AMERICAN NURSES ASS OCIATION,

et al., P lai nt iffs,

v. MICHAEL O. LE AVITT, et al.,

De fend ant s. UNITED STAT ES DIS TRICT COURT F OR THE D ISTRIC T OF CO LU M BIA

Ci vi l A cti on 06 -01 08 7 (H HK)

M EM OR

AN DU M OP IN ION Plaintiffs, the America

n Nurses A ssociation, and two of its constituents, the New York State Nurs e s A sso c iatio n a nd the Was hin g ton

State Nurs e s A sso c iatio n, br ingthi s a c tio n a g a ins t Michae l O. L eavitt, Secr etar y of the United States De partment of H ealth and H uman Service s and Mar k McClellan, Administrator of the Ce nters for Medica re a nd Medica id Services (collec tively , “HHS” or

the “Sec reta

ry”) se ekinga dec laratory judgme nt. Plainti ffs a ssert that HHS has unlawf

ully permitted inade quate staf fing of re g istered nur ses at hospitals that pa rt ic ipate in t

he Me dic are pr og ra

m. They argue that the Me dicar e Ac t, and re g ulations promulg ated by

HHS pursuant to it, require HHS to ensure “ the immediate ava ilability of a
re g ist e re d nur se fo r b e ds ide c are of any patie nt. ” B y

de e min g ho sp ita ls i n c omp lia nc e wi th t his require ment if they

are acc redited by

the J oint Com mission on Accre ditation of Hospitals (“Joi nt Commi ssion”), a pr ivate org anization, plaintiffs contend that HHS unlawf ully fails to ensure
c o mp l i an c e w i thth i s r e qu i r e m e n tan d u n l aw f u l l y d e l e g a t e s i t s a

u th o r i ty t o a

p r i v a t e p arty. Be fore the cour

t is the moti on of the Sec reta ry to dismi ss for lac k of subject matter jurisdiction and for f

ailure to state a

claim upon which r elief ma y be g rante d [#24] and theThe Joint Commi ssion is a private non-pr ofit acc rediting org anization run by the 1 Americ an Medic al Association, the Ame rica n Hospital Association, the Amer ican Colleg e of P h y s i c i an s - A m e r i c anS o c i e ty o f In t e r n a l M e d i c i n e , an d

th e A m e r i c anD e n t a l A s s o c i a t i o n . It rec eives its fundingthroug h fee s paid by hospitals to rece ive ac cre ditation review a nd consulting se rv ic e s. 2 motion of plaintiffs “for or der of jurisdiction or, in the alternative, to permit jurisdictional discovery” [#27] . Upon consider ation of the motions, the oppositions t here to, and the re cord of thi s c a se , th e c ourt

c on c lud e s th a t th e Se c re tary ’s mot ion mus t be g ra

nte d a nd the pla int if

fs ’ motion mus t be denied. I. BACKG ROUND A. P artie s and Claim s for Relief Plaintiffs are nonpr ofit membership org anizations that repre sent the intere sts of reg istered nurses. The y

promote patient saf

ety , workplac e rig hts, appropriate staff ing, w orkplac e and environmenta l health and sa fety , and the public he alth. Pla int if fs a lle g e that in a de qu a te nurs e sta ff inga t ho sp ita ls a c c re dit e d b y the Joint Com mis sio n ha s le d th e ir me mbe rs to s uf

fe r h arm s, 1 inc lud ingsh if

ts whe re the y

are no t a ble to c omp le te patie nt c are ta sk s in a mann e r t he y be lie ve is
nece ssary and saf e or take nec essar

y rest bre aks. Amongother re lief, plaintiffs see k: (1) a decla ratory judgme nt that the failure of HHS to assure that the J oint Com mission i mposes sta nd ard s at le a st e qu iva le nt t o th os e pr omu lg a te d b y HH S c on sti tut e s a c tio n unla wf ull y wi thh e ld and re sults in t he improper participation of hospitals in t he Medic are prog ram, a nd (2) a de c larator y jud g me nt t

hat thro ug h th is f

a ilure HH S is e ng a g ingin a n unla wf ul d e le g a tio n o f i ts responsibilities to the J oint Com mission. C ompl. ¶¶ 60-63.3

B. St at ut or y a nd R e gul at or y Ba c kgr ound In order to participate in the Medica re pr og ram, a

hospital must m eet the statutory de fi nit ion of a “ ho sp ita l” fo un d in

se c tio n 1 39 5x(e ) o f t

he Me dic are Ac t, whic h li sts c e rt a in conditions of participation. 42 U.S.C . § 1395x (e) . The Sec reta ry may ref use to enter

into an
a g re e me nt o r m ay

te rm inate an a g re e me nt a ft e r d e te rm ini ngthat a ho sp ita l f

a ils su bs tanti a lly

to meet these conditions. Id . § 13 95 c c (b )( 2) (B ). Th e re are nin e dif fe re nt c on dit ion s. Th e fi rs t
e ig ht a re su bs tanti ve and

inc lud e on e c on dit ion

sp e c if ic a lly a ime d at nu

rs ingre qu ir e me nts : a hospital must “provide[] 24-hour nur sing se rvice rende red or supervised by

a re g istered pr of e ssi on a l nu

rs e , a nd ha [ve ] a l ic e ns e d p ra c tic a l nu rs e or re g ist e re d p ro fe ssi on a l nu rs e on duty at all times.” Id . § 1395x (e) (5). The ninth condition requires hospitals to “mee t[ ] such other require ments as the Secr etar y finds nece ssary

in the interest of the health and sa fety of individuals who are f

urnished ser

vices in the institution.” Id . § 1395x (e) (9). HHS promulg ated a

regulation interpretingsection 1395x(e) with respe ct to nursing require ments. See42 C.F .R. § 4 82 .2 3. Th e re g ula tio n, wi th r e sp e c t to nurs e sta ff ing , s tate s: Th e nurs ing

se rv ic e mus t ha

ve a de qu a te numbe rs of

lic e ns e d r e g ist e re d nur se s, licensed pr actica l (vocational) nurses, a nd other pe rsonnel to provide nur sing c are to all patients as nee ded. The re must be supe rvisory and staff personne l for ea ch depar tment or nursing unit to ensure, whe n neede d, the immediate ava ilability of a reg istered nur se for

bedside c are of any

patient [hereinaf

ter, the “ bedside av a il a b il it y r e qu ir e me n t” ]. Id
. Under

the Medica

re A ct, if an institution is acc redited by the J oint Com mission i t shall be deeme d to meet the re quirements of se ction 1395x (e) with two exceptions. Id . § 1395bb(a)
. Relevant to this case , such ac cre ditation shall not be deemed to mee t a re quirement promulg ated4

pursuant to sec tion 1395x (e) (9) if that require ment is highe r than the r equire ments presc ribed for
acc reditation by

