|
Headlines
from Medicare and Medicaid Guide
New rules protect patients' genetic information
The genetic information of patients will have greater protections
through new regulations issued on October 1, 2009, by the U.S. Departments
of Health and Human Services (HHS), Labor, and the Treasury. The Interim final rule will help ensure that genetic information
is not used adversely in determining health care coverage and will
encourage more individuals to participate in genetic testing, which
can help better identify and prevent certain illnesses. The Interim final rules with request for comments were issued
jointly by the three federal agencies and a separate notice of proposed
rulemaking from HHS implements Title I of the Genetic Information
Nondiscrimination Act of 2008 (GINA).
Under GINA, and the Interim final rule, group
health plans and issuers in the group market cannot: (1) increase
premiums for the group based on the results of one enrollee's
genetic information; (2) deny enrollment; (3) impose pre-existing
condition exclusions; or (4) do other forms of underwriting based
on genetic information. In the individual health insurance market,
GINA prohibits issuers from using genetic information to deny coverage,
raise premiums, or impose pre-existing condition exclusions.
Further, under GINA and the new interim final regulations, group
health plans and health insurance issuers in both the group and individual
markets cannot request, require, or buy genetic information for underwriting
purposes or prior to and in connection with enrollment. Plans and
issuers are generally prohibited from asking individuals or family
members to undergo a genetic test. The interim final regulations from
HHS are effective on December 7, 2009, and comments from the public
are due on or before January 5, 2010.
HHS proposed rule
HHS, through its Office for Civil Rights (OCR), issued a notice
of proposed rulemaking with a 60-day comment period, to propose changes
to the Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule to prohibit health plans from using or disclosing genetic
information for underwriting purposes. Comments on the proposed rule
are due by December 7, 2009.
Proposed rule, 74 FR 51698,
Oct. 7, 2009, ¶220,754.
Baucus sees 60 plus votes for health reform
Senate Finance Committee Chairman Max Baucus (D-Mont.) said
that he believed all Senate Democrats plus a possible handful of
Republicans will vote for the massive health reform bill currently
being forged by Democratic leaders and White House officials. At
the same time Senate Majority Leader Harry Reid (D-Nev.) revealed
that he has held private meetings with a few Republican lawmakers,
fueling speculation that Sen. Susan Collins (R-Maine) and possibly
one or two other GOP senators are leaning towards supporting the
bill.
"The overriding goal is healthcare reform and that's going to
trump everything," said Baucus following a Senate Democratic Caucus
meeting to discuss the merger of the two separate bills approved by
the Senate's Finance and Health, Education, Labor and Pensions Committees.
The three Senate leaders Reid, Baucus, and Sen. Christopher
J. Dodd (D-Conn) met for the second time on Oct. 15 with White House
officials to discuss the details of the merger. Reid said there would
be no more meetings until Oct. 19 although staff members would continue
working through the weekend. Reid has said he expects that Senate
debate would begin by the end of the month.
The Senate Finance Committee on October 13 approved by a 14-9
margin an $829 billion healthcare proposal that drew the support
of one Republican and all Democrats on the Committee. The Congressional
Budget Office's analysis of the Senate Finance Committee's amended
proposal for the America's Healthy Future Act of 2009 reported in
report 1581, is reproduced with this report; see ¶53,162.
House action
On the House side, Speaker Nancy Pelosi (D-Calif), told reporters
on October 15 that she had submitted the House version of the health
care reform bill to the Congressional Budget Office for scoring.
Pelosi said she expects that the final House bill would include a
strong public option and that House lawmakers would seek to keep that
provision in the bill that emerges from conference with the Senate.
In a separate action, the House Ways and Means Committee formally
sent a copy of the America's Affordable Health Choices Act
of 2009 (HR 3200) to the House Budget Committee with reconciliation
instructions. Republican lawmakers said the committee action was
designed to preserve the opportunity to move health reform legislation
as part of the budget reconciliation process.
Classification of beds by Secretary was abuse
of discretion
The Secretary of HHS abused his discretion and acted arbitrarily
and capriciously in classifying certain beds as available for indirect
medical education (IME) reimbursement purposes, according to a U.S.
District Court. The hospital disagreed with the method used by the
Secretary to compute its IME adjustment.
