Court Opinion

ID: 1029497
Source: CourtListenerOpinion
Date Created: 2013-07-05 07:58:39.218653+00
Date Added: 2024-06-11T12:39:10.830711
License: Public Domain

UNPUBLISHED

                  UNITED STATES COURT OF APPEALS
                      FOR THE FOURTH CIRCUIT

                               No. 08-1447

BEVERLY HEALTHCARE LUMBERTON,

                Petitioner,

           v.

MICHAEL   O.  LEAVITT,   Secretary  of the       United   States
Department of Health & Human Services;           UNITED   STATES
DEPARTMENT OF HEALTH & HUMAN SERVICES,

                Respondents.

On Petition for Review of an Order of the United States
Department of Health & Human Services. (C-06-20; A-07-134)

Argued:   May 13, 2009                       Decided:   July 22, 2009

Before WILKINSON, MICHAEL, and MOTZ, Circuit Judges.

Petition for review denied by unpublished per curiam opinion.

ARGUED:   Joseph  L.   Bianculli,  HEALTH   CARE  LAWYERS,  PLC,
Arlington, Virginia, for Petitioner.    Erica Cori Matos, UNITED
STATES DEPARTMENT OF HEALTH & HUMAN SERVICES, Atlanta, Georgia,
for Respondents. ON BRIEF: Peter D. Keisler, Assistant Attorney
General, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C.;
Thomas R. Barker, Acting General Counsel, Dana J. Petti, Chief
Counsel, Region IV, UNITED STATES DEPARTMENT OF HEALTH & HUMAN
SERVICES, Atlanta, Georgia, for Respondents.

Unpublished opinions are not binding precedent in this circuit.
PER CURIAM:

             Beverly        Healthcare      Lumberton         (Beverly)      challenges

civil money penalties (CMPs) imposed by the Centers for Medicare

& Medicaid Services (CMS) for violations of the Medicare and

Medicaid     statutes        and    regulations.             These   penalties      were

sustained     by    an    administrative         law   judge    (ALJ),      with   minor

adjustments,        and   affirmed     by   the    Departmental        Appeals     Board

(DAB)   of   the     U.S.    Department      of    Health      and   Human   Services.

Because we find no reversible error in the DAB’s decision, we

deny Beverly’s petition for review.

                                            I.

             Beverly is a skilled nursing facility located in North

Carolina that participates in both the Medicare and Medicaid

programs.      The North Carolina Department of Health and Human

Services     (the    state    survey     agency),      the    agency   in    charge   of

surveying healthcare facilities that participate in Medicare and

Medicaid,     conducted       a    complaint      survey     against   Beverly      that

ended August 4, 2005.              The survey found that Beverly was not in

substantial compliance with three requirements for participation

in Medicare and Medicaid programs.                     Specifically, Beverly was

found   to   have     (1)    failed    to   provide     an     environment     free   of

abuse, in violation of 42 C.F.R. § 483.13(b); (2) failed to

report and investigate allegations of abuse, in violation of 42

                                            2
C.F.R.      §§ 483.13(c)(2),        (3);    and    (3)   failed    to     develop   and

implement policies to prevent abuse of residents, in violation

of 42 C.F.R. § 483.13(c).

                  These   violations     stemmed   primarily      from    an   incident

that       took    place    April   9,    2005,    involving    one      of    Beverly’s

residents, George Hunt 1 .               Hunt was an 87-year-old man with a

history of insomnia, falls, and dementia.                      Hunt had fractured

his hip in a fall in December of 2004, which resulted in a

physician ordering a soft safety belt to help restrain Hunt in

his wheelchair.            In the early morning of April 9, 2005, Hunt was

sitting in his wheelchair at the nurse’s station when he removed

the soft waist restraint belt keeping him in the wheelchair and

became combative with the two nurses at the station, Marilyn

Marino and Octavia Taylor.                 Both nurses attempted to prevent

Hunt from falling and to persuade him to relinquish the waist

restraint, which he continued to hold.                     The nurses called a

nursing assistant, Charles Robinson, to come and assist them

because the nursing assistant who was present was too small to

handle Hunt.          While attempting to subdue Hunt, Robinson grabbed

Hunt’s right arm and tried to get the restraint out of Hunt’s

       1
       The description of the incident by the ALJ and DAB was
taken primarily from a nurse’s note prepared by Nurse Marilyn
Marino shortly after the incident. Because the complaint survey
uncovered multiple complaints, the resident at issue here is
sometimes referred to in the record as Resident #2, or R2.

