Assignments
HEREFORHELP1
HSAChap.4.docxWhat You Will Learn
• In general, laws serve a protective purpose. A wronged party can seek damages through litigation. Litigation against nursing homes has been on the rise, but it does not improve quality of care; conversely it increases health care costs.
• There are different ways of classifying laws. Nursing homes must comply with all applicable federal, state, and local laws and regulations.
• Civil law encompasses tort law and contract law. Tort generally constitutes the violation of some duty. Certain tortious acts can result in punitive damages in addition to compensatory damages.
• An offer and its acceptance and a stated consideration are the two main conditions that must be met for a contract to be legally enforceable. Only contracts executed between competent parties are legal.
• Nursing home administrators and other professionals can be held personally liable when they knowingly do something wrong.
• Corporations can be held liable for the tortious conduct of their employees under the doctrine of respondeat superior. Clear differentiation between an employee and a contractor is important. An agent is not held liable when acting within the scope of his or her authority.
• Three main types of ownership can be formed under corporate law. Type of ownership has tax and other implications.
• All nursing facilities must be licensed to legally conduct business. Certification and accreditation are voluntary, but most nursing homes are certified to admit patients covered under Medicare and Medicaid.
• Patient rights, advance directives, and patient privacy under the Health Insurance Portability and Accountability Act (HIPAA) are vital areas for nursing home administrators to understand. The facility must have privacy policies and enforce procedures required under HIPAA.
Introduction
The legal environment is vast and complex. The purpose of this chapter is to provide basic legal knowledge necessary for day-to-day management of assisted living, nursing care facilities, and other long-term care (LTC) services. When issues arise that could have potentially substantial legal ramifications, the administrator should have access to expert legal counsel. Large multifacility corporations generally have their own corporate attorneys. Small corporations and independent facilities should engage a reputable law firm to help the administrator deal with legal and regulatory issues when they crop up. A basic understanding of the law to prevent potential legal actions and seeking legal counsel before minor issues turn into major problems are vital elements of effective management.
Purpose of Laws
Public policy is often formulated and carried out through laws. This is because laws provide a basic mechanism to ensure the enforcement of public policy. An organized society formulates laws to prescribe rules of conduct that are enforced by public authority under threat of punishment for violations. In business transactions, laws and regulations serve a protective purpose. They are designed to protect all parties involved. For instance, laws protect the employees working for an organization, the clients receiving services from the organization, suppliers furnishing goods and services to the organization, and the community in which the organization conducts business. Further, the organization itself is protected against illegal activities of others. Finally, in a free society, private organizations are also protected against unlawful government action. Like other organizations, health care providers can use laws to protect their own interests. For example, in some states, nursing homes have sued to stop proposed cuts in payment from government sources.
Nursing Home Litigation
Litigation refers to legal action brought before a court of law. Litigation involves two main parties. A plaintiff is one who brings legal action by filing a complaint with a court to seek damages or other legal remedies. The other party is called a defendant , against whom a lawsuit is brought.
By seeking legal redress against a nursing home, the plaintiff wishes to obtain compensation for pain and suffering or death. Legal action may also get the public’s attention through media reports. The main drawback of litigation as a method of nursing home oversight is that it provides remedies for harm that has already occurred. It is also questionable whether litigation changes management’s behavior in preventing harm to others. Research shows that the threat of litigation is not likely to lead to widespread improvements in nursing home quality (Konetzka et al., 2013). Another downside of litigation is that it increases health care costs.
Nursing home malpractice has been an area ripe for litigation. During the 1990s, the nursing home industry became the fastest growing area of litigation in health care, and the pace of litigation has picked up (Stevenson & Studdert, 2003). Because of litigation resulting in enormous jury awards, nursing homes have come under increased financial pressure. Nursing home litigation has also become a major area of practice for many law firms. Attorney Charles Huber (2006) gave three main reasons for increased nursing home litigation:
1. Parents of baby boomers are reaching the age when they may need nursing home care. Compared with previous generations, the baby boomers appear to be more litigious and have a greater sense of entitlement.
2. People who have to admit their loved ones to a nursing home often feel guilty for doing so. They may also have unreasonable expectations both in terms of the care provided and the potential outcomes. This is also the mindset of many jurors.
3. Physicians contribute to the problem by taking a wait-and-see approach in communicating their prognoses instead of clearly telling the family what is to be reasonably expected.
Research shows that staffing levels are strongly associated with paid losses for malpractice claims. Nursing homes with higher registered nurse to resident ratios are less likely to experience malpractice paid-losses (Zhao & Haley, 2011). Hence, nursing homes can improve the odds of minimizing litigation claims by improving the level of registered nurse staffing.
Classifications of Laws
Laws can be classified in several different ways. Figure 4–1 provides a simple classification arrangement.
Figure 4–1 Classifications of Laws
Federal, State, and Local Laws
Laws are formulated at the federal, state, and local levels of government. Generally, federal laws supersede state and local laws. This is called federal preemption . Accordingly, states and local jurisdictions can enact and enforce only those laws that do not conflict with federal law (Pozgar, 2002, p. 5). On the other hand, the United States is governed under the principle of federalism , which gives the states considerable power in matters of governance. Certain matters have been specifically delegated to the states. For example, states have the authority to regulate long-term care insurance, establish Medicaid reimbursement for nursing homes, and license health care facilities and personnel. In other areas, both federal and state laws may apply. For example, federal law requires the payment of a minimum wage to workers and specifies the hourly minimum wage. A state may establish its own minimum wage, but it has to be higher than the federal minimum wage. Laws passed by the local governments (counties, cities, and municipalities) are generally referred to as ordinances . For example, local zoning ordinances prescribe land use for commercial or residential purposes.
Constitutional, Statutory, Administrative, and Common Law
The judicial system in the United States relies on four main sources of law: constitutional law, statutory law, administrative law, and common law. Constitutional law is based on the Constitution of the United States, which is the supreme law of the nation. The U.S. Constitution defines the structure and powers of government and the rights of individuals. The Supreme Court of the United States is the final arbiter in constitutional matters. For example, in June 2012, the Supreme Court ruled that the mandate under the Affordable Care Act to require all citizens to have health insurance was constitutional, but it could not mandate the states to expand their existing Medicaid programs. Statutory law comprises statutes passed by legislative bodies, such as the U.S. Congress, state legislatures, or legislative bodies of local governments. Administrative law is formulated by the departments or agencies of the executive branch of government. It consists of rules and regulations, which are generally used to implement statutory laws crafted by the legislative branch. For example, the U.S. Department of Health and Human Services (DHHS) has been issuing rules and regulations to implement the Affordable Care Act. Common law (also referred to as case law) is the body of legal principles and precedents that have been handed down in the form of court decisions. In rendering a decision, a court must review the merits of the case before it. However, it is also obligated to apply settled principles of law from previous cases embracing similar facts and involving similar principles (Landry, 1997). Common law is the only source available when statutory and administrative law are silent about a matter before a court.