The hospital, owned by Los Angeles County and eligible to receive
Medicare IME payments, reported 246 beds on its cost report, although
it was licensed for 537 beds. The reported number was determined by
a walk-through of the facility. The fiscal intermediary, following
a physical inspection, increased the number to 382. The intermediary
and the hospital reached a stipulation reducing the number of beds
at issue to 49: 18 beds in storage rooms, 17 beds in on-call rooms,
and 14 beds in closed units. During a hearing before the Provider
Reimbursement Review Board, all but 29 of the beds at issue were resolved,
18 beds located in storage rooms, and 11 in closed units.
To be defined as an "available bed" under 42 C.F.R. §412.105, it must be able to be "immediately" opened and occupied. The Provider Reimbursement Manual mandates that
a bed be permanently maintained for lodging inpatients, but an administrative
bulletin issued by the Blue Cross and Blue Shield Association expands
the requirement by insisting that the "beds can be adequately
covered by [nurses]," allowing as much as 24 to 48
hours to get nurses on duty. The court determined that the Secretary
failed to consider the changing capacity of the hospital since the
space where the 18 beds were located would not be available for routine
care but rather, was needed for storage. With regard to the 11 beds
located in closed wings of the hospital, the Secretary failed to consider
that these beds could not be adequately staffed within 24 to 48 hours.
County of Los Angeles v. Leavitt, C.D.
Cal., July 8, 2008, ¶303,139.
Fraudulent payments for controlled substances
preventable
Medicaid spending for controlled substances is vulnerable to
fraud and abuse, according to a recent study by the Government Accountability
Office (GAO). The agency studied Medicaid expenditures for federal
fiscal years (FY) 2006 and 2007 in five states: California, Illinois,
New York, North Carolina and Texas, focusing on ten controlled substances.
The drugs included pain relievers such as morphine, methadone, oxycodone
and hydrocodone, benzodiazepine sedatives and stimulants. Most of
the drugs were included on the list of Class II controlled substances
maintained by the Drug Enforcement Administration (DEA). Class II
are defined as drugs having currently accepted medical uses, but also
have a high potential for physical abuse, which may lead to addiction
or psychological dependence.
Types and frequency of fraud
and abuse
GAO studied three types of fraud or abuse: (1) "doctor
shopping," or visits to multiple physicians to obtain overlapping
prescriptions for the same type of drug; (2) prescriptions filled
for deceased beneficiaries or "written" by deceased doctors;
and (3) prescriptions written by providers who were excluded from
participation in Medicare and Medicaid. In addition to the reviews
of expenditures in all five states, GAO studied 25 particular cases
in depth. The investigation revealed two additional types of abuse
involving practitioners: over prescribing controlled substances to
specific beneficiaries and prescribing substances for which the practitioner
did not have a DEA authorization.
Doctor shopping was the most common type of fraud or abuse.
During the period studied, about 65,000 beneficiaries received prescriptions
for the same drug(s) from six or more practitioners, often for overlapping
periods of time. Beneficiaries obtained the drugs to feed addictions,
sell them on the street, or both. One parent, addicted to stimulants,
obtained multiple, overlapping prescriptions for her child, who had
attention deficit hyperactivity disorder, from several physicians.
About 400 beneficiaries received prescriptions from between 21 and
112 different practitioners and filled them at as many as 46 different
pharmacies during the two years studied. The states' data systems
had not identified most of the recipients who were doctor shopping
or using excessive services.
GAO noted that these beneficiaries comprised less than 1 percent
of the total number of Medicaid beneficiaries in the five states.
The $63 million spent on these questionable prescriptions represents
about 6 percent of the spending on the ten controlled substances studied.
In testimony before Congress, Gregory D. Kutz, GAO's Managing Director
Forensic Audits and Special Investigations, noted that the estimated
costs of doctor shopping are understated for three reasons: (1) only
the payment for the drugs is included, so that the costs of related
physician, emergency room or other services is unknown; (2) unidentified
prescribers are not counted; and (3) GAO studied only ten of the most
widely abused drugs, not all controlled substances.
GAO found that prescriptions were written and filled for about
1,800 deceased beneficiaries, at a cost to Medicaid of about $200,000.
Prescriptions were written in the names of about 1,200 deceased physicians,
for which Medicaid paid about $500,000.
Payments to banned providers
According to GAO, 65 practitioners and pharmacies wrote or filled
prescriptions while they were excluded from participation in Medicaid
for fraud or diversion of controlled substances. Medicaid approved
the claims at a cost of $2.3 million. During the period under study,
none of the five states checked the list of excluded providers to
prevent these improper payments. The number of banned practitioners
may actually be higher because states paid claims that either did
not identify the prescribing physician or did not include a tax identification
number.
