In Pennsylvania, PMHNPs are mandatory reporters, meaning that if the provider suspects a child they are treating is the victim of abuse, they are required to report to Childline, a system through the Department of Public Welfare. Initially, I had wrongly assumed that child abuse reporting was straightforward, but it quickly became apparent that it was not as simple as it seemed. While researching this topic, I had some questions: is substance abuse during pregnancy considered child abuse, and if so, what would my role be as the PMHNP?
The first article to discuss was published by the Guttmacher Institute, a research and policy organization focused on sexual and reproductive rights. Interestingly, each state varies in two main areas: whether or not substance abuse during pregnancy is categorized as child abuse and the legal burden for treating clinicians. In the United States, twenty-four states, including the District of Columbia, consider substance abuse during pregnancy child abuse (Substance use during pregnancy, 2022). Of those twenty-four states, only Indiana prevents medical providers from releasing substance abuse information without the patient’s consent. Some states expanded child welfare laws to address prenatal drug exposure and legally consider it abuse or neglect; therefore, allowing states to terminate parental rights if a child is born exposed to drugs (Substance use during pregnancy, 2022). For Pennsylvania, substance abuse during pregnancy is not considered child abuse; however, providers in this state are required to report diagnosed or suspected substance use during pregnancy. Apart from the legality of reporting, providers should be mindful in their approach to pregnant clients abusing substances. Research has proven that women using substances during pregnancy fear implications and avoid seeking treatment (Atkins & Durrance, 2020). Avoiding prenatal care raises concerns for the well-being of the mother and fetus. There is little evidence to support that more punitive policies regarding substance abuse during pregnancy are efficacious because there has been no downward trend of neonatal abstinence syndrome (NAS) in those states.
Regarding the ethical aspect of child abuse reporting, McTavish et al. (2019) published an article exploring the perceptions of children and caregivers on the mandatory reporting process. A noteworthy finding from this article was that the mother’s experience with Child Protective Services (CPS) could be traumatic and exacerbate stress or stressors that caused the potentially harmful behavior and necessitated CPS’s involvement (McTavish et al., 2019). Similar to the first article, the question that arises is- is mandatory reporting doing more harm than good? It seems silly to question if reporting suspected child abuse would be more damaging, but the other factors involved are the mother’s perceptions. Like in the case of an expectant mother abusing substances, avoiding care for fear of consequences causes a reduction in access to quality care and, in turn, jeopardizes the child’s well-being. McTavish et al. (2019) argue that mandatory reporting has a limited evidence base to support that its construct reduces the recurrence of child maltreatment or improves the child’s well-being.
Both child abuse reporting articles have implications for PMHNPs in the therapeutic relationship. It is important to disclose any reporting duties early on when building a therapeutic relationship. Early disclosure and preventative interventions should support mothers rather than being punitive. If mothers and children feel comfortable disclosing essential information, the outcomes are more favorable than avoiding care.
Elder Abuse Reporting
Each state has some form of elder abuse reporting law with variations. States differ in their definition of elder abuse, mandated reporters, circumstances triggering a report, the reporter’s role if the victim is competent and able to act on their own, and how to report if a victim lives in a nursing home versus their own home. The Pennsylvania Department of Aging (2022) outlines that PMHNPs are mandated reporters and are required to report any suspected elder abuse to the local Area Agency on Aging. If the alleged abuse is sexual, a serious bodily injury occurred, or death was suspicious, the clinician must make an additional report to local law enforcement.
The article I selected to review for the legal aspect of elder abuse primarily focuses on the various complexities of elder abuse. Research on elder abuse is challenging because there is no nationally uniform description of elder abuse. As previously mentioned, it varies at the state level (Roberto, 2016). Commonly, elder abuse is underestimated because the victims are reluctant to report it due to embarrassment, fear of reoccurrence, fear of nursing home placement, or acceptance of long-standing abuse. Clinicians are mandatory reporters and, therefore, responsible for reporting when there is a reasonable cause they believe an elder is the victim of abuse or neglect (Roberto, 2016). Reporting the abuse is a mandated breach of confidentiality, but reporting and investigating becomes complicated if the suspected victim refutes it. For example, suppose a non-emergent report is made, and Adult Protective Services (APS) launches an investigation. In that case, a court order or search warrant would be required if the older adult or their legal guardian does not consent. APS needs to prove probable cause to receive the court’s assistance. While the clinician may feel conflicted about maintaining the client’s dignity and self-determination, their duty is to protect their client’s well-being. Once the report is made, providers are not required to remedy or mitigate the risk. If clinicians struggle to identify elder abuse, some tools like the Conflict Tactics Scale (CTS) can help identify elder abuse (Roberto, 2016).
