (BCBA) who is supervising you to discuss expectations regarding your new position. During the meeting, your supervisor said that the company manager has a requirement that you request 10-hours per week of one-on-one therapy for each new client the company serves when submitting your requests for hours to your clients’ insurance providers. Your supervisor also told you that you will be training RBTs to implement the behavior intervention plans (BIPs) so that you can oversee as many clients as possible. From your experience working with your current clients, you realized that not every client requires 10-hours of applied behavior analysis (ABA) therapy per week and you asked, “What if each new client does not require that many therapy hours?” Your supervisor responded that it is an unwritten company policy. Suddenly, you were faced with an ethical dilemma and you had to decide how best to handle the situation. 

Response

• Committee Input: 
• • Dosage should be directly related to medical necessity (there are no set minimum/maximums of treatment) 
  • • Recommendations include bringing proposed tx plan/assessment with dosage to review specific details (why your recommendation is less than 10 hours etc.) with Supervisor and BCBA. You can address this without acknowledging the unwritten rule – simply explain your treatment plan objectively with supporting evidence to defend your recommendation (think of it as doing a live or clinical review with the Supervisor). 
  • If this is unsuccessful, you should follow the ethical decision process outlined by the BACB to help guide you in next steps/reporting requirements. 
• Exploration: 
• • Access and review definition of medical necessity from the funding source (you could also use this as supporting documentation when meeting with Supervisor) 
  • Is there another program available? For example, does the company separate out types of services (consultative, comprehensive, focused?). It this is the case, maybe the 10 hours is the cut off for the focused model but this consumer could be supported in another capacity (like a consultative model) rather than a prescriptive dosage for consumers? 
• Relevant Codes: 
• • 2.09, 3.01, 4.03, 5.03, 7.01

Scenario

I work for an ABA company that offers in home ABA services. I have three plus families that live within a couple mile radius of each other. Multiple parents have asked me if I know of any other children or families around that are similar age skill set etc. The parents are wanting to have a play date / create a friendship with another child with autism. I have not disclosed any information about other families due to HIPPA to the families that are asking. 

How can I assist these families that have expressed wanting to connect with each other without violating HIPPA? If i give phone numbers or names I am violating their privacy even though they have asked me to do this?

Is it covered in an roi? Can there be a special roi? How can I make sure I am protecting privacy but also assisting me families create a supportive community with each other? What do others do to connect families? 

Response

• Committee Input: 
• • Parents can sign ROI so that emails can be exchanged and then they can coordinate it 
  • Suggest Facebook groups 
  • Create a social group; collect the ROI prior 
  • You would want to be careful connecting those clients (future implications/relationship doesn’t go well, how does this impact rapport etc.) 
• Exploration: 
• • Have the parents check Facebook groups, NextDoor app, peanut app or direct them to your agency’s Facebook page to post for playdates. 
• Codes: 
• • 2.06; 2.08

Scenario

Client that is being billed through insurance by the Agency that I work for is being accepted into college courses. He would like a letter of recommendation from his supervisor for some scholarship opportunities. Is it ethically appropriate to provide a letter for his college? What would be precautious steps to take in the event that we can provide a letter? Would this be better to provide during billable or non-billable therapy/supervision? What are some possible HIPPA considerations? Ethical issue: Dual relationship, Monetary concerns (if client receives scholarship for college), Billable/non-billable/spare time concerns.

Response

• Committee Input: 
• • Potential dual relationship issue 
  • Can the client give their own consent to be able to release of PHI? 
• Exploration: 
• • Avoid the multiple relationship. “Our ethical code states that” 
  • Coaching the client through asking other teachers/professional people 
• Codes: 
• • 1.06B; 1.07A

Scenario

A school district posted a job opening for a BCBA, and said they would take someone non-certified, as long as the person pays for their own supervision. Would another district BCBA still be responsible for providing supervision, especially during the time between supervision ending (1500 hours completed) and time of certification? 

Response

• Committee Input: 
• • What would the BCBA doing within their job? 
  • What is the job description? If candidate is a supervisee, supervision is required 
• Exploration: 
• • Ensure that you are not mis-representing the credential. 
  • Be careful of dual relationship with the supervisor. 
  • Behavior Analysts in the school typically have large caseloads, would they have the support to take on additional supervisees? 
  • Make sure your contract is clearly written about support of supervision/payment 
  • Plan how you are going ensure support 
• Codes: 
• • 10.7; 6.0; 5.05; 8.03

Scenario

I am a founder and executive director for a school for children with ASD. We have a female HS student who has an iPhone with access to her own social media accounts. She is very socially motivated. She comes from a single parent, low SES home. Her mother can be challenging to work with. We have found recently on her phone inappropriate content. Solicitations for attention from men that we don’t think she knows…your basic nightmare. Obviously the first step would be making her mother aware of this, but I highly suspect that won’t go anywhere.  I will still do that as a first measure.  Is this a CPS call? What social services might be available to ensure this student is safe? She is obviously an extremely vulnerable young adult.

Response

• Committee Input: First step includes meeting with parent, disclosing content that was found on phone and the nature of how the content was discovered. Invest in sex ed curriculum (evidence based)/programming available to remediate maladaptive behavior and increase skills. Provide recommendations to parent for monitoring/parental controls (ie. Disney Circle). Establish open communication between parent/school site to support ongoing check-ins on status. 
• Exploration: Policies and procedures related to reasonable permission to review social media account of students. Parental consent to access student phones/accounts. Consider including policies and procedures around access to technology/consent at onset of services? Consider level of permission. Collaborate/reach out to attorney to determine what is within limits of law etc. Reach out to third parties for staff/parent inservices/training(s) related to online safety and sex ed – PR, Specialists (therapists, online safety specialists) and PD. 
• Codes: 2.05, 4.02

Scenario

Using testimonials on website, no disclaimers

Response

• Committee Input: Reach out to organization’s leaders (BCBAs) as soon as possible to resolve (lead with education). Provide guidance on code and potential action items. Follow up on website/with BCBA after initial conversation. Document actions taken (include dates) 
• Exploration: If parents wrote the testimonial, consent is implied to use names; Are owners BCBAs (yes). Who is managing the solicitation/posting of testimonials (owners should provide education regarding the PECC)? 
• Codes: 8.05; 2.06;

Scenario

I got in a car accident today in front of a client’s house. The client’s mom came outside after she heard the accident and saw the position of the cars. I had to move my car because I was blocking the street. Would it be appropriate if I ask her if she could be a witness? Or would that be an ethical violation? I have to go to court in February. When the police officer asked if I knew the client’s mom I told him I couldn’t answer that because of HIPAA.

Response

• Committee Input: Protection of the consumer (PHI) as intention; as a “witness” there is no obligation to disclose nature of professional relationship.
• Exploration: What aspects of HIPAA are related to incident (where is the breach)? What is the nature of the professional relationship/context/environmental factors? Impact on harmful effects of multiple relationships – is this applicable in the specific situation? How does that relationship impact whether or not to request support? Check organization’s internal policies and procedures; reach out to internal HR or HIPAA Officer for guidance (incident report??). 
• Codes: 1.06