the J oint Com mission unl ess the Secr etar y deter mines the J oint Com mission’s standard is at least equivale nt to that promulgated by the Secr etar

y . Id . In addition, notwithstanding a

ny other provision, if the Sec reta ry finds that a hospital has sig nificant defic iencies, the hospital shall be deeme d not to meet the conditions the hospital has bee n treated
as mee ting pur suant to section 1395bb(a ). Id . § 1395bb(d). The Medic are Act re quires the Sec reta ry to enter into agree ments with states to determine whether instit utions in t hat state qua lify as hospitals within the meaningof the Ac t, and to the
e xtent th e Se c re tary

fi nd s it a pp ro pr iate , s he may

tr e a t an in sti tut ion

c e rt if ie d b y the state a s a hospital. Id . § 13 95 a a (a ). Th e Se c re tary may a lso e nte r i nto an a g re e me nt w ithany state to
surv e y ho sp ita ls d e e me d to me e t th e c on dit ion s o f p art ic ipatio n und e r s e c tio n 1 39 5b b( a ) ( i.e . to meet the r equire ments beca use they have be en ac cre dited by

the J oint Com mission) on a selec tive sample basis or on the ba sis of substantial alleg ations. Id . § 1395aa( c). HHS has promulg ated r egulations further spe cify ing how it will enforce the conditions of participation at acc redited hospitals. See42 C.F .R. § 4 88 .7 . U nd e r t he se re g ulatio ns , H HS, throug h the re levant state a g ency , may require a surve y

of an a ccr edited provide r to validate a hospital’s acc reditation on a r epre sentative sample ba sis or in response to substantial alleg ations of noncomplianc e. Id .; se e als o id . § 488.10 (desc ribing the Secr etar y ’s authority

under 42 U.S.C. § 1395aa and bb) . For non-ac cre dited hospitals, HHS will determine on the basis of a state surve y

whether the hospital is eligible to par ticipate in the Medic are prog ram. Id . § 488.12. Deter minations by

HHS that a hospital is in compliance with the c onditions of participation are made a s often as H HS deems nec essar y . Id . § 488.20.Or g anizatio na l st and ingis o nly pr op e r whe re the c ha lle ng e d c on du c t ha s d ir e c tly 2 harme d an org anization’s ability to provide ser

vices. Nat'l Taxpayers Union, Inc . v. United States , 6 8 F .3 d 1 42 8, 14 33 (D .C. Cir . 1 99 5) . F ru str a tio n o f a n o rg anizatio n’ s o bje c tiv e s a lon e “ is the ty pe of a bstract c oncer

n that does not impart standing .” Id. Plaintiffs alleg e that they have ha d to sp e nd

re so ur c e s to mon ito r s ta ff ingle ve ls b e c a

us e of the a lle g e d v iol a tio n. HH S r ig htl y po int s o ut, ho we ve r, that ha vin g to j ug g le lim ite d r e so ur c e s is a c ha lle ng e fa c e d b y

a ll org anizations, and the alleg ed violation does not aff ect plaintiffs’ ability

to conduct such m o n i t o ri n g. T hu s , th e c o urt re j ec t s p l ai n t i ff

s ’ a s s ert i o nth at th ey

h av e o rga n i z at i o n al s t an d i n g. 5 II. AN AL YSI S HHS moves to dismis s this action under F eder al Rules of Civil P roce dure 12( b)(1) and 12 (b )( 6) . H HS c on te nd s th at th e c ourt do e s n ot h ave su

bje c t matte r j ur isd ic tio n und e r R ule 12(b)( 1) bec ause pla intiffs do not have standingto sue either a s org anizations or on behalf of their member

nurses. HH S further c ontends that this court does not have subject matter jurisdiction because revie w of plaintiffs’ claims is not available unde r the Administrative Procedur es Ac t. Finally , HHS asser ts that plaintiffs fail to state a c laim upon which re lief may be g ra nte d und e r R

ule 12 (b )( 6) be c a

us e the y los e on the me ri ts. A. P laintif

fs H ave Standin g in T heir Capacity as Re presentat ives of T heir Me m ber Nur se s. HHS argues that plaintiffs lac k both standing in their own rig ht and re prese ntational standing to assert the putative rig hts of their member nurses. While the court a g ree s with HHS that pl a int if

fs la c k s tand ingin t

he ir ow n r ig ht, it a g re e s w ithpla int if fs that th e y

have sta nd ingto pr os e c ute thi s a c tio n in

a re pr e se nti on a l c a

pa c ity on be ha lf of the ir me mbe rs . 2 Whe n a n o rg anizatio n b ri ng s su it i n a re pr e se ntatio na l c a

pa c ity , th e or g anizatio n mu st de mon str a te that at le a st o ne of its me mbe rs “ wo uld

have sta nd ingto s ue in [h e r] o wn ri g ht, [that] th e int e re sts a t st ake are g e rm ane to t he or g anizatio n’ s p ur

po se , a nd ne ith e r t he c la im
asser ted nor the r elief r equeste d require s individual members’ par ticipation in the lawsuit.”6

Fr ie nd s o f th e Ea rth , I

nc . v . La idl

aw E nv tl. Se rv s. , 528 U.S. 167, 169 (2000); se e als o I nt'l Cnt r. for Tech. Assessment v . Johanns , 473 F. Supp. 2d 9, 14 (D.D .C. 2007). F or an o rg anizatio n’ s me mbe r t o h ave sta nd ingin h e r o wn

ri g ht, sh e “ mus t de mon str a te an ‘a ctual or immediate ’ ‘injury -in-fa ct’ that is ‘fa irly trac eable ’ to the cha lleng ed conduc t and ‘likely ’ to be ‘r edre ssed by a fa vorable decision.’” Tozzi v. U.S. Dep't of Health and Human Se rv s. , 271 F.3d 301, 307 ( D.C. Cir. 2001) (quoting Luj an v . D e fe nd e rs o f W ild lif e , 5 04 U. S. 555, 560-561 (1992) ). Where the pla intiff seeks r eview unde r the Administrative Proce dures Ac t of an a g e nc y ’s fa ilure to c omp ly wi th a statut e , th e jud ic iary

ha s im po se d a n a dd iti on a l li mit wh ic h r e qu ir e s th e pla int if f t o s ho w that it s a lle g e d in jur y fa lls wi thi n th e “ zon e of

int e re sts ” soug ht to be protec ted by the statutory

provision whose violation forms the leg al basis for he r complaint. See Clarkev. Sec s. Indus. Assn. , 479 U.S. 388, 395-96 (1987). HHS contends that the me mber nurse s lack standing . In particula r, HHS conte nds that member nur ses ca

nnot establish that their injuries are trac eable to HHS’s alleg ed violation or that their injuries ar e likely

to be re dresse d by

a fa vorable court de cision. HHS also asser ts that the injuries alleg edly

suffe red by

the member

nurses a re not within the zone of intere sts protected by the Medica

re A ct and ther efor e that the membe r nurse s do not have prude ntial standing. H HS’s arguments are without merit.