The ethical dilemma that arises in elder abuse is autonomy. Saghafi et al. (2019) discuss that those who oppose mandatory reporting for elder abuse argue that it violates autonomy and compromises the client’s privacy. Older adults who are mentally competent have the right to make decisions for themselves; however, the autonomy to maintain their independence is acceptable only if it is reasonably and ethically possible for that provider. While the concern for violating autonomy is valid, allowing psychological abuse to continue violates respect, and allowing neglect, physical, or financial abuse to occur violates non-maleficence (Saghafi et al., 2019). Cultural and religious differences among providers, combined with no universal definition or legislation for elder abuse, pose the biggest challenge in protecting the rights of the elderly.
The most significant implications of the legal and ethical considerations to elder abuse reporting in clinical practice are autonomy and concern for privacy. While mandated reporters have a duty to report suspected abuse, are they taking away a competent older adult’s autonomy and jeopardizing confidentiality by reporting suspected abuse? If a PMHNP questions their role in reporting elder abuse, they can collaborate with a colleague or involve legal counsel.
References
Atkins, D. N., & Durrance, C. P. (2020). State Policies That Treat Prenatal Substance Use As Child Abuse Or Neglect Fail To Achieve Their Intended Goals. Health Affairs, 39(5), 756–763. https://doi.org/10.1377/hlthaff.2019.00785
Mandatory abuse reporting. Pennsylvania Department of Aging. (2022). Retrieved August 31, 2022, from https://www.aging.pa.gov/organization/advocacy-and-protection/Pages/Mandatory-Abuse-Reporting.aspx
McTavish, J. R., Kimber, M., Devries, K., Colombini, M., MacGregor, J. C., Wathen, N., & MacMillan, H. L. (2019). Children’s and caregivers’ perspectives about mandatory reporting of child maltreatment: A meta-synthesis of qualitative studies. BMJ Open, 9(4), 1–13. https://doi.org/10.1136/bmjopen-2018-025741
Roberto, K. A. (2016). The complexities of elder abuse. American Psychologist, 71(4), 302–311. https://doi.org/10.1037/a0040259
Saghafi, A., Bahramnezhad, F., Poormollamirza, A., Dadgari, A., & Navab, E. (2019). Examining the ethical challenges in managing elder abuse: A syst
ematic review. Journal of Medical Ethics and History of Medicine. https://doi.org/10.18502/jmehm.v12i7.1115
Substance use during pregnancy. Guttmacher Institute. (2022, August 3). Retrieved August 30, 2022, from https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy.
Discussion#2 Week 2 discussion
A federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated establishing national standards to prevent the disclosure of sensitive patient health information without Patients’ knowledge or consent. It aims to offer a solid legal safeguard to guarantee the confidentiality of personal health information. It ensures patients easily access information about their treatment and healthcare (Center for Disease Control and Prevention, 2022).
Article One
This article discusses the role of information blocking and patients’ access to their healthcare information. It points out that under HIPAA, patients must have access to their healthcare information except under certain circumstances where some covered entities prevent such access. The Cures Act addresses patients’ denial of access to their health records, emphasizing that patients may request their healthcare records in any form of their choosing. As an obligation, entities must maintain confidentiality, availability, and integrity of patients’ data (Rose,2021).
The Ethical and Legal issues related to HIPAA as they concern psychiatric-mental health practice for children or adolescents and Adults
Parents of a child with a mental health condition are informed of the Patient’s condition. Parents provide proof that shows them as the healthcare decision maker; however, the provider can also use his judgment not to treat the parent as a personal representative if there are concerns that doing so might put the child’s safety at risk (Murzl et al., 2017).
