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PG Briefing

 

July 12, 2019

Legal and Clinical Ethics in Serving LGBT+ Older Adults

Robert Rodè and William McDonough (Voigt, Rodè, Boxeth & Coffin)
Jane Danner (Volunteers of America National Services)

This Briefing is brought to you by AHLA’s Post-Acute and Long Term Services Practice Group.

Elder-care and housing providers including skilled nursing, assisted living, home care, hospice, independent living, adult day care, and the myriad of combined settings work with and serve their clients daily making clinical and ethical decisions along the way. Many times, when these providers contact their lawyer for the “answer” to their questions they might not contemplate the response to involve both a legal and ethical analysis. Circumstances, however, require lawyers to vet ethical issues and standards as well as focus on the legal issues at the heart of the inquiry. While the response may seem like a straightforward “legal answer” to the question posed, counselors have a responsibility to be aware of and sensitive to their clients’ ethical standards pursuant to their current practice, as well as organizational, facility, and individual licensure requirements.

When the analysis focuses only on clinical and/or legal aspects and ignores both the client’s and lawyer’s ethical requirements, the “best legal answer” and the client’s ability to provide the “best person-centered services” are compromised. Keeping this in mind, as lawyers fortunate enough to work in these areas, we know how important it is to stay abreast of the ever-changing clinical, legal, and ethical standards and expectations of our clients and those they serve as well as those of regulators, families, and loved ones. The legal and ethical analysis becomes more complicated when taking into consideration the challenges lesbian, gay, bisexual, and transgender (LGBT+)1 older adults face.

Current Terminology

It is important for lawyers, caregivers, and businesses to be cognizant of the current terminology used within the LGBT+ community. For example, a transgender individual or ally may use various pronouns and adjectives to describe themselves based upon their unique experiences, and a culturally aware organization and lawyer should be aware of this language and how to approach the subject in both a respectful and understanding manner.2 The “+,” for the purposes of this article, includes all individuals who do not identify as cisgender heterosexuals and their allies including, but not limited to, those who identify as: non-binary, asexual, pansexual, and intersex.3

Challenges to Care

According to a National Health Statistics Report published by the Centers for Disease Control & Prevention (CDC), 97.7% of adults over the age of 18 identified as heterosexual in response to a 2013 survey.4 A study cited by the CDC estimated the transgender population in the United States to be approximately 1 million people in 2017,5 or approximately 0.3% of the general population.6 Research indicates that the LGBT+ community is more at risk for HIV/AIDS7 and chemical dependency issues,8 and often lacks support systems found in the general population.9 While ageism exists for all elders, LGBT+ older adults often experience intensified effects of internal and external ageism. For example, LGBT+ elders are at higher risk for being socially invisible and depressed10 and for lacking necessary services and supports.11 LGBT+ older adults also experience disability, smoking and excessive drinking, mental distress, victimization, and denial of health care and housing services at higher rates than their non-LGBT+ peers.12

LGBT+ older adults are five times less likely to access senior services than non-LGBT+ peers.13 By not accessing these services, LGBT+ older adults are more susceptible to increased isolation, depression, substance abuse, and institutionalization.14 Services & Advocacy for LGBT Elders (SAGE), a national LGBT+ advocacy organization, and the Movement Advancement Project, an independent think-tank focused on spreading equality for the LGBT+ population, published a report in 2017 on LGBT+ aging.15 The report identifies three key challenges faced by LGBT+ older adults: (1) social isolation, (2) poverty and economic insecurity, and (3) poorer mental and physical health than their non-LGBT+ peers.16

LGBT+ older adults also perceive bias and discrimination in health and housing services. Although benefits may be available to same-sex couples they may not actively seek them as some feel they will suffer discrimination in doing so from their experience of systematic prejudice. An example of this is the same-sex couple who have been together for 50 years but always presented as “friends.” They may know same-sex marriage is legal and about benefits afforded to married couples, but are afraid to publicly announce their identity as they grew up together in an era where being gay was considered wrong and diagnosed as a mental illness.17 Another example is an eligible military veteran hesitating to apply for Veterans Assistance benefits due to the longstanding policy of “Don’t Ask, Don’t Tell” and the publicly recognized bigotry faced by some in the military.

