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Recoupment of Medicaid payments only justified by clear violations of policy.

Topic: Health Law, Decided by Judge Brown 
Docket Number: 1420530 , Decision Date: 2014-05-02 
Attachment: Click here to download the decision. 

The Georgia Department of Community Health (DCH) was authorized to recoup payments made to a Medicaid provider for one of three alleged violations.  Specifically, it could recoup payments where the provider did not comply with the Provider Manual’s requirement to include Body Mass Index (BMI) [..] Read More..

Bound by current license until application for an increase is granted.

Topic: Health Law, Decided by Judge Miller 
Docket Number: 1433318 , Decision Date: 2014-05-29 
Attachment: Click here to download the decision. 

The Department of Community Health properly fined a personal care home $25,000 for repeat violations of capacity and level-of-care license and rule violations. The fact that the personal care home had a pending application for an increase in capacity did not justify admitting more residents [..] Read More..

Therapies must meet definition of “skilled nursing services” to qualify child for Katie Beckett.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: 1417446 , Decision Date: 2014-03-27 
Attachment: Click here to download the decision. 

Petitioner’s need for several different therapies, including music and social skills therapy, was insufficient to demonstrate the Katie Beckett level-of-care requirement, because such therapies are not contemplated in the regulatory definition of “skilled nursing services.”

SOURCE termination remanded for failure to provide discharge planning.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ******* , Decision Date: 2014-04-24 
Attachment: Click here to download the decision. 

The Department of Community Health’s decision to terminate Petitioner from the Service Options Using Resources in Community Environments (SOURCE) program was remanded to the Department because the Department failed to provide adequate discharge planning. Remand was appropriate even though (1) Petitioner did not meet the [..] Read More..

Reckless transportation violation justifies transportation restrictions and fine.

Petitioner, a child care learning facility, was appropriately fined and subject to a 12-month-transportation restriction after the facility erroneously transported a pre-K student, without parental authorization, to an elementary school in which he was not enrolled.  The violation arose as a result of a decision [..] Read More..

Maintenance of resident files necessary for safety.

Topic: Health Law, Decided by Judge Miller 
Docket Number: 1433337 , Decision Date: 2014-04-16 
Attachment: Click here to download the decision. 

Petitioner, a personal care home, was fined $601 by the Department of Community Health (DCH) for failing to keep resident files for two of its residents.  Petitioner mistakenly believed that residents need not have files if they have lived in the personal care home for [..] Read More..

Therapy several times a week insufficient to meet Katie Beckett institutional level of care.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: ******* , Decision Date: 2014-03-07 
Attachment: Click here to download the decision. 

Petitioner’s physical limitations were not intense or frequent enough to qualify for the level of care provided in a hospital, skilled nursing facility, or intermediate care facility, as required to be eligible for the Katie Beckett class of assistance.  One unit of skilled occupational and [..] Read More..

Cognitive loss caused by seizures within target population for SOURCE.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ******* , Decision Date: 2014-03-05 
Attachment: Click here to download the decision. 

The Department of Community Health (DCH) could not terminate Petitioner’s SOURCE benefits on the grounds that his limitations stem from a developmental disability, thereby placing him outside the program’s target population.  Petitioner was not born mentally disabled or developmentally delayed but, rather, suffered cognitive loss as [..] Read More..

Personal care home fined for serious rule violation.

Topic: Health Law, Decided by Judge Miller 
Docket Number: 1421814 , Decision Date: 2014-02-27 
Attachment: Click here to download the decision. 

The Healthcare Facility Regulation Division of the Department of Community Health (DCH) properly fined a personal care home (PCH) for a rule violation that posed a serious threat to residents. The PCH had exterior doors that required a key to open from the inside and [..] Read More..

Notice of termination of Medicaid benefits must be accurate.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ***** , Decision Date: 2014-02-20 
Attachment: Click here to download the decision. 

The Division of Family and Children Services (DFCS) was not permitted to terminate Petitioner’s Medicaid benefits for failure to participate during the review process.  Petitioner presented credible evidence that she had, in fact, cooperated with the review process.  Other theories given to support the termination [..] Read More..

Medicaid applicant must be responsible for paying medical bills to qualify for spend-down eligibility.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ***** , Decision Date: 2014-02-20 
Attachment: Click here to download the decision. 

Petitioner may be eligible for Adult Medically Needy (AMN) Medicaid if she is able to submit medical bills in excess of the Medically Needy Income Level for which she is personally responsible to pay.  While she submitted evidence of $40,000 worth of medical expenses to [..] Read More..

Mental illness cannot qualify a person for the SOURCE program.

Topic: Health Law, Decided by Judge Woodard 
Docket Number: ***** , Decision Date: 2014-02-18 
Attachment: Click here to download the decision. 

Petitioner was removed from participation in the Service Options Using Resources in Community Environments (SOURCE) program.  While she has several physical ailments, they would not necessitate nursing home care in the absence of SOURCE services.  Her other needs are the result of a mental illness, [..] Read More..

An owner or administrator with a criminal record may not operate a personal care home.

Topic: Health Law, Decided by Judge Malihi 
Docket Number: 1420852 , Decision Date: 2014-01-17 
Attachment: Click here to download the decision. 

Georgia law forbids the State from issuing a Personal Care Home license to any applicant with a criminal record.  However, it is not enough for the owner or administrator to have committed any violation of the law.  The violation for which the owner has been [..] Read More..

Facility fined because inadequate staff training endangered a resident.

Topic: Health Law, Decided by Judge Malihi 
Docket Number: 1420851 , Decision Date: 2014-01-17 
Attachment: Click here to download the decision. 

