Legal & Regulatory Powerpoint

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Legal & Regulatory Powerpoint

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