Research shows the stigma felt by LGBT+ older adults negatively affects their trust in seeking health or housing services for themselves or their LGBT+ loved ones. LGBT+ older adults often name housing discrimination as a primary concern in life.18 A Minnesota study found that 80% of LGBT+ older adults “did not know if they would receive safe services from a provider if their [LGBT+] status were known.”19 The 2015 update of “LGBT Older Adults in Long-Term Care Facilities: Stories From the Field” demonstrates this felt bias and fear experienced by the LBGT+ older adult respondents. Specifically,

  • 89% believed facility staff would likely discriminate against an openly LGBT+ older adult living under their care;
  • 75% were not sure if they were allowed to be open with staff;
  • 53% predicted staff would abuse or neglect an “out” resident;
  • 20% reported being refused admission or re-admission and some even shared their stay had been terminated for no reason;
  • 11% knew of times where staff refused to acknowledge or follow a spouse’s or significant other’s health care authority;
  • A number reported their visitors were unduly restricted because they were “out”; and
  • A number reported fear that other long term care residents would discriminate against them, including purposefully isolating them if they were “out.”20

Regulatory Requirements

As attorneys in this area, we need to be mindful of the regulatory requirements on clients when serving LGBT+ older adults. The Centers for Medicare & Medicaid Services (CMS) has been proactive in some of these areas. For example, Phase III of Medicare and Medicaid Requirements for Participation (RoPs) for Long Term Care Facilities is effective November 28, 2019 and adds guidance, including specific language to Requirement F551, “Resident Representative,” which makes clear a “same-sex spouse must be afforded treatment equal to that afforded to an opposite-sex spouse . . .”21 The following are a list of RoPs that should be reviewed and considered:

  • F550: “Resident Rights”;22
  • F559: “Choose/Be Notified of Room/Roommate Change”23
  • F560: “Right to Refuse Certain Transfers”24
  • F561: “Self Determination”25
  • F563: “Right to Receive/Deny Visitors”26
  • F572: “Notice of Rights and Rules”27
  • F582: “Medicaid/Medicare Coverage/Liability Notice”28
  • F620: “Admissions Policy”29
  • F675: “Quality of Life”30
  • F684: “Quality of Care”31
  • F699: “Trauma-Informed care” [Phase III]32
  • F740: “Behavioral Health Services”33
  • F741: “Sufficient/Competent Staff”34
  • F742: “Treatment/Service for Mental/Psychosocial Concerns”35
  • F745: “Provision of Medically Related Social Services”36
  • F835: “Administration”37
  • F836: “License/Comply with Federal/State/Local Law/Professional Standards”38
  • F838: “Facility Assessment”39
  • F895: “Compliance and Ethics Program” [Phase III]40
  • F940-949: various “Training Requirements”41

Organizations and their leaders must provide dignified person-centered care to remain legally and regulatory compliant. Person-centered care respects and values the uniqueness of the individual and seeks to maintain and restore the personhood of individuals.42 For example, F699, added by Phase III, represents a new regulatory requirement for facilities and relates to trauma-informed care. F699 states “the facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.”43 Trauma-informed care results from an event or set of circumstances an individual experiences that is physically or emotionally harmful or life threatening and has lasting adverse effects on the individual’s functioning and mental, physical, emotional, social, or spiritual wellbeing. A recent training for care providers on trauma-informed care in long term care explained that an older adult’s “trauma world view” included thoughts of:

  • “My own actions, thoughts, and feelings are unsafe”;
  • “I expect crisis, danger and loss”;
  • “Other people are unsafe and can’t be trusted”;
  • “I have no worth and no abilities”; and
  • “No place is safe.”44

With the increased focus on patient-centered care, including requirements like F699, organizations must prepare to better serve the aging population, including LGBT+ older adults, by ensuring residents receive “culturally competent” care that takes into account their “experiences and preferences.” F699 also requires that facilities provide care “in accordance with professional standards of practice.” As an example, we discuss below ethical standards that apply to social workers and nurses in the long term care setting, as well as ethical standards that apply to lawyers in advising their clients. These ethical standards may overlap with regulatory requirements, particularly regarding the focus on patient-centered care and wellbeing, but also may conflict in other respects depending on the perspectives of the patient, the patient’s representatives and loved ones, providers, and regulators.