Rules and regulations established by an agency must be consistent with the statute under which they are promulgated (Pozgar, 2002, p. 6). They provide administrative interpretations of the statutes and contain details for carrying them out. For example, state regulations prescribe the conditions under which a nursing facility may be licensed or the qualifications a person must have to be licensed as a nursing home administrator (NHA). Regulations also govern facility certification under Medicare and Medicaid rules (discussed later in this chapter).
Public and Private Laws
Public laws affect society as a whole. For example, criminal law deals with wrongs committed against society. Private laws affect an individual, family, or small group. For example, a contract between two parties falls in the category of private law because the contract affects only the parties who entered into the contract. Harm caused to an individual or damage to one’s property by another also fall under private law. Thus, private law deals with civil matters.
Civil and Criminal Law
Civil law is the body of laws governing private legal affairs, such as private rights and duties, contracts, and commercial relations. In civil law, a private party (individual or corporation) files the lawsuit and becomes the plaintiff (Standler, 1998). Civil penalties in the form of monetary damages—as opposed to jail terms—ensue from a breach of what the law prescribes.
The second category of law, criminal law , defines crimes and provides punishments for them. A crime is an offense committed against the general public, regardless of the number of individuals wronged. Jail terms, fines, or both may be imposed for criminal offenses. Examples of crime include theft, murder, disorderly conduct, and sexual abuse. In addition to such common criminal acts, other types of actions specific to health care may also constitute crimes. Billing the Medicare program for services that are not medically necessary, billing for services that were not performed, or gross violation of commonly recognized standards of care may constitute Medicare fraud, which is a criminal offense. A reckless disregard for the safety and well-being of patients may constitute criminal negligence. Crimes are ranked as felonies and misdemeanors. A crime classified as a felony is of a serious nature and is subject to a jail term of more than 1 year. A misdemeanor is a less serious crime that may be punishable by a jail term of less than 1 year.
The wrongdoer who commits a crime is subject to prosecution by the state. A public prosecutor, not a private party, brings the case before a court. Prosecution of an action that has been deemed a crime may still allow the wronged party to pursue civil action when the same conduct violates both criminal and civil laws.
Tort and Contract Law
Civil law distinguishes between tort and breach of contract. Generally, injury must be sustained to claim damages. Injury can be in the form of physical, financial, or emotional harm.
Tort Law
A tort is defined as a civil wrong—other than a breach of contract—committed against a person or a corporation. Tort may also involve interference with another’s rights, either intentionally or otherwise.
In broad terms, a tort almost always constitutes the violation of some duty. It can be in the form of wrongdoing—that is, something was done incorrectly or something that should have been done was omitted (Miller & Hutton, 2000, p. 361). On admitting a patient, the facility becomes duty bound to meet the patient’s total care needs. If the facility is not equipped to meet all of the patient’s needs because of staff shortages, lack of training, or any other reason, the patient should not be admitted. If an admitted patient’s condition deteriorates so that a higher level of care would be more appropriate, the facility must make the needed transfer arrangements, including safe transportation to another facility.
In tort law, compensatory damages are generally awarded to “make the person whole again.” However, the court may also award punitive damages in excess of the actual losses suffered. Punitive damages are also called exemplary damages because their intent is to make a public example of the defendant, supposedly to deter future wrongful conduct by others. Punitive damages are generally awarded when the defendant’s conduct is determined to be egregious or blatant. Such conduct may also be prosecuted under criminal law. Egregious conduct generally falls into four categories:
1. Malicious intent. Also called malice , it involves knowingly doing something with the desire to cause harm. The plaintiff is required to demonstrate that the defendant carried some ill will toward the plaintiff and that the defendant acted on that ill will to cause serious injury (Thornton, 2006).
2. Gross negligence. This is more than ordinary negligence (discussed later). In gross negligence , the defendant would have acted with conscious indifference to the rights, safety, or welfare of another and should have known of the potential harm he or she might cause.
3. Blatant disregard for the rights of others. Punitive damages are particularly important in torts involving harm to the plaintiff’s dignity (e.g., invasion of privacy) or other breaches of civil rights, where the actual monetary injury to the plaintiff may be small (Standler, 1998).
4. Fraud. This is a knowing disregard of the truth that results in harm. It involves deception and an intent to defraud someone.
A landmark 2001 verdict from Texas, Fuqua v. Horizon/CMS Healthcare Corporation, illustrates the kind of circumstance in which punitive damages may be warranted. In one of the largest-ever jury verdicts at the time in a nursing home malpractice lawsuit, brought by Cecil Fuqua on behalf of the estate of his mother, Wyvonne Fuqua, the plaintiff was awarded $2.7 million in compensatory damages and an additional $310 million in punitive damages. The suit was filed after the death of 76-year-old Wyvonne Fuqua in 1997. Fuqua had been admitted to a nursing home in Fort Worth, Texas, in 1994, following a stroke. In late 1996, Fuqua began developing severe pressure ulcers. As her condition deteriorated, the nursing home staff allegedly did not apprise the family of Fuqua’s condition and did not discharge her to a facility that could adequately treat her pressure ulcers. In April 1997, Ms. Fuqua’s adult children moved her to a local hospital. She arrived in a state of malnutrition, with 16 pressure ulcers, of which 9 were Stage III and 5 were Stage IV (the most severe type in which bone or muscle may be exposed). Fuqua died 2 months after she left the nursing home (Schabes, 2002).
Contract Law
A civil wrong involving the violation of a specific agreement between two parties constitutes a breach of contract , not a tort. In a civil case, the remedy is often in the form of recovery of damages. However, the injured party has the duty to mitigate (i.e., reduce) potential damages. For example, an employee who is separated from an organization in breach of a contract that existed between the employee and the organization has the duty to try to find other employment. Punitive damages are not available in breach of contract cases.
