Court Opinion

ID: 6339089
Source: CourtListenerOpinion
Date Created: 2022-05-10 15:12:39.176059+00
Date Added: 2024-06-11T15:49:10.344779
License: Public Domain

IN THE COMMONWEALTH COURT OF PENNSYLVANIA

D.C. and J.C., in their                 : CASE SEALED
own right and as Parents and            :
Natural Guardians of Z.C. a minor,      :
                         Petitioners    :
                                        :
               v.                       : No. 13 C.D. 2021
                                        : Submitted: March 10, 2022
Department of Human Services,           :
                      Respondent        :

BEFORE:     HONORABLE PATRICIA A. McCULLOUGH, Judge
            HONORABLE STACY WALLACE, Judge
            HONORABLE MARY HANNAH LEAVITT, Senior Judge

OPINION NOT REPORTED

MEMORANDUM OPINION
BY JUDGE WALLACE                                   FILED: May 10, 2022

      D.C. and J.C. (Parents), parents of Z.C. (Child), petition for review of an
order of the Department of Human Services (DHS), Bureau of Hearings and
Appeals (BHA) that affirmed the decision of Keystone First Health Plan (Keystone
First) denying Parents’ request to increase from one to two home health aides
(HHA) for Child’s care. Additionally, DHS requests to dismiss Parents’ petition as
moot. For the following reasons, we deny DHS’s Application to Dismiss Parents’
petition as moot and affirm the decision of the BHA.
      The facts of this case, as adopted by the BHA, are undisputed. Child is an
11-year-old male who has various needs due to multiple diagnoses. See Certified
Record (C.R.), Item No. 4 at 200.        Child carries a genetic mutation and is
diagnosed to be within the Autism Spectrum. Id. at 200-01. Additionally, Child is
diagnosed with Unspecified Intellectual Disabilities, Attention-Deficit/Hyperactive
Disorder (ADHD), Mixed Expressive-Receptive Language Disorder, Unspecified
Hyperkinetic Syndrome of Childhood, and a seizure disorder. Id. at 200-01. Due
to these conditions, Child requires assistance with all activities of daily living
(ADLs) including bathing, grooming, and dressing. Id. at 201. Child also has
behavioral issues, which require that he be under constant supervision due to
outbursts, aggression, destructive behaviors, lack of awareness of danger, and risk
of elopement. Id.
      Child attends the Camphill School and is a full-time resident in the life-skills
support program. Id. At school, he has an Individualized Education Program
(IEP), which includes physical therapy, occupational therapy, and speech therapy.
Id. He also has a one-on-one aide who assists him with ADLs. Reproduced
Record (R.R.) at 262a. During breaks from school, Child resides with Parents,
who both work full time outside of the home. C.R., Item No. 4 at 200.
      Child is serviced by Keystone First, which is a Physical Health Managed
Care Organization (PH-MCO). Keystone First is one of multiple Managed Care
Organizations (MCOs) contracted with DHS to administer HealthChoices Program
(HealthChoices) benefits to Medical Assistance (MA) recipients.
      On July 15, 2020, Dr. Amy Siegel submitted a request to Keystone First for
skilled nursing and an HHA for Child Monday through Friday 8:00 a.m. to 6:00
p.m. and Saturday and Sunday 9:00 a.m. to 3:00 p.m. R.R. at 9a. Keystone First

                                          2
approved the request for the HHA and denied the request for skilled nursing as
Child’s physical needs did not require skilled nursing. C.R., Item No. 4 at 201.
       On July 23, 2020, Dr. Maurice Rozwat (Rozwat) sent a request to Keystone
First indicating that Parents were requesting HHA hours be increased to have two
HHAs provided during the previously approved times. R.R. at 19a. In his request,
Rozwat indicated that Child requires qualified staff to assist with his ADLs and
basic hygiene and noted Child’s elopement risk, lack of awareness of danger, self-
injurious behaviors, aggression, and need for constant supervision. Id.
       Keystone First denied the request finding that a second HHA was not
medically necessary. R.R. at 22a. Keystone First noted that the requested services
were to address Child’s behavioral needs rather than his physical needs and that
this was not a support or service provided by an HHA. Id.
       Parents filed a grievance with Keystone First, which was denied. R.R. at 3a-
8a. Parents then appealed Keystone First’s decision to the BHA.
       On November 4, 2020, the BHA held a hearing and subsequently affirmed
Keystone First’s decision.
       Parents now petition this Court for review and raise two issues. First,
Parents assert that the BHA failed to properly apply the DHS regulations covering
HHA services.1 Second, Parents assert that the Administrative Law Judge’s (ALJ)
findings of fact categorizing Child’s needs as behavioral rather than medical are
unsupported by substantial evidence. We disagree.