1. The m ember n urses’ inju ries are fairly trace able to the alleged violation and like ly to b ere dresse d b

y a f av orab le ac tio n of the c ourt. The pa rties ag ree that the alleg ed injury stems from the under staffingof re g istered nur ses in acc redited hospitals. The c ourt finds that the injuries complaine d of, name ly loss of breaksSom e of the oth e r i nju

ri e s a lle g e d b y

the me mbe r n

ur se s, su c h a s in a

bil ity to p e rf or m to 3 the sta nd ard s o f t

he ir pr of e ssi on , a re no t le g a lly

c og niza ble . N or have pla int if

fs a lle g e d w ith su ff ic ie nt p art ic ula

ri ty that th e ir me mbe rs are inj ur e d a s Me dic are re c ipi e nts .

7 and poor w orkingconditions, are le g ally cog nizable. Be cause HHS’s ar g uments that the

3
me mbe r n

ur se s’ inj ur ie s are no t f

a ir ly tr a c e a ble to H HS’ s a lle g e d v iol a tio n a nd are no t li ke ly

to be re dresse d by

a fa vorable action of the court a re f ounded on the same basic pr emise, the c ourt addre sses the ca

usation and re dressibility require ments toge ther. HHS contends that plaintiffs have not shown any causa l connec tion between the alleg ed understaf fingof nurse s and HHS’s de cision that the beside availability standard f

alls under section 1395x(e)(5) (and the ref ore a hospital acc redited by

the J oint Com mission m ay be dee med to b e in c omp lia

nc e wi th i t) . In p art ic ula

r, HH S argue s th a t th e “ de e min g ” re qu ir e me nt i s o nly provisional and so the only differ ence betwee n beingan (e )(5) require ment and an ( e)( 9) require ment is how the condition of par ticipation is enforc ed. The only differ ence betwee n enfor ceme nt of provisions that fall under ( e)( 5) and ( e)( 9), ac cordingto HHS, is that under (e )(5) , states monitor hospitals on a repr esentative sample basis or in re sponse to substantial alleg ations of noncomplianc e, while unde r (e )(9) , states monitor hospitals on a periodic ba sis. L ikewise, HHS contends that the only action the c ourt may

take is to direc t it to enforce the bedside
ava ila bil ity re qu ir e me nt u

nd e r ( e )( 9) and

thu s b y pe ri od ic mon ito ri ng . T he me mbe r n ur se s’ inj ur ie s are un lik e ly

to b e re dr e sse d, a c c or din g to H HS, be c a us e pla int if

fs c ann ot s ho w that if HHS enfor ced the bedside availability provision under (e )(9) there would be better staffing beca use they cannot show that periodic monitoring is superior to sample-ba sed and a lleg ationdriven monitoring
.8

Fur ther, HH S contends that the hospitals, and not HHS, are responsible for the staff ing of
nurses a nd that this makes it even har der f or plaintiffs to show that HHS’s a ction or inac tion
cause s the understa ffingor would re dress it. Fina lly , HHS argues that there is no substantive differ ence betwee n its bedside availability require ment and the Joint Commi ssion’s require ment that ho sp ita ls p ro vid e nurs ingse rv ic e s tw e nty -f our h ours a

da y , s e ve n d ay s a

we e k w itha t le a st one on-pr emise re g istered nur se fur nishing or supe rvising the service , and ther efor e plaintiffs
c ann ot s ho w that de e min g a c c re dit e d h os pit a ls i n c omp lia nc e wi th t he be ds ide ava ila

bil ity
re qu ir e me nt c a

us e s unla wf ul u nd e rs ta ff ing . N or c ou ld t he y sh ow , a c c or din g to H HS, that a favor able judg ment would not simpl y lead to HHS dete rmining that the J oint Com mission’s standard is e quivalent to the bedside a vailability

standard le avingthe member nurses’ a lleg ed injuries unredr essed. Plaintiffs rejoin that the under staffingof re g istered nur ses in acc redited hospitals ca n be attributed to HHS’s fa ilure to categ orize the bedside availability require ment under ( e)( 9) and associate d failure to ensure that hospitals meet this hi g her standa rd by deemingacc redited hospitals in compliance with it. Plainti ffs a rgue that the Joint Commi ssion’s standards a re not the same a s the HHS regulations in thi s reg ard be cause around the clock c overa g e by one reg istered nur se is not the same a s having enoug h staff to provide the immediate ava ilability of a reg istered nur se to g ive bedside c are whene ver ne eded. Mor eover , plaintiffs contend that
e sta bli sh ingtr a c e a

bil ity do e s n ot r e qu ir e the m to pr ov e that pe ri od ic surv e yingis s up e ri or to sample-ba sed and a lleg ation-driven monitoringbeca use this would require them to prove a nother
c a se – th a t th e re are de fi c ie nc ie s in the pe ri od ic surv e y s. F ina lly , p la int if fs c on te nd

that th e ir9

inj ur ie s w ou ld b e re dr e sse d b y a fa vo ra ble c ourt de c isi on re qu ir ingHH S to e sta

bli sha sy ste m to
ensure that the J oint Com mission s tandar ds are at least e quivalent to those established by HHS. The que stion presented is whe ther plaintiffs c an demonstrate that the under staffingthey alleg e ca uses their injuries is fa irly trac eable to the g overnme nt’s cate g orizing the be dside
av a i l a b i l i ty r e qu i r e m e n tun d e r

( e ) ( 5 ) i n s t e a d

o f ( e ) ( 9 ) an d

w o u l d l i k e l y b e r e dr e s s e d

b y a de c larator y jud g me nt f

ro m th is c ourt

that th e g ov e rnme nt m

us t c a te g or ize the be ds ide ava ila bil ity require ment under ( e)( 9). When a plaintiff’ s “asse rted injury arises f rom the g overnme nt’s alleg edly unlawful re g ulation (or lac k of re g ulation) of so me on e e lse ,” it i s p art ic ula rl y dif fi c ult to demonstrate c ausation and r edre ssability
. Lujan , 504 U.S. at 562. Where the c halleng ed g overnme nt action allows conduc t that would otherwise be unlawful, howe ver, standingexis ts. Renal Physic ians Ass’n v . U .S . D e p’ t of He alt h a nd Hu ma n S e rv s. , 4 89 F .3 d 1 26 7, 12 75 (D .C. Cir. 2007). Section 1395bb deems that a hospital acc redited by

the J oint Com mission has met the require ments of sec tion 1395x (e) (5); it does not do so with respec t to the require ments of sec tion 1395x (e) (9) that a

re hig her tha

n the J oint Com mission requirements unless the Sec reta ry deter mines that the J oint Com mission’s st andar d is at least equivale nt to that promulgated by HH S. 4 2 U .S. C. § 13 95 bb (a ). On c e a ho sp ita l is de e me d a c c re dit e d, HH S ma y on ly re vo ke its status as a “ hospital” if it finds “sig nificant de ficienc ies,” id. § 1395bb(d), or deter mines that the hospital “fails substantially to meet the applica

ble provisions of sec tion 1395x ,” id . § 13 95 c c (b )( 2) ; see also Def s.’ Mot. at 36 (“Ahospital deemed to mee t these re quirements by
re c e ivi ngJoint

