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Legal Issues in Nursing Home Admissions

Published online by Cambridge University Press:  29 April 2021

Extract

Entering a nursing home involves a significant loss of personal autonomy. Whether the resident or someone else, such as a court or conservator, makes the decision, personal freedom becomes subject to rules, policies and practices that often seem to favor the convenience of the facility over the autonomy of the resident. The previously independent resident may now find that a “financial guarantor” must co-sign the admission agreement and a staff nutritionist decide what the resident will eat.

As the impact of nursing home care on individual autonomy becomes more apparent, greater attention has focused on the rights of nursing home residents. Many of those rights derive from the admissions agreement signed when the resident enters the facility. While theoretically subject to negotiation, the boilerplate contracts used by most nursing homes subject the consumer to undeniable coercion in making an important consumer choice.

Type
Article
Copyright
Copyright © 1990 American Society of Law, Medicine & Ethics

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References

Taylor, E.A., Draft Report: Unnamed Nursing Home Investigation (Seattle: Federal Trade Commission, 1981). Although the author of the report recommended additional regulation, the agency declined to adopt her recommendation and issued the 139-page report in draft form with disclaimers.Google Scholar
Id., at 47Google Scholar
Ambrogi, D.M. and Leonard, F., Nursing Home Admission Agreements: State Studies, National Recommendations (San Francisco: California Law Center on Long Term Care [CALC], 1988); Ambrogi, D.M., Doctor, D. and Swan, J.H., The Admission Process in California Nursing Homes and Its Impact on Resident Autonomy (San Francisco: CALC, 1988); Subcommittee on Law and the Elderly, Maryland Nursing Home Contracts, A Manual for Residents and Advocates (Baltimore: Maryland State Bar Association, 1987); Schneider, M.D. and Oliver, L., North Dakota Long Term Care Facilities Admission Contract Terms; Survey of North Dakota Nursing Homes (Bismarck: Legal Assistance of North Dakota, 1987); Ambrogi, D.M. and Gerard, L.E., Autonomy of Nursing Home Residents: A Study of California Admission Agreements (San Francisco: CALC, 1986); Irion, J.S. Jr., A Study of Illegal and Questionable Terms in Louisiana Nursing Home Admission Contracts (Baton Rouge: Louisiana State Ombudsman Program, 1985); Wacker, R.R., Long-Term Care Admission Agreements in Colorado: A Review (Denver: Advocacy Assistance Program, 1985); Legal Services for the Elderly, Illegal and Questioned Terms in Nursing Home Resident Contracts: A Report to the Nursing Home Ombudsman (Augusta: Maine Committee on Aging, 1983).Google Scholar
Ambrogi, and Gerard, , supra.Google Scholar
California Health and Safety Code 1599.60-.84. This statute went into effect on January 1, 1988.Google Scholar
22 Maine Revised Statutes Annotated 1826–7 (1985). Maryland Health-Gen. Code Ann. 19–345 (1988). Minnesota Statutes 80D.04, 144.6501 (1989).Google Scholar
Omnibus Budget Reconciliation Act of 1987 (OBRA), Subtitle C, PL 100–203, 1819(c)(5) and 1919(c)(5) (1987). There will be a new section under Residents' Rights entitled “Admissions Policy”. As of October 1, 1990, facilities certified for participation in Medicaid and/or Medicare may no longer require applicants for admission to waive their rights to Medicaid or Medicare benefits; they may not require “oral or written assurances” that applicants for admission are not eligible, or will not apply, for Medicaid or Medicare; and they must provide oral and written information about applying for benefits and receiving refunds to all applicants for admission. Most importantly, after that date, they will no longer be able to require a third party guarantee of payment (i.e., a personally liable financial guarantor) for any applicant, whether private pay or on Medicaid or Medicare.Google Scholar
