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Durable power of attorney for healthcare is not equivalent to advance directive

Topic: Health Law, Decided by Judge Brown 
Docket Number: 1707847 , Decision Date: 2016-12-13 
Attachment: Click here to download the decision. 

Staff members of a personal care home (PCH) did not perform CPR on a resident upon discovering him unconscious.  The owner of the PCH argued that its staff members were not obligated to perform CPR because the resident had a durable power of attorney for [..] Read More..

Transfer penalty must be applied month of asset transfer or date of Medicaid eligibility

Topic: Health Law, Decided by Judge Teate 
Docket Number: ******* , Decision Date: 2016-12-16 
Attachment: Click here to download the decision. 

After she received a $41,000 lump-sum settlement in a lawsuit, a nursing home resident made a gift of $23,724.  She simultaneously loaned $16,000 to her daughter, who executed a promissory note obligating her to repay the sum in monthly installments for the resident’s nursing home [..] Read More..

Revocation of driver’s license upheld where driver susceptible to loss of consciousness.

Topic: Health Law, Decided by Judge Teate 
Docket Number: 1645561 , Decision Date: 2016-09-13 
Attachment: Click here to download the decision. 

The Department of Driver’s Services properly revoked a driver’s license because the driver suffered a loss of consciousness and his providers did not thereafter produce documentation that he had been free of episodes of unconsciousness for one year.

DCH may recoup reimbursements paid to provider due to agency error.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1732250 , Decision Date: 2017-06-26 
Attachment: Click here to download the decision. 

Mobile Med, Inc. sought and obtained reimbursement for supplying Medicaid members with two ventilators each—one primary, and one “back-up” ventilator—over the course of two years, despite a provision in the Department of Community Health’s (DCH) provider manual that allowed for reimbursement for only one ventilator [..] Read More..

Duplicate food stamp benefits must be recouped from the ineligible household.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1649344 , Decision Date: 2016-08-09 
Attachment: Click here to download the decision. 

Where two households claimed the same child as a household member for the purpose of obtaining food stamp benefits, resulting in the issuance of duplicate benefits, the correct action was to recoup benefits from the head of household that falsely claimed that the child continued [..] Read More..

SOURCE participation not limited to SSI recipients.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: ***** , Decision Date: 2016-08-25 
Attachment: Click here to download the decision. 

Financial eligibility for the Service Options Using Resources in Community Environments (SOURCE) Program is not dependent upon whether the individual is categorically eligible for Medicaid due to his or her receipt of Supplemental Security Income.  Rather, under the terms of the Waiver, eligibility extends to [..] Read More..

Medicaid-ineligible spouse must be included to determine income limit for Medicare Savings Programs.

Topic: Health Law, Decided by Judge Miller 
Docket Number: ***** , Decision Date: 2016-07-27 
Attachment: Click here to download the decision. 

Pursuant to its policy manual, the Division of Family and Children Services determined the income limit for Q-track Medicaid programs according to the federal poverty level for an individual where the applicant had a Medicaid-ineligible spouse.  This policy contradicted the plain language of the Medicaid [..] Read More..

Acceptance of partial payment insufficient to show alteration of Admission Agreement.

Topic: Health Law, Decided by Judge Miller 
Docket Number: ***** , Decision Date: 2016-06-06 
Attachment: Click here to download the decision. 

The fact that the owner of a personal care home accepted partial payments from a resident did not alter the terms of the Admission Agreement where the resident assured the owner he would make up for the difference in payment at a later date.  Therefore, [..] Read More..

Civil penalty amount unsupported where no residents were in facility’s care.

Topic: Health Law, Decided by Judge Howells 
Docket Number: 1627302 , Decision Date: 2016-02-18 
Attachment: Click here to download the decision. 

The Department of Community Health was authorized to fine a community living arrangement (CLA) based on the failure of the owner to be present, or ensure that a staff member was present, during an annual inspection.  However, the Department’s proposed fine amount was unsupported inasmuch [..] Read More..

Facility’s failure to provide adequate supervision during outing resulted in resident’s death.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1630927 , Decision Date: 2016-04-20 
Attachment: Click here to download the decision. 

The owner of a personal care home organized a river tubing outing for four of its residents, all of whom had some level of cognitive impairment.  The owner was the only staff member on hand to supervise the residents during the outing, and was unable [..] Read More..

Functional limitations must be attributable to intellectual disability, not age, to meet ICF/ID level of care.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: ******* , Decision Date: 2016-01-05 
Attachment: Click here to download the decision. 

The Department of Community Health denied Petitioner’s application for coverage under the Katie Beckett deeming waiver because her caregivers did not demonstrate that she met any institutional level of care. The Court upheld the denial, finding that, although Petitioner appeared to exhibit the requisite functional [..] Read More..

Evasive, unreliable testimony regarding criminal record insufficient to establish mitigation.

Topic: Health Law, Decided by Judge Miller 
Docket Number: 1616599 , Decision Date: 2015-11-04 
Attachment: Click here to download the decision. 

The Department of Community Health denied an application for authorization to work at a personal care home due to two felony convictions.  Although the applicant initially testified that she had since been involved in no criminal activity, she admitted during cross-examination that charges of financial [..] Read More..

Parolee qualified to work at personal care facility due to mitigating factors.

Topic: Health Law, Decided by Judge Miller 
Docket Number: 1616603 , Decision Date: 2015-11-03 
Attachment: Click here to download the decision. 