Commis sio n a c c re dit a tio n . . . c an b e te rm inate d [f ro m it s a bil ity to p art ic ipate in the Medica

re pr og ram] only

if that enfor ceme nt mechanism re veals ‘sig nificant’ de ficienc ies.”).The c ourt does not re ach the question of whethe r the standa rds ar e equiva lent, but finds 4 that plaintiffs have sufficie ntly alleg ed that they

are not. 10 There fore , if the bedside a vailability

require ment is a section 1395x(e)(9) “other require ment,” HHS may

require compliance in the first instance, where as if it is a section 1395x (e) (5) r equire ment, HHS must ini tially deem a hospital in compliance a

nd may require
c omp lia nc e on ly if it d e te rm ine s th a t th e ho sp ita l ha s si g nif ic ant d e fi c ie nc ie s o r f

a ils su bs tanti a lly to meet the conditions of par ticipation. I f the be dside ava ilability require ment is more string ent tha n th e Joint

Commis sio n’ s r e g ist e re d nur sin g re qu ir e me nt, the n if a ho sp ita l is un lawf

ull y 4 de e me d to me e t th a t st and ard be c a us e it i s a c c re dit e d, it unla wf ull y wi ll b e a ble to p art ic ipate in the Medica

re pr og ram, so longas the Sec reta ry does not find sig nificant de ficienc ies or substantial failure, by

meetinga lower

standard tha

n if it were not so deemed. See R enal Physicians Ass’n , 489 F.3d at 1275. Meetingthis lower standar d would presumably require a lower r eg istered nur se to patient ratio thus being fa irly trac eable to the injuries of which the member nur ses complain – fe wer brea ks and poor wor

king c onditions. L ike wi se , if

the c ourt we re to r ule that H HS m ay

no t de e m ho sp ita ls i n c omp lia nc e wi th th e b e s i d e av a i l a

b i l i ty r e qu i r e m e n tb a s e d

o nth e i r a c c r e d i t a t i o nw i th o u ta

f i n d i n g o f e qu i v a l e n c y, the n if the Joint Commis sio n s tand ard

is l ow e r t ha n th e be ds ide ava ila

bil ity sta nd ard , h os pit a ls whose pa rticipation is based on their a ccr editation could be r equire d to meet the hig her standa rd without a finding of sig nificant de ficienc ies or substantial fa ilure. I t appea rs likely to the court that a hospital that desire d to maintain its participation in the Medicar e program would then ha ve g reater ince ntive to ensure that it complied with the bedside ava ilability require ment and there fore , notwithstanding the f act that the hospitals ar e a third pa rty , a “f avora ble dec ision11

would cre ate ‘ a sig nificant incr ease in the likelihood that the plaintiff would obtain relief . . . .’” See Klamath W

ater Users Ass’n v . FERC , 5 3 4 F. 3 d 7 3 5 , 7 3 9 (D
. C
. C i r. 2 0 0 8 ) ( qu o t i n g Utah v. Evans , 536 U.S. 452, 464 (2002)). Mo re ov e r, the la

ngua g e of the statut e is n ot a s c le ar a s H HS c on te nd s w ithre sp e c t to whether the “de eming ” itself is provisional. HHS points to three provisions of the Medic are Act for the pr oposition t hat the “de eming ” is provisional. First, it points to section 1395aa(c ) which authorizes HHS to enter into an a g ree ment with a state to surve y hospitals that have bee n deeme d to meet the conditions of sec tion 1395x (e) . The statutory languag e, howe ver, doe s not require the Secr etar

y to do so and does not clea rly overr ide sec tion 1395bb(a)’ s directive that acc redited hospitals “shall be dee med” to mee t the require ments of sec tion 1395x (e)
. See 42 U.S.C. § 1395aa( c). Se c on d, HH S po int s to se c tio n 1 39 5b b( d) wh ic h p ro vid e s th a t an a c c re dit e d h os pit a l found to have “sig nificant de ficienc ies” shall “be deeme d not to meet the re quirements” of section 1395x(e). Id . § 13 95 bb (d ). B ut, a s d isc us se d a bo ve , s ur e ly

thi s sig nif ic an t defic iencies sta nd ard c re a te s a highe r b ar f

or re mov ingde e me d s tatus tha n w e re a ho sp ita l no t so de e me d in the first instance . Third, HHS points to the section 1395bb(a) , which for bids the g rantingof deeme d status with respec t to J oint Com mission s tandar ds that are less stringe nt than HHS’s require ments under se ction 1395x (e) (9). This provision, howeve r, mere ly makes plaintiffs’ point – that (e) (9) pr ovisions are tre ated diff ere ntly than other pr ovisions. I f the “ deeming ” is not provisional, a fa

vorable ruling could re sult in a highe r substantive standar d beingrequire d of hospitals in order to par

ticipate in the Medic are prog ram, a nd the eleme nts of causation and
re dr e ssi bil ity

wo uld be me t.HHS also argues that Cong ress c lear ly meant to exclude nurses f rom using the 5 Me dic are statut e s and

re g ulatio ns a s a

fo rum to a ir

the ir g ri e va nc e s a g a ins t ho sp ita ls, po int ingto the leg islative history . As discussed po st at note 8, howe ver, the court doe s not read the le g isl a tiv e his tor

y a s in dic a tin g an inte nt t o p re c lud e thi s su it. 12 2. The

membe r nur

se s’ all e ge d in juri es a re with in the

zo ne of inte re sts prote c te d b

y the Me dic are

Ac t. In a dd iti on

to d e mon str a tin g inj ur

y , c a us a tio n, and

re dr e ssi bil ity

to m e e t th e re qu ir e me nts of Article I I I , plaintiffs must also demonstrate that the a lleg ed injuries of the ir member nur ses ar e within the zone of interests soug ht to be protec ted by the Medica

re A ct. HHS ar g ues that the
me mbe r n

ur se s c ann ot d o th is b e c a

us e nurs e satis fa c tio n is no t w ith in t he zon e of

int e re sts pr ote c te d o r r e g ulate d b y

the Me dic are Ac t; r a the r t he c on dit ion s o f p art ic ipatio n at is su e in t his
case are for the be nefit of patients. Pl aintiffs re join that the zone of interests test is not particula rly demandingand does not re quire a n indication of congressional purpose to benef it the
wo uld -b e pla int if