The relations and legal obligations between a patient and a health care provider were the setting for Tunkl v Regents of the University of California, 383 P.2d 441, 32 Cal. Rptr. 33 (1963). Tunkl, involving a dispute over an exculpatory provision in a hospital's patient admission agreement, represents the first important judicial statement on adhesion contracts.Google Scholar
Madden v. Kaiser Foundation Hospitals, 552 P.2d 1178, 131 Cal. Rptr. 882 (1976).Google Scholar
Uniform Commercial Code 2–302 (1962).CrossRefGoogle Scholar
A&M Produce Co. v. FMC Corp., 135 Cal. App. 3d 473 (1982).Google Scholar
U.S. General Accounting Office, Medicaid and Nursing Home Care: Cost Increases and the Need for Services—Problems for the States and the Elderly (Washington, D.C.: GPO, 1983).Google Scholar
Id., at 53.Google Scholar
Institute of Medicine, Improving the Quality of Care in Nursing Homes (Washington, D.C.: National Academy Press, 1986).Google Scholar
Id. In recent testimony before the FTC, a representative of a national nursing home reform coalition confirmed that free market forces are still impaired by occupancy rates that exceed 90% in much of the country, guaranteeing a “seller's market.”Google Scholar
Id., p. 58.Google Scholar
Ambrogi, Doctor and Swan, supra note 3.Google Scholar
Harris, S., “Rethinking Admissions”, AHCA Journal, 12 (1986).Google Scholar
See, e.g., Cal. Health & Safety Code 1599.65(a). In 1986, Health Care Financing Administration advised the Maryland State Office of Licensing and Certification that it was illegal for facilities to have other persons sign an admission contract instead of the resident unless the resident had been found by a court to be incompetent or certified by doctors to be incompetent. Maryland Department of Health and Mental Hygiene memorandum on “Devolving of Patients' Rights”, September 4, 1986.Google Scholar
Ambrogi, and Gerard, , supra note 3. See also Buckingham, S.C., Admission Agreements of Maryland Nursing Homes Admission Contracts (Baltimore: Maryland Department of Health and Mental Hygiene, 1987).Google Scholar
Minors are legally incompetent to sign a contract, whether or not they actually lack this capacity. But in contrast to elders, young adults—once of age—are rarely questioned on contractual capacity, no matter how bad their judgment proves to be.Google Scholar
See, e.g., Ambrogi and Gerard, supra, at B-3.Google Scholar
For example, almost 80% of all 70-year old persons suffer from defective visual acuity (less than 20/40 vision); by age 80, this figure has risen to nearly 90%. (Harris, Fact Book on Aging: A Profile of America's Older Population, 100 (Washington: The National Council on the Aging, 1978)).Google Scholar
California Health and Safety code 1599.64 requires use of 10-point type on plain white paper, and use of “clear, coherent and unambiguous language.” Illinois regulations require that nursing home admission contracts “shall be written in clear and unambiguous language and shall be printed in not less that 12 point type”. (Regulation 03.03.11.00.) Although there is no federal law governing type size and language in nursing home admission agreements, under a recent federal court order, Explanation of Medicare Benefits (EOMB) forms must be made in not less than 10-point type, in “the simplest English possible”, and in both upper and lower case printing. (The Gray Panthers et al. v. Heckler, Medicare and Medicaid Guide (CCH) 34,981, U.S. District Court, District of Columbia, Nov. 4, 1985).Google Scholar
Johnson, , “Weighing in on the Flesch Scale”, 8 Student Lawyer 78 (Jan. 1980). Some states require insurance policies and other consumer documents to achieve a certain minimum score on the Flesch scale. For example, Mass Gen. Laws Ann., Ch. 1752B requires insurance policies to achieve a Flesch score of at least 50.Google Scholar
Ambrogi, and Gerard, , supra, B-5.Google Scholar
California Association of Health Facilities (CAHF), Model Admission Agreement, 13 (Sacramento: CAHF, 1986).Google Scholar
Perdue v. Crocker National Bank, 216 Cal. Rptr. 345, 702 P.2d 503, 38 Cal.3d 913 (1985).Google Scholar
See, e.g., Cal.Civ. code 1750 et seq.Google Scholar
Ambrogi, & Gerard, , supra, at C-1.Google Scholar
Glengariff v. Snook, 471 N.Y.S. 2d 973, Medicare and Medicaid Guide (CCH) 33,605 (N.Y.S. Ct., Nassau County, 1984).Google Scholar