       1
         In Parents’ Brief, Parents specifically frame the issue by asserting that the regulations
covering HHA services “mandate reimbursement.” See Pet’rs’ Br. at 10. However, the record
does not indicate that Parents have made payment for a second HHA thereby requiring
reimbursement. Rather, based on the record, Parents are requesting coverage for a second HHA.
Therefore, we address this issue as Parents’ assertion that the BHA failed to properly apply the
DHS’s regulations regarding HHA service coverage.

                                                3
      Our standard of review of a BHA order limits us to determining whether the
decision is in accordance with applicable law, whether the decision is supported by
substantial evidence, or whether constitutional rights were violated. Casey Ball
Supports Coordination, LLC v. Dep’t of Hum. Servs., 160 A.3d 278, 283 (Pa.
Cmwlth. 2017) (citing Cambria Cnty. Home & Hosp. v. Dep’t of Pub. Welfare, 907
A.2d 661, 667 (Pa. Cmwlth. 2006)).
      First, we address Parents’ argument that the BHA failed to properly apply
the DHS regulations covering HHA services.
      Under Pennsylvania’s MA program, DHS provides payment to MCOs for
recipients’ health services. 55 Pa. Code § 1229.21. An MCO member is eligible
for all services covered by the contract between DHS and the MCO. 55 Pa. Code §
1229.22. The regulation specifies that DHS will only make payment where the
medical service or provider is, among other things, deemed medically necessary.
55 Pa. Code § 1101.66(a).
      The regulation’s policy, which is consistent with the HealthChoices Physical
Health Agreement (Agreement), at 25 (version effective January 1, 2021),2 defines
“medically necessary services” as services that will, or are reasonably expected to:
“prevent the onset of an illness, condition, injury, or disability[,] . . . reduce or
ameliorate the physical, mental, or developmental effects of an illness, condition,
injury, or disability[, or] . . . assist the recipient to achieve maximum functional
capacity in performing daily activities[.]” 55 Pa. Code § 1101.21a(1)-(3).
      Where personal care services are medically necessary, DHS covers the cost
of HHA services.       55 Pa. Code § 1249.54.          HHA covered services include

2
  The Agreement is available on DHS’s portal: https://www.dhs.pa.gov/HealthChoices/HC-
Services/Documents/HC%20Agreement%202021.pdf (last visited May 9, 2022).

                                            4
assistance with bathing, personal hygiene, ambulation, or exercise, administration
of medications, and retraining the recipient in self-help skills. 55 Pa. Code §
1249.54(b)(1)-(5).     The regulation specifically excludes domestic services,
housekeeping, and childcare from HHA covered services.              55 Pa. Code §
1249.54(c).
      At the hearing, Dr. Pamela McCarter (McCarter), Pediatric Medical Director
for Keystone First, testified for DHS. When asked about HHA services, McCarter
stated that HHAs assist with ADLs and went on to explain:

              ADLs are – that’s an acronym for activities of daily
              living. So things like washing, wiping after using the
              bathroom, washing your hands afterwards, brushing your
              teeth, getting showered, getting dressed, things of that
              nature, feeding. They’re all included in [HHA] level of
              care, as well as physically assisting . . . . That would
              include things like transferring from a wheelchair to a
              bed or into a stander. Changing diapers in children that
              are older and beyond the diaper kind of age. Things that
              you would not expect a normal babysitter to do. Those
              are the kinds of things that a[n] [HHA] does. It’s the
              hands-on physical care of a . . . child under our program .
              . . who has a disability that precludes them [sic] from
              being able to do their own developmentally appropriate
              activities of daily living.

R.R. at 217a. When asked whether an HHA provides behavioral interventions to
address behaviors like headbanging or aggression, McCarter stated, “No . . . in
their normal course of work with a developmentally delayed individual, [an HHA]
will have to redirect sometimes their [sic] behavior . . . but . . . that is not their
primary focus, and they [sic] are not trained specifically for that.” R.R. at 218a.
McCarter explained that there are behavioral health specialists available who work
“in conjunction with the physical care that the [HHA] provides.” R.R. at 224a. She

                                          5
noted that HHAs and behavioral health specialists “have two distinct areas of the
scope of their practice, but they support each other.” R.R. at 224a.
      McCarter specifically addressed her opinion that Child’s physical care needs
require one HHA:

             Q. Does it remain your opinion that it is medically
             necessary for this member to have one Home Health
             Aide provided by Keystone First?

             A. Yes. He eats a normal diet. He’s incontinent. He
             wears Pull-Ups. And so he needs help with his activities
             of daily living and basic hygiene. He does need
             supervision. But that should be adequate for a single
             [HHA] to care for those specific needs.