                                            3
left    hand.       After     Hunt      pulled        his    arm    away     and       refused    to

release       the   restraint      to      Robinson,         one    of     the    nurses       asked

Robinson to let go of Hunt’s arm, and then managed to persuade

Hunt to give up the restraint.                       Robinson then “grabbed [Hunt’s]

arms roughly” while the nurses re-applied the restraint.                                     Admin.

App’x A at 369; Admin. App’x B at 450.                            After the restraint was

back   in     place,   Robinson         released       Hunt’s       arms,        but    Hunt    then

removed the restraint for a second time.                             Robinson “then tried

to    grab    [Hunt’s]      arms     but    [Hunt]          started       swinging      at     him.”

Admin. App’x A at 370; Admin. App’x B at 451.                                   At that point,

Robinson “grabbed both of [Hunt’s] wrists and would not let go.”

Admin. App’x A at 370.             Admin App’x B at 451.                   Nurse Marino then

suggested       that   Hunt     needed       to       go    to     bed,    as     it    was     past

midnight.       Robinson “angrily answered, ‘He’s not going to bed,’”

and    then    wheeled   Hunt      to      his       room    to    clean     and       change    him

because he had become incontinent either before or during the

incident.       Admin. App’x A at 370; Admin. App’x B at 451.

               About ten minutes later, Robinson returned with Hunt,

who had been cleaned and changed.                      Hunt “appeared upset” and his

“eyes were watery and his lips were quivering.”                                  Admin. App’x A

at 370; Admin. App’x B at 451.                       Hunt then pointed to his wrist

and said to Nurse Marino, “you broke my heart.”                                  Admin. App’x A

at 370, B at 451.             Nurse Marino observed redness and edema on

Hunt’s wrists three to four inches up his forearm, as well as

                                                 4
redness on his hand.                Hunt told Nurse Marino that it hurt, and

when she touched his wrist he pulled away and said “ow.”                                    Admin.

App’x A at 370-71.               When Nurse Marino returned the next morning

(April       10),    Hunt       showed      her   his     right      arm,       which   had   dark

bruises       on    the       wrist.        Nurse       Marino   had       begun    preparing    a

nurse’s note on the day of the incident, April 9, 2005, and

completed the note on April 11, 2005.                                Robinson continued to

work over the weekend and provided care to multiple residents,

including Hunt, without further incident.

               The       Director      of    Nurses        (DON)      at    Beverly,      Roxanne

Thompson,          was    not    contacted        on      the    date      of     the   incident.

Thompson learned of it when she came in to work on Monday, April

11, and she then reviewed the weekend incident log.                                     That same

day    she    began       a    routine      investigation          into     the    incident    and

received       Nurse          Marino’s      note.          In    a     follow-up        interview

conducted by the North Carolina surveyor, Thompson said that had

she been on duty at the time of the incident, Robinson would

have     been       suspended          immediately.              Instead,          Robinson    was

suspended on April 11 and subsequently terminated on April 14.

However,       Thompson’s          investigation           ultimately           concluded     that

Robinson had not abused the resident.                                Thompson finished her

report and filed it with the state survey agency on April 12,

2005.     She also filed a required “five day report” on April 15,

2005.

                                                    5
                 The complaint survey that concluded on August 4, 2005,

also cited two other incidents.                  On March 22, 2005, a family

member      of     another     resident 2   at    Beverly      filed    a   grievance

asserting that a nursing assistant had told the resident that

she “better not turn the call light back on again” because the

nurses were short staffed.              Admin. App’x A at 394; Admin. App’x

B at 465.         The action was documented on April 8, 2005, and the

five day report was filed on May 24, 2005.                      By that time, the

nursing assistant involved in the incident no longer worked at

Beverly for unrelated reasons.