An applicant was denied authorization to work in a personal care home owing to her conviction for three non-violent felony offenses in 2009.  At the time she sought authorization, the applicant was on parole and had yet to complete the terms of her sentence.  However, [..] Read More..

Hearsay evidence insufficient to show unlicensed operation of personal care home.

Topic: Health Law, Decided by Judge Walker 
Docket Number: 1554338 , Decision Date: 2015-07-08 
Attachment: Click here to download the decision. 

The Department of Community Health determined that Petitioner was operating an unlicensed personal care home based on residents’ statements that Petitioner provided them with regular meal services and assistance with their medications.  However, the residents’ out-of-court statements were insufficient to establish that Petitioner was providing [..] Read More..

Storing residents’ medications does not constitute operation of personal care home.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1537427  , Decision Date: 2015-07-08 
Attachment: Click here to download the decision. 

The Department of Community Health sought to fine the owners of an informal “halfway house” $104,000 for allegedly operating an unlicensed personal care home.  However, the “assistance” provided by the owners – storing the residents’ medications in a personal vault and taking them out of [..] Read More..

Cost of in-home services must be within program guidelines.

Topic: Health Law, Decided by Judge Howells 
Docket Number: ***** , Decision Date: 2015-05-14 
Attachment: Click here to download the decision. 

Petitioner, an individual with significant care needs owing to a brain injury, applied for in-home services through the independent care waiver program (“ICWP”).  Because Petitioner required care twenty-four hours per day due to her mental and physical deficits, and she received no informal support from [..] Read More..

Boarding house fined for temporarily operating as an unlicensed personal care home.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1545013 , Decision Date: 2015-05-12 
Attachment: Click here to download the decision. 

A boarding house was subject to a fine for providing services that could only be performed by a licensed personal care home.  During a site visit, the facility was found to have kept the residents’ medications in lockers, and investigators discovered that the facility’s owner [..] Read More..

Agency waived deadline for requesting administrative review through course of conduct.

Topic: Health Law, Decided by Judge Baxter 
Docket Number: 1508817 , Decision Date: 2015-04-07 
Attachment: Click here to download the decision. 

The Department of Community Health (“the Department”) instructed multiple Medicaid providers to contact a representative of Hewlett Packard (“HP”), its agent, after notifying them that it would seek recoupment of alleged overpayments attributable to errors in its claims processing system.  The providers were not notified [..] Read More..

Personal care home fined for retaining non-ambulatory residents.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1541315 , Decision Date: 2015-04-15 
Attachment: Click here to download the decision. 

The Department of Community Health’s imposition of a fine against a personal care home was upheld due to the personal care home’s retention of two residents who were unable to ambulate independently, a serious safety violation.

Mortgage payments not an allowable deduction from patient liability.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: ******* , Decision Date: 2015-04-15 
Attachment: Click here to download the decision. 

A recipient of Medicaid under the Nursing Home class of assistance is not entitled to deduct the amount of her mortgage payments from the amount she was required to contribute to the cost of her care pursuant to Federal regulations or the State Medicaid Plan.

State bears the burden of demonstrating that a SOURCE recipient’s communication deficits are caused by a non-covered diagnosis.

Topic: Health Law, Decided by Judge Malihi 
Docket Number: ***** , Decision Date: 2014-10-27 
Attachment: Click here to download the decision. 

Petitioner, a SOURCE recipient, was entitled to remain on the SOURCE Program absent evidence that her severe communication deficits were attributable to developmental or psychiatric diagnoses, which are not covered by SOURCE.

Reimbursement denied where provider failed to document that inpatient services met program criteria.

Topic: Health Law, Decided by Judge Brown 
Docket Number: 1450910 , Decision Date: 2014-12-23 
Attachment: Click here to download the decision. 

Crisp Regional Hospital, a Medicaid-enrolled provider, did not document the medical necessity of services provided to a patient in its care.  Specifically, the hospital did not write on “utilization review notes” that the patient met “severity of illness or intensity of service” criteria for the [..] Read More..

Incurred Medical Expenses must be allowed as a deduction at an amount equal to the Medicaid reimbursement rate.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: ***** , Decision Date: 2014-08-01 
Attachment: Click here to download the decision. 

After Petitioner, a nursing home resident, was approved to receive Medicaid, the Department of Community Health (DCH) was required to deduct the expenses that he incurred at the nursing home three months prior to his Medicaid application, or incurred medical expenses (IMEs), from his share [..] Read More..

No stay of SOURCE benefit termination as discharge planning was provided.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ***** , Decision Date: 2014-06-09 
Attachment: Click here to download the decision. 

Judge Walker denied Petitioner’s request to stay the termination of SOURCE benefits pending adequate discharge planning, finding that a referral to Fayette Senior Services for housekeeping and home delivered meals was adequate.  Nevertheless, even if the Department of Community Health had failed to comply with [..] Read More..

Home modification covered under the Independent Care Waiver Program.

Topic: Health Law, Decided by Judge Malihi 
Docket Number: ******* , Decision Date: 2014-05-13 
Attachment: Click here to download the decision. 

Respondent, the Department of Community Health, Division of Medical Assistance incorrectly denied Petitioner’s request to have an automated door and lock installed on her home.  Petitioner, an individual with spinal muscular atrophy, established that the installation met the definition of an environmental modification covered under [..] Read More..

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