1. Failure to
provide nursing services with reasonable promptness. According to the record, on April
28, 2007, the date of the appeal, the Petitioner was hospitalized in a
transition unit undergoing discharge planning. After discharge, on or about
May 8, 2007, the record shows that ten (10) hours per day of nursing services
was authorized by Respondent to be provided in Ms. Waddle’s home under the Head
and Spinal Cord Injury (HASCI) waiver. The Appellant shall specify the reasons
why her allegation that nursing services have not been provided is not moot.
In other words, Appellant shall specify why services should have been provided
prior to the time of discharge from the hospital and why the agencies had not
discharged their responsibility to the Appellant by providing the post
discharge nursing services. See paragraph 5, below, for any issues about
sufficiency and scope of the services received by Ms. Waddle.
2. Failure to
notify the Petitioner of MR/RD waiver eligibility and failure to offer services
with reasonable promptness. The MR/RD waiver is the Mental Retardation/Related Disability waiver
and is designed for individuals with those conditions. Related disabilities
are conditions, such as cerebral palsy, which are defined by State and federal
laws regulations and policies. It appears from the record that upon discharge
from the hospital, presumably by referral to the Department of Disabilities and
Special Needs (DDSN), Ms. Waddle was determined to be eligible for the HASCI
waiver. It appears that Ms. Waddle began receiving services at or near the
time of discharge under the HASCI waiver. Appellant shall specify any duty the
Respondent or the DDSN had to notify the Appellant of another waiver program.
If the Respondent had such a duty and failed in that duty, Appellant shall
specify the nature of the failure.
3. Failure to
perform a PASARR assessment and specialized services prior to discharging
Petitioner to an institutional setting. PASARR is the acronym for preadmission screening and
annual resident review. As set forth in 1919(e)(7) of the Social Security Act
[42 USC § 1396r(e)(7) and 42 CFR § 483.100 et seq.], the rule requires assessments
designed to prevent inappropriate admissions to nursing facilities of
individuals who are mentally retarded or who are mentally ill. As is apparent
from the record, the Hearing Officer had been informed that Ms. Waddle was
offered home-based services under the HASCI (and EPSDT program, as described
below) waiver. Therefore, it could have appeared to the Hearing Officer that
the issue was moot or never relevant to the case, since it may not have
appeared to the Hearing Officer that Ms. Waddle was being admitted to a nursing
home. Appellant shall specify why the Department of Health and Human Services
(DHHS) or the DDSN had a duty had to screen Ms. Waddle, and if so, how the lack
of a PASARR screening adversely affected Ms. Waddle, and what remedy the
Hearing Officer could have provided.
4. Failure to
provide EPSDT Services. EPSDT is the acronym for early and periodic screening, diagnosis, and
treatment. It is a program within the Medicaid Program described at numerous
locations within the Medicaid statutes and regulations, most succinctly at 42
CFR § 440.40(b). It is designed to make sure Medicaid children get access to
regular pediatric check-ups, immunizations, lab work, health education, vision
and dental screens, and any medical services necessary to treat or ameliorate
any discovered medical condition. Since it was apparent from Ms. Harrison’s
letter of May 9, 2007, that Ms. Waddle had been in a transition unit of a
hospital at the time of the appeal being evaluated by the hospital staff, and
then was discharged, not to a nursing home, but home with HASCI and EPSDT
services, the Hearing Officer might have assumed that the evaluative and
service purposes of the EPSDT program were never relevant or had been
achieved. Therefore, Appellant shall specify what duty the DHHS or DDSN had to
perform screening in addition to that performed by the hospital staff, what
unmet services (See 5., below) were identified as being necessary for Ms.
Waddle, and how those services were requested by the Appellant and denied by
the Respondent.
5. Improperly
limiting the services offered to Ms. Waddle. To be sure, Ms. Waddle, as a Medicaid recipient
under the age of 21 was entitled to any Medicaid reimbursable services that are
medically necessary. Although that sounds like a fiscally irresponsible Carte
Blanche policy for prescribing physicians, it is not. The Medicaid Program
also has the responsibility to place appropriate limits on services based upon
medical necessity and utilization control procedures, not to mention the
necessity of operating within the State’s budget. Appellant shall specify what
medically necessary services and devices were requested by the Petitioner and
denied by the DHHS or DDSN. Appellant shall provide any copies of the request
for services and the denial or specify how the request and denial were made.
THEREFORE
IT IS ORDERED:
That
Petitioner, within twenty (20) days of the date of this order, fully and
completely answer the questions posed hereinabove, in writing, and serve the
same upon Respondent and file a copy thereof with this Court.