f. I ns te a d, a c c or din g to p la int if fs , it is e no ug h th a t th e ir

int e re sts c on ve rg e wi th tho se of the patie nts . 5 Pr ud e nti a l st and inge nc omp a sse s “ the re qu ir e me nt t hat a pla int if f’ s c omp la int

fa ll w ith in the zone of intere sts protected by the law invoked.” Elk GroveUnified Sch. Dist. v. Newdow , 5 4 2 U. S
. 1 , 1 2 (2 0 0 4 ) ( qu o t i n g Allen v. W right , 4 68 U. S. 7 37 , 7 51 (1 98 4) ). Th e c ourt ne e d n ot, howeve r, “inquire whether there has bee n a congressional intent to bene fit the would-be pla int if f; ” ins te a d it

mus t in qu ir e wh e the r t

he pla int if

f’ s in te re sts a ff

e c te d b y the a g e nc y

a c tio n in question are amongthose interests “a rguably . . . to be protec ted” by

the statutory

provision. Nat’l Credit Union Admin. v. First N at’l Bank &Trust Co. , 522 U.S. 479, 489 (1998). The zone of intere sts test is not “espe cially demanding ,” Am . Ch iro

prac tic As s’n, In c . v . Le av itt , 431 F.3d 8 1 2 , 8 1 5 (D
. C
. C i r. 2 0 0 5 ) ( qu o t i n g Clarke , 479 U.S. at 399-400), a nd is intended to “excludeThe other require ments for a ssociational standing , that the intere sts at stake ar e 6 g erma ne to the org anization’s purpose and that neither the c laim asserte d nor the re lief re quested re qu ir e s th e pa

rt ic ipatio n o f i nd ivi du a l me mbe rs in t he laws uit , a

re e a sil y me t. P la int if

fs ’ purpose is to repr esent the inter ests of re g istered nur ses, including appropr iate staff ing, a nd no individual nurse is nece ssary to adjudicate whether

HHS has complied with the Medic are Act or t o i s s u e ad ec l ar at o ry

j u d gm en ts o d et erm i n i n g. 13 on ly tho se wh os e int e re sts are so marg ina lly re late d to or

inc on sis te nt w iththe purp os e s im pli c it in the statute that it cannot re asonably be assumed that Congre ss intended to permit the suit,” Nat ’l As s’n o f H om e Bu ild

e rs v . U .S . A rm yCor ps of E ng ’r s , 417 F.3d 1272, 1287 ( D.C. Cir. 2 0 0 5 ) ( qu o t i n g Clarke , 479 U.S. at 399). Her e, the membe r nurse s’ injuries fa ll within t he zone of intere sts arguably to be protec ted by

the Act. The Act see ks to provide quality medical c are to its beneficiar ies and the re fo re imp os e s c on dit ion s, inc lud ingre qu ir e me nts re late d to ne c e ssa ry nurs ingc a

pa bil iti e s, upon hospitals in order to par ticipate in the program. Unde rstaff ing of nurses, the injury complained of

, arguably leads to lower

quality car e and the ref

ore the interests of the me mber
nurses a re “ sufficie ntly

cong ruent” with the cong ressional purpose
. Se e Citi ze ns Ex po sing Tr uth about Casinos v. Kempthorne , 492 F.3d 460, 464 ( D.C. Cir. 2007). Moreove r, whe re nur sing
c on dit ion s are po or

du e to a la c k o f r e g ist e re d nur se s, the int e re sts of pla int if fs and the patie nts
conver g e. See A m. Chiropractic Ass’n, Inc. , 431 F.3d at 816. Plainti ffs have standingto sue on be ha lf of the ir me mbe r n

ur se s. 6 B. Som e of Plaintiff s’ Claim s Are Reviewable Under the Adm inis trat ive P roce dures Act . HH S a lso c ha lle ng e s th e c ourt ’s su bje c t matte r j ur isd ic tio n to he ar p la int if fs ’ c la ims
un de r t he Ad min istrativ e Pr oc e dure s A c t. S e c tio n 7 01 of the Ad min ist rativ e Pr oc e dure s A c t, authorizing judicial re view of a g ency action, states: “T his chapter applies . . . except to the14

extent that – (1) statutes prec lude judicial re view; or (2) ag ency action is committed to ag ency discretion by

law.” 5 U .S.C. § 701(a). HHS cha lleng es the c ourt’s jurisdiction under both of the se e xce pti on s. As an initial matter, the c ourt ag ree s with HHS that, to the ex tent plaintiffs alleg e, in a g e ne ra lize d s e ns e , th a t th e Se c re tary “ is n ot u sin g e no ug h v ig or to e nf or c e c omp lia

nc e wi th conditions of participation related to hospital staff ing of reg istered nur ses,” De fs.’ Mot. at 32, revie w of that a lleg ation is preclude d by section 701 of the A dminist rative Proc edure s Act as action “c ommitt ed to ag ency discretion by

law.” T he “c ommitt ed to ag ency discretion by

law” exception is “very

narr ow,” Citi

zens to Pres. Ov erton Park v . Volpe , 401 U.S. 402, 410 (1971), but an ag ency ’s dec ision not t o take e nforc ement ac tion is presumed to lie within thi s exception, Hec kler v . Chaney , 470 U.S. 821, 831-32 (1985). In particula r, the Medic are Act g rants the Secre tary a g reat deal of latitude in determining how it will enforce the conditions of participation. See4 2 U
. S
. C
. § 1 3 9 5 c c ( b ) ( 2 ) ( “ T h e S e c r e t ar y may ref use to enter

into an
a g r e e me n t . . . [o r ] may

ref use to rene w or may terminate suc h ag ree ment afte r the Sec reta ry – . . . has dete rmined that the provide r fa ils subst antially to meet the applica

ble provisions of sec tion 1395x . . . .”) ( emphasis adde d). HHS also cha lleng es the c ourt’s jurisdiction under se ction 701(a) (1) a s prec luded by
s t at u t e. C i t i n g Bloc k

v . Cm ty . Nu tri tio n I

ns t. , 4 67 U. S. 3 40 (1 98 4) , H HS a rgue s th a t th is provision prec ludes judicial revie w of plaintiffs’ claims bec ause the statutory scheme g ives administrative and judicial r emedies to c erta in regulated entities, but not to the public or other int e re ste d p art ie s. Pla int if fs re joi n th a t Block

is inapplicable a

nd instead ar g ue that the c ourt should look to Bowen v. M ich. Acad. of Family Phsyicians , 476 U.S. 667 (1986), bec ause the y doHHS’s citation to the leg islative history is unavailing . In its report, the Senate Fina nce 7 Commi ttee desc ribed the va rious methods of appe al under the Medica