A contract is a legally binding agreement between two or more parties to carry out a legal purpose. For instance, two parties cannot enter into a contract to commit fraud. Although most contracts are executed in writing, certain verbal agreements can also be legally viewed as contracts. A contract essentially represents a mutual assent or “meeting of the minds.”
Contracts are commonly encountered in health facility administration. Contracts may concern patients or parties responsible for them, certain employees, independent providers of services to the facility’s patients, construction contracts, lease contracts, loan agreements, purchasing contracts, etc.
For most contracts to be legally enforceable, two main conditions must be met:
1. Making of an offer and its acceptance should have occurred, indicating that an agreement has actually been reached. All parties to a contract should sign a written document to affirm the agreement.
2. Promise of a price or benefit—called consideration—should be stated. A consideration is something of value promised to another in exchange for something else of value. The party that is being required to perform under the contract will receive the consideration upon performance. For example, a roofing contractor will receive the agreed-upon payment only when the job is done in accordance with the specifications of a contract between the facility and the roofing contractor.
Only contracts executed between competent parties are legal. To be considered competent , the parties must be of sound mind and of legal age. Thus, agreements with minors or those who do not have the mental capacity to enter into a contract because of mental illness, intellectual disability, dementia, or substance abuse are not enforceable. In most cases, competence can be determined by a physician. In more difficult situations, the matter is referred to a court. Agreements reached under duress may also be unenforceable. Unless a court determines a contract to be invalid, and therefore unenforceable, the parties must perform according to the terms of the agreement. Otherwise, the aggrieved party can bring a complaint before a court for breach of contract and recover damages.
When admitting a patient, a nursing home enters into a contract with the patient or someone acting on behalf of the patient, such as a family member. The admission agreement is a contract that spells out the services the nursing home will provide and the cost of those services. The nursing home can be sued for breach of contract if a patient is harmed and if the harm is determined to have resulted because services promised in the contract were not delivered. On the other hand, the patient or a responsible party who signed the admission agreement may be sued for nonpayment.
Personal and Corporate Liability
Liability refers to the potential damages ensuing from legal action. Liability may be ascribed to an individual or a corporation.
Personal Liability
As a general rule, both tort law and criminal law ascribe personal liability to an individual who commits wrongful acts. For example, falsification of medical or business records may be grounds for criminal prosecution of the individual committing those acts. The administrator and other employees of a long-term care facility can be held liable, under certain circumstances, when their actions result in injury to someone else. The administrator would be held personally responsible only when he or she has acted on his or her own behalf, has engaged in a tortious act (i.e., behavior that constitutes a tort), or has remained passive about something that results in a tort when he or she knew or should have known but failed to take action. It is advisable for health facility administrators to carry professional liability insurance for situations in which the organization’s insurance may not cover certain acts of the administrator. On the other hand, most suits involving health care facilities concern medical malpractice (discussed later). Administrators are not medical providers, but rather deal with administrative concerns and regulatory compliance, so they cannot be held liable for medical malpractice, as ruled in Howard v. Estate of Harper,—So.2d—(2006 WL 3026398, Sup. Ct., Miss., 2006).
Maggie Hazelton, who was 83 years old, was admitted to Driftwood Nursing Center on April 9, 1999, and was discharged on May 30. She was readmitted in June of the same year and then discharged to a hospital in August. Two days later Maggie died in the hospital. Darlene Hester, administratrix of the decedent’s estate, filed suit against the nursing home and its administrator, Richard Smith. The lawsuit alleged personal injuries and wrongful death. Hester alleged that the patient was a victim of neglect and, as a result, had suffered pneumonia, falls, unexplained injuries, urinary and kidney infections, weight loss, and ultimately death. Hester asserted that the nursing home’s negligent conduct caused the patient to lose her dignity and caused her death to be preceded by extreme and unnecessary pain, degradation, anguish, unnecessary hospitalization, and emotional trauma. In his defense, Smith filed a motion for summary judgment , that is, a prompt disposition of the case without a trial. The trial court granted the motion for summary judgment and entered final judgment of dismissal in favor of Smith. In essence, the court held that Smith could not be held personally liable for any alleged negligence on the part of any of the employees of the nursing home. Later, the Court of Appeals of Mississippi affirmed the summary judgment in favor of Smith (Tammelleo, 2007).
In addition to earlier discussions, individuals may be held liable for unlawful acts, whether or not those acts result in injury to others. An example of this kind of unlawful act would be possession or use of illegal drugs.
Personal tort liability may result from either negligent or intentional acts.
Negligence
Gross negligence was discussed earlier as egregious conduct; it is more difficult to prove than ordinary negligence. Ordinary negligence is the failure to exercise the degree of care that a reasonable person would have exercised in similar circumstances. Ordinary negligence is commonly associated with carelessness and breach of duty. A nursing facility has a duty to exercise due care. For instance, it must have adequate equipment and staff to provide services as required by the needs of its patients.
An act of negligence is not sufficient for establishing liability unless it has resulted in injury. A facility that fails to install an alarm system to monitor patients who may wander out of the facility is not liable unless a patient has actually wandered away and sustained injury. For a plaintiff to establish injury from negligence, four conditions must be present:
1. A duty must be owed. For instance, nursing facilities have the duty to maintain a safe environment and provide services that meet acceptable standards.
2. There must be a breach of duty.
3. An injury must be sustained.
4. A direct cause-and-effect relationship must be present between the breach of duty and the injury sustained.
The duty that is breached can be in the form of an act of commission, such as a nurse giving the wrong medication. Conversely, it can be an act of omission, such as a nurse failing to give the prescribed medication.
Difference Between Negligence and Malpractice
The four key elements of tort law apply to both ordinary negligence and medical malpractice. Malpractice , or medical malpractice, is defined as failure to provide services according to accepted standards of care so that harm is caused to the recipient of care. Malpractice calls into question professional judgment employed by a health care professional or a facility’s staff. Clinical practice guidelines outline standards of care for certain medical conditions. In addition, standards of care may be defined in established regulations or in written procedures or policies of the facility. In the absence of these, expert professional opinion or consensus becomes necessary to establish whether or not care delivered to a patient was in accordance with professional standards.
