HCAD 650 UMDC Health Law Litigation and Managerial Legal Compliance Discussion


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(1)Stop and Repeat as you watch the video

(2) Rereview the video before each discussion or assignment

(3) Download the PowerPoint to review specific areas you need to work on before each discussion and assignment.

complete the discussion question assigned. Answer ALL guided questions under Part 1 and Part 2 in ONE post.

Review the document The Law, Compliance Tools, and Managerial Actions  posted in the Compliance Library.

Use only classroom materials to complete the discussion. This would include the textbooks, weblinks, and the Classroom law library, and Compliance library.

Part 1:  Critical Analysis of the Law

Identify, cite the code, and give a short description of one health law found in the common health care statutes document. For the health law selected, evaluate the following.

Evaluate whether the law is a federal or state law, civil or criminal, public or private. How do you know?

Why is it important to know when a statute has been modified by administrative regulation, court decision, or new statute? How can you find out about these changes?

What are the penalties associated with non-compliance with your law? Why would it be important to you and your organization to avoid these penalties? How could you comply with the law you described?

Evaluate the role of the health care administrator or health information technology administrator in legal compliance.

Why is your role important in preventing litigation and supporting legal compliance?

What tools are available for legal compliance? Name one compliance tool from the Week 12 Managerial Compliance Tools list and describe the tool.  Evaluate how the tool would control this risk.

How can you take action to reduce legal risk? (Describe at least one managerial action you could take and how you would use the tool you just described to limit legal liability.)

Part 2:  Strategic Compliance with the Law

You are an administrator for Big City Hospital Inc., a large medical center. Your medical center has just received a Summons indicating that a Complaint has been filed in the state district court in your city claiming that Dr. Quick, Nurse Sleep, and your medical center were negligent during a recent surgery.

The claim is that the doctor left before the surgical count, the nurse didn’t notice a missing sponge during the count, and the patient now has an x-ray showing that there is a sponge in the abdomen. The medical records do not reflect that a sponge count was even completed. Your state of Maryland has an arbitration process that has been completed and the lawsuit has started.

As part of the lawsuit, you receive a litigation hold letter requesting that all documents related to the lawsuit be preserved including electronically stored information (ESI).

  • Why is it important to preserve documents for litigation?
  • How would you do this? Describe three actions you would take to preserve documents (prevent destruction) for this lawsuit.

    What key documents would need to preserve because they relate to what happened?

  • When a case goes to court, good medical record documentation can make the difference in winning or losing a lawsuit.
  • How can medical record documentation limit or increase legal liability? What should a strong medical record include?
  • As a result of this lawsuit, what three actions would you take to improve medical record surgical care documentation including adequate documentation of the sponge count?
  • Laws, Compliance Tools and Managerial Actions
    Success Tip: Talk about the law, compliance tools and managerial actions in all