             I should add that we do, on occasion approve two
             [HHAs] for a member, but in my experience, those cases
             are for a member who is physically unable to be managed
             by one person safely. So a very large adolescent male
             with cerebral palsy or muscular dystrophy who is not
             able to be moved by just one person because of the
             weight, for instance, and the size, in those instances, we
             have provided either a Skilled Nurse or . . . two [HHAs].
             But those are the exception rather than the rule. And it’s
             because the physical care can’t be provided by one single
             individual. In [Child’s] case, his physical care appears to
             be not that extensive. It’s the behaviors that make him
             difficult to care for [sic].

R.R. at 231a-32a. On cross-examination, McCarter was specifically asked about
the difference between physical versus behavioral needs. McCarter explained:

             [Child’s] behaviors are physical acts like headbanging,
             biting, maybe pushing. They are physical acts, but
             they’re a behavior that he’s exhibiting. They are not
             physical needs that a[n] [HHA] would be asked to
             address such as going to the bathroom in a diaper, not
             being able to brush their teeth, not being able to wipe
             themselves after they use the toilet.

                                         6
R.R. at 239a.
      Here, the ALJ specifically addressed 55 Pa. Code § 1249.54 regarding HHA
payment conditions in his decision and properly considered the relevant testimony
regarding HHA services. See C.R., Item No. 4. In its decision, the ALJ outlined
the personal care services covered by HHA services as addressed in the
regulations. Id. The ALJ concluded that the services covered by HHAs do not
include behavioral services but are limited to physical care services.           The
regulations support the ALJ’s decision. Therefore, the ALJ did not err as a matter
of law.
      The second issue raised by Parents is that the ALJ’s findings of fact in
denying Parents’ request for a second HHA as “behavioral,” not “medical,” are
unsupported by substantial evidence. Parents contend that the ALJ’s determination
was unsupported by substantial evidence and based on a capricious disregard of the
evidence. Parents specifically assert that the ALJ’s decision was based on a
capricious disregard of the evidence because the ALJ “made no meaningful
findings concerning witness credibility[,]” see Pet’rs’ Br. at 16, and “ignore[d] Dr.
Rozwat’s opinion that [Child] needs two HHAs to be available at home to
supervise and care for him while [Parents] are at work.” See Pet’rs’ Br. at 17.
Parents also assert that the ALJ “ignored the persuasive testimony of [the nurse]
that it would be very difficult for a single HHA to follow [Child’s] plan of care,
including providing or making meals for Child.” Pet’rs’ Br. at 17.
      In appeals to the BHA, the ALJ, as fact-finder, assesses witness credibility
and evidentiary weight. See Arcurio v. Dep’t of Pub. Welfare, 557 A.2d 1171,
1173 (Pa. Cmwlth. 1989); Birdsboro & Birdsboro Mun. Auth. v. Dep’t of Env’t
Prot., 795 A.2d 444, 448 (Pa. Cmwlth. 2002).           Where the record contains
substantial evidence and the ALJ’s determinations are the result of weighing the

                                         7
evidence and resolving issues of credibility and conflicting testimony rather than
the result of capriciously disregarding evidence, we will not disturb an ALJ’s
decision. See Bennett v. Unemployment Comp. Bd. of Rev., 33 A.3d 133, 136 n.3
(Pa. Cmwlth. 2011); Macioce v. Zoning Hearing Bd. of the Borough of Baldwin,
850 A.2d 882 (Pa. Cmwlth. 2004). A capricious disregard of the evidence occurs
where the ALJ fails to resolve conflicts in the evidence, fails to make essential
credibility determinations, or completely ignores overwhelming evidence without
comment. Hinkle v. City of Phila., 881 A.2d 22, 27 (Pa. Cmwlth. 2005). We must
decide whether the ALJ willfully or deliberately ignored evidence that any
reasonable person would have considered to be important. Wise v. Unemployment
Comp. Bd. of Rev., 111 A.3d 1256, 1263 (Pa. Cmwlth. 2015). In making that
determination, this Court may not find facts or reweigh the evidence. Erhart v.
Dep’t of Pub. Welfare, 632 A.2d 5, 7 (Pa. Cmwlth. 1993).
      As outlined above, McCarter testified to Child’s physical care needs versus
Child’s behavioral care needs. McCarter explained that Child’s behavioral issues
are not physical needs that could appropriately be addressed by an HHA but are
behavioral needs. R.R. at 232a. She noted that HHAs are not trained in the
management of behavioral needs and that they are present to provide physical care
services. R.R. at 232a. She specified that, in this case, Child’s physical care needs
are not “that extensive[,]” and that it is his behaviors that present a challenge in his
care. R.R. at 232a.
      Parents argue that a second HHA is required because Child “cannot use the
bathroom, make his own meals, change his diapers or otherwise care for himself,”
Pet’rs’ Br. at 12. While an HHA provides these services, the evidence in the
record supports the BHA’s finding that based on Child’s physical needs, these