GAO's recommendations
GAO recommends that CMS provide guidance to enable states to
adopt a comprehensive fraud control program for prevention, detection,
and monitoring, as well as investigation and prosecution. The preventive
controls would include data sharing among organizations or agencies
and "system edits" that automatically bar processing
of claims by excluded providers or entities debarred from federal
contracts. The system would make periodic checks of death records
such as the Social Security Administration's Death Master Files to
detect and stop payment for prescriptions filled for or written in
the name of someone who is dead. System edits also would be used to
detect duplicate enrollment, continuation of enrollment after death,
and doctor shopping. Agencies also should increase their drug utilization
review and impose restrictions on beneficiaries' access to multiple
providers to prevent doctor shopping. The GAO believes prosecution
of fraud is hampered by federal regulations that give Medicaid Fraud
Control Units very limited authority to pursue beneficiary fraud and
ban use of federal funds for routine screening activities.
GAO Report, No. 09-957, Sept. 30, 2009; Testimony of Gregory D. Kutz, Managing Director Forensic Audits and
Special Investigations, No. GAO-09-1004T, Sept. 30, 2009.
Slow progress in improving children's access
to dental care
State Medicaid programs (including the District of Columbia)
have improved children's access to dental care since May 2007, but
fell short of goals, according to a study by the Government Accountability
Office (GAO). In a survey of all 51 state Medicaid programs, GAO examined
the extent to which children on Medicaid received preventive dental
care or any dental services at all, the actions that states took to
improve access, the monitoring and maintenance of information needed
to determine effectiveness and the barriers to further improvement.
GAO also examined CMS' oversight of states' compliance with the goals
and requirements for Medicaid dental services.
Too few providers
Children seeking dental services continue to face the same obstacles;
the most common major barrier continues to be difficulty finding a
dentist who will accept new Medicaid patients. Forty-nine states reported
that the lack of available providers was a barrier to children's access
to care. Distance to the nearest available provider and difficulty
obtaining transportation also were common problems.
State Medicaid programs have taken a variety of actions to recruit
and retain more dentists, including raising reimbursement rates, streamlining
the billing and payment process, easing prior authorization requirements
and meeting with dental provider groups to encourage them to serve
more children on Medicaid. Some states also work with other agencies
that provide scholarships or loans in return for a commitment to serve
low-income patients.
Dental providers report additional barriers that discourage
their participation, particularly Medicaid patients missing appointments.
The government's response is that Medicaid can only pay for services
provided. Failure to follow a recommended treatment plan also was
reported.
Medicaid agencies also have increased access by expanding services
at other locations, for example, encouraging and paying for physicians
to apply sealants, increasing funding for more staff positions at
clinics and providing some dental services at schools.
State agencies reported that parents often did not seek dental
care for their children because of a lack of awareness of oral health
and the risks of untreated tooth decay. Forty-eight states engaged
in some form of outreach and education to eligible children and their
parents in order to address this problem. These actions included publishing
literature on the importance of oral health, translating it into other
languages and putting it on a web site, maintaining current lists
of participating dentists, and providing incentives for parents to
take their children to the dentist. States working with managed care
organizations (MCOs) required the MCO to provide education and to
assist in arranging for dental care.
GAO Report, No. GAO-09-723, Sept. 30,
2009; GAO Testimony, No. GAO-10-112T, Oct. 7, 2009.
Decisions and Developments
CMS Manuals
Verification status for all hospitals qualifying
for disproportionate share hospital payments under the "Pickle
Amendment"
Medicare Claims Processing
Manual, Pub. 100-04, Transmittal No. 1828, Oct. 9, 2009, ¶158,481.
Office of Inspector General reports with medical
review implications to prevent improper payment of questionable claims
One-Time Notification Manual, Pub. 100-20,
Transmittal No. 574, Oct. 9, 2009, ¶158,483.
Implementation of HIPAA version 005010 flat
files institutional (837I) and inbound 837 professional (837P)
One-Time Notification Manual, Pub. 100-20,
Transmittal No. 575, Oct. 9, 2009, ¶158,484.
2010 update to the file layout for the Medicare
physician fee schedule database
Medicare
Claims Processing Manual, Pub. 100-04, Transmittal No. 1825,
Oct. 8, 2009, ¶158,479.