                 In the remaining incident, on April 8, 2005, a third

nursing assistant was reported for yelling at a resident 3 .                       The

nursing assistant involved was suspended on April 11, 2005, and

terminated on April 14, 2005.               A twenty-four hour report found

in Beverly’s files was undated and the five day report for the

incident was dated April 19, 2005.

                 The   state   agency   took     no   action    on     these   initial

reports.         The citations at issue were instead issued by State

Surveyor Patrick Campbell, who arrived at Beverly’s facility on

July       27,    2005,   to    investigate      an    unrelated       complaint    of

       2
       This resident is referred to as Resident #1, or R1, in the
record.
       3
       This resident is referred to as Resident #3, or R3, in the
record.

                                            6
inadequate    care.        Campbell     had      been        sent    to   investigate     a

complaint that involved care provided by his own sister, who was

a nurse at Beverly’s facility.              This conflict of interest should

have disqualified Campbell from proceeding with the survey, but

the   conflict     was     unknown     to   Beverly          at     the   time.      After

reporting that he could not substantiate the complaint he was

sent to investigate, Campbell proceeded, apparently of his own

initiative, to begin a search of unrelated records at Beverly.

In the course of that search, Campbell found Nurse Marino’s note

on the April 9 incident.              Upon completing his investigation on

August 4, 2005, Campbell cited Beverly for the three violations

listed   above,     based    primarily          upon    Nurse       Marino’s      note   and

subsequent interviews.

             The   state     survey    agency         then    recommended         that   the

Secretary of the U.S. Department of Health and Human Services

(Secretary),       through    the      Centers         for     Medicare     &     Medicaid

Services (CMS), impose penalties against Beverly.                               CMS found

that Beverly was not in substantial compliance with 42 C.F.R.

§§ 483.13(b), (c), and (c)(2), (3) and that Beverly’s violations

constituted    “immediate      jeopardy”         to    its     residents       during    the

period from April 9 to April 14, 2005 (when nursing assistant

                                            7
Robinson was terminated). 4             As a result, CMS imposed a CMP of

$3,050 a day for April 9 through April 14, 2005.                         CMS also found

a continuing violation, at a lower severity level, for which it

imposed a CMP of $1,000 a day for April 15 through August 4,

2005. 5    The daily penalties ceased accruing on August 4, when

Beverly submitted a plan of action stating that all staff had

been “in-serviced” on proper policy regarding abuse allegations.

Beverly     also    stated    that     it    had    completed     a   review    of     all

grievances     between       January    1,       2005,   and    August    4,   2005,    to

ensure they had all been reported and investigated.

             Beverly requested a hearing, and the case was heard

before an ALJ.         The ALJ sustained all of CMS’s findings, with

the sole exception that he applied the $3,050 CMP from April 9

through April 11, 2005, rather than through April 14, because he

concluded that “immediate jeopardy” had ended once Robinson was

suspended.         Beverly    appealed       to    the   DAB,   which     affirmed     the

ALJ’s decision in its entirety.                  On April 3, 2008, Beverly filed

      4
        Each deficiency is placed in one of four severity
categories: (i) no actual harm with potential for minimal harm;
(ii) no actual harm with potential for more than minimal harm
that is not immediate jeopardy; (iii) actual harm that is not
immediate jeopardy, and (iv) immediate jeopardy to resident
health or safety. 42 C.F.R. § 488.404(b)(1). Deficiencies are
also classified as “isolated,” “constitut[ing] a pattern,” or
“widespread.” Id. § 488.404(b)(2).
      5
          CMS also imposed other penalties not at issue here.

                                             8
a petition to reopen the DAB’s decision pursuant to 42 C.F.R.

§ 498.100,          which     the     DAB    summarily           denied     on      May    2,    2008.

Beverly then filed a petition for review in this court under 42

U.S.C. § 1320a-7a(e).

                                                   II.

               Beverly        raises        four    challenges         to      the     Secretary’s

imposition of CMPs.                 First, Beverly contends that the Secretary

failed     to       establish         any    of     the       three    alleged         violations.

Second,        Beverly        argues        that       the     Secretary         erred      in    his

determination            as   to     the     level       of    non-compliance             (immediate

jeopardy).           Third, Beverly asserts that the CMPs imposed are

unreasonable.            Finally, Beverly maintains that the DAB erred in

overlooking the state surveyor’s conflict of interest.