Negligence, on the other hand, would fall within the common knowledge and experience of a jury or fact finder; malpractice falls in the domain of professional judgment. The main difference between the two is in the context of what a reasonable person should have done (negligence) versus violation of clinical standards of care (medical malpractice). During a court trial, expert testimony is needed to establish malpractice; it is not needed to establish negligence. Hence, the threshold to prove malpractice is much higher than it is for ordinary negligence.
Intentional Torts
An intentional tort is a willful act that violates the rights or interests of others. Willful means that a person knows and desires the consequences of his or her acts. Actions commonly regarded as intentional torts are assault, battery, false imprisonment, invasion of privacy, defamation of character, fraud, and intentional infliction of mental distress.
• An assault creates a threatening environment in which a person fears being touched in an offensive, insulting, provoking, or potentially injurious manner. No physical contact has to occur, but the assaulted individual must reasonably believe that the aggressor has the ability to carry it out presently. If the aggressor actually touches the other individual without consent, that action results in battery . In this context, restraining a patient without a physician’s order or the patient’s consent may amount to battery.
• False imprisonment is the unlawful restriction of freedom. Unlawful use of restraints may constitute false imprisonment in addition to battery. Restraints are regarded as an intervention, and harm caused by medical intervention can make the nursing home liable (Yorker, 1988). Also, generally accepted medical procedures and the state health code must be followed when isolating patients who have a contagious disease.
• Invasion of privacy concerns both privacy and confidentiality. A patient’s name, pictures, or private affairs should not be made public without proper authorization. Unreasonable search or intrusion, such as opening personal mail without consent, is a violation of a patient’s privacy rights. Patients’ medical records belong to the long-term care facility, but these records are confidential. Release of information to persons not involved in patient care requires the patient’s authorization, or its release may be governed by law (see the section on Right to Privacy and Confidentiality).
• Defamation of character involves making false reports that result in damage to someone’s reputation. The false reports may be in written form (constituting a libel ), or they may be spoken (constituting a slander ).
• Fraud occurs when harm or loss is incurred because of a knowing disregard of the truth. Fraud is almost always an egregious act and a crime.
• Intentional infliction of mental distress is considered intentional tort when some outrageous conduct results in mental or emotional trauma. Patients and their families must be treated in a civil manner. Health care professionals can be held liable when outbursts of anger, abusive language, or other irrational behavior results in mental distress.
Corporate Liability
The ultimate legal responsibility for the facility’s operations and for their outcomes is vested in the governing body or board. Responsibility for daily management is delegated to the administrator. Generally speaking, individual members of the governing body are not held personally liable for negligence amounting to errors of judgment. They may, however, be held liable for gross or willful negligence. Hence, board members acting in good faith can have wide latitude in fulfilling their roles and responsibilities. Acting in good faith (Latin: bona fide) generally means how a reasonable person would have acted under similar circumstances. On the other hand, board members may be held criminally liable in cases involving fraud or engaging in activities for personal gain.
The law regards corporations as individuals and as entities separate from their owners. The corporation is often held liable for actions of its directors, officers, and employees, notwithstanding the personal liability of individuals. The doctrine of respondeat superior and the concept of agency are two main areas with which health facility administrators should become familiar.
Respondeat Superior
All people are responsible for their own-tortious conduct. At times, however, the law will hold liable for a tort not only the tortfeasor (i.e., person who commits the tort) but also the organization that hired the tortfeasor. In most instances, the nursing facility is held liable for the wrongful acts of its employees when such acts are committed during the course of their employment. It does not matter if the organization takes all reasonable steps in selecting, training, and supervising its employees.
A corporation’s liability for the acts of its officers or employees is known as vicarious liability , which is founded on the legal doctrine of respondeat superior (let the master respond). A supervisor is not regarded as an employer and is not held liable except for his or her own personal acts, as described in the previous section. Also, respondeat superior does not absolve the employee of personal liability, nor does it obligate the employer to provide liability protection to its employees.
The doctrine of respondeat superior does not apply to the wrongful acts of an independent contractor, who is responsible for his own acts. Hence, it is important to differentiate between an employee and a contractor, but this distinction is not always clear in law. For instance, it is a common practice in long-term care facilities to contract rehabilitation services. Generally, a facility would not be liable for the wrongful acts of contracted therapists treating patients in the facility. However, if the facility exercises some measure of control over the therapists (such as patient scheduling, billing, and compliance with the facility’s policies) and if the therapists are represented to clients as employees of the facility, they may not qualify as independent contractors under law. On the other hand, a facility is not liable for the actions of a nonemployed attending physician who generally is not under the control of the facility’s staff.
Often, whether or not someone should be regarded as a contractor does not become clear until a case is brought to trial before a court. However, NHAs can minimize legal exposure by adhering to the following practices:
• Review and document the qualifications and credentials of providers who may be rendering services to the facility’s residents as independent contractors.
• Verify and document that all personnel providing services to patients are duly licensed if they are required to be licensed under state laws.
• Ensure that licensed professionals do not provide services outside their scope of practice.
• Investigate, document, and report any professional misconduct to the appropriate licensing authority.
Agency
An agent is someone who is authorized to act on behalf of another, called a principal. For example, the NHA is, in many instances, an agent of the corporation that employs him or her. The corporation (i.e., the principal) would generally be liable for the acts of commission or omission of its agent when the latter acts within its authority. For example, when the administrator enters into a contract with a third party within the scope of his or her authority, any liability ensuing from a breach of contract will fall on the corporation. The administrator will not have personal liability. On the other hand, if the third party has been led to believe that the agent is a principal, the agent would be liable if a breach of contract occurs. Individual partners in a partnership, or institutions in a joint venture, are considered each other’s agents. For example, partners are liable for tortious actions of other partners.
Corporate Law
Statutes concerning the rights and responsibilities of private corporations may be loosely referred to as corporate law .
Types of Ownership
An organization’s ownership structure defines, in a broad sense, its rights and responsibilities. This structure has implications for how the organization and the owners are taxed, whether the organization or the owners have liability for civil offenses, and what rights and responsibilities the organization and its owners have. There are three main classes of ownership:
• Public
• Private nonprofit
• Private for-profit (proprietary)
Public Facilities
A public facility is owned by the government. It may be operated under a specific statute enacted by a city or county. That statute would include the specific duties and limitations for the organization. Often, such statutes specifically outline the charity mission for which the institution may have been created. In some instances, the statute may prohibit leasing of the facility to a private corporation. Other aspects of facility management may be governed by statute.
