HEARING - U.S. Senate Special Committee on Aging

143
492 541W, New Developmenis 10,941
no later than June 2(). l)914 ili pan i-, hal II ii st) orderei.
submit a prcsiwxrd judlgmtcmi siorni i u sh this
decisinn toerther with ;.ny . 'ri , *.rders
and supporting mcmrr3nda.
I1 35;3751 Fifty Residents of Park Pleasant Nursing Home v. Commonwealth of Pennsylvania.
Pennsylvania Commonwealth Court. No. 2905 C.D. 1984. Jan. 10, 1986.
Before: RocEss. MACPHAIL, Judges, and BARBIERI, Senior Judge.
Medicaid: Level-tf-Care Change
Pennsylvania-Notice, hearing, and appeals concerning benefit-Level-of-care
change-Adequacy of agency notice.-Even though agency regulations forming the basis for the
reduction in the level of care rendered to fifty nursing residents are valid, agency determinatimnt
reducing the residents' level of care are reversed since notices sent to those residents of the
recommended reduction were inadequate under both federal and state regulations. First, no reason
was given for the intended reductions in each of the residents- level of care and no specific
regulations supporting the recommendations were cited. Further, references to the ag ency s regulatbins
that were listed in the notice concerned inspection of care procedures, not 0he le initios of
silled care which were relied upon in making the recommendations. Finally. the notice was devoid
of detail and contained no explanation of the basis for the proposed evel-of-care reduction.
See! l4 765.15 14,765.41, 15.632.
(Text of Decision] (a) For an individual service provided to
RoGERs, judge: This is the appeal of fifty the recipient to be considered a skilled care
nursing home residents of the Park Pleasant service, the service must:
Nursing Home (residents) who have been receiv- (i) Be needed by the patient on a daily
ing skilled nursing care under the Medical As3si- basis.
tassce Pregratt.' Following an annual inspection, . .
the Pennsylvania Department of Public Wed. (ii) Be ordered by a physician.
fare's (DPW) Inspection of Care tetm recoin. (iii) Require the skills of, and be provided
mended that the care of the appellant residents either directly by or under the supervision of,
be reclassified from skilledi to intermediate, medical professionals.
DPW sent notices to the residents recertifying Be provio t pe o d
them in accordance with the recommendation. (iv) Be provided to the patint n dai
'The residents appealed this determination nd sis.
two days of hearings were held at which the (v) Be one that can only be provided, as a
hearing officer upheld DPW's recommendations. practical matter, in a skilled nursing facility
The hearing officer's decision was affirmed by on an inpatient basis.
DPW's Office of Hearings and Appeals. The . * * -
residents filed a request for reconsideration (vi) Be documented i the recipient's medi.
which was denied by DPW's Executive Deputy cal record daily.
Secretary The residents have filed a petition for (vii) Be included and not excluded as a
review of the order of recertification, asking us skilled care service in the Skilled Nursing
to remand their cases for reevaluiation because, Care Assessment Handbook. 55 Pa. Code
as they assert, DPW's procedures were contrary t 1181, Appendix E lI(n).
to law and its own regulations. The residents claim that these criteria do not
The residents first claim that the DPW regu- allow for an analysis of the patient's condition
Lations which formed the basis for the reduction as a whole, which has been found to be necessary
in the level of care to them must be invalidated by those courts interpreting a similar provision
since `(these] regulations examine only the defining "skilled nursing facility services" in the
treatment and services provided in determining Social Security Act, which states in pertinent
whether care is skilled or not." The DPW regu- pars:
lations classify skilled care services as follows: [Tihe term 'skilled nursing facility ser-
I1. SkilledCare Serv'ics. vices" means services which are or wert
Ttle XIX .1 the Sreil Oeeonizl A" (Medirso)d 42 Syvmoi. thich ehoe no pnkipte muss:
comsp sith Itk
USC f f t396 1396c The Stenlirid Pgs. is . mg.ers.. nquirenmnt. o the Sobl Seurity Act snd reglttio
Live ledenturate araueosmest. .nd stoes trth as iti proims4ated th-ee.
Medicare and Medicaid Guide i 35,375