See, e.g., 42 C.F.R. 405.1121 (k)(13). 22 Maine R.S.A. 1826(2)(D). Cal. Health and Safety Code 1289.3-.5 (1988); 22 Cal. Admin. Code 72529.Google Scholar
See Wadleigh, , Personal Property of Nursing Home Residents: Remedies for Loss and Theft, 6771 (San Francisco: CALC, 1984), for practical suggestions.Google Scholar
See, e.g., Cal. Health & Safety Code 1599.62. 22 M.R.S.A. 1826(2)(D). Minn. Statutes 80D.04.Google Scholar
Varney v. Ditmars, 217 N.Y. 223, 111 N.E. 822 (1916).Google Scholar
Minnesota and North Dakota are the exceptions, with laws equalizing the rates for private pay and Medicaid residents.Google Scholar
Medicaid recipients have the most to lose if the agreement inadequately or inaccurately describes covered services, because they have only a small monthly “personal needs allowance” ($30–50 in most states) with which to cover all expenses not covered by Medicaid. The 1987 OBRA reforms attempt to rectify this lack of clarity by requiring the federal Health Care Financing Administration (HCFA) to define those items and services to be included in the Medicare and Medicaid rates, and those which may be charged to the resident's personal funds. 42 U.S.C. 1395i-3(f)(7), 1395r(f)(7).Google Scholar
Office of Research and Demonstrations, Health Care Financing Administration, Short-Term Evaluation of Medicaid: Selected Issues 123, No. 84-9. (Washington, DC: U.S. Department of Health and Human Services, 1984).Google Scholar
42 C.F.R. 405.1121(k).Google Scholar
Glengariff v. Snook, supra. 42 U.S.C. 1396h(d). Cal. Welf. & Inst. 14110.8. See also Ambrogi and Gerard, supra, D-8.Google Scholar
U.S.C. 1395e-3(c)(5)(A)(i), 1395r(c)(5)(A)(ii) (one of the most significant provisions of the 1987 OBRA reforms).Google Scholar
42 U.S.C. 1395i-3(c)(5)(A)(i), 1395r(c)(5)(A)(i).Google Scholar
Sabatino, C., “Nursing Home Admission Contracts and Residents Rights”, in Personal and Estate Planning for the Elderly, 99 (Washington, D.C.: American Bar Association,1989).Google Scholar
42 U.S.C. 1320a-7b(d).Google Scholar
42 U.S.C. 1396r(c)(5)(B).Google Scholar
The OBRA legislation contains a somewhat revised statement of residents' rights, 42 U.S.C. 1395i-3(c), 1396r(c).Google Scholar
See, e.g., Cal. Health & Safety Code 1430.Google Scholar
National Citizens Coalition for Nursing Home Reform (NCCNHR), A Consumer Perspective on Quality Care: The Residents’ Point of View, (Washington, DC: NCCNHR, 1985).Google Scholar
Ambrogi, and Gerard, , supra, E-6.Google Scholar
See, e.g., Cal. Health & Safety Code 1599.72.Google Scholar
See, e.g., Cobbs v. Grant, 104 Cal. Rptr. 505 (1972)Google Scholar
Most states have strict statutory procedures for surrogate health care decision-making.Google Scholar
42 C.F.R. 405.1121(k)(4), 442.311(c).Google Scholar
42 U.S.C. 1395i-3(c)(2)(A), 1396r(c)(2)(A).Google Scholar
OBRA requires 30-days notice in most cases with fairly stringent due process safeguards. 42 U.S.C. 1395i-3(c)(2) and (e)(3), 1396r(c)(2) and (e)(3).Google Scholar
See footnotes 5 and 6, supra.Google Scholar
See, e.g., Cal. Health & Safety Code 1599.61. Maryland Health-Gen. Annotated Code 19–308.3(b).Google Scholar
The recent OBRA nursing home law legislated many of the reforms directly, rather than through the contract itself. For example, states must develop written notices addressing the rights of Medicaid beneficiaries in the nursing home admission process (deposits, retroactivity, bed-holds, etc.) yet these protections are not required to be in the contract language itself. OBRA, 4211.Google Scholar
See, e.g., 22 Maine Revised Statutes Annotated 1826.2.A., C.,D.,E., and H.Google Scholar
Ambrogi, and Leonard, , supra.Google Scholar
See Horvath, D. and Nemore, P., “Nursing Home Abuses as Unfair Trade Practices”, 20 Clearinghouse Review 801 (1985).Google Scholar
See Nursing Home Admissions Contracts in Maryland (Baltimore: Maryland State Bar Association, 1988) and Consumer Guide to Nursing Home Admission Agreements (San Francisco: California Law Center on Long Term Care, 1988) as examples of materials which could be made available to the public by state agencies.Google Scholar