re A ct, including the pr ov isi on fo r h os pit a ls t o a

pp e a l a de te rm inatio n th a t th e y

are ine lig ibl e , a

nd the n s tate s, “ [i]t is intended that the r emedies pr ovided by these re view proc edure s shall be exclusive.” S. Rep. 89- 404 at 1995 (1965). T here is nothing to sug g est, howeve r, that the Committee meant any more 15 no t c ha lle ng e any

de te rm inatio n b y

the Se c re tary

that a pr ov ide r i s in e lig ibl e or

ha s su bs tanti a lly failed to mee t the standard, but instea d the method by which such de terminations are made. Pla int if fs are c or re c t. Th e Ad min istrativ e Pr oc e dure s A c t c on fe rs a g e ne ra l c a

us e of a c tio n f or tho se a dv e rs e ly
a ff e c te d w ith in t

he me anin g of

a statut e , b ut w ith dr aws it t o th e e xten t th e re le va nt s tatut e pr e c lud e s ju dic ia l r e vie w. 5 U .S. C. § 70 1( a )( 1) . “ Whe the r a nd to what e xten t a

pa rt ic ula r s tatut e prec ludes judicial revie w is determined not only from its express lang uag e, but also fr om the structure of the statutory

scheme , its objectives, its legislative history , and the nature of the administrative ac tion involved.” Block, 467 U.S. at 345. “The mere fac t that some acts ar e made revie wable,” howeve r, “should not suffic e to support an implication of e x clusion as to others.” Abbott Labs. v. Gardner , 387 U.S. 136, 141 (1967). Th e c ourt fi nd s th a t ju dic ia l r e vie w o f p la int if fs ’ c la ims is n ot b arr e d b y the statut e beca use the statute spe aks only to the mandated r eview pr ocedur e for instit utions or ag encie s dis satis fi e d w itha

de te rm inatio n b y

the Se c re tary

“ that it is n ot a pr ov ide r o f s e rv ic e s” or

that it “fa ils subst antially

to meet” the c onditions of 1395x (e)
. See 42 U.S.C. § 1395cc(h) (1)( A). Plaintiffs seek to cha lleng e the method by which these deter

minations are made , i.e. whethe r a h o s p i t al m ay

b e d ee m edi nco mp l i an ce wi thth e b ed s i d e a v ai l ab i l i ty re qu i re m en tth ro u gh
a c c re dit a tio n. Th is i s v e ry dif fe re nt f ro m th e de te rm inatio n o f whic h th e statut e sp e aks , th a t a specific fac ility

is not in compli ance with the conditions of participation. 7than that for a hospital wishing to cha lleng e a de termination of inelig ibilit y , the provisions for administrative and judicial r eview in the A ct ar e exclusive. The Committee simply did not a dd re ss c ha lle ng e s b y

oth e r p art ie s to oth e r d e te rm inatio ns . 16 This case is quite simi lar to Bowen , in which the Court held that a pr ovision of the Medica re A ct spec ifying a

nd limit ing judicia l reviewof the Sec reta ry ’s deter mination as to the
amou nt o f p ay me nt t o b e ma de or

amou nt o f b e ne fi ts t o b e c ov e re d “ sim ply do e s n ot s pe ak to challeng es mounted ag ainst the method by which such a

mounts are to be de termined rather than the determinations the mse lve s. ” 47 6 U .S. a t 67 5. I t is qu ite dif fe re nt f ro m Block, in which the plaintiffs wante d to challeng e the same deter mination for which judicial r eview ha d been specifie d and limited in the statute, namely to challeng e the milk order s on the basis that they made r econstituted milk uneconomica l for handle rs to proce ss. Block, 467 U.S. at 344. And, unlike in Block, th e pe rs on s f or wh om j ud ic ia l r e vie w i s sp e c if ie d in the Me dic are Ac t, n ame ly the ho sp ita ls d iss a tis fi e d w iththe Se c re tary ’s de te rm inatio n th a t th e y are ine lig ibl e or

fa il t o substantially

meet the c onditions of participation, ca nnot circumve nt the specifie d administrative and judicial proc ess to challeng e the same deter mination. They

could only

challeng e the method by which it is made. An additional consider ation weig hing in f avor of permitting judicia l reviewis that ruling oth e rw ise wo uld

re su lt i n a

la c k o f a fo rum in wh ic h th is a sp e c t of

the Se c re tary ’s a c tio ns c ou ld be re viewed. See id. at3 5 2
. T h e a gen ci es an d i n s t i tu t i o n s au th o ri z edt o b ri n g s u i tt o ch al l en ge the Secr etar

y ’s deter mination that they

are ineligible f

or the program would not have the incentive to cha lleng e whe ther the be dside ava ilability require ment is more string ent than the equivalent Joint Commi ssion standard. See id. at 351-52.17

C. P lai nt iffs F ailto St at e a C lai m Upo n Whi c h Re lie f Ma y Be G r ant e d. HHS also moves to dismiss plaintiffs’ cla ims under Fe dera l Rule of Civil Procedur e 12(b)( 6) for

failure to state a c laim upon which re lief may be g rante d. To survive a 12(b)( 6) mot ion , a pla int if f m us t a lle g e a

pla us ibl e e nti tle me nt t o r e lie f b y se tti ngfo rt

h “ any se t of fa c ts consistent with the alleg ations.” Be ll A tl. Cor p. v . Two mb ly , 550 U.S. 544, ---,127 S. Ct. 1955, 19 69 (2 00 7) ; Kowal v. MCI Communs. Corp. , 16 F.3d 1271, 1276 ( D .C. Cir. 1994). “While a complaint attacke d by

a Rule 12(b) (6) motion to dismi ss does not need de tailed fa ctual alleg ations . . . a plaintiff’s oblig ation to provide the g rounds of his entitle[ment] to relief require s more than labe ls and conc lusions . . . . Factua l alleg ations must be enoug h to raise a rig ht to relief a

bove the spe culative leve l.” Bell Atl. Corp. , 127 S. Ct . at 1964-65 (c itations and internal quotation marks omitted). Thus, the c ourt nee d not “ac cept infe renc es dra wn by plaintiffs if such infe renc es ar e unsupported by the fa cts set out in the complaint. Nor must the court a cce pt leg al conc lusions cast in the form of f actua l alleg ations.” Kowal , 16 F.3d at 1276. Pla int if fs ’ c omp la int

c on ta ins thr e e a lle g a tio ns : ( 1) that “ the ‘d e e me d’ status of ho sp ita ls participating in Medic are is assumed by HHS notwithstanding the hig her r equire ments of HHS reg ardingnurse staf

fing ” re sulting in inadequate staff ing, Compl. ¶¶ 40, 58; (2) that “due to the officia l neg lect of H HS, [ some] hospi tals have c onsistently failed to provide sufficie nt reg istered
nurs e sta ff

ingto m ake a

re g ist e re d nur se imm e diate ly ava ila ble wh e n n e e de d, y e t th os e ho sp ita ls p art i ci p at e i nan d

