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Legal & Regulatory Powerpoint

Legal & Regulatory Powerpoint






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    Legal & Regulatory Powerpoint Legal & Regulatory Powerpoint Presentation Transcript

    • Legal and Regulatory Environment
      • Laws prescribe rules of conduct that are enforced by public authority
      • Violation is threatened with punishment
      • Laws serve mainly a protective purpose
      • Two main reasons why the long-term care sector is heavily regulated:
      • The government is a major payer
      • The clients are often frail and vulnerable
      • Two main categories of laws:
      • Civil law
      • Criminal law
    • Sources of Law
      • Common law : Past court decisions (legal precedents)
      • Statutory law : Laws made by the legislative branch
      • Administrative law : Rules and regulations crafted by the executive branch
    • Civil Law Tort Law Contract Law Tort: A civil wrong other than a breach of contract Contract: A specific agreement between two parties
    • Civil law: Characteristics
      • Deals with relationships between private parties
      • When seeking remedy for injury, the plaintiff is a private party
      • Penalties for wrongful acts are in the form of monetary damages
    • Criminal law: Characteristics
      • Defines crimes and provides for punishments for crimes
      • A crime is an offense against the general public
      • Jail terms, fines, or both may be imposed
      • The wrongdoer is prosecuted by a public prosecutor, but a harmed private party may also pursue civil action.
    • Crimes Specific to Health Care Delivery
      • Billing programs for services not delivered
      • Providing and billing for services that are not medically necessary
      • Gross violation of commonly recognized standards of care
      • Reckless disregard for the safety and well-being for patients
    • Tort Damages
      • Award of monetary damages to make the person whole again
      • Punitive (exemplary) damages for egregious conduct, such as
        • Malice
        • Gross negligence
        • Blatant violation of individual rights
        • Fraud
    • Contract
      • Legally binding agreement
      • Between competent parties
      • To carry out a legal purpose
      • An agreement generally involves:
      • - offer and acceptance
      • - meeting of the minds
      • - consideration
    • Regulations
      • Classified as administrative law
      • Crafted by administrative agencies of the government
      • Interpret statutes and furnish details for implementing the statutes
      • Carry the force of law
      • Enforced by administrative agencies that crafted the regulations
    • Non-profit Ownership
      • Prohibited from distributing profits to individuals
      • Must serve a charitable purpose
      • Tax exempt
      • Private donors can claim charitable deductions on their tax returns
    • Proprietary Ownership
      • Three main types:
      • Corporation
      • Partnership
        • General
        • Limited
      • Sole proprietorship
    • Desirable Qualifications of Board Members
      • Respected community leaders
      • Technical expertise in some area (health care, finance, law, etc.)
      • Be able to bring community and client perspectives
    • Current NHA Issues
      • Lack of uniform qualifications for licensure across states
      • Most states do not mandate a bachelor’s or higher degree in health care management
      • Shortage of qualified administrators
    • Licensing of Health Professionals
      • All states require nurses, therapists, and physicians to be licensed
      • Some states also license other health professionals
      • Licensing laws govern to main areas:
      • - minimum qualifications
      • - scope of practice
    • Personal Liability
      • The administrator and other employees can be held personally liable for
      • Committing wrongful acts that cause harm
      • Failure to do something they should have done and harm occurs as a result of the omission
      • Unlawful acts regardless of whether harm occurs
    • Personal Tort Liability Negligent acts Intentional acts Breach of duty that results in injury Willful actions in which the consequences are known and desired
    • Injury from Negligence
      • Four conditions must be present:
      • A duty must be owed
      • A breach of duty must occur
      • An injury must result
      • A direct cause-and-effect relationship must exist between the breach of duty and the resulting injury
    • Types of Intentional Torts
      • Assault and battery
      • False imprisonment
      • Invasion of privacy or breach of confidentiality
      • Defamation: libel and slander
      • Fraud
      • Infliction of mental distress
    • Respondeat Superior
      • The nursing facility is held liable for the wrongful acts of its employees
      • Individuals may also be held personally liable
      • The organization is liable even if it takes all reasonable steps to select, train, and supervise employees
      • A supervisor is not an employer and cannot be held liable for the acts of employees he or she supervises
    • A facility may be held liable for the wrongful acts of contractors if:
      • The facility exercises control
      • Contractors are represented to clients as employees of the facility
      • The facility fails to review the qualifications and credentials of independent contractors rendering services to patients
    • Facility Licensure
      • A nursing home cannot operate without having been licensed by the state
      • Licensure requires compliance with state nursing home standards and with the national Life Safety Code
      • Generally, the license must be renewed annually
    • Facility Certification
      • Optional if the facility wants to serve Medicare and/or Medicaid patients
      • The facility must comply with uniform federal standards called Requirements of Participation
      • The law requires substantial compliance rather than zero tolerance
      • Three types: SNF, NF, ICF/MR
      • Dual certification: SNF and NF
    • Facility Accreditation
      • Optional
      • Accrediting body: JCAHO
      • Most nursing homes have chosen not to be accredited because
      • - deemed status is not conferred
      • - fees are high
      • Research shows a high correlation between accreditation status and quality
    • Requirements of Participation (2) Equal access
      • This requirement applies to certified facilities
      • Such facilities are required to admit patients on a first-come-first-served basis regardless of the patient’s source of payment
      • Patients in certified facilities must receive similar services
    • Enforcement of Certification Standards
      • Survey process is the main tool
      • Five different types of surveys: standard, abbreviated, extended, special, validation
      • Citation of deficiencies
      • Plan of correction
    • Deficiencies
      • Violation of a standard
      • Resident-centered: violation affecting a single resident (e.g., an incontinent resident has not been cleaned).
      • Facility-centered: violation affecting an operational system, such as infection control
      • Severity and scope
    • Possible Sanctions
      • Directed plan of correction requiring external consultation
      • Denial of payment
      • Fines
      • Temporary management appointed by the state
      • Termination from Medicare and Medicaid
    • Antidiscrimination Laws
      • Title VI of the Civil Rights Act of 1964
      • prohibits denial of benefits based on race, color, or national origin
      • Section 504 of the Rehabilitation Act of 1973
      • prohibits discrimination based on physical or mental handicap
      • Also protects people with HIV/AIDS
    • Patient Rights
      • Governed by the Patient Self-Determination Act of 1990
      • To be informed of one’s rights
      • Privacy and confidentiality
      • Freedom from abuse, neglect, and misappropriation of property
      • Option to make decisions about one’s own care
    • Substitute Decision-Making and Advance Directives
      • Role of family members
      • Legal guardian
      • Advance directives:
        • Living will
        • Do-not-resuscitate order
        • Durable power of attorney
    • HIPAA 1996
      • Governs the use and disclosure of patients’ protected healthcare information (PHI)
      • It is illegal to gain access to PHI except for
      • - delivering health care
      • - carrying out facility operations
      • - reimbursement
      • Exceptions: Emergencies, patient’s transfer to another facility, legal requirements
      • Other uses or disclosures require the patient’s written authorization
    • HIPAA (contd.)
      • Facility must protect transfer of PHI
      • Facility must have a privacy policy detailing how the facility will use and disclose PHI
      • A copy of the policy must be given to each patient or his/her guardian
      • Policy must be posted in the facility
      • Violations are subject to civil and criminal penalties