                                                   A.

               CMS’s findings of fact are conclusive “if supported by

substantial evidence on the record considered as a whole.”                                         42

U.S.C.     §     1320a-7a(e).                The        Supreme       Court      has       described

“substantial          evidence”        in     other       contexts        as     “such     relevant

evidence       as    a    reasonable         mind        might    accept       as    adequate      to

support a conclusion.”                 Richardson v. Perales, 402 U.S. 389, 401

(1971)    (National           Labor    Relations          Act).       CMS      may    impose     CMPs

(among other remedies) when it determines that a long-term care

facility has failed to substantially comply with participation

                                                   9
requirements.       42 U.S.C. § 1395i-2(h)(2)(B)(ii) (“The Secretary

may impose a civil money penalty in an amount not to exceed

$10,000   for    each      day    of    noncompliance.”);         42    C.F.R.    488.301

(“Noncompliance means any deficiency that causes a facility to

be not in substantial compliance.”).                     “Substantial compliance”

is defined as a “level of compliance with the requirements of

participation       such     that      any   identified     deficiencies         pose    no

greater risk to resident health or safety than the potential for

causing minimal harm.”            42 C.F.R. § 488.301.            We address each of

the alleged violations in turn.

                                             1.

             Beverly was cited for violating 42 C.F.R. § 483.13(b),

which prohibits abuse of residents.                    Facilities participating in

Medicare and Medicaid programs are forbidden from using “verbal,

mental,     sexual,     or     physical      abuse,      corporal       punishment,      or

involuntary seclusion.”             42 C.F.R. § 483.13(c)(1)(i).                 See also

§ 483.13(b).        The U.S. Department of Health and Human Services

(USHHS) defines “abuse” as “the willful infliction of injury,

unreasonable      confinement,           intimidation,       or        punishment    with

resulting physical harm, pain, or mental anguish.”                           42 C.F.R.

§ 488.301.      The Secretary’s interpretive guidelines state that a

resident has been physically abused when (1) physical contact

was made (2) that was intentional or careless, (3) there was

resulting    harm     or   a     likelihood       of   physical    injury,       pain,   or

                                             10
death to the resident, and (4) there was a lack of reasonable

justification for the contact.             USHHS State Operations Manual at

6-4,                                    available                                      at

http://www.michigan.gov/documents/mdch/bhs_ch6_mom_abuse_etc_223

590_7.pdf.       There   is   a    “presumption     that     physical         abuse   has

occurred whenever there has been some type of impermissible or

unjustifiable physical contact with a resident that has resulted

in injury or harm to the resident.”                    Id.     The USHHS manual

includes “squeezing . . . any part of the resident’s body” as an

example    of     potentially       abusive      treatment.             USHHS     State

Operations Manual at 6-4.           However, the manual also states that

physical      contact    during     care,       comfort,     or    assistance          is

permissible when “the type of contact involved and the amount of

force used are absolutely necessary in order to provide care.”

USHHS State Operations Manual at 6-5.                  When the contact occurs

“in the course of attempting to restrain a resident’s behavior

in an emergency,” it is permissible if “both the type of contact

involved and the amount of force used are reasonably necessary

in order to prevent that resident from injuring himself/herself,

injuring another person, or damaging property.”                   Id.

              The ALJ’s conclusion that Robinson’s conduct amounted

to abuse was based almost exclusively on Nurse Marino’s note,

which   the     ALJ   found   to   be    “the   most    complete        and    reliable

account concerning the incident.”               J.A. at 301.        The ALJ found

                                          11
that Robinson treated the elderly resident in an “angry manner”

that   was    “not       accidental       or   necessary          in    providing        care    and

services      to    the       resident.       In    fact,     it       was   intentional         and

retaliatory.”           J.A. 302.        The ALJ also accepted Nurse Marino’s

description of the resident’s physical injury.                               According to the

ALJ, the only reasonable interpretation of Nurse Marino’s note

was    that     the      incident      constituted          abuse.           In    making       this

finding, the ALJ chose not to credit later interviews in which

nurses and nursing assistants who were involved, including Nurse

Marino,      said     that     they     did    not       consider       Robinson’s        conduct

abusive.        Beverly        argues     that      the    ALJ     erred     by    disregarding

evidence      that      conflicted        with      Nurse     Marino’s        note,      and     the

facility attempts to characterize Robinson’s conduct as “poor

technique,” rather than abuse.