Private Nonprofit Facilities
A privately owned facility incorporated as a nonprofit (also called not-for-profit) entity is prohibited from distributing its profits to individuals. A nonprofit nursing facility is not prohibited from earning a profit, but the facility must serve a charitable purpose. Nonprofit corporations are exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The law provides for federal exemption from taxation to any organization operated exclusively for “religious, charitable, scientific or educational purposes.” These organizations are also exempt from state income and sales taxes and may be exempt from local taxes, such as property taxes. Tax law also enables nonprofit entities to obtain private donations, for which the donors can claim a charitable deduction on their income tax returns.
The owners and administrators of nonprofit facilities must be particularly careful that the privileges afforded under the law are not abused. “Charity” does not mean that the facility is required to provide free care to anyone. It does mean that the facility must make its services available at the lowest feasible cost and that it should not force anyone who cannot pay for services to move out. To provide care to residents who are unable to pay, the facility may participate in government funding programs such as Medicaid, obtain private donations, or cover such costs out of its own profits.
Private For-Profit Facilities
A for-profit (or proprietary) facility is operated to generate a profit that can be distributed to its owners or shareholders. Proprietary enterprises are also required to pay all federal, state, and local taxes. There are three types of proprietorships:
• Corporations
• Partnerships
• Sole proprietorships
A corporation is formed as a legal entity that is entirely separate from its owners. For-profit corporations may be owned by a group of private investors or by a parent corporation, such as a nursing home chain or a proprietary hospital. The parent corporation may also be publicly owned, in which case the company’s stock is available to any investor through the stock market.
A partnership is an association of two or more individuals or organizations for the purpose of conducting business for profit. A partnership is specifically created for the purpose of sharing profits among the partners. They also share the expenses and liabilities of the partnership. In a general partnership , there is no limit on the potential liability of the partners. On the other hand, a limited partnership can be established to limit the individual liability of partners. Limited partners are liable only to the extent of their investment, as long as they do not participate in the management and control of the operations (Miller & Hutton, 2000, p. 25). Thus, limited partners can be viewed as mere investors in a business enterprise.
A sole proprietorship consists of a single owner who has not incorporated the business. All income of the business is taxed as personal income of the owner, and the owner’s potential liability is unlimited. Because of the many complex tax and legal issues they entail, nursing facilities are rarely operated as sole proprietorships.
Licensure, Certification, and Accreditation
Licensure, certification, and accreditation carry different meanings, but all three serve at least one main purpose—to establish minimum standards of quality and to enforce compliance with those standards. Exhibit 4–1 provides a summary of the main distinctions between licensure and certification.
Exhibit 4–1 Differences Between Nursing Home Licensure and Certification
Licensure
• State function
• Mandatory
• Basic requirement for operating a nursing home
• Does not make a facility eligible for public funds
• There is one licensing category for nursing care facilities
• With the exception of the Life Safety Code®, licensing standards differ between states
Certification
• Federal function
• Optional
• A facility must first be licensed before it can apply for certification
• Required for receiving public funds
• Uniform federal standards for all states
• There are three categories depending mainly on the source of government funding and types of patients served:
1. Skilled Nursing Facility—Medicare, postacute, short stay
2. Nursing Facility—Medicaid, long stay (if the patient qualifies)
3. Intermediate Care Facility for Individuals with Intellectual Disabilities—Medicaid, long stay, intellectual disability/developmental disability patients only
Licensure
A license is a legal requirement without which it will be unlawful to operate a nursing facility. License to operate a nursing facility is issued by the state in which the facility is located.
The licensure process starts at the planning stage, before a new facility can even be built. If an existing facility is acquired, it must be relicensed. Once a facility has been built or acquired, its licensure status must be maintained, generally through an annual renewal process. Many states have certificate of need (CON) laws that require a state planning agency to approve building of a new facility or expansion of an existing one. In some states, transfer of ownership must also go through the CON approval process. State CON requirements define several aspects of building or acquiring a facility:
• The type of expenditures that are subject to review. A state may allow a certain number of beds to be built without the CON review.
• The criteria for evaluating need for additional beds or services.
• The procedures for review, which include public hearings.
The licensure function generally falls within the purview of each state’s health department. A license is granted on the condition that the facility meets standards that specify minimum thresholds for staffing, adequacy of services, building construction specifications, and compliance with fire and safety regulations mandated by the Life Safety Code®. The Life Safety Code® standards are national. Standards in the remaining areas are developed by each state, and they vary from one state to another.
Licensure also requires that the facility supply information about the professional credentials of the principal owners and key employees, such as the administrator and the director of nursing. If a principal owner or key officer has had a criminal conviction, facility license may be denied or revoked.
Certification
All facilities must be licensed, but certification is not mandatory. Certification is required for admitting patients enrolled in the Medicaid or Medicare programs. In contrast to licensure, which is a state function, certification is a federal function. The Centers for Medicare and Medicaid Services (CMS), a federal agency under the DHHS, has established certification standards with which nursing facilities must comply to retain their certification status.
The Nursing Home Reform Act as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) created two categories of nursing homes for certification purposes. A nursing home certified to admit Medicare patients is certified as SNF (skilled nursing facility). Such a facility can be freestanding or a distinct part —that is, a section of a nursing home that is certified apart from the rest of the facility. When SNF certification applies to a distinct part, Medicare patients can be admitted only to that particular section of the facility. SNF certification conforms to the original intent of the Medicare legislation (that is, Social Security Amendment of 1965), according to which Medicare would cover only posthospital services in a nursing facility.
An LTC facility serving only Medicaid patients (but not Medicare patients) is certified as NF (nursing facility). SNF and NF are both legal terms associated with certification, not necessarily with the level of services. A facility may be dually certified as both SNF and NF. Facilities that have dual certification can admit both Medicare and Medicaid patients. Over 90% of certified nursing homes have dual certification.
The federal standards for the delivery of care in SNFs and NFs are the same. For federal certification purposes, a previous ICF (intermediate care facility) category has been abolished. However, because the Medicaid program is administered by each state, some states distinguish among levels of care within the NF category. The state of Tennessee, for example, created level I NF (NF-1) and level II NF (NF-2) categories. In the NF-1 category, services are less intensive than they are at the NF-2 level. Other states maintain the ICF category to provide services to Medicaid patients who do not require the degree of care and treatment that a skilled nursing facility is designed to provide. These states pay nursing homes a lesser amount for the ICF level of care.