Ethical Standards

Social services specifically must adhere to the National Association of Social Work (NASW) Code of Ethics, which offers a set of values, principles, and standards to guide decision making and conduct when ethical issues arise.45 The NASW is based on six core principles of social service: (1) service—to assist people in need; (2) social justice; (3) dignity—respecting the worth of a person; (4) integrity—practicing in a trustworthy manner according to mission and value; (5) significance of human relationships—recognizing the importance of relationships in the helping process; and (6) competence—continually developing and enhance knowledge.46

While nursing ethics, standards, and rules vary by state, the American Nurses Association (ANA) has published nine guiding provisions (along with interpretative statements) titled “The Code of Ethics for Nurses,” which is intended to provide guidance for all nurses nationally and internationally.47 The ANA updated the Code of Ethics for Nurses in 2001 and again in 2015 to reflect evolving standards of care.48 The nine provisions are intended to guide nurses’ fundamental values, to address boundaries of duty and loyalty, and to address duties beyond individual patient encounters.49 Principal among these is Provision 1 which states, “[t]he nurse practices with the compassion and respect for the inherent dignity, worth, and unique attributes of every person.”50

The ANA and NASW code of ethics set forth similar principles, including but not limited to, respect, dignity, justice, self-determination, and the protection of rights while providing guidance and standards of practice. F895, added by Phase III, relates to ethics and compliance and requires there are “programs implemented to prevent and detect civil and administrative violations in promoting quality of care,” setting a standard to uphold ethical practices. These principles and regulations will not eliminate situations where there is conflicts and differences of opinion that require further consultation, but at their cores they create awareness that the whole patient is paramount. As in the trauma-informed care standard, both the NASW Code of Ethics and ANA Code of Ethics for Nurses underscore the importance of providing care and services that considers a patient’s individual circumstances.

Lawyers also, of course, have a framework for the ethical practice of law. The American Bar Association (ABA)’s Model Rules of Professional Conduct identifies the “legal profession is largely self-governing.”51 Lawyers are “advisors,” “advocates,” “negotiators,” and “evaluators”—all at the same time.52 The Model Rules instruct that a lawyer’s ethical dilemmas are guided by “moral and ethical considerations,”53 “personal conscience,” and the “approbation of professional peers.”54 As lawyers, we must know our clients and help them navigate applicable laws and regulations, including recognizing that representing elder health care and housing providers goes beyond end-of-life decisions or bioethics.

What advice should an attorney give when family members object to their father sharing a room with a transgender roommate for personal or religious reasons? What counsel do we give a director of social services when some residents and staff (including the administrator who you have worked closely with for many years) are treating a resident’s significant other poorly because she is openly gay? What recommendations do we consider when a lesbian resident couple’s adult children are objecting to the relationship or them spending time together alone? Does it matter to your practice and counsel if you do or do not support same-sex marriage?

The ABA Model Rules are helpful. ABA Model Rule 1.2 (“Scope of Representation and Allocation of Authority Between Client and Lawyer”) provides that a lawyer must “abide by a client’s decision concerning the objectives of representation.”55 However, a lawyer cannot counsel a client to engage, or assist in, “conduct that the lawyer knows is criminal or fraudulent.”56 In discussing the legal consequences of certain conduct, an attorney “may counsel or assist a client making a good faith effort to determine the validity, scope, meaning or application of the law.”57 ABA Model Rule 1.7 (“Conflicts of Interest: Current Clients”) states “a lawyer shall not represent a client if the representation involves a concurrent conflict of interest . . . [which occurs when] there is a significant risk that the representation . . . will be materially limited by . . . a personal interest of the lawyer.”58 Representation or continued representation may conflict with the lawyer’s “personal conscience” and “moral and ethical considerations.”59 ABA Model Rule 1.13 (“Organization as Client”) makes it clear that an attorney retained by a facility represents the organization as an entity and not the employees (e.g., nurses, administrators, social workers, etc.) working for the facility.60

