Barnett v. Commonwealth, Department of Public Welfare

491 A.2d 320, 89 Pa. Commw. 16, 1985 Pa. Commw. LEXIS 934
Commonwealth Court of Pennsylvania·Decided April 26, 1985·No. Appeal, No. 2236 C.D. 1983·Published·Cited by 2 cases

Opinion

Opinion by

Judge Colins,

This Petition for Review is on behalf of several nursing home patients (petitioners)1 who have been receiving skilled nursing care under the Medical Assistance Program.2 Following an evaluation by a Pennsylvania Department of Public Welfare (DPW) Inspection of Care Team,3 the DRW determined that petitioners should be reclassified from skilled care to intermediate care. Petitioners appealed this determination, and a hearing was held on June 6, 1983, at [18] which, a hearing examiner ruled in favor of the DPW. On July 22, 1983, the decision of the hearing examiner was affirmed by the DPW Office of Hearings and Appeals. Petitioners filed a request for reconsideration with the Executive Deputy Secretary of the DPW on August 5, 1983, which was denied on September 1, 1983. This appeal followed.

Petitioners were reclassified subsequent to a revision of DPW’s regulations concerning skilled and intermediate nursing care facilities.4 This revision came about following an audit of the Allegheny County Nursing Home by federal officials in 1980. The auditors discovered that physicians were qualifying patients for skilled care under DPW regulations, but also discovered that these same patients would not qualify for skilled care under federal regulations. Therefore, in July of 1982, DPW proposed a new classification system and a revision of its regulations in order to comply with federal law.

The United States Department of Health and Human Services (HHS) rejected the 1982 proposal as being inconsistent with federal law.5 The DPW had to once again revise their regulations and resubmit them to the HHS for approval. DPW’s revised and final regulations were adopted on January 8, 1983, and contained criteria drafted in collaboration with a representative of the Health Care Financing- Administration (HCFA), a branch of the HHS. After reviewing [19] the final regulations, HCFA responded by letter received March 31, 1983 by the DiPW. The letter provided in part:

A thorough review of the level of care criteria was conducted by both HCFA Regional Office and headquarters staff. The revised State definition is now consistent with federal statute and regulation regarding the definition of skilled nursing care.

Although DPW’s new system of classification was approved by the HHS, petitioners are now contending that the new regulations, which reclassify them from skilled nursing care to intermediate nursing care, do not comply with federal regulations, that the hearing examiner’s decision was not supported by substantial evidence, and that the Secretary of the DPW abused bis discretion in denying the petition for reconsideration.6

We disagree.

DPW regulations classify skilled care services as follows:

II. Skilled Care Services
(a) For an individual service provided to the recipient to be considered a skilled care service, the service must:
[20] (i) be needed by the patient on a daily •basis;
(ii) be ordered by a physician;
(iii) require the skills of, and be provided either directly by or under the supervision of medical professionals;
(iv) be provided to the patient on a daily basis;
(v) be one that can only be provided, as a practical matter, in a skilled nursing facility on an inpatient basis;
(vi) be documented in the recipient’s medical record daily; and
(vii) be included and not excluded as a skilled care .service in the Skilled Nursing Care Assessment Handbook.

55 Pa. Code §1181, Appendix EII(a).

Skilled care services are further broken down into two categories, .skilled nursing services and skilled rehabilitative services.7 If a patient does no,t need or receive a skilled care service specified in the categories of skilled nursing and skilled rehabilitative services, he may still qualify for skilled care service under the following conditions:

[I]n rare instances, a particular medical condition may occur which complicates the recipient’s medical state to the degree that the treatment of the recipient’s medical condition must be rendered or supervised by medical professionals on a daily basis. Although any of the services required in the treatment of this con[21] dition could be performed by a properly instructed person, that person would not have the ability to understand the relationship between the services and to evaluate the ultimate effect of one service or the other.... It is the necessity of the immediate involvement of medical professionals in the treatment of the recipient’s special medical condition that qualifies the recipient to be determined medically eligible for skilled nursing care....

55 Pa. Code §1181, Appendix EII(c).

The analogous federal regulations can be found at 42 C.F.R. §§409.31-409.36. After carefully reading the federal and state regulations, we have come to the conclusion that they are consistent with each other. However, petitioners maintain that the federal regulations would allow them to qualify for skilled care services under 42 C.F.R. §409.33(a). Section 409.33(a) provides in relevant part:

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Barnett v. Commonwealth, Department of Public Welfare, 491 A.2d 320, 89 Pa. Commw. 16, 1985 Pa. Commw. LEXIS 934 (Pa. Ct. App. 1985).

491 A.2d 320 (Barnett v. Commonwealth, Department of Public Welfare) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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