SC Administrative Law Court Decisions

Rudolph Hassel (Hassel) was denied continuation of Medicaid benefits by the South Carolina Department of Health and Human Services (DHHS) for failure to meet the standards set by the South Carolina Level of Care Criteria for Medicaid-Sponsored Long Term Care (Care Criteria). This matter is before the Administrative Law Judge Division (ALJD) since Hassel has appealed the DHHS decision.

Medicaid, a medical assistance program funded by state and federal governments, requires a review to determine the individual's financial status and the medical necessity for the service being sought. In South Carolina, DHHS administers the Medicaid Program and, as a part of the review of medical necessity for nursing home assistance, requires the individual to meet the standards set by the Care Criteria. See S. C. Code Regs. 126-375B(3) and C. The Care Criteria address an individual's medical needs and functional abilities.

Not only must the Care Criteria be met before receiving Medicaid assistance for nursing home care but also periodic reassessments are conducted to ensure that individuals continue to meet the Care Criteria. These reassessments are recorded in a standardized format known as Minimum Data Sets (MDS) and if the Care Criteria are no longer met, the nursing home facility notifies DHHS and Medicaid stops paying for the individual's nursing home care. Individuals who disagree with the assessment may request an administrative hearing that is conducted by the DHHS Division of Appeals and Hearings.

In a reassessment in September of 1997, Hassel was found to no longer meet the Care Criteria. Hassel was notified of the determination and a hearing was conducted on November 19, 1996 by a hearing officer. The hearing officer issued a decision on November 22, 1996 finding Hassel did not meet the Care Criteria at the time of the September 1996 reassessment. This appeal to the Administrative Law Judge Division (ALJD) ensued pursuant to S. C. Code Ann. § 1-23-380 (Supp. 1996) and S. C. Code Ann. § 44-6-190 (Supp. 1996).

Oral arguments on the appeal of this case were heard on May 5, 1997. Upon consideration of the briefs, the arguments presented, and a review of the applicable law, the decision of the hearing officer is affirmed.

Does substantial evidence support the DHHS hearing officer's decision that, at the time of the assessment in late September of 1996, Mr. Hassel did not meet the requirements of the South Carolina Level of Care Criteria for Medicaid-Sponsored Long Term Care?⁽¹⁾

A. Scope of Review

This matter is an appeal under the appellate jurisdiction of the Administrative Procedures Act. S. C. Code Ann. § 1-23-380(A)(6) (Supp 1996). As the appellate body, the ALJD must determine if substantial evidence supports the factual basis of the decision made below with the burden of establishing a lack of substantial evidence on Hassel as the party appealing. See Waters v. S.C. Land Resources Conservation Comm'n, ___ S.C. ___, 467 S.E.2d 913 (1996). Substantial evidence is established when the record as a whole allows reasonable minds to reach the same conclusion reached by the hearing officer. Bilton v. Best Western Royal Motor Lodge, 282 S.C. 634, 321 S.E.2d 63 (Ct. App. 1984). The fact that different conclusions could be reached from the record does not demonstrate a lack of substantial evidence. Grant v. S.C. Coastal Council ___ S.C. ___, 461 S.E.2d 388 (1995). Indeed, in reviewing the facts found by the hearing officer, the appellate body may not substitute its judgment for that of the officer who rendered the decision below and the appellate body may not reweigh the evidence on questions of fact. Lark v. Bi-Lo, 276 S.C. 130, 276 S.E.2d 304 (1981). On the contrary, the factual findings of the hearing officer are presumed to be correct. Rodney v. Michelin Tire Co., ___ S.C. ___, 466 S.E.2d 357 (1996)

B. Application of Substantial Evidence Rule

The argument made by Hassel is essentially an attack on the facts determined by the hearing officer. To prevail, Hassel must show a lack of substantial evidence supporting the factual findings.

1. Factual Issue In Dispute

An individual meets the Care Criteria for intermediate care in one of two ways. First, he may show a need for an intermediate service and have at least one functional deficit regarding activities of daily living. Second, he may have at least two functional deficits. The difficulty in Hassel's argument is that he is unable to demonstrate a functional deficit.

2. Evidence in the Record

The evidence submitted by Hassel at the hearing primarily addressed behavioral problems but not functional deficits. In reaching a decision, the hearing officer agreed with Hassel that a medical problem was present. The hearing officer found a need for intermediate care involving supervision of moderate problem behavior. See Decision at Findings of Fact #12, p.5, and # 1 on pages 6 and 7. Thus, to prevail, Hassel also needed to show at least one functional deficit to meet the Care Criteria. However, the evidence submitted by Hassel does not sufficiently address the issue of whether a functional deficit is established.

Rather, the record contains evidence supporting a conclusion that no functional deficit exists. The MDS reporting form at sections G and H addresses each of the possible functional deficits. See Respondent's Exhibit #1. Hassel demonstrated independence in the activities of locomotion, transfer, eating, dressing, and toilet use. He was continent in bowel and bladder functions. The activity needing some supervision was bathing. However, a functional deficit under the Care Criteria requires extensive, hands-on assistance. At the time of the September 1996 assessment, the record does not support a finding of "extensive, hands-on assistance" with any of Hassel's activities of daily living.

Finally, the issue is not whether the appellate body could find evidence to reach a different conclusion from that reached by the hearing officer. Rather, the appellate standard of "substantial evidence" prohibits the ALJD from reweighing the evidence. To reverse the hearing officer, the record must be such that the findings of the hearing officer are unsupported by substantial evidence. Thus, even if some need for "extensive assistance" could be found in the evidence, the most that can be said is that such evidence, when considered in conjunction with the specific information contained in the assessment report at Sections G and H, might allow reasonable minds to reach differing conclusions. However, the "substantial evidence rule" would still require upholding the hearing officer's decision in light of the requirement that the hearing officer's findings must be presumed to be correct unless convincingly proved otherwise by Hassel. In this case, Hassel has not been able to demonstrate a lack of substantial evidence supporting the findings made by the hearing officer.

Conclusion

Accordingly, at the time of the September 1996 reassessment, the record contains substantial evidence supporting the hearing officer's decision that Hassel did not meet the Care Criteria requirements. Thus, the decision of the hearing officer is affirmed.

AND IT IS SO ORDERED.

RAY N. STEVENS

Administrative Law Judge

June 5, 1997

Columbia, South Carolina

1.

The hearing officer decided whether Mr. Hassel's medical condition and functional abilities met the requirements for the South Carolina Medicaid Program so as to allow Medicaid payment for his nursing home care. Contrary to the assertion by Hassel, the hearing officer did not decide any issue on whether the nursing home could discharge Hassel against his will. Thus, the only issue here is whether Medicaid should continue to fund Hassel's care.