SC Administrative Law Court Decisions

Medicaid, a joint venture between the states and the federal government, provides medical assistance to needy individuals. One form of medical assistance is the South Carolina Community Long Term Care (CLTC) program. The purpose of the program is to provide home services to individuals who without such services might otherwise be forced to reside in an institutional facility rather than remain in their home.

Laura J. McClam (McClam) was receiving nineteen hours of personal care services through CLTC, but, in February 2001, her services were reduced. A hearing before a South Carolina Department of Health and Human Services Hearing Officer upheld the reduction in services and that decision has now been appealed to the ALJD.

An appeal before an ALJ triggers the review criteria of S.C. Code Ann. § 1-23-380(A)(6) (Supp. 2001). See S.C. Code Ann. § 1-23-380(B) (Supp. 2001) (where an ALJ is directed to conduct a review "in the same manner prescribed in [§ 1-23-380](A)."). Section 1-23-380(A)(6) establishes the following:

The court may reverse or modify the decision if substantial rights of the appellant have been prejudiced because the administrative findings, inferences, conclusions or decisions are:

(a) in violation of constitutional or statutory provisions;

(b) in excess of the statutory authority of the agency;

(c) made upon unlawful procedure;

(d) affected by other error of law;

(e) clearly erroneous in view of the reliable, probative and substantial evidence on the whole record; or

(f) arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.

In this case, McClam argues two positions. First, she argues that the decision below is clearly erroneous in view of the reliable, probative and substantial evidence on the whole record. Second, she asserts that the decision is characterized by an abuse of discretion.

1. Controlling Law

An ALJ "will not substitute [the ALJ's] judgment for that of the [Hearing Officer] as to the weight of the evidence on questions of fact." S.C. Code Ann. § 1-23-380(A)(6) (Supp. 2001). Thus, once a factual determination is made by the Hearing Officer, the ALJ cannot re-weigh the evidence in an attempt to come to an independent conclusion on the factual dispute. Rather, the ALJ will rely upon the Hearing Officer's factual determinations unless those determinations are "clearly erroneous in view of the reliable, probative, and substantial evidence on the whole record." S.C. Code Ann. § 1-23-380(A)(6)(e) (Supp. 2001).

Thus, the analysis is one of identifying the factual determinations made and then deciding if the determinations on the record as a whole can be viewed as supported by substantial evidence. In determining if substantial evidence supports the Hearing Officer's factual determinations, the ALJ does not look for "a mere scintilla of evidence nor evidence viewed blindly from one side, but [rather looks for] evidence which, when considering the record as a whole, would allow reasonable minds to reach the conclusion that the agency reached." Palmetto Alliance, Inc. v. South Carolina Pub. Serv. Comm'n, 282 S.C. 430, 432, 319 S.E.2d 695, 696 (1984). Accordingly, if such evidence is present, the factual determinations will not be overturned.

2. Law Applied

In the final analysis, the Hearing Officer found that the evidence warranted a reduction in PC I hours since "a 'responsible party' or care giver was/is able to prepare needed meals in the afternoon." This finding is supported by at least three broad areas of "substantial evidence."

First, the Hearing Officer found that services to be provided by CLTC are "dependent upon the individual client's needs" and that the objective of the PC I services "is to preserve a safe and sanitary home environment" but not to replace care provided by others. Within the context of assessing McClam's "individual client needs" and within the view that PC I services do not replace care provided by others, the Hearing Officer heard evidence from several informed individuals who made personal observations of McClam in her home environment. In particular, these observations demonstrated McClam "despite [her] age and infirmities, . . . is functionally average or above average in terms of the HCBWS population in CLTC Area 9."

Second, the record is clear that the afternoon hours of service are not critical to proper care for McClam. Indeed, the Hearing Officer found evidence that "minimal assistance was required in the afternoon hours." For example, in the afternoon, the CTLC service-provider "would select a prepared meal and warm it . . . would also turn the bed down, lay the Petitioner's gown on the bed, position the bedside commode and leave the light on."

Third, the record developed in this case shows that such afternoon hours did not present a degree of services that could not be provided by existing care givers. For example, the Hearing Officer found that McClam's son lives next door and that he "provides needed transportation and manages [McClam's] financial affairs [and that while the son] is not able to stand for lengthy periods of time . . . it is clear that he is able to provide meals for himself [and that in] the afternoon, the [CTLC service-provider] merely warmed a meal, which was already available." Under this record, substantial evidence supports the factual determination that McClam's son "is able to provide an evening meal to [McClam]." In addition, the Hearing Officer heard evidence of the assistance of Daisy Burgess (Burgess). As to Burgess, she came to McClam's home on an almost daily basis, shopped for McClam, provided cooked meals, and washed McClam's hair. Obviously, Burgess' assistance as to meals is not insignificant.

Accordingly, under the record as a whole, the evidence supports the Hearing Officer's determination that a reduction in PC I hours was warranted since "a 'responsible party' or care giver was/is able to prepare needed meals in the afternoon."

1. Controlling Law

McClam argues the Hearing Officer's decision resulted from arbitrariness amounting to an abuse of discretion. A decision "is arbitrary if it is without a rational basis, is based alone on one's will and not upon any course of reasoning and exercise of judgment, is made at pleasure, without adequate determining principles, or is governed by no fixed rules or standards." See Deese v. South Carolina State Bd. of Dentistry, 286 S.C. 182, 184-5, 332 S.E.2d 539, 541 (Ct.App.1985).

2. Law Applied

The decision to reduce McClam's hours of care is not arbitrary. Indeed, McClam was observed by responsible individuals of the Department of Health and Human Services (DHHS). These individuals, evaluated McClam's mobility, alertness, and her overall ability to care for herself. Plainly, the decision to reduce benefits resulted from a systematic and objective evaluation with the conclusions from that evaluation confirming that a reduction of some hours was warranted.

Finally, this is not a case in which the hours of reduction are draconian. Rather, while some aid has been removed, a substantial degree of assistance is offered.

Monday (2 hours in the morning and 1 hour in the afternoon); Tuesday (1 hour in the morning and 1 hour in the afternoon); Wednesday (2 hours in the morning and 1 hour in the afternoon); Thursday (1 hour in the morning and 1 hour in the afternoon); Saturday (1 hour in the morning); Sunday (1 hour in the morning).

Such an arrangement is rational and is not an abuse of discretion.

The decision of the South Carolina Department of Health and Human Services Hearing Officer to reduce the CLTC benefits to Laura J. McClam is upheld.

AND IT IS SO ORDERED.

____________________________

RAY N. STEVENS

Administrative Law Judge

Dated: June 25, 2002

Columbia, South Carolina