A third certification category is ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities). To qualify for Medicaid reimbursement, ICFs/IID must be licensed by the state and must comply with federal standards. The Conditions of Participation—found in the Code of Federal Regulations at 42 CFR Part 483, Subpart I, Sections 483.400 to 483.480—specify eight areas in which standards must be met: management, client protections, facility staffing, active treatment services, client behavior and facility practices, health care services, physical environment, and dietetic services.
According to certification regulations, the term “facility” does not necessarily imply a separate physical structure. The term can be used for the facility as a whole or, within the context of certification, it may apply to a distinct part.
A few facilities have elected not to participate in the Medicaid and Medicare programs. These noncertified facilities can admit only those patients who have a private source of funding for nursing home care. Although Medicare and Medicaid patients cannot be admitted to noncertified facilities, private-pay patients —those who have a private source of funding—are not restricted to noncertified facilities. Such patients may be admitted to SNF or NF certified beds as well. Hence, most nursing homes are certified because they can serve private-pay patients as well as those on public assistance. Figure 4–2 illustrates how a facility can have distinctly certified sections.
Accreditation
In contrast to licensure and certification, which are government functions, accreditation is a private function. Hence, accreditation is totally voluntary. The Joint Commission (previously Joint Commission for the Accreditation of Health care Organizations)—a private nonprofit organization—accredits hospitals, nursing homes, and other types of health care sites and has issued its own standards for the purpose of accreditation. Compared with hospitals, relatively few nursing facilities have opted to seek accreditation. From its inception, Medicare regulations have conferred deemed status on hospitals accredited by the Joint Commission. Deemed status is a Medicare rule that a hospital accredited by the Joint Commission is deemed to have met the Medicare certification criteria. Nursing facilities, however, are not given deemed status on the basis of accreditation. Accreditation does have its advantages. For example, accreditation status is highly correlated with a facility’s ability to comply with certification standards (Wagner et al., 2012a). Joint Commission accredited facilities also show improvement on various measures of quality. Even after several years of accreditation, there is no evidence of decrease in quality (Wagner et al., 2012b). Regardless, many facilities find that accreditation fees are high in relation to the benefits reaped. Another organization, Commission on Accreditation of Rehabilitation Facilities (CARF), is an independent, nonprofit accrediter of health and human services that include adult day care programs, assisted living facilities, nursing facilities, home and community services, case management, and dementia care programs (CARF International, 2013).
Figure 4–2 Distinctly Certified Units in a Nursing Home
Patient Rights
Patient rights are founded on both legal and ethical principles. Patient autonomy is the ethical principle governing patient rights. Autonomy includes notions such as self-determination and independence of choice and action without coercion from others. In addition, patients have the right to nondiscrimination; freedom from abuse, neglect, and misappropriation of property; and privacy and confidentiality.
Right to Self-Determination
In health care facilities, patients must be informed of their rights. The Patient Self-Determination Act of 1990 also requires health care providers to protect and promote patient rights. Many states require that health care facilities develop a patient’s bill of rights. Other states have taken the initiative in proposing these rights (see Exhibit 4–2 for an illustration of the rights proposed by North Carolina). Whether or not required by state law, facilities should have a bill of rights in printed form to inform residents and family members of these rights.
The Patient Self-Determination Act of 1990 also governs a patient’s right to make decisions about treatment and covers issues regarding advance directives, which are briefly discussed later. All documents pertaining to patients’ rights should be appropriately maintained in their medical records.
Informed Consent
Informed consent is the right of a patient to make an informed choice about medical care. Express consent may, however, be waived or implied under certain circumstances, such as emergency situations in which a physician may determine that delay incurred in the process of obtaining consent may result in harm to the patient.
To make an informed choice, the resident must be given sufficient information to make a decision. The patient has the right to refuse treatment, even when the treatment is medically advisable. Legal consent, however, requires that the patient has actually understood whatever he or she is consenting to. So, if a resident is not legally competent to give consent, another individual who has legal authority to act on the patient’s behalf must give consent. Obtaining consent from family members is a widely accepted practice, but it may give rise to legal issues, especially if the family decides to withhold treatment against medical advice. Sometimes, a patient who is legally incompetent may have a court-appointed guardian who is legally empowered and responsible for making decisions in the patient’s best interest. The legal guardian’s decisions overrule those of family members. Substitute decision making (i.e., decision by someone other than the patient) is not always a simple matter. An ethics committee is a multidisciplinary forum that is generally called upon to make decisions in the patient’s best interest, particularly when legal avenues are not clear cut. Other alternatives available when the patient loses the capacity to make decisions and indicate consent are discussed in the next section.
Exhibit 4–2 North Carolina’s Bill of Rights for Nursing Home Residents (Condensed Version)
Every Resident Shall Have The Following Rights:
1. To be treated with consideration, respect, and full recognition of personal dignity and individuality.
2. To receive care, treatment, and services that are adequate and appropriate, and in compliance with relevant federal and State statutes and rules.
3. To receive at the time of admission and during stay, a written statement of services provided by the facility, including those required to be offered on an as-needed basis, and of related charges. Charges for services not covered by Medicare and Medicaid shall be specified. The patient will sign a written receipt upon receiving this information.
4. To have on file physician’s orders with proposed schedule of medical treatment. Written, signed evidence of prior informed consent to participation in experimental research shall be in patient’s file.
5. To receive respect and privacy in the medical care program. All personal and medical records are confidential.
6. To be free of mental and physical abuse. Except in emergencies, to be free of chemical and physical restraint unless authorized for a specified period of time by a physician according to clear and indicated medical need.
7. To receive from the administration or staff of the facility a reasonable response to all requests.
8. To associate and communicate privately and without restriction with persons and groups of the patient’s choice at any reasonable hour. To send and receive mail promptly and unopened. To have access to a telephone where the patient may speak privately. To have access to writing instruments, stationery and postage.
9. To manage his/her own financial affairs unless other legal arrangements have been implemented. The facility may also assist the patient, but is required to follow stringent guidelines.
10. To have privacy in visits by the patient’s spouse, and if both are patients in the same facility, they shall be given the opportunity, where feasible, to share a room.
