Plott Nursing Home v. Sylvia Mathews Burwell

779 F.3d 975, 2015 U.S. App. LEXIS 3379, 2015 WL 872261
CourtCourt of Appeals for the Ninth Circuit
DecidedMarch 3, 2015
Docket12-70174
StatusPublished

This text of 779 F.3d 975 (Plott Nursing Home v. Sylvia Mathews Burwell) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Plott Nursing Home v. Sylvia Mathews Burwell, 779 F.3d 975, 2015 U.S. App. LEXIS 3379, 2015 WL 872261 (9th Cir. 2015).

Opinions

Opinion by Judge KLEINFELD; Partial Concurrence and Partial Dissent by Judge CHRISTEN.

OPINION

KLEINFELD, Senior Circuit Judge:

Plott Nursing Home (“Plott”) petitions for review of a civil money penalty imposed by the Secretary of the United States Department of Health and Human Services for Plott’s violations of the Medicare Act’s standards of care for nursing home patients.

I. The Regulatory Scheme

Skilled nursing facilities that participate in the federal Medicare and Medicaid programs must satisfy minimum standards of patient care in order to receive reimbursement for patient services.1 The Centers for Medicaid and Medicare Services (“CMS”), a division of the United States Department of Health and Human Services, contracts with state agencies to conduct unannounced compliance surveys of participating skilled nursing facilities.2 The surveys must be performed at least every 15" months.3 Most surveyors are Health Facilities Evaluator Nurses (HFENs). To become qualified as an HFEN in California, an individual must be a registered nurse and have one year of nursing experience, and six months of nursing supervisory experience.4 A Master’s Degree in a health-related field can be substituted for the required nursing experience and a Bachelor’s of Science degree in Nursing can be substituted for the required supervisory experience.5 All successful applicants must score at least 70% on the HFEN Training and Experience Examination.6 Among other subjects, the examination tests knowledge of health facilities and services regulations, standards of patient care, medical terminology, techniques of health facility management, and investigative methods.7 [978]*978Survey teams may also include surveyors with specialized knowledge, such as dieticians and pharmacists. CMS guidance requires the number of surveyors be assigned based on the size of the facility, the history of non-compliance, the existence of special care units and the need for inexperienced surveyors to accompany experienced surveyors as part of their training.8 All surveyors assigned to a facility should have received the required training, and at least one member of the team should be a registered nurse.9

Surveyors record violations, otherwise known as “deficiencies” and rate them as to scope and severity. The deficiencies are then referred to CMS for various enforcement actions, including program disqualification, temporary management, denial of reimbursement payments, state monitoring, transfer of residents, closure of the facility, directed plans of correction and training, and civil money penalties.10 Before imposing a remedy, CMS must consider the scope and severity of a deficiency, the relationship of the deficiencies to each other, and the facility’s prior history of noncompliance.11 If a facility is cited for deficiencies reflecting a substandard quality of care during three consecutive surveys, CMS must deny reimbursement payments and monitor the facility.12

In this case, the state surveyors cited Plott for deficiencies and CMS imposed a civil money penalty. CMS may impose “per day” or “per instance” civil money penalties based on a deficiency’s scope and severity.13 The penalties start at $50 per day, and are imposed in $50 increments.14 For deficiencies of lesser severity, CMS may impose penalties ranging from $50 to $3,000 per day.15 For deficiencies with the highest severity rating of “immediate jeopardy” the facility may be fined $3,050 to $10,000 per day.16 If penalties are imposed per instance, instead of per day, the permissible range is $1,000 to $10,000.17

The penalty must be “reasonable.” 18 In setting the civil money penalty amount, CMS must take into account several factors, including the scope and severity of the deficiency, the facility’s history of noncompliance, repeated deficiencies, the facility’s financial condition, and the facility’s degree of culpability.19 The statute directs CMS to “provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies.”20

Nursing facilities are entitled to a hearing before an administrative law judge (“ALJ”) to challenge civil money penalties.21 CMS has the initial burden of proving a prima facie case of noncomplianee. Then the burden switches to the facility to [979]*979prove, by a preponderance of the evidence, that they were in “substantial compliance.” 22 “Substantial compliance” means a level of noncompliance such that “any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm.”23

A facility may appeal the ALJ’s decision to the Department of Health and Human Services Appeals Board (“Board”), which reviews the ALJ’s findings for substantial evidence on the record as a whole. The Secretary has delegated to the Board her “authority to make final decisions on review of ... decisions of Administrative Law Judges involving enforcement actions, including ... civil money penalties.”24 “Any person adversely affected by a determination of the Secretary” may appeal the Board’s decision to a United States Court of Appeals.25

II. Plott’s 2008 Surveys

Plott Nursing Home is a Medicare and Medicaid participating skilled nursing facility in California. On September 24, 2008, the California Department of Public Health conducted an unannounced survey of Plott. Ten surveyors completed the survey. Eight of Plott’s surveyors were HFENs, one was a registered dietician, and one was a Health Facilities Evaluator Supervisor (HFES).26

During compliance surveys, state surveyors identify categories of deficiencies with a “Tag” designation.27 The “Tag” identifies the regulatory provision allegedly violated.28 Each Tag also has an accompanying alphabetical scope and severity code ranging from A to L.29

Scope and severity levels A through C indicate that the cited deficiency poses no actual harm and has a potential for minimal harm. Levels D through F indicate the deficiency poses no actual harm, but has the potential for more than minimal harm. Levels G through I indicate that the deficiency poses actual harm that does not rise to immediate jeopardy. Levels J through L indicate that the deficiency poses immediate jeopardy to resident health or safety. In each of the four alphabetical levels, the lowest letter indicates the deficiency is “isolated,” the middle letter indicates that there is a “pattern” of the deficiency, and the highest letter indicates that the problem is “widespread.” Facilities whose deficiencies do not rise beyond a C in scope and severity are considered in substantial compliance. No penalty is imposed for facilities who are found to be in substantial compliance.30

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Keene Corp. v. United States
508 U.S. 200 (Supreme Court, 1993)
Thomas Jefferson University v. Shalala
512 U.S. 504 (Supreme Court, 1994)
CLAIBORNE-HUGHES HEALTH CENTER v. Sebelius
609 F.3d 839 (Sixth Circuit, 2010)
Debbra Hill v. Michael Astrue
698 F.3d 1153 (Ninth Circuit, 2012)
Smith v. Marsh
194 F.3d 1045 (Ninth Circuit, 1999)

Cite This Page — Counsel Stack

Bluebook (online)
779 F.3d 975, 2015 U.S. App. LEXIS 3379, 2015 WL 872261, Counsel Stack Legal Research, https://law.counselstack.com/opinion/plott-nursing-home-v-sylvia-mathews-burwell-ca9-2015.