The privacy rule applies universally to all protected health information; however, psychotherapy notes obtain special protections. The Privacy Rule describes psychotherapy as documents prepared by the clinician during contact with the patients but are viewed as separate from the rest of the Patient’s medical records. Therefore, the privacy rule dictates that the Patient’s authorization be obtained before the psychotherapy note’s release for any reason, including treatment (HHS.gov, 2022).
Article Two
This article discusses that patients’ legal rights to amend their healthcare records are limited to those receiving care at healthcare organizations operated by the federal government.
Individuals have the right to access and amend their PHI through organizations like healthcare plans, clearinghouses, and providers who complete some transactions electronically, as well as the business partners of these organizations; however, regardless of the location of the record or the format, the patient health information are, patients’ right to access must be granted within 30 days when requested (Burton et al., 2017).
The Ethical and Legal issues related to amending health records as they concern
psychiatric-mental health practice for children or adolescents and Adults
Parents or legally recognized agents of a minor patient must request an amendment of patients’ records. At the same time, the original document would not be altered or removed when the request is granted while the amended document is linked to the original. An adult patient may request an amendment of their healthcare record if noted as incorrect, and the provider must correct the information that the Patient disagrees with; however, if the provider does not agree to the request, the Patient must submit a statement of disagreement to the provider.
Article Three
This article discusses the ethical arguments for and against online psychotherapy. It identifies various benefits of online psychotherapy, which include service availability and flexibility; improved communication; benefits relating to client traits like remote location; convenience; and economic advantages. The article also identifies the disadvantage of online psychotherapy as privacy issues, need for special training, specific communication issues related to technology, research gaps, and emergency issues (Stoll et al., 2020).
The Ethical and Legal issues related to online psychotherapy as they concern
psychiatric-mental health practice for children or adolescents and Adults
Teletherapy is developing quickly, and ethical issues are involved, which is the significant difficulty in maintaining client privacy. Therapists who work with adult and child clients must be aware of rules and legislation and adopt best practices to prevent HIPAA violations (Stoll et al., 2020).
Article Four
The article addresses and provides guidelines on when it is acceptable under HIPAA for a health care provider to disclose protected health information of patients receiving treatment for mental health disorders. It talks about HIPAA privacy regulations and exchanging information connected to mental health. It also discusses when HIPAA permits sharing healthcare information with parents of minor patients and their capacity to consent to treatment. It outlines when HIPAA permits healthcare providers to share information with family members of patients
with mental health problems. Lastly, the article discusses when HIPAA permits the clinician to communicate with law enforcement on patients in the emergency department for mental health issues.
The Ethical and Legal issues related to disclosure as they concern psychiatric-mental
health practice for children or adolescents and Adults
Parents typically access their children’s protected health information as personal representatives. However, parents might not be the minor children’s representatives in certain situations. Minor patients are considered individuals in this situation and have the right to consent to care.
Healthcare providers may share healthcare information with patients’ family members and friends involved in patients’ care if the Patient does not oppose (U.S. Department of Health and Human Services Office for Civil Rights (n.d)).
How this Information Apply to Clinical Practice
Information blocking affects clinical practice by preventing usability, quality, and safety of Patient’s health records, causing delays in completing tasks and increasing frustration for end-users which is the provider (American Medical Association, 2022).
Amendment to patient records affects clinical practice by casting doubt upon the quality-of-care patients receive and may be viewed negatively by regulatory authorities. Amending documents may make malpractice claims challenging to defend. In Illinois, amending medical records make it challenging for providers to process claims for payment as this raises questions for the provider (Paszkowska, 2018).
Online psychotherapy increases access to evidence-based care for the underserved population. In clinical practice, it increases revenue and enables the delivery of psychotherapy to patients with overwhelming schedules. In Illinois, online psychotherapy provides patients access to an alternative to traditional psychotherapy settings (American Psychological Association, 2022)
Disclosure of protected health information in clinical practice improves the quality of care provided to patients as these aids in securing the exchange of patient information with other interdisciplinary team members, thereby reducing legal risks or liabilities resulting from not sharing information. In Illinois, patient information disclosure requires clinicians to preserve patients’ privacy and obtain written and signed consent before patient information is shared (Levy et al., 2018).
Conclusion
HIPAA aims to prevent crucial patient information from being made publicly available and gives patients control over their healthcare information, thereby safeguarding the public’s interest. However, it has a significant financial impact on hospitals, medical care facilities, and medical research