              Beverly’s         arguments          notwithstanding,           we    cannot       say

that    either          the    ALJ’s      or       the     Secretary’s            decision       was

unsupported by substantial evidence.                        Nurse Marino’s note, which

was the most contemporaneous description of the incident, states

that    nursing         assistant      Robinson          roughly       handled      an    elderly

resident      in    a    manner     the    nurse          found    excessive.            Robinson

grabbed and held the resident’s arms at least twice, and there

is no dispute that this contact resulted in injury.                                 While there

is also evidence that cuts in Beverly’s favor –- for instance,

the    Social      Security      Administration             concluded        that    the     abuse

                                               12
allegation was unsubstantiated –- it was for the ALJ to make

determinations in the proceeding before him as to the weight of

evidence and credibility of witnesses.                   He chose to credit Nurse

Marino’s note over later statements, and that note alone, due to

its thoroughness and proximity to the event, was sufficient to

constitute substantial evidence of abuse.

                                            2.

            Beverly       was    also      cited       for    violating    42   C.F.R.

§ 483.13(c)(2),         which    requires        participating         facilities     to

“ensure    that   all     alleged         violations     involving      mistreatment,

neglect,    or    abuse    .     .    .    are   reported      immediately      to   the

administrator      of     the    facility        and     to    other    officials     in

accordance with State law.”                Further, facilities must promptly

investigate all allegations of abuse and “[t]he results of all

investigations     must     be       reported    to    the    administrator     or   his

designated representative and to other officials in accordance

with State law . . . within 5 working days of the incident.”                         42

C.F.R. § 483.13(c)(4).           Under North Carolina law, facilities are

required to file an initial “24-hour report” within twenty four

hours of an alleged incident of abuse and also a “five day

report” following a fuller investigation.                     10A N.C. Admin. Code.

13D.2210(b), (d).

           There is no doubt that Beverly failed to timely report

each of the cited incidents.                 The twenty-four hour report for

                                            13
the April 9, 2005, incident was filed on April 12 (two days

late), and the five day report was filed on April 15 (one day

late).     The March 22, 2005, complaint was not documented until

April 8 (sixteen days late), and its five day report was not

filed until May 24 (two months late).                      The April 8, 2005, report

of a nursing assistant yelling at a resident had an undated

twenty-four hour report on file, but its five day report was not

filed     until    April     19       (six   days     late).          Thus,    there      was

substantial       evidence       to     support      the     ALJ’s     conclusion        that

Beverly had violated the reporting requirements.

            Beverly        asserts       that      the     late    reporting        of    the

incident     involving          nursing      assistant        Robinson        was   not     a

violation         because         the        allegations             were       ultimately

unsubstantiated      and        because      DON    Thompson       filed      the   reports

within     twenty-four       hours        and      five    days,     respectively,         of

learning of the incident herself.                         Both arguments must fail.

First, it is the allegation that triggers the responsibility to

report.     Cedar View Good Samaritan, DAB No. 1897, at 11 (2003).

Even if the ALJ found there was no abuse, Beverly’s failure to

promptly    investigate          and    report      the     allegation        violated     42

C.F.R. § 483.13(c)(2) and 10A N.C. Admin. Code. 13D.2210(b),

(d).     Second, it is irrelevant that the DON did not learn of the

incident for two days.                 The federal statute requires a report

within    five    days     of     the    incident,        while    the      state   statute

                                             14
requires reports within one and five days of when the health

care facility (not a specific person) learns of the allegation –

- which in this case occurred when the resident, Hunt, alerted

Nurse Marino to his injury.               See 42 C.F.R. § 483.13(c)(2); 10A

N.C. Admin. Code. 13D.2210(b), (d).                         Thus, the time at which

Thompson learned of the incident is irrelevant to the deadline

for filing the required reports.

