Regulation and Enforcement Notes

  • Regulation and Enforcement The health care sector has been the object of numerous regulations, for two main reasons\n\nRegulation and Enforcement\n\nThe health care sector has been the object of numerous regulations, for two main reasons: (1)\n\nThe government is a major payer for individuals receiving health care services under Medicare,\n\nMedicaid, and other public programs. By committing a significant amount of tax dollars to the\n\ndelivery of health care, the government retains a vested interest in how the money is spent by\n\nprivate organizations that deliver health care. (2) Health care in general, and long-term care in\n\nparticular, provide services to the frailest and most vulnerable individuals in society. Many of\n\nthem are physically and/or mentally incapacitated and have no one else to act on their behalf.\n\nThe regulatory system is deemed obligated to protect vulnerable populations against negligence\n\nand abuse, to ensure that they receive needed services for which they are eligible, and to\n\nensure that the services provided meet at least certain defined minimum standards of quality.\n\nAdministrative agencies have the power to enforce the rules and regulations that they\n\nformulate. The most important federal agency regulating nursing facilities certified as skilled\n\nnursing facilities (SNF) or nursing facilities (NF) is the Centers for Medicare and Medicaid\n\nServices (CMS), an administrative agency under the U.S. Department of Health and Human\n\nServices (DHHS). The U.S. Department of Justice enforces compliance with the accessibility\n\nstandards for the disabled. Workplace safety rules are enforced by the Occupational Safety and\n\nHealth Administration (OSHA), an agency of the U.S. Department of Labor.\n\nNursing Home Oversight\n\nRegulatory oversight for clinical care delivered in certified nursing homes is authorized under\n\nthe Nursing Home Reform Act (OBRA-87). States can use their enforcement powers to take\n\naction against facilities that do not comply with federal and state standards. Regulatory\n\noversight, however, has its weaknesses. Monitoring for compliance is based on periodic\n\ninspections and complaint investigations. Inspections of a nursing home may take place as much\n\nas 15 months apart. This sporadic system of monitoring does not guarantee that compliance\n\nwith standards is continuous. Complaint investigations can be conducted any time, but they take\n\nplace only when a complaint is filed against the nursing home by a patient, family member,\n\nfriend, or employee.\n\nNursing home oversight begins with state licensing regulations. Second, the Nursing Home\n\nReform Act prescribes regulations, referred to as Requirements of Participation, that govern\n\nfederal certification. Although the CMS is responsible for overseeing compliance, the actual task\n\nof monitoring for compliance is delegated to each state. The agency responsible in each state\n\n(generally the health department or department of human services, under contract from the\n\nCMS) to carry out monitoring and compliance with the state licensure standards and the federal\n\nRequirements of Participation is referred to as the State Survey Agency. Monitoring is carried\n\nout through an annual inspection, called a survey, of the facility.\n\nRequirements of Participation The Requirements of Participation (also referred to as conditions of participation) are standards\n\nthat are widely regarded as minimum standards of quality for nursing facilities. There are 185\n\nregulatory standards, which are classified under 15 major categories. A summary of the 15\n\nbroad requirements appears in Exhibit 5–1, which is meant for illustrative purposes only. The\n\nactual regulations can be found in the Code of Federal Regulations (CFR), Title 42, Part 483.\n\nExhibit 5–1 Requirements of Participation for SNF, NF, and Dual Certification (Illustrative Only)\n\n1. Resident rights. These include the right to see a physician of one’s choice, to be fully\n\ninformed of one’s medical condition and treatments, to refuse treatment, to formulate advance\n\ndirectives, to authorize the facility to manage personal funds and require accounting for the\n\nfunds, to have personal privacy and confidentiality, and to voice grievances without fear of\n\nretaliation. In addition, residents cannot be prevented, coerced, or discriminated against in the\n\ncourse of exercising their rights as citizens of the facility or citizens of the United States.\n\n2. Admission, transfer, and discharge rights. These rights provide residents certain safeguards\n\nagainst transfer or discharge from a facility and allow one to return to the same facility after\n\nbrief periods of hospitalization or therapeutic leave. It also requires equal access and delivery of\n\nservices regardless of the source of payment."},{"left":"","right":""},{"left":"","right":""},{"left":"","right":""}]

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