11. To enjoy privacy in his/her room.
12. To present grievances and recommend changes in policies and services personally, through other persons or in combination with others, without fear of reprisal, restraint, interference, coercion, or discrimination.
13. To not be required to perform services for the facility without personal consent and the written approval of the attending physician.
14. To retain, to secure storage for, and to use his personal clothing and possessions, where reasonable.
15. To not be transferred or discharged from a facility except for medical, financial, or their own or other patient’s welfare, nonpayment for the stay or when mandated by Medicare or Medicaid. Any such transfer shall require at least 5 days’ notice, unless the attending physician orders immediate transfer, which shall be documented in the patient’s medical record.
16. To be notified within 10 days after the facility’s license is revoked or made provisional. The responsible party or guardian must be notified as well.
Reproduced from North Carolina Division of Aging and Adult Services. Residents’ Rights. Available at: http://www.ncdhhs.gov/aging/rights.htm#r1. Accessed January 2014.
Advance Directives
When a patient lacks decision-making capacity, an advance directive provides an avenue for the patient to convey his or her wishes about medical treatment in the event of cognitive impairment. Advance directives must be prepared before a person loses his or her competency for making decisions. Three types of commonly used advance directives include a living will, a do-not-resuscitate order, and a durable power of attorney. A living will specifies a person’s wishes regarding medical treatment in the event this person becomes incompetent. The main drawback with this approach is that it cannot possibly conceive all possible situations in which the advance directive may become necessary. A do-not-resuscitate order (DNR) specifies that the person does not wish to have heartbeat or breathing restored in the event of a cardiac or respiratory arrest. By executing a durable power of attorney (DPOA) , a person appoints another individual to make decisions on his or her behalf after the person becomes incompetent. A DPOA should not be confused with a power of attorney (POA). A POA is an agreement in which a person (called the principal) gives another person (called the attorney-in-fact, not to be confused with an attorney or a lawyer who practices law) the authority to make decisions on behalf of the principal. A POA is generally drawn for the purpose of handling the principal’s financial affairs. Health care decisions can be included, but such authority must be specified in the POA. It is important to note that an attorney-in-fact can make medical decisions on behalf of a principal only if the principal is incompetent to make his or her own decisions. An attorney-in-fact cannot make decisions contrary to the wishes of the patient to the extent that the patient is able to indicate what he or she wants.
Right to Nondiscrimination
From a legal perspective, patients in nursing facilities and those seeking admission to a facility have all the rights of citizenship that are guaranteed to every American by the Constitution of the United States. Additional protections against discrimination are included in federal and state laws. Title VI of the Civil Rights Act of 1964 applies to programs receiving federal funds. The law prohibits denial of benefits on the basis of race, color, or national origin. Denial of benefits may be construed to mean discrimination in admission, segregation by race or ethnicity, and unequal treatment in other respects. Section 504 of the Rehabilitation Act of 1973 prohibits any facility receiving federal funds from discriminating on the basis of physical or mental handicap. Admission to a facility may be denied only if that facility does not provide the level of services that a patient in a protected category requires. Individuals with HIV/AIDS are also protected under the Rehabilitation Act. The Americans with Disabilities Act (ADA) of 1990 goes beyond the requirements of the Rehabilitation Act. It specifically states that “no individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation.”
Right to Freedom from Abuse, Neglect, and Misappropriation of Property
OBRA-87 added further rights regarding freedom from resident abuse, neglect, and misappropriation of resident property in nursing homes. Abuse is defined as “willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.” Neglect means “failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” Misappropriation of resident property means “deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent.”
The Balanced Budget Act of 1997 calls for denial of payment under Medicare and Medicaid to facilities charged with abuse and mistreatment of patients. The law also directed the states to establish nurse aide registries. Part of the information contained in the registry pertains to findings of abuse, neglect, and misappropriation of resident property. This information is designed to ban nurse aides who have been abusive in the past from employment in nursing facilities.
Elder Justice Act
The Elder Justice Act was signed into law in March 2010 and was made part of the Affordable Care Act. The law intends to enhance coordination of elder justice activities; establish forensic centers to develop expertise in elder abuse, neglect, and exploitation; strengthen adult protective services; and require LTC providers to prevent and respond to elder abuse, neglect, and exploitation. Under the law, LTC facilities that receive at least $10,000 under the federal Social Security Act must comply with certain reporting and notification requirements. They must also report to the DHHS and local law enforcement any suspicions of abuse regardless of whether or not such abuse results in bodily injury. It is also illegal for a facility to take any retaliatory action against an employee who reports suspected elder abuse as required by the law. LTC facilities and individual employees can face fines of up to $300,000 for noncompliance.
Right to Privacy and Confidentiality
Facilities are required to preserve patients’ privacy in the delivery of care and treatments. It is important for nursing home associates to realize that the facility is considered the patients’ home. Facility administration should institute practices such as knocking before entering a resident’s room, drawing privacy curtains for personal care, and ensuring appropriate dressing and grooming of residents. Facilities are also required to keep patient information confidential. The responsibilities of nursing homes, however, go far beyond ensuring the basic rights to privacy, dignity, and confidentiality.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides for some of the strongest safeguards to maintain the confidentiality of patient information. HIPAA makes it illegal to gain access to personal medical information for reasons other than health care delivery, operations, and reimbursement. To the extent it is necessary to promote quality of health care, information can be shared among physicians, nurses, and other professionals. It can also be used for getting reimbursement for services delivered and to facilitate operations such as transfer of a patient from one facility to another. However, the legislation mandates the exercise of strict controls on the transfer of personally identifiable health data between two entities.
The Privacy Rule under HIPAA applies to all medical records and other identifiable health information regardless of whether the information is electronic, on paper, or orally transferable. Patients have significant rights to understand and control how their health information is used:
• Health care organizations are required to provide a notice to patients detailing the ways in which the facility will use or disclose the patient’s protected healthcare information (PHI) , which is defined as individually identifiable health information that relates to the past, present, or future physical or mental health of, or the provision of health care to, a patient (Battaglia, 2003).
• Patients generally have the right to examine their medical records. They can obtain copies of their records, but the medical establishment can charge a reasonable fee for copying and sending the information. Patients also have the right to request corrections of any errors in their records.