re ce i v e f un d s fr o mth e M ed i ca re p ro gra m , ” C o mp . ¶ 4 1 ; an d (3 ) t h at “[ t ] h ro u gh its failure to re quire [the J oint Com mission] to have a n equivalent r eg istered nur se staff ing standard . . . H HS has unlawfully deleg ated its authority

to” the Joi nt Comm ission, C ompl. ¶ 59.18

The c ourt addre sses ea ch to assess whe ther plaintiffs have set for th any set of fa cts consistent with these alleg ations plausibly entitling them to re lief. 1. Classi

fying bedside av ailabili ty as an (e)( 5) standard in stead of an (e) (9) standard. Pla int if fs a lle g e that H HS h a s unla wf ull y tr e a te d th e be ds ide ava ila bil ity re qu ir e me nt a s a
se c tio n 1 39 5x(e )( 5) , in ste a d o f a se c tio n 1 39 5x(e )( 9) , r e qu ir e me nt a nd have the re fo re un lawf

ull y deeme d acc redited hospitals to be in complianc e with it. They write, “ Upon information and belief, the ‘dee med’ status of hospitals par ticipating in Me dicar e is assumed by HHS notwithstanding the hig her r equire ments of HHS re g ardingnurse staf fing ,” Compl. ¶ 40, and “HHS . . . ha[s] failed to implement statutory and re g ulatory

require ments that [t he Joi nt Commi ssion] standards be at least e quivalent to require ments established by the Secr etar

y of HH S a s a pr e re qu isi te to h avin g [Joint C omm iss ion ] ac c re dit a tio n b e de e me d a pp ro va l to participate in the Medica

re Prog ram,” Compl. ¶ 58. The que stion of whether

the bedside a

vailability

standard is a

n (e) (5) or

(e) (9) standa

rd and ther efor e whe ther HH S unlawfully deeme d hospitals in compliance with it is a pure que stion of law. Poi nti ngto t

he pr e ambl e to t

he re g ulatio n p ro mul g a tin g the be ds ide ava ila bil ity require ment, HHS argues that it is clear that the Secr etar

y promulg ated this requir ement, along with the other nursingstandards, unde r (e )(5) , and that the Sec reta ry ’s construc tion of her own regulations is entitl ed to substantial defe renc e. Fur ther, HH S argues that the Sec reta ry ’s construction is rea sonable be cause it reasona bly interpre ts the (e) (5) r equire ment that a hospital have “ 24-hour nur sing se rvice s rende red or supervised by

a re g istered pr ofessional nurse .”19

Plaintiffs rejoin that the re g ulatory history reve als that section 1395x(e)(9) was the foundation for

the bedside a

vailability

require ment, pointing to the 1966 F eder al Reg ister Notice p r o mu l g a t i n g th e i n i t i a l s e to f s t an d ar d s w h i c hd i f

f e r e n t i a t e d b e tw e e nth e “ s p e c i f

i c [ s t a tu t o r

y]
r e qu i r e m e n t s ” an d

o th e r r e qu i r e m e n t s c o n s i d e r e d n e c e s s ar y. Th e y argue that it

wo uld be qu ite possible to comply

with the statutory

nursing require ment of twenty -four hour nursingservice s rende red or

supervised by

a re g istered nur se without ensuringthe re gulatory require ment of availability

of a r eg istered nur se at the be dside when ne eded, a nd there fore asser

t that the bedside
ava ila bil ity re qu ir e me nt m

us t be an a dd iti on a l r e qu ir e me nt. Pla int if fs c onte nd

that th is r e a din g is
r e i n f o r c e d b y th e r e g u l a t o r

y h i s t o r y, pointing to a 1997 Notice of Proposed Rulemaking which they argue also juxt aposes the ( e)( 1)-( 8) re quirements with the (e )(9) require ments set forth in 42 C.F.R. § 482 (which c ontains the nursing standards)
. The c ourt “a ffor ds g reat defe renc e to an a g ency ’s interpre tation of its own regulation:
un de r w e ll- re c og nize d p re c e de nt, [it] c an r e je c t th e Se c re tary ’s int e rp re tatio n o nly if it i s p la inl y
err oneous or inconsistent with the re g ulation.” Sec’ y of Labor v. Twentymile Coal Co. , 411 F.3d 25 6, 26 0 ( D. C. C ir . 2 00 5) ; see also Bowles v. Se minole Rock & Sand Co. , 325 U.S. 410, 414 (1945). He re, H HS’s interpre tation of its own regulation is not pl ainly err oneous or inconsistent with the regulation. The re g ulation at issue in this case is found at 42 C.F .R. § 482.23, entitled “Conditions of pa rt ic ipatio n: Nur sin g se rv ic e s. ” I t e sse nti a lly state s th e statut or

y re qu ir e me nt at th e outse t: “The hospital must have an org anized nursing service that provides 24-hour nursing service s. The nursingservice s must be furnished or supe rvised by a re g istered nur se.” I t then lay s out three standards – one for or g anization, one for staf fing and deliver

y of ca re, a nd one forPlaintiffs’ citations to the regulatory history do not demonstrate that the Sec reta ry ’s 8 interpre tation is plainly

err oneous or inconsistent with the re g ulation. All that the 1966 Fede ral Reg ister notice e stablishes is that there a re both spec ific statutory

require ments and other require ments considere d nece ssary . I t does not do any thing to indicate under which the bedside availability

require ment falls. See 31 Fe d. Reg . 13,421, 13,424 (Oc t. 18, 1966). The same is true of the 1997 Notice of Proposed Rulemaking . When it st ates “ Under this authority ” the Sec reta ry ha s p ro mul g a te d th e re g ulatio ns a t 42 C.F .R. Part 48 2, it d oe s n ot s pe c if

y wh e the r i t me ans on ly (e) (9) or all of the c onditions of participation. See 62 Fe d. Reg . 66,726, 66,727 (De c. 19, 1997). 20 prepa ration and a dminist ration of dr ug s. Id . The be dside ava ilability require ment is found in the
su bs e c tio n a dd

re ssi ngsta ff

ingand de liv e ry of c are . T he re is n oth ingin t he re g ulatio n to su g g e st that it was promulg ated unde r the Sec reta ry ’s (e )(9) authority

or that it does any

thing other

than elabor ate upon the me aningof the statutory standard stated at the outset. The prea mble contained in the Fe dera l Reg ister explaining the r egulation’s nursing service s provisions lends further support to the Secre tary ’s interpre tation. That pre amble re fer s specific ally to “Section 1861(e )(5) of the Social Sec urity