ABA Model Rule 2.1 (“Advisor”) tells us that a lawyer must “exercise independent professional judgment and render candid advice”61 and may refer to relevant “moral, economic, social, and political factors” in addition to the law.62 Rule 2.1 adds additional guidance that while the attorney is “not a moral advisor” the lawyer may “refer to relevant moral and ethical considerations in giving advice,” which recognizably “impinge upon most legal questions and may decisively influence how the law will be applied”63 and adds that a lawyer is also “a public citizen having special responsibility for the quality of justice.”64 ABA Model Rule 4.4 (“Respect for Rights of Third Persons”) is helpful in reminding all attorneys that “[i]n representing a client, a lawyer shall not . . . use methods of obtaining evidence that violate the legal rights of [a third person]”65 and that while our primary duty is to the client it does not imply that a lawyer may disregard the rights of third persons.66

The ethical standards that impact the decision making of lawyers, social workers, and nurses are often aligned and seek to ensure residents receive the highest level of care possible. However, conflict may arise for a variety of reasons including who the client is for lawyers, nurses, and social workers and their obligations to their respective clients. For example, on a long term care and assisted living campus the clients being served by the social workers and nurses are the residents of the nursing homes and assisted living facilities. While a lawyer may represent these clinicians as it relates to their individual licenses, the lawyer’s clients in this context most often is the facility that has obligations to all residents, their employees, and other stakeholders.

Case Scenario

The following case scenario helps to highlight the legal and ethical considerations that may arise in advising facility clients that provide care to LGBT+ older adults. This hypothetical depicts potential real-life situations facing LGBT+ older adults and the regulatory requirements and ethical issues that may arise.

Dorothy and Blanche are living as a lesbian couple who have been married for 40 years and have three children, Rodney, Rose, and Rebecca. Deborah identifies as a cis-gendered lesbian female. Blanche identifies as a transgendered female lesbian. Blanche outwardly appears as female and has been on hormone therapy for several years but has not been able to afford her gender confirming surgery. All of Blanche’s legal documentation (license, marriage certificate, etc.) identifies her as a male and lists her birth name, Robert. Blanche’s medical record states she is male but identifies as female and is in the process of transitioning. Due to Blanche’s transition, Rodney and Rose no longer speak to her. Rodney is the only local child and has been appointed Blanche’s health care agent under a health care directive (HCD) as the family does not want Dorothy to have to act in that capacity. The HCD was put into effect during a prior health scare before Blanche came out to her family as transgendered and when she and Rodney were on good terms. Recently, Blanche had a stroke and is in the hospital and requiring extensive therapy and support services, which she cannot receive at home. Dorothy is unable to care for Blanche at home and the decision has been made for Blanche to move into the only local nursing home, which is run by a religious organization, is classified as a nonprofit, accepts Medicaid, and does not support same-sex couples. Blanche and Dorothy likely will not be able to afford to pay privately for long term care services for an extended period.

At first glance, some issues are immediately apparent like decision makers and resident rooms/roommates. For example, who at the facility will understand Blanche as a whole person on or even pre-admission as required by F550, F559, F572, F620, F675, F684, F699, F742, F838, ANA Provision 1, and NASW Principles 3 and 6?67 The facility admitting Blanche may not have previous experience with this type of situation, and staff may be unprepared to address any issues that may arise. However, even without experience, the facility must not discriminate against admitting Blanche based upon her gender identity or sexual orientation or the facility may be cited under F564.68 Upon or prior to admission, identifying Blanche’s designated decision makers and support network is an immediate need. Ethically, it is also necessary to ensure nurses and social workers have the proper education and background to care for Blanche and ensure she receives dignity and respect.69

