Opinion ID: 2783588
Heading Depth: 2
Heading Rank: 2

Heading: Plott’s 2008 Surveys

Text: 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 23 42 C.F.R. § 488.301. 24 58 Fed. Reg. 58,171. 25 42 U.S.C. 1395i-3(h)(2)(B)(ii); 42 U.S.C. 1320a-7a(e). 26 A HFES is a supervisor that has the same qualifications as an HFEN, but also has work experience as an HFEN. Job Description for California Department of Public Health (CDPH) Health Facilities Evaluation Nurse available at http://www.cdph.ca.gov/services/jobs/Documents/ HFEIISup8H1AT.pdf PLOTT NURSING HOME V. BURWELL 9 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 In September 2008, the surveyors cited Plott for 33 different Tag numbered deficiencies above a D in scope and severity. Four of the 33 were a G, H, or I, (actual harm, but not immediate jeopardy) the rest were a D, E or F (no actual 27 See SOM, supra note 8, at Appendix PP – Guidance to Surveyors for Long Term Care Facilities. 28 Id. 29 Id. at Chapter 7, § 7400.5.1. 30 42 C.F.R. § 488.402(d)(2). 10 PLOTT NURSING HOME V. BURWELL harm, but potential for minimal harm.) A follow-up survey in December 2008 found one additional D level deficiency. The state agency referred all 3431 deficiencies to CMS. Based on the 33 September deficiencies, CMS fined Plott $500 per day from September 24 through December 3, 2008, and $100 per day from December 4 through December 15, 2008 for the one December deficiency. Plott requested an ALJ hearing to dispute the results of both surveys. The ALJ consolidated the two proceedings and noted at the beginning of the hearing that many of the surveyors only had two years of surveying experience, and that there was a large number of “low level” deficiencies. He said “my initial impression is a lot of these deficiencies are very finely honed. They are very pointed deficiencies . . . usually I see gross problems.” After a four-day evidentiary hearing, the ALJ upheld the entire penalty imposed by CMS on the basis of three deficiencies for three different patients, two during the September 2008 survey and one during the December 2008 survey. During the September survey, Plott’s care of Resident Six violated the standard of care for bed sores,32 and Plott’s care of Resident Five violated the standard 31 Plott states in their brief that they were cited for 96 deficiencies. This is because some of the 34 Tag coded deficiencies cited in the two surveys applied to more than one patient. Plott counts every occurrence of the alleged deficiency where the surveyors counted the code once and the scope and severity code takes into account instances where the deficiency applied to more than one patient. 32 42 C.F.R. § 483.25(c) “Pressure Sores. Based on the comprehensive assessment of a resident, the facility must ensure that– (1) [a] resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and (2) [a] resident having pressure sores receives necessary PLOTT NURSING HOME V. BURWELL 11 of care for urinary tract infections (“UTIs”).33 During the December survey, Plott violated the standard of care for UTIs for another patient. During informal dispute resolution prior to the ALJ hearing, CMS deleted the deficiency alleging that residents have access to the outdoor garbage containers. CMS failed to make a prima facie case on five other deficiencies,34 such as a staff member storing a lunchbox in a resident’s room, slow response to call lights, and foods served at the wrong temperature, when CMS presented no evidence to support these deficiencies at the hearing. The ALJ did not review the 25 remaining deficiencies from the September survey, even though CMS initially imposed the $500 per day civil money penalty based on all 33 deficiencies. The ALJ held that it was “not necessary to address all the other alleged deficiencies from the September 2008 survey” because the bedsore and UTI violations “provide a sufficient basis for the enforcement remedies that CMS proposes.” treatment and services to promote healing, prevent infection and prevent new sores from developing.” 33 Id. § 483.25(d) “Urinary Incontinence. Based on the resident’s comprehensive assessment, the facility must ensure that– (1) [a] resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; and (2) [a] resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.” 34 Deficiency Tags 241, 246, 252, 282 and 364 were not argued in CMS’s closing brief. 12 PLOTT NURSING HOME V. BURWELL The Department of Health and Human Services Appeals Board affirmed the $500 per day penalty based on the bedsores and UTI deficiencies from the September survey, but reversed the UTI deficiency and eliminated the $100 per day penalty from the December survey. The Board found that the $500 per day penalty was reasonable because Plott had a history of noncompliance and was cited for the same two deficiencies in 2005 and 2007.35 The Board further held that the ALJ was not required to review the other 25 contested, but unreviewed, deficiencies. Plott appealed the Board’s decision. We affirm the Secretary’s determination that Plott violated the quality of care for bed sores,36 but reverse the determination for violating the quality of care for urinary tract infections37 because it is not supported by substantial evidence on the record as a whole. We also hold that Plott is entitled to administrative review of all deficiencies that CMS cited and remand with directions to review or dismiss the 25 violations that the ALJ and Board did not review.