Instructions for retrieving the 2010 pricing
and Healthcare Common Procedure Code reporting system data files
Medicare Claims Processing Manual, Pub. 100-04,
Transmittal No. 1826, Oct. 9, 2009, ¶158,480.
Inclusion of the physician speciality code
for geriatric psychiatry to the Contractor Reporting of Operational
and Workload Data Form F
Medicare Financial
Management Manual, Pub. 100-06, Transmittal No. 159, Oct.
9, 2009, ¶158,482.
DAB Decisions
Provider's right to appeal termination
A hospital's request for a hearing was properly dismissed because
CMS withdrew its proposed sanction of terminateing hospital's provider
agreement. The hospital filed a request for an administrative law
judge (ALJ) hearing to appeal the findings and conclusions set forth
in a survey of deficiencies (SOD). The hospital complained that the
SOD contained factual inaccuracies that caused tangible harm to the
hospital. An ALJ may dismiss a hearing request if the party requesting
the hearing has no right to a hearing, 42 C.F.R. 498.70(b). A
finding that a hospital accredited by the Joint Commission on Accreditation
of Hospitals (JCAHO) is not in compliance with Medicare conditions
of participation or a finding that the hospital is no longer deemed
to meet the conditions of participation is not an "initial determination subject to review under 42 C.F.R. 498.3(d).
The regulations made clear that a JCAHO hospital has no right
to an ALJ hearing solely to contest findings of noncompliance, such
as those set forth in a SOD, when a proposed termination has been
rescinded. Although the hospital argued that the ALJ decision violated
its procedural due process rights, it is well established that administrative
forums do not have the authority to ignore unambiguous statutes or
regulations on the basis that they are unconstitutional. The ALJ's
dismissal of the hospital's request was affirmed.
Florida
Health Sciences Center, Inc. d/b/a Tampa General Hospital v. CMS, HHS Departmental Appeals Board, Appellate Division, Doc. No. A-09-84,
Dec. No. 2263, July 29, 2009, ¶121,901.
SNF noncompliance
Substantial
evidence supports the finding of the administrative law judge (ALJ)
that a skilled nursing facility (SNF) was not in substantial compliance
with Medicare participation requirements and that the SNF's noncompliance
posed an immediate jeopardy when the SNF, among other things, failed
to ensure that one of the residents received necessary treatment for
her pressure sores. The SNF's request to add expert witness testimony
not presented to the ALJ was denied because the SNF could not provide
good cause for failing to do so in the earlier proceeding. The SNF
was noncompliant with 42 C.F.R. §483.10(b)(11) when
it failed to immediately consult with the resident's physician after
the resident developed numerous pressure sores, including a stage
II pressure sore that had deteriorated. The SNF was also noncompliant
with 42 C.F.R. §483.25(c) in its care of the resident, when
it failed to ensure pressure sore healing and prevention. For example,
when the resident's pressure sore had grown larger and other pressure
sores developed despite various interventions, the SNF failed to determine
the reasons and consult with the doctor. Instead the SNF merely continued
with the prescribed intervention.
The SNF was also noncompliant with 42 C.F.R. §483.75 which
required it to use its resources effectively to maintain the well-being
of its residents.
A violation of §483.75 may be derived from the finding
that it was noncompliant with other participation requirements, such
as its violations of §§483.10(b)(11) and 483.25(c). Finally,
the SNF's noncompliance posed an immediate jeopardy given that its
inattention to the resident's pressure sores was likely to seriously
harm the resident.
Stone County Nursing & Rehabilitation
Center, HHS Departmental Appeals Board, Appellate Division,
Doc. No. A-09-90, Dec. No. 2276, Oct. 1, 2009, ¶121,910.
SNF requirements
An administrative
law judge's (ALJ) decision sustaining the imposition of civil money
penalties (CMPs) against a skilled nursing facility, based on allegations
of resident abuse by a certified nurse assistant (CNA), failed to
consider all the evidence presented in the light most favorable to
the facility. During a survey of the facility, the state survey agency
found that the SNF was not in compliance with 14 SNF conditions of
participation, including three rising to the immediate jeopardy level.
Following the facility's appeal, CMS moved for summary judgment,
which was granted by the ALJ with regard to some of the resident abuse
findings under 42 C.F.R. §483.13(b). An ALJ
is required to review and consider all of the proffered evidence when
considering whether a genuine issue of material fact exists. While
the ALJ claimed to have considered all evidence presented by CMS and
the SNF, from the ALJ's decision, it appears that he relied only on
factual assertions contained in briefings. Further, he cited mainly
CMS' exhibits and only one exhibit submitted by the SNF and the resulting
tone of the decision shows that the exhibits were not used merely for purposes of illustration."