Although Blanche has not had gender confirming surgery, she identifies as a woman. Room placement in this situation may be a concern to a care center, especially considering shared occupancy. How will our client provide privacy to the couple for conjugal visits and do they need to make sure staff and other residents will treat them with dignity and respect? Should the facility fail to inform Blanche she may have Dorothy visit her at any time, the facility may be cited under F564. Should the facility place Blanche in a private room? Utilization of private rooms for transgender individuals may be discriminatory and could foster isolation of the individual leading to a citation under F603.70 Further complicating the analysis is that Medicaid does not consistently pay for private rooms. If the facility places Blanche in a private room and Medicaid will not fund it, the facility’s options are to charge her privately or charge her at the shared room rate. This may create further conflict as other residents may become aware of Blanche getting a private room for the shared rate and treat her differently. Or placing Blanche in a private room and charging her accordingly may be a discriminatory business practice. Although a private room may be an option, it should not be the only option.

It may be hard to conceptualize, but the ethical standards applicable to nurses, lawyers, and social services in this scenario could put these individuals at odds. A lawyer for the organization above may be retained to defend a policy with regulators or even in court that would allow for the facility to refuse admission to LGBT+ individuals or argue for why the facility should place residents in rooms that matches the gender of their birth. A nurse or social worker may be opposed to these policies as they conflict with ensuring all patients receive care with dignity and compassion.

Looking at the case scenario above, Blanche has a decision maker who may not want her to receive hormones or be placed in a room with a cis-gendered woman. Blanche and Dorothy are legally married and, although Dorothy is a decision maker as her spouse, Rodney is the designated decision maker via HCD, which was put in place prior to Dorothy coming out as transgender. How does this impact who the decision maker is? How can the provider ensure this person is acting on behalf of the resident and their history does not impede Blanche receiving the highest level of practicable care to meet her physical and psychosocial needs? The nurse and social worker would likely object to Rodney’s placement and cessation of hormone therapy as it could result in negative psychosocial outcomes and additional health concerns. The lawyer representing the facility, on the other hand, may feel the only choice is to view this through the lens of risk management and mitigation and may want to abide by Rodney’s wishes. This is not to say the lawyers, nurses, and social workers cannot come together to determine a solution that works in the best interests of Dorothy and the facility, but being aware of the potential conflict and other standards can help prepare lawyers for these discussions and to find solutions.

Lawyers should proactively walk through similar scenarios with their clients to develop policies and procedures for residents (including marketing materials) throughout their entire stay from admission to discharge to even post-discharge—considering the regulatory and ethical standards discussed herein. Having an open discussion with our clients facilitates the provision of patient-centered care while heading off potential ethical issues and legal risk. National and local provider and licensing associations, Lambda Legal, SAGE, ground-breaking work done by providers themselves like Volunteers of America National Services,71 and advocacy and training organizations such as Training To Serve72 are good resources to use as part of this process.