                                           8
services can be provided by one HHA. McCarter specifically testified that Child’s
physical care needs could be met by one HHA. R.R. at 232a. At school, Child has
a one-to-one aide who assists him with ADLs. R.R. at 262a. The record does not
support the argument that two HHAs are required to tend to Child’s physical care
needs. Conversely, the record supports the ALJ’s finding that Child’s needs are
behavioral and require services other than what an HHA can supply.
      The ALJ considered the evidence of record and indicated that Parents’
argument is contradicted by the records and testimony that were submitted. See
C.R., Item No. 4. The ALJ acknowledged the nurse’s testimony and found that
even her testimony as to Child’s behaviors supported DHS’s argument that Child’s
actions are “behavioral.” For the reasons set forth above, we conclude that the
ALJ’s findings are not a capricious disregard of the evidence. Rather, the BHA’s
decision is supported by substantial evidence.
      This leads us to the final issue, whether Parents’ petition is moot now that
Child has been enrolled in the Person/Family Directed Support (PFDS) waiver
administered by DHS’s Office of Developmental Programs. See Appl. to Dismiss,
dated October 6, 2021; Pet’rs’ Answer to Appl. to Dismiss, dated October 13,
2021. The doctrine of mootness requires that an actual case or controversy exists
“at all stages of review[.]” In Re Gross, 382 A.2d 116, 119 (Pa. 1978). It is well
settled that we do not “render decisions in the abstract or offer purely advisory
opinions[.]” Harris v. Rendell, 982 A.2d 1030, 1035 (Pa. Cmwlth. 2009) (citation
omitted). Additionally, a legal question may be rendered moot on appeal due to
intervening factual changes that occur during the pendency of the case. Gross, 382
A.2d at 119-20.

                                         9
      We note that while Parents filed the petition for review in January 2021, it is
undisputed by the parties that as of July 22, 2021, Child is authorized to receive in-
home and community support services through the PFDS waiver. Id. Through the
PFDS waiver, Child is approved for 10 hours per day, 7 days per week of in-home
(and community support) services for the 13 weeks per year that Child is home
from school. Id. These habilitation services assist individuals with acquiring,
maintaining, and improving the skills necessary to live in the community and
address the safety needs of the individual. Id. DHS argues that because Child is
now approved to receive services from two individuals, one HHA to assist Child
with ADLs, and another provider who can address his safety needs, this renders the
pending petition for review moot as Parents’ concerns are being addressed by
having two service providers in the home. Id. We disagree that the issue is moot.
      The issue before this Court is regarding coverage for a second HHA, and
this issue is still ripe for review. For this reason, this decision resolves a
controversy and is not merely advisory. As outlined above, per the regulations,
HHAs provide specific physical care services. We note that Parents’ request was
not for an additional support person, but specifically for a second HHA. This
distinction is important as the issue in this case is not whether Child needs
additional services, as the ALJ agreed that Child needs services, but whether a
second HHA’s services are required for his physical care needs. The services that
have been approved through the PFDS waiver is not an HHA. Parents continue to
request a second HHA despite Child being approved for the PFDS waiver. Thus,
while intervening factual changes occurred during the pendency of this appeal, the
factual changes were not relevant to the issue regarding coverage for a second
HHA. Therefore, the issue before this Court is not moot.

                                         10
      For the reasons set forth above, we conclude that the BHA’s decision is in
accordance with the law and supported by substantial evidence. Additionally, the
issue before the Court is not moot. Accordingly, we deny DHS’s Application to
Dismiss the Petition for Review and affirm the decision of the BHA.

                                            ______________________________
                                            STACY WALLACE, Judge

                                       11
            IN THE COMMONWEALTH COURT OF PENNSYLVANIA

D.C. and J.C., in their                :   CASE SEALED
own right and as Parents and           :
Natural Guardians of Z.C. a minor,     :
                         Petitioners   :
                                       :
               v.                      :   No. 13 C.D. 2021
                                       :
Department of Human Services,          :
                      Respondent       :

                                   ORDER

            AND NOW, this 10th day of May 2022, Respondent’s Application to
Dismiss the Petition for Review For Mootness is DENIED, and the December 16,
2020 Final Administrative Action Order of the Department of Human Services,
Bureau of Hearings and Appeals, is hereby AFFIRMED.

                                       ______________________________
                                       STACY WALLACE, Judge