Opinion ID: 424821
Heading Depth: 2
Heading Rank: 2

Heading: The Meaning of Extraordinary, Concentrated, and Continuous Care

Text: 34 The Deputy Administrator framed the issue in this case as (w)hether the care required by patients in [the rehabilitation center met] the Regulation's requirement of being extraordinary, concentrated and continuous .... R. 0010. We must determine whether the Secretary's decision that this requirement was not met is supported by substantial evidence in the administrative record. 35 Substantial evidence is not necessarily a preponderance of the evidence, but it is more than a mere scintilla. Substantial evidence is evidence that a reasonable mind might accept to support a given conclusion with reference to the administrative record as a whole. See, e.g., Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971). 36 The Secretary urges that overwhelming evidence supports the Secretary's determination that plaintiff's rehabilitation unit provides care different from the extraordinary, concentrated and continuous care provided by recognized special care units. Appellant's br. at 28 (emphasis added). Thus, the Secretary argues the care provided in the rehabilitation center is not extraordinary, concentrated, and continuous. We do not find this argument persuasive. 37 The regulation in effect for 1977 and 1978 did not require that all special care units provide care identical to that provided in, for example, coronary or intensive care units. Rather, the regulation required that the level of care provided in a special care unit be comparable to the level of care provided to patients in such recognized units. And, contrary to the Secretary's assertions, the level of care provided in the rehabilitation center was comparable to the level of care provided in the Hospital's coronary and intensive care units--units that were properly accorded special care unit treatment for Medicare reimbursement purposes. 38 The uncontroverted testimony in this administrative record clearly demonstrates that nursing staff-patient ratios and operational costs of the rehabilitation center were much closer to those of the recognized special care units than to those of the Hospital's routine service areas. Moreover, the rehabilitation center, like the recognized special care units, did not employ nurse's aides although such employees are regularly engaged to perform tasks in routine service areas. These factors figured heavily in the PRRB's determination that the rehabilitation center was, in fact, a special care unit. 39 The Secretary adopted the factual findings of the PRRB. In reversing the PRRB's ultimate determination, the Secretary concluded that these facts did not support special care unit status for the rehabilitation center because the extraordinary, concentrated, and continuous care requirement implicitly included a requirement that the unit care for critically ill patients. As we already have explained, however, the Secretary's interpretation of 42 C.F.R. Sec. 405.452(d)(10) was not justified under the plain meaning of that regulation. 40 The uncontroverted facts, as found by the PRRB and adopted by the Secretary, clearly demonstrate a level of care consonant with that provided in recognized special care units. This care, moreover, was extraordinary, concentrated, and continuous within the plain meaning of those words. There is no evidence in the administrative record to support the Secretary's contrary determination. 41 Furthermore, we agree with the district court that the intermediary's two specific approvals of treatment of the rehabilitation center as a special care unit constitute additional evidence of the Secretary's interpretation of 42 C.F.R. Sec. 405.452(d)(10) before that regulation was amended. 5