The ALJ also gave differing weights to the evidence presented,
considering that he recited CMS' allegations regarding the incidents
in question in his decision. A reasonable trier of fact would have
considered all the evidence presented and would have viewed the allegations
in the light most favorable to the SNF. Summary judgment was vacated
and the case remanded to the ALJ for further proceedings.
Illinois Knights Templar Home v. CMS, HHS Departmental Appeals
Board, Appellate Division, Doc. No. A-09-71, Dec. No. 2274, Sept.
30, 2009, ¶121,908.
Civil money penalties
A skilled
nursing facility (SNF) failed to adequately supervise a resident and
remove all foreseeable harm when a resident choked to death after
consuming food. A facility is required to take all reasonable steps
to ensure that a resident receives supervision that meets her assessed
needs to mitigate foreseeable risks of harm, according to the regulations
at 42 C.F.R. 483.25(h). The SNF argued the administrative law judge
(ALJ) had disregarded Provider Reimbursement Review Board and court
decisions that gives facilities "the flexibility to choose the
methods of supervision" to prevent accidents as long as the
methods chosen are consistent with the resident's needs.
In this case, a cognitively impaired resident with a high risk
for difficulty in swallowing was under a doctor's orders not to consume
food or liquids. The SNF was well aware of the nothing by mouth order,
yet the staff did little to monitor or stop the resident from consuming
food and drinks. The SNF was not required to implement particular
interventions but the SNF staff could have done more to protect the
resident. In addition, the resident was not provided adequate supervision
to prevent the accident that killed her. The ALJ's finding of immediate
jeopardy, the imposition of civil money penalties, and the suspension
of the SNF's authority to conduct a nurse aid training and competency
program was supported by substantial evidence. The findings of the
ALJ were affirmed.
Meridian Nursing Center v. CMS, HHS Departmental Appeals Board, Appellate Division, Doc. No. A-09-82,
Dec. No. 2265, Aug. 12, 2009, ¶121,902.
Inadequate supervision
The administrative law judge (ALJ) properly ruled that a skilled nursing
facility (SNF) violated the requirement of 42 C.F.R. §483.25(h) to provide adequate supervision and devices to prevent accidents
and that the violation posed immediate jeopardy to a resident. The
SNF had assessed the resident as at high risk for falls and was aware
that a fall could result in serious injury or death. The ALJ's error
describing the alarm removed by the SNF was not material because the
noncompliance arose from the SNF's failure to respond to the resident's
risky behavior after the removal. The ALJ's statement that a finding
of immediate jeopardy was not necessary to support the penalty was
immaterial because the ALJ addressed each element and found immediate
jeopardy. Because of the immediate jeopardy finding, the two-year
prohibition of the SNF's nurse aide training and competency evaluation
program was legally required.
Plum City Care Center v. CMS, HHS Departmental Appeals Board, Appellate Division, Doc. No. A-09-95,
Dec. No. 2272, Sept. 29, 2009, ¶121,906.
Pressure sore prevention
The
administrative law judge (ALJ) correctly ruled that the skilled nursing
facility (SNF) violated the requirement of 42 C.F.R. §483.25(c) to provide necessary treatment and services to treat pressure sores
to promote healing and prevent new sores from developing and that
the violation posed immediate jeopardy to residents. The SNF failed
to: (1) follow the orders of the residents' physicians to apply medication
and change dressings at specified intervals to treat stage IV pressure
sores; (2) follow the physicians' orders to take specific measures
to minimize the risk of development or expansion of pressure sores;
(3) document the treatment or services provided; (4) inform the physicians
when the residents developed new pressure sores or existing sores
expanded; and (5) discuss proposed changes in the residents' plan
of care.
Columbus Nursing and Rehabilitation Center v. CMS, HHS Departmental Appeals Board, Appellate Division, Doc. No. A-09-83,
Dec. No. 2273, Sept. 29, 2009, ¶121,907.
Effective date of FQHC certification
The administrative law judge properly determined that the effective
date of three permanent units of a federally qualified health center's
(FQHC) enrollment in Medicare was May 2, 2007, the date on which CMS
accepted the FQHC's signed Medicare participation agreement. CMS argued
that the effective enrollment date was no sooner than that date, because
until then, CMS had not approved the units' application.