    Evaluate what the law requires the organization to do.
    Evaluate how compliance tools can be used to ensure legal compliance or
    correct legal problems.
    Evaluate how specific management actions can be taken to use compliance tools
    and ensure legal compliance.
    What is a law?
    A law arises from a Constitution, statute, regulation or court decision at the federal or
    state level. It sets the standard of conduct of what is required. Laws often include
    penalties that state what will happen if the requirements of the law are not met. This
    can include financial penalties or jail time. For example, HIPAA ;aw has both civil and
    criminal penalties.
    Tip: Always start by knowing what the law requires and what the penalties are for noncompliance.
    Federal/State Type of Law
    Citation Example and Web Link
    U.S. Const. Art I
    United States
    Code of
    42 U.S.C. 325 (2021)
    U.S. Court of
    29 C.F.R. 151 (2021)
    Advocate Health Care Network v. Stapleton, No. 1675 (2017)
    Jones v. Smith, No. 3:2021cv12349 (2nd Cir. 2021)
    U.S. District
    Markson v. Knox, No. 1:2021cv01334 (Md. Ct. 2021)
    Maryland Const. Art. IV
    State Statute
    Maryland Mental Health Facilities §10-404 (2018)
    State Rule
    COMAR (2020)
    State Cases
    North Hospital v. Zenick, No. 34ag/21 (MD. Ct. App.
    What is a Compliance or Risk Management Tool?
    A compliance or risk management tool is something that is used to help an organization
    comply with the law. Any tool that is used to solve a problem should be evaluated to
    determine how it will apply to correct the specific problem. For example, a general tool
    such as a corporate checklist would need to be adapted to include items on the
    checklist to ensure that the company met a specific compliance goal such as avoiding
    discrimination in hiring.
    Tip: Any managerial tool should be adjusted to meet the specific problem. Evaluate
    how to use the general principles of the tool to correct specific problems. Give reasons
    to support how your tools resolve the legal problem.
    Tip 2: Use the week 12 managerial tools for compliance links throughout the course
    to assist with compliance tools for assignments.
    Tool Examples
    How it could be used to limit risk or comply with the law
    Litigation Hold Letter
    A litigation hold letter is issued to ensure that electronic and
    other evidence is preserved for litigation by putting a hold
    on destruction of relevant evidence while litigation is
    A contract should comply with the law and include contract
    clauses to limit the risk of the organization should a dispute
    arise. A contract should be adapted to meet the needs of
    the specific situation and risks.
    Contracts and Contract
    Cloud Based Contract
    Management System
    Corporate documents
    including policies and
    Enterprise Document
    Management (EDM)
    HHS OIG Compliance
    COSO Internal Control
    Health Information
    Code of Ethics from a
    Organization or from
    the Hospital, Clinic or
    Care Facility
    Security Risk
    Assessment (SRA)
    Health Information
    Technology or other
    Internal Audits
    A cloud based contract management system helps ensure
    that the organization complies with the requirements of the
    contract and tracks the life cycle of the contract to limit risk
    from non-renewal or renegotiation.
    Corporate documents set the standards, vision, rules for
    the organization to meet. They ensure consistency of
    managerial actions and should be complied with. Any
    management actions should comply with both law as well
    as organizational documents and policies.
    An Enterprise Document Management System (EDM)
    creates is a way to keep all organizational documents in
    digital forma for prompt review and retrieval. This gives the
    organization a system wide process to manage, use, and
    archive documents.
    The HHS OIG Compliance protocol provides elements an
    organization can use to comply with the law and limit the
    risk of fraud and abuse.
    The COSO Internal Control Framework provides a number
    of controls that can be used in order to reduce risk within an
    organization. General principles of control can be adapted
    to manage specific organizational risks..
    Health Information Technology can be used as a
    compliance and risk management tool when the tool is set
    up to comply with specific legal requirements and to limit
    risk of non-compliance.
    A Code of Ethics sets an ethical standard for those who
    belong to the organization. Many organizations require a
    person to sign the Code of Ethics as indication that they
    agree and will comply with the ethical standards. This
    ensures high ethical behavior which improves the likelihood
    of legal compliance as well and limits the risk of
    This is an assessment of the security risk to health
    information within an organization. It is required by law and
    helps ensure compliance with the law.
    Internal audits give an organization a chance to catch
    problems before an outside auditor, government regulator,
    or accreditation agency comes in and finds a problem. This
    allows the organization to correct the problem in order to
    comply with legal requirements.
    Checklists can be for a variety of activities and include a
    surgical checklist, hiring, termination, or evaluation checklist
    to ensure that all steps for safety are taken before a
    procedure or activity. Checks can ensure consistency in
    legal compliance no matter who is conducting the activity.
    AHRQ, NCQA, Joint
    Guidelines. and HHS
    OIG Compliance
    Sample Forms and
    Training Tools
    Guidelines provide a tool to meet high standard of practice.
    They are not enforced like the law, but set high standards
    that improve compliance and prevent problems.
    Sample forms can help an organization set up a form for
    patient intact, informed consent, consent refusal, prevent
    violence, or encourage patient safety, ensure advanced
    directives comply with state law, or take other actions in a
    way that minimizes risk and complies with the law.
    Formal training tools can be used to provide employee
    training on HIPAA, OSHA Safety, or other issues to
    encourage patient safety, legal compliance, etc.
    What are Managerial Actions?
    Managerial actions are things that you can DO as a manager to comply with the law.
    These actions may include ways to use compliance and risk management tools to
    comply with the law. Something that the government does is not a managerial action.
    For example, issuing a litigation hold letter would be a managerial action to preserve
    evidence when a lawsuit is anticipated.
    Tip: Any recommended managerial actions should be specific to the problem and
    correct the problem, reduce the risk, and prevent future problems. Always explain how
    the recommended action will do this. Include reasons to support your recommended
    managerial actions.
    Managerial Action
    Related Tool
    Legal Problem it could correct
    Issue a Litigation
    Hold Letter as soon
    as you know a
    lawsuit will be filed.
    Add an arbitration
    clause to a contract
    to keep a contract
    dispute out of court
    and the public
    Create a new policy
    on bullying to
    prevent bullying in
    the workplace.
    Litigation Hold Letter
    This would ensure evidence is
    preserved for the lawsuit that is
    anticipated before issuing the
    litigation hold letter.
    This could keep an contract issue
    form going to court and limit
    public exposure to the issue.
    Contract clauses
    Corporate Documents
    When an issue arises a policy
    can be created to prevent the
    issue in the future and ensure
    that if it arises it is consistently
    Train employees on
    Training Tools
    how to use the
    health information
    technology system to
    keep PHI private and
    secure with a quiz at
    the end of training as
    a knowledge check..
    Establish a
    Corporate Documents
    corrective action
    plan for an employee
    who is chronically
    late to work with a 30
    day follow up
    Create a checklist for Checklists
    patient discharge to
    ensure everything
    that needs to be
    completed prior to
    discharge is
    Conduct an internal
    medical record audit
    to see if initial visit
    coding is supported
    by the medical
    Create a hospital
    Forms and Guidelines
    protocol for opioid
    use disorder (OUD)
    screening based on
    national guidelines to
    ensure consistent
    screening of all
    handled in conjunction with the
    Any training should be specific to
    the legal problem and provide
    specific information to employees
    so that the problem is less likely
    to recur.
    This allows the manager to
    correct a problem a specific
    employee is having. It should be
    followed up with review to see if
    the corrective actions were
    properly implemented by the
    employee after a preset period
    such as 30, 60 and/or 90 days.
    This ensures that patient meets
    medical criteria for discharge, has
    received any training or
    medication for discharge, and
    that the discharge is in
    compliance with the law.
    An internal audit allows the
    organization to review its own
    records related to legal standards
    and make needed changes to
    comply with the law before an
    outside auditor, regulator or
    accreditor comes in to audit and
    finds a problem.
    Protocols ensure consistent
    actions for all who do the same
    Forms ensure that the
    information that needs to be
    captured to comply with the law is
    on the form.
    Week 1: Sources of Law, Litigation, and Managerial
    Legal Compliance
    Additional Resources
    Sources of Law
    Web Links
    • The U.S. Legal System https://corporate.findlaw.com/litigation-disputes/the-u-s-legalsystem.html
    • (Federal)Court Role and Structure: http://www.uscourts.gov/about-federal-courts/court-roleand-structure
    • Comparing Federal and State Courts https://www.uscourts.gov/about-federal-courts/court-roleand-structure/comparing-federal-state-courts
    Litigation Process
    • Office 365: How to Setup a Litigation Hold on a Mailbox