1 Rajean P. Moone, Jane Danner & Robert F. Rodè, Gay and Gray: Policy in a Rapidly Aging Community, The Routledge Handbook of LGBTQIA Administration and Policy 290 (Wallace Swan ed., 1st ed. 2019) (“The authors recognize that language evolves and welcome inclusive ways used to describe a diverse community while respecting all across the lifespan.”).
2 A variety of resources are available that articulate how and why certain pronouns are used. These resources are continuing to evolve. See GLAAD, Tips for Allies of Transgendered People, https://www.glaad.org/transgender/allies (last visited Mar. 26, 2019). See also LGBT Resource Ctr., Gender Neutral Pronouns, https://lgbtrc.usc.edu/trans/transgender/pronouns (last visited Mar. 26, 2019); David Galowich, How to Respectfully Use Gender Pronouns In The Workplace, Forbes, Aug. 2, 2018, https://www.forbes.com/sites/forbescoachescouncil/2018/08/02/how-to-respectfully-use-gender-pronouns-in-the-workplace/#1e5639c46c40.
3 Michael Gold, The ABCs of L.G.B.T.Q.I.A.+, N.Y. Times, June 21, 2018, https://www.nytimes.com/2018/06/21/style/lgbtq-gender-language.html.
4 Brian W. Ward, James M. Dahlhamer, Adena M. Galinsky & Sarah S. Joestl, Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013, Nat’l Health Statistics Reports, (July 15, 2014), https://www.cdc.gov/nchs/data/nhsr/nhsr077.pdf.
5 Ctrs. for Disease Control & Prevention, HIV Among Transgender People (Nov. 30, 2018), https://www.cdc.gov/hiv/group/gender/transgender/index.html.
6 The U.S. population as of December 31, 2018 was 326,213,213, according to U.S. Census Bureau, U.S. and World Population Clock, https://www.census.gov/popclock (Mar. 25, 2019, 2:30 PM).
7 According to the CDC, in 2016, “Gay and bisexual men accounted for 67% of the 40,324 new HIV diagnoses.” Ctrs. for Disease Control & Prevention, HIV and Gay and Bisexual Men (Sept. 28, 2018), https://www.cdc.gov/hiv/group/msm/index.html.
8 Nat’l Inst. on Drug Abuse, Substance Use and SUDs in LGBT Populations (Sept. 5, 2017) https://www.drugabuse.gov/related-topics/substance-use-suds-in-lgbt-populations#references.
9 Karen I. Fredriksen-Goldsen, et al., The Aging and Health Report: Disparities and Resilience Among Lesbian, Gay, Bisexual and Transgender Older Adults, Seattle Inst. for Multigenerational Health (2011), http://www.age-pride.org/wordpress/wp-content/uploads/2011/05/Full-Report-FINAL-11-16-11.pdf.
10 Richard Wight, Allen LeBlanc, Ilan Meyer & Frederick Harig, Internalized Gay Ageism, Mattering and Depressive Symptoms Among Midlife and Older Gay-Identified Men, 147 Social Science & Med. 200 (2015).
11 Jennifer Boggs, et al., The Intersection of Ageism and Hetrosexualism: LGBT Older Adults’ Perspectives on Aging-in-Place, 12 Clinical Med. & Research 1 (2014).
12 Fredricksen-Goldsen, supra note 9.
13 Id.
14 Id.
15 SAGE, Marriage, Medicare and Medicaid: What Same-Sex Couples Need to Know (June 13, 2017), www.lgbtagingcenter.org/resources/pdfs/SAGE%20SHIP%20SHEET%20Medicare%20Marriage%20FINAL%20Web.pdf.
16 Id.
17 1987 marked when homosexuality was no longer a diagnosis. See Neel Burton, When Homosexuality Stopped Being a Mental Disorder: Not until 1987 did homosexuality completely fall out of the DSM, Psychology Today (Sept. 18, 2015), https://www.psychologytoday.com/us/blog/hide-and-seek/201509/when-homosexuality-stopped-being-mental-disorder.
18 Opening Doors: An Investigation of Barriers to Senior Housing for Same-Sex Couples, Equal Rights Ctr. (2014) https://www.lgbtagingcenter.org/resources/pdfs/OutandAging.pdf. (Last visited May 16, 2019).
19 Catherine F. Croghan, Rajean P. Moone, & Andrea M. Olson, 2012 Twin Cities LGBT Aging Needs Assessment Survey Report, United Way (2012), http://pfundfoundation.org/wp-content/uploads/2015/08/12046-PFund-LGBT-Aging-Report_online.pdf.