• Patients have the right to request restrictions on the uses and disclosures of their information. Releasing individual medical information for any purpose other than patient care should be done only with the patient’s express written consent. In addition, the patient’s authorization must be made with informed consent; the patient must be aware, in a general way, what information will be released and what use will be made of the information. The information released should be strictly limited to that required to fulfill the purpose of the authorization. Authorizations should be retained as a part of the official medical record.
• The Privacy Rule sets restrictions and limits on the use of patient information for marketing purposes. Pharmacies, health plans, and other entities must first obtain an individual’s specific authorization before disclosing patient information for marketing.
In January 2013, the DHHS issued revisions to HIPAA in conjunction with the Health Information Technology for Economic and Clinical Health (HITECH) Act. More stringent rules now apply to disclosure or breaches of confidential PHI, inclusion of vendors and subcontractors as “business associates” who must comply with HIPAA requirements, restrictions on the use of PHI for marketing purposes, patient authorization related to the use of PHI for research purposes, and the patients’ right to receive electronic copies of their PHI (Thompson Coburn LLP, 2013).
To comply with HIPAA, a nursing facility must have a detailed privacy policy in place. It should be crafted with the help of legal counsel. Upon admission, a copy of the policy should be given to the patient or guardian, and receipt of the privacy notice must be acknowledged in writing. The policy must also be posted at a prominent location within the facility, and on the facility’s website, if one exists. Violations of the Privacy Rule are subject to civil as well as criminal penalties. HIPAA violations are not actionable in a court. Aggrieved parties are required to file a complaint with the Office of Civil Rights of the DHHS. Privacy violations can be litigated, but not under the HIPAA law.
Terminology for Review
abuse
accreditation
administrative law
admission agreement
advance directive
agent
assault
battery
breach of contract
certificate of need
certification
civil law
common law
compensatory damages
competent
consideration
constitutional law
contract
corporate law
corporation
crime
criminal law
deemed status
defendant
distinct part
do-not-resuscitate order
dual certification
durable power of attorney
egregious conduct
ethics committee
false imprisonment
federal preemption
federalism
felony
for-profit facility
fraud
general partnership
good faith
gross negligence
guardian
informed consent
injury
intentional tort
liability
libel
limited partnership
litigation
living will
malice
malpractice
misappropriation of resident property
misdemeanor
neglect
NF
nonprofit
ordinances
ordinary negligence
partnership
plaintiff
private laws
private-pay patients
public facility
public laws
punitive damages
respondeat superior
slander
SNF
sole proprietorship
statutory law
summary judgment
tort
vicarious liability
For Further Thought
1. Review the case, Fuqua v. Horizon/CMS Healthcare Corporation, embedded in this chapter. (a) What main lesson can be learned from this case? (b) What do you think may have been the main reasons for awarding huge punitive damages in this case?
2. Review the Maggie Hazelton case embedded in this chapter. (a) On what basis did both the trial court and the appellate court rule in favor of Richard Smith? (b) Who should be held liable? (c) Discuss the liability issue from the perspective of both personal liability and corporate liability.
Case
Ordinary Negligence or Medical Malpractice?
Catherine Hemming was a resident at Oak Woods Nursing Center. She suffered from dementia and diabetes, had suffered several strokes, and required 24-hour care that included assistance with grooming, eating, toileting, and bathing. The patient’s condition impaired her judgment and reasoning ability and, in turn, caused cerebral atrophy (loss of brain cells). Ms. Hemming had no control over her movements in bed, and hence, was prone to sliding about without sensing her position in bed. This lack of control was addressed in the patient’s plan of care in which the facility’s medical director authorized the use of various physical restraints. These included bed rails to keep the patient from sliding out of the bed, and a restraining vest that would keep her from moving her arms, thereby impeding her ability to slide. The physician’s orders also included wedges or bumper pads that were placed on the outer edge of the mattress to keep the patient from hurting herself by striking, or by entangling herself in the rails. According to nursing home regulations, the use of restraints of this sort must be authorized by a physician to prevent overuse and excessive patient confinement.
Ms. Hemming died of asphyxiation after her neck got caught between the raised bed rails and the mattress. The day before her death, two nursing assistants had found the patient tangled in her restraining vest, gown, and bed sheets. The employees untangled her, repositioned her, and used wedges and pads so that she would not slide into the gap between the mattress and the bed rail. Whether the aides informed their supervisor about the risk remained unclear.
Denise Benton, as personal representative of Hemming’s estate, sued Oak Woods. After subsequent amendments to the initial complaint, the case eventually came before the state’s Supreme Court. In claiming medical malpractice, Benton’s complaint made four specific allegations: (i) Oak Woods failed to ensure that Ms. Hemming was provided an accident-free environment; (ii) Oak Woods failed to train its staff to assess the dangers posed by bed rails and the risk of potential asphyxiation; (iii) Oak Woods failed to inspect the beds, bed frames, and mattress to ensure that the risk of positional asphyxia did not exist; and (iv) Oak Woods failed to take adequate corrective measures and protect Ms. Hemming after she had been found entangled in her bedding on the day before her death from asphyxiation. The complaint alleged that the facility had notice of the risk of asphyxiation through the nursing assistants, but despite this knowledge of the problem did nothing to rectify it.
Questions
1. The state’s Supreme Court did not rule uniformly on the four allegations contained in the lawsuit. One of them did not constitute either malpractice or negligence. Provide explanations and identify which allegation(s) constituted ordinary negligence, which one(s) constituted medical malpractice, and which one was neither.
2. Can any of these be held personally liable? (a) the two nursing assistants, (b) the nurse supervisor, (c) the administrator. Provide explanations.
Notes: 1. There are different types of bed rails that can be prescribed based on a patient’s medical history and behavior. 2. This is a real court case that was initially brought before a county circuit court. All names have been disguised.
FOR FURTHER LEARNING
HIPAA violations and enforcement. American Medical Association.
REFERENCES
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Tammelleo, A. D. (2007). Officers of nursing home not liable for nurse’s negligence. Retrieved December 2008 from http://www.entrepreneur.com/tradejournals/article/169824266.html.
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Wagner, L. M. et al. (2012a). Impact of voluntary accreditation on deficiency citations in U.S. nursing homes. The Gerontologist, 52(4), 561–570.
Wagner, L. M. et al. (2012b). Joint commission accreditation and quality measures in U.S. nursing homes. Policy, Politics & Nursing Practice, 13(1), 8–16.
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