The Healthcare Facility Regulation Division of the Department of Community Health appropriately fined Petitioner, a Community Living Arrangement (CLA), for its failure to train its staff to address a resident’s Behavioral Support Program. The failure to train violated CLA rules, which require a facility to [..] Read More..

Medically Fragile Daycare benefits cannot be terminated where required to prevent regression.

Topic: Health Law, Decided by Judge Langston 
Docket Number: ***** , Decision Date: 2013-12-30 
Attachment: Click here to download the decision. 

Petitioner, a child in the Medically Fragile Daycare (MFDC) program, was granted six additional months in the program because she (1) meets the Skilled Nursing Level of Care, (2) receives 100% of her daily calories via a G-tube, (3) has services ordered by a physician, [..] Read More..

Need for supplemental oxygen insufficient to participate in Medically Fragile Daycare.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ***** , Decision Date: 2014-01-16 
Attachment: Click here to download the decision. 

State was permitted to terminate Petitioner’s participation in the Medically Fragile Daycare (MFD) component of the Georgia Pediatric Program (GAPP).  While Petitioner may need supplemental oxygen on occasion, he has an established regimen of therapy.  In such a case, the administration of oxygen is not [..] Read More..

Probation and fine of ambulance service provider that provided service outside of its designated zone was affirmed.

Topic: Health Law, Decided by Judge Howells 
Docket Number: 1311102 , Decision Date: 2013-01-17 
Attachment: Click here to download the decision. 
Attachment: Click here to download the decision on appeal. 

The Superior Court of Fulton County affirmed OSAH’s decision, which had been adopted by the Department’s agency reviewer, to place Petitioner, a licensed ambulance service provider, on probation and to fine it for providing ambulance services outside of its designated zone.  The Superior Court also [..] Read More..

Stable medical condition without cognitive loss or functional impairment insufficient to qualify for SOURCE.

Topic: Health Law, Decided by Judge Malihi 
Docket Number: ***** , Decision Date: 2013-12-19 
Attachment: Click here to download the decision. 

The Department of Community Health (DCH) correctly determined that Petitioner does not meet the minimal requirements to qualify for intermediate nursing home level of care under the Service Options Using Resources in Community Environments Program (SOURCE).  In order to meet the level of care necessary [..] Read More..

Personal Care Home fined and denied an increase in capacity because of serious rule violations.

Topic: Health Law, Decided by Judge Howells 
Docket Number: 1409962 , Decision Date: 2014-01-10 
Attachment: Click here to download the decision. 

The Healthcare Facility Regulation Division of the Department of Community Health (DCH) correctly fined a personal care home (PCH) for three rule violations posing serious threats to one or more residents.   First, the PCH had an exterior door that required a key to open from [..] Read More..

The Department may not reduce skilled nursing hours when it jeopardizes the child’s health.

Topic: Health Law, Decided by Judge Schroer 
Docket Number: ******* , Decision Date: 2013-11-25 
Attachment: Click here to download the decision. 

Reducing a child’s skilled nursing hours did not meet the state’s obligation to provide early and periodic screening, diagnostic, and treatment (EPSDT) through the Georgia Pediatric Program (GAPP), because the child’s condition was extremely fragile and there was a high risk of rapid deterioration and [..] Read More..

Occassional skilled needs do not qualify for GAPP.

Topic: Health Law, Decided by Judge Miller 
Docket Number: ******* , Decision Date: 2013-11-26 
Attachment: Click here to download the decision. 

Petitioner’s health condition improved to the extent that he no longer required skilled nursing or skilled rehabilitation services on a daily basis.  Because he failed to meet the nursing facility level of care, he no longer qualified  for participation in the Georgia Pediatric Program (GAPP) .

State’s decision to terminate Petitioner’s benefits under the Katie Beckett Waiver reversed.

Topic: Health Law, Decided by Judge Malihi 
Docket Number: ***** , Decision Date: 2014-01-03 
Attachment: Click here to download the decision. 

State maintained that Petitioner did not meet the requisite Level of Care because he did not actually receive skilled nursing services recommended by his physicians.  However, Respondent’s own Manual indicates that a determination of whether an individual meets the Skilled Nursing Facility Level of Care [..] Read More..

Incorrect processing of Medicaid application results in remand to DFCS.

Topic: Health Law, Decided by Judge Walker 
Docket Number: ***** , Decision Date: 2013-11-12 
Attachment: Click here to download the decision. 

The Division of Family and Children Services (DFCS) failed to determine Petitioner’s eligibility for the Independent Care Waiver Program (ICWP), the Medicaid class of assistance for which she applied.  Instead, DFCS erroneously processed a QI-1 Medicaid application on her behalf, before issuing a denial.  DFCS [..] Read More..

State must provide respite care where needed and must consider caregiver fatigue.

Topic: Health Law, Decided by Judge Miller 
Docket Number: ***** , Decision Date: 2013-11-07 
Attachment: Click here to download the decision. 

Forty hours of skilled nursing services under the Georgia Pediatric Program (GAPP) was found insufficient in amount, duration, and scope to reasonably achieve the purpose of correcting or ameliorating Petitioner’s condition.  Judge Miller rejected both the conclusion of the Department of Community Health (DCH) that [..] Read More..

Worsening of medical condition warrants increase in GAPP nursing hours.

Topic: Health Law, Decided by Judge Baxter 
Docket Number: ******* , Decision Date: 2013-11-05 
Attachment: Click here to download the decision. 

The State was not permitted to deny a medically necessary increase in the number of skilled nursing hours Petitioner receives under the Georgia Pediatric Program (GAPP). Petitioner needs daily monitoring by a skilled nurse or trained caregiver to assist with deep suctioning, breathing, monitoring, and administering narcotic medication.  [..] Read More..

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