20 LGBT Aging Ctr., LGBT Older Adults in Long-Term Care Facilities: Stories from the Field, www.lgbtagingcenter.org/resources/pdfs/NSCLC_LGBT_report.pdf (last visited Mar. 25, 2019).
21 42 C.F.R § 483.10(b)(3); cited as F551 in the State Operations Manual Appendix PP “Rights Exercised by Representative.”
22 42 C.F.R § 483.10(a) (including the right to be treated with dignity and person-centered care) and 42 C.F.R § 483.10(b) (including the right to be free from discrimination).
23 42 C.F.R § 483.10(e)(4-6).
24 42 C.F.R § 483.10(e)(7-8).
25 42 C.F.R § 483.10(f).
26 42 C.F.R § 483.10(f)(4).
27 42 C.F.R § 483.10(g)(1).
28 42 C.F.R § 483.10(g)(17-18).
29 42 C.F.R § 483.15(a)(1-7).
30 42 C.F.R § 483.24.
31 42 C.F.R § 483.25.
32 42 C.F.R § 483.25(m).
33 42 C.F.R § 483.40.
34 42 C.F.R § 483.40(a). This includes caring for “residents with a history of trauma/or post-traumatic stress disorder.” 42 C.F.R. § 483.10(a)(1).
35 42 C.F.R § 483.40(b)(1).
36 42 C.F.R § 483.40(d).
37 42 C.F.R § 483.70.
38 42 C.F.R § 483.70(a).
39 42 C.F.R § 483.70(e).
40 42 C.F.R § 483.85.
41 42 C.F.R § 483.95(a-i).
42 Larke N. Huang, Rebecca Flatow, Tenly Biggs, Sara Afayee, Kelley Smith, Thomas Clark, and Mary Blake, SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach, Substance Abuse and Mental Health Services Administration HHS Publication No. (SMA) 14-4884 (July 2014), https://store.samhsa.gov/system/files/sma14-4884.pdf. See also ASS’N FOR BEHAVIORAL AND COGNITIVE THERAPIES THE BEHAVIOR THERAPIST, Considerations for Clinical Work and Research With Transgender and Gender Diverse Individuals (Vol. 41, No. 5 June 2018).
43 42 C.F.R § 483.25(m).
44 Scott A. Webb, TIC: Trauma-Informed Care In Long Term Care, Lake Superior Quality Innovation Network and Quality Improvement Organizations Ctrs. for Medicare & Medicaid Servs. (May 16, 2019).
45 Nat’l Ass’n of Social Workers, Read the Code of Ethics, https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English (last visited Mar. 26, 2019).
46 Id.
47 AM. NURSES ASS’N, The Code of Ethics for Nurses with Interpretative Statements, https://www.nursingworld.org/coe-view-only (last visited Mar. 22, 2019).
48 Id. at 48.
49 Id. at XIII.
50 Id. at 1.
51 Model Rules of Prof’l Conduct, Preamble, ¶ 10 (2018).
52 Id.¶ 12.
53 Id. ¶ 16.
54 Id. ¶ 7.
55 Id. at r. 1.2(a).
56 Id. at r. 1.2(d).
57 Id.
58 Id. at r, 1.7(a)(2).
59 MODEL RULES OF PROF’L CONDUCT, Preamble, ¶ 7.
60 MODEL RULES OF PROF’L CONDUCT r. 1.13(a).
61 Id. at r. 2.1.
62 Id.
63 Id.
64 Id.; preamble ¶ 1.
65 Model Rules of Prof’l Conduct r. 4.4(a).
66 Id.
67 42 C.F.R § 483.10(a); 42 C.F.R § 483.10(e)(4-6); 42 C.F.R § 483.10(g)(1); 42 C.F.R § 483.15(a)(1-7); 42 C.F.R § 483.24; 42 C.F.R § 483.25; 42 C.F.R § 483.25(m); 42 C.F.R § 483.40(b)(1); 42 C.F.R § 483.70(e); Am. Nurses Ass’n, The Code of Ethics for Nurses with Interpretative Statements, at 1, https://www.nursingworld.org/coe-view-only (last visited Mar. 22, 2019); Nat’l Ass’n of Social Workers, Read the Code of Ethics, at 3 & 6 https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English (last visited Mar. 26, 2019).
68 42 C.F.R. § 483.10(f)(4)(vi); cited as F564 in the State Operations Manual Appendix PP.
69 ANA Provision 1 and NASW Principles 3 and 6.
70 42 C.F.R. §483.12(a)(1); cited as F603 in the State Operations Manual Appendix PP.
71 Volunteers of Am. Nat’l Svcs., Press Release (July 31, 2015), www.voaseniorliving.org. (“Volunteers of America National Services has been recognized nationally and internationally for their initiative to train all staff in its healthcare, housing and other services to help meet the needs of the lesbian, gay, bisexual and transgender people as they age as well as provide an inclusive and welcoming environment.”).
72 Training to Serve, www.trainingtoserve.org.
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