The FQHC opened its permanent units in 1994, 1996 and 2000,
and consequently obtained changes to its grant under the Public Health
Services Act for each unit. For these and other reasons, the FQHC
asserted that the three units were not new in 2007, and that therefore,
the effective date for each of the FQHC's permanent units participation
in the Medicare program was the corresponding date on which each unit
was opened, not May 2, 2007.
Under 42 C.F.R. 491.5(a)(3), however, the
FQHC was required to have each of its permanent units independently
considered for approval as FQHCs. It was not until 2007 that the FQHC
requested CMS approval for the permanent units as Medicare FQHC locations
and provided the regulatory assurances of compliance with Medicare
FQHC requirements. Upon receipt of these requests and assurances in
2007, CMS accepted a signed agreement for the units and properly specified
the effective date of participation as May 2, 2007.
Waianae
Coast Comprehensive Health Center, HHS Departmental Appeals
Board, Appellate Division, Doc. No. A-09-94, Dec. No. 2270, Sept.
28, 2009, ¶121,904.
Date of ESRD enrollment
The
administrative law judge erred in holding that the effective date
of enrollment for an end-stage renal disease (ESRD) supplier was the
date the supplier's enrollment application was verified and approved
by CMS, rather than the date the state survey agency completed its
survey and found no deficiencies with respect to the ESRD supplier.
Under 42 C.F.R. §489.13, the effective date of participation —
i.e., the effective date of Medicare reimbursement — is the
date the state survey agency completes its survey if the supplier
meets all applicable federal requirements on that date. CMS failed
to identify any applicable federal requirement that an ESRD's application
must be approved by CMS or a contractor before an ESRD can be enrolled
in Medicare. Nothing in either the wording or history of the enrollment
regulations provided by CMS supported CMS' position that the verification
and approval of the supplier's enrollment application was an applicable
federal requirement for this type of provider.
Renal CarePartners
of Delray Beach, LLC, HHS Departmental Appeals Board, Appellate
Division, Doc. No. A-09-100, Dec. No. 2271, Sept. 28, 2009, ¶121,905.
Revocation of billing privileges
The administrative law judge (ALJ) properly revoked a physician's
Medicare enrollment and billing privileges after he was convicted
of a federal felony of conspiracy to defraud the U.S., by falsely
certifying that applicants for U.S. citizenship were disabled. Although
the crime was not explicitly listed in the regulations governing the
revocation of enrollment and billing privileges, 42
C.F.R. §424.535(a)(3)(i), CMS found the crime to be detrimental
because it was similar to financial crimes at 42 C.F.R. §424.535(a)(3)(i)(B) and involved dishonesty
as well as fraud. CMS has discretion to determine which convictions
will be the basis for denying enrollment or revalidation and an ALJ
may not review that decision.
Further, and despite the physician's arguments to the contrary,
his other claims also failed because: (1) he received timely and adequate
notice of the revocation determination; (2) CMS did not mislead the
physician about the basis of the revocation; (3) his due process rights
were not deprived; (4) revocation can be based on crimes not involving
health care and solely on his felony conviction; and (5) the contractor
had the authority to issue the revocation.
Fayed v. CMS, HHS Departmental Appeals Board, Appellate Division, Doc. No. A-09-65,
Dec. No. 2266, Aug. 18, 2009, ¶121,903.
Termination of provider agreement
A home health agency failed to properly furnish the required
skilled nursing services to patients under its care and the termination
of its Medicare provider agreement was appropriate. A home health
agency is required to provide skilled nursing services by a registered
nurse (RN) who implements a plan of care, regularly evaluates the
patient's needs, and furnish services, as stated in 42 C.F.R. §484.30. The home health agency argued the administrative law judge (ALJ)
erred in concluding facts that sufficiently demonstrated it was out
of compliance with the conditions of participation. The evidence showed:
(1) a patient had a bandaged wound that required immediate care, but
the RN declined to care for the wound until told to do so; and (2)
another patient who had terminal lung cancer had his pain levels document
by the RN at 8 and 10, 10 being the most severe, but the RN failed
to immediately report this to his physician and did nothing to alleviate
the patient's suffering. The ALJ had sufficient evidence to conclude
the patients were either harmed or there was potential to harm the
patients. The ALJ's decision was affirmed.
Aspen Grove Home
Health v. CMS, HHS Departmental Appeals Board, Appellate
Division, Doc. No. A-09-62, Dec. No. 2275, Oct. 1, 2009,¶121,909.
|
 |