Act” ( codified at 42 U.S.C. § 1395x (e) (5)) and the r egulations that implement “this statutory require ment.” 51 F ed. Reg . 22010, 22018 (June 17, 1986). Moreove r, the Sec reta

ry ’s interpre tation is reasona ble. The statutory

presc ription, “24- hour nursingservice s rende red or supervised by

a re g istered pr ofessional nurse ,” 42 U.S.C. § 1395x (e) (5), is ambiguous and ca n rea sonably

be interpr eted to incor

porate the bedside availability

require ment. See Sm iley v. Citibank ( S.D.) , N.A. , 517 U.S. 735, 740-41 (1996) ( “ C o n g r e s s , w h e ni tl e f

tamb i g u i ty i na

s t a tu t e m e an tf

o r i mp l e m e n t a t i o nb y ana g e n c y, understood the a

mbiguity would be re solved, first and f oremost, by

the ag ency .”). There fore , 8 plaintiffs fail to state a

claim upon which r elief ma y plausibly be g rante d wi th r e sp e c t to the ir alleg ation that HHS has improper ly cate g orized the bedside availability standard a s an sec tion 1395x (e) (5) standa

rd.21 2. Failing to enforce the bedside av ailabili ty standard. Plaintiffs also alleg e that “due to the officia l neg lect of H HS, [ some] hospi tals have
c on sis te ntl y

fa ile d to pr ov ide su ff

ic ie nt r e g ist e re d nur se sta ff ingto m ake a

re g ist e re d nur se immediately

available when ne eded, yet those hospitals participate in and re ceive funds from the Medica re pr og ram.” Comp. ¶ 41. Th e c ourt a g re e s w ithHH S th a t th is a lle g a tio n is e sse nti a lly that the Secr etar

y “is not using e noug h vigor to enforc e complianc e with the conditions of participation related to hospital staff ing of reg istered nur ses,” De fs.’ Mot. at 32, and the ref ore the court lac ks jurisdiction over this alleg ation under se ction 701(a) (2) of the Administrative Procedur es Ac t. See su

pra P artI I B. 3. Unl

awf ully de le ga ting its aut hority to t he Jo int C omm iss ion . Plaintiffs’ third alleg ation is that “[t] hroug h its failure to re quire [the J oint Com mission] to h ave an e qu iva le nt r e g ist e re d nur se sta ff ingsta nd ard
. . . H HS h a s unla

wf ull y de le g a te d it s
a uth or ity to” the Joint

Commis sio n. Com

pl. ¶ 5 9. HH S argue s th a t pl a int if fs fa il t o s tate a

c la im for whic h relief

may be g rante d beca

use while the le g islature ca nnot deleg ate its power

to make law, it c an ma

ke a law t o d e le g a te a

po we r t o d e te rm ine so me fa c t up on wh ic h th e law m ake s it s
own ac tion depend. He re, H HS contends, the Sec reta ry mere ly takes notice of the fa ct of whether the J oint Com mission has accr edited a hospital whe n she dec ides how to enfor ce the conditions of section 1395x(e) as r equire d by statute. Plaintiffs rejoin that a fe dera l ag ency may not deleg ate to a pr ivate entity the ag ency ’s statutory

obligations absent an af

firmative showing of congressional a

uthorization. They

argue that HHS unlawf

ully does this when it allows the J oint Com mission t o deter mine that its nursing standa rds ar e at lea st equivalent to the HHS be ds ide ava ila

bil ity sta nd ard . H HS i s c or

re c t.22

Once ag ain, the cour

t is face d with a pure ly

leg al issue. B eca

use the c ourt holds that HHS lawfully

interpre ted the bedside availability standard a s stemming fr om its section 1395x (e) (5) a

uthority , there is no need for the Secr etar

y to determine e quivalency with the J oint Commi ssion standard and the ref ore the Secre tary

has not deleg ated this authority , lawfully or
un l aw f u l l y, t o th e J o i n tC o m m i s s i o n . T o th e e x t e n tp l a i n t i f f s m ak e th i s a l l e g a t i o nm o r e b r o a d l y, HHS is corre ct that the Secr etar y ’s deter mination that an acc redited hospital is dee med to meet the re quirements of se ction 1395x (e) (5) is not only authorized by

Congr ess, see United States v. W iddowson , 916 F.2d 587, 592 ( 10th Cir. 1990) (“The rele vant inquiry in any subdeleg ation
c ha lle ng e is whe the r C on g re ss i nte nd e d to pe rm it the de la g a te e to d e le g a te the a uth or ity confe rre d by

Congr ess”) (citingUnited States v. Giordano , 416 U.S. 505, 512-23 (1974)) , but deleg ates to the Joint Commi ssion only a findingof fa ct, i.e. whe ther or not a hospital meets the J oint Com mission’s st andar ds, and not a de leg ation of the powe r to make la w, see United States v. Grimaud , 220 U.S. 506, 520 (1911) (“ The leg islature ca nnot deleg ate its power

to make a la

w, but it can make a

law to deleg ate a

power to determine some f

act or state of thing s upon which the law make s or intends to make its own ac tion depend.”) (interna l citation omitt ed). Plaintiffs have the re fo re fa ile d to state a c la im u po n w hic h r e lie f m ay

be g ra nte d w ithre g ard

to t he ir alleg ation of improper

deleg ation. D. P lai nt iffs’ M ot ion for Or de r of Ju r isdi c ti on o r To P e r m itJur isdi c ti ona l D isc ov e r y is De nie d. The c ourt has dete rmined that it has subject matter jurisdiction over plaintiffs’ a lleg ations that HHS has improper ly

cate g orized the bedside availability standard a

nd improperly

deleg ated its a uth or ity to t he Joint Commis sio n. I t ha s d e te rm ine d th a t it do e s n ot h ave jur isd ic tio n w ith23

respe ct to plaintiffs’ alleg ation that HHS has fa iled to enforc e the c onditions required to be a hospital. Bec ause the court ha s determined its jurisdiction, it need not addre ss plaintiffs’ motion for a n order of jurisdiction, which motion relies on plaintiffs’ c omplaint and briefingon HHS’s motion to di smiss. P laintiffs also re quest to be per mitted to conduct jurisdictional discovery should the court dete rmine that it does not have subje ct matter jurisdiction over their cla ims. When reque sting jurisdictional discover y a plaintiff must make a

“deta iled showing of what discovery it wishes to conduct or what results it thi nks such discover y would produce .” United States v. Philip Morris Inc. , 116 F. Supp. 2d 116, 130 n.16 (D.D .C. 2000). Be cause plaintiffs have fa ile d to argue wi th a ny sp e c if ic ity wh a t e vid e nc e the y

be lie ve the y

c ou ld f ind to supplement their cur

rent a lleg ations, their re quest for jurisdictional discove ry is denied. III . C ON CL USI ON For the fore g oing r easons, HH S’s motion t o dismiss is GRANTED and pla intiffs’ motion for or der of

jurisdiction, or, in the alternative, to permit jurisdictional discovery is DENI ED. An appropr iate orde r ac companies this memora ndum opinion.

Henr

y H. Kenne dy , J r. Un i t edS t at es Di s tri ct J u d ge