    Litigation Holds
    • Alison, J.R. Five Ways to Keep Disputes out of Court, Harvard Business Review (January –
    February 1990) https://hbr.org/1990/01/five-ways-to-keep-disputes-out-of-court
    • Determining Litigation and Statutes of Limitation Requirements for Records Retention
    Programs https://irch.com/determining-litigation-and-statutes-of-limitation-requirements-forrecords-retention-programs/
    • Litigation Holds: Ten Tips in Ten Minutes
    • Implementing a Litigation Hold with file hold Implementing a litigation hold with FileHold |
    • Sample Litigation Hold letter https://iaals.du.edu/sites/default/files/documents/resources/05__sample_letters_-_litigation_hold_and_electronic_data_preservation.pdf
    Legal Compliance and Risk Management
    • Tips for Implementing an Effective Compliance Program

    Web Links
    • What is Risk Management in Health care? NEJM Catalyst (April 25, 2018)
    • Park, H., et,. al, Controlling Legal Risk for Effective Hospital Management. World J. Men’s
    Health (April, 2018) 34(1)
    • HHS OIG: Measuring Compliance Program Effectiveness: A Resource Guide (2017) Microsoft
    Word – HCCA OIG Resource Guide (002) (hhs.gov)
    Medical Record Documentation
    Web Links
    • NCQA Guidelines for Medical Record Documentation https://www.ncqa.org/wpcontent/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
    • Make sure your documentation meets guidelines https://www.karenzupko.com/make-sureyour-documentation-meets-guidelines/
    • AHIMA: Integrity of the Healthcare Record: Best practices for HER Documentation (2013
    update) https://library.ahima.org/doc?oid=300257#.YG0sdOhKiUk
    • Cahill, R. The Defensible Medical Record. The Doctors Company.
    • Surgical Documentation Primer.- American College of Surgeons. (A.C.S.)
    • WHO Surgical Safety Checklist https://www.who.int/teams/integrated-healthservices/patient-safety/research/safe-surgery/tool-and-resources
    Find the Law Resources
    • Online Legal Dictionary https://dictionary.law.com/
    • Findlaw Cases and Codes https://caselaw.findlaw.com/
    • U.S.Constitution – https://constitutionus.com/
    • U.S. Laws, Codes & Statutes – U.S.Constitution, U.S.Code, State Codes
    • Federal Statutes – The United States Code (U.S.C.) https://www.law.cornell.edu/uscode/text
    • Federal Regulations – electronic Code of Federal Regulations (C.F.R.) https://ecfr.io/
    • State Regulations – https://www.law.cornell.edu/regulations
    • U.S.Supreme Court https://www.supremecourt.gov/
    • Supreme Court of the United States (SCOTUS) Blog https://www.scotusblog.com/
    • Federal Circuit Courts of Appeals https://law.justia.com/cases/federal/appellate-courts/
    • Federal district court cases https://law.justia.com/cases/federal/district-courts/
    • State court web sites https://www.ncsc.org/information-and-resources/state-court-websites

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