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Administrative Law Court
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SC Administrative Law Court Decisions

CAPTION:
Brook Waddle vs. SCDHEC

AGENCY:
South Carolina Department of Health and Human Services

PARTIES:
Appellant:
Brook Waddle

Respondents:
South Carolina Department of Health and Human Services
 
DOCKET NUMBER:
07-ALJ-08-0626-AP

APPEARANCES:
n/a
 

ORDERS:

ORDER OF REMAND

This matter is before me on appeal from Order of Dismissal dated November 16, 2007, issued by Kimberly B. Burrell, a Hearing Officer of the Division of Appeals & Hearings of the S.C. Department of Health and Human Services.

Upon consideration of the oral arguments and briefs of Counsel as well as the record before me, it appears that this matter has reached its present posture either by misunderstanding, failure to cooperate, or both, and assignment of culpability therefore will, at this point, serve no useful purpose. The significant impasse seems to have been the failure to produce a “Memorandum of Understanding” as requested by the Hearing Officer. It further appears that it is in the interest of judicial economy that this case proceed on its merits, without assessment of blame, by Appellant providing the information described below to the Respondent, the Hearing Officer and this Court.


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.


That upon such service and filing, this matter is hereby REMANDED to the Division of Appeals & Hearings of the S.C. Department of Health and Human Services for hearing within forty-five (45) days from the date of this Order.

Any appeal from the ultimate Order of the Division of Appeals and Hearings shall be assigned to the undersigned.

March 2, 2009

Columbia, SC

__________________________________

John D. McLeod, Judge

S.C. Administrative Law Court


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