                                              3.

            Finally,         Beverly    was    cited       for       violating    42   C.F.R.

§ 483.13(c),      which       states    that       facilities         “must    develop      and

implement      written         policies       and     procedures          that      prohibit

mistreatment, neglect, and abuse of residents.”                           CMS found that

Beverly    had     failed      to     follow       proper    procedures          related    to

immediately reporting allegations of abuse against residents to

the    facility       administrator.          The    ALJ    found       that    Beverly    had

failed to follow its own procedures –- which provide that “any

associate      (employee)       who    suspects       that       a    resident     has     been

abused     must        immediately        notify        the          executive      director

(administrator)         and    appropriate         state     agencies      in     accordance

with    law”     --    by     not   timely     reporting         the     three     incidents

outlined above.             J.A. at 303.           The ALJ further concluded that

these failures to implement Beverly’s own policies “indicate[d]

a wider systemic problem in the facility,” and that “the failure

                                              15
to actually implement facility policy against abuse and neglect

leaves residents at real risk for serious harm.”                      J.A. at 308.

             Beverly      argues    that       the     ALJ’s      determination          is

improper     for   three     reasons.          First,       it    asserts       that    its

employees did not fail to follow procedure because the procedure

is only triggered when someone actually suspects an abuse has

occurred.      This argument has little traction, however, because

federal      law    requires        Beverly’s          procedures          to     require

investigation of all allegations of abuse, not just those that

facility     employees      believe      are        legitimate.      See    42     C.F.R.

§ 483.13(c)(2).        Beverly thus violated § 483.12(c) either by not

having adequate reporting policies or by having them and failing

to follow them.        Second, Beverly argues that it is pointless to

punish the two-day delay in reporting the Robinson incident to

the state survey agency because no one was working at the agency

over   the     weekend.      This     misses        the     point,    however,         since

Beverly’s    primary      failure   was    the       lack    of   reporting       to    the

facility administrator and DON so that proper action could be

taken.     Instead, the DON did not learn of the incident for two

days   while    Robinson     continued         to    work    at   Beverly.         Third,

Beverly argues that the ALJ should not have concluded that the

three incidents at issue constituted a systemic pattern, and

contends     instead      that   these     were       isolated       incidents.           We

conclude, however, that Beverly’s multiple failures to report

                                          16
allegations of abuse over a short period, spanning roughly two

months, amounted to substantial evidence on which the ALJ could

properly base his finding of a systemic violation.

                                              B.

            Beverly      claims        that    CMS’s         determination       that    the

alleged    violations      amounted       to        “immediate     jeopardy”       was    in

error.    In cases when a CMP is imposed, “CMS’s determination as

to the level of noncompliance . . . must be upheld unless it is

clearly    erroneous.”           42     C.F.R.        498.60(c)(2).              “Immediate

jeopardy” is defined in the Code of Federal Regulations as “a

situation in which the provider’s noncompliance with one or more

requirements of participation has caused, or is likely to cause,

serious injury, harm, impairment, or death to a resident.”                                42

C.F.R. § 488.301.          Thus,       “[a]        finding    of   immediate       jeopardy

. . .    does    not   require     a    finding       of     present     harm,    but    also

encompasses      a     situation       that    is      ‘likely     to     cause’     harm.”

Hermina Traeye Memorial Nursing Home, DAB No. 1810 (2002).

            Under the clearly erroneous standard of review, the

ALJ reduced the length of the immediate jeopardy period by three

days, concluding that it had ended on April 11, 2005, rather

than April 14.         We hold that this determination was itself not

clearly    erroneous.            Both     Nurse        Marino      and     Nurse     Taylor

recognized that nursing assistant Robinson’s actions at the very

least    might    have    constituted         abuse.         Yet   the    incident       went

                                              17
unreported for two days, during which time Robinson continued to

work at Beverly and give care to the resident he had allegedly

abused.        The fact that no further harm occurred is irrelevant,

as only the possibility of harm is required under § 488.301.

CMS’s      determination,         and      the    ALJ’s       reaffirmation,        that     the

potential harm was serious is also not clearly erroneous.                                    The

record     suggests       that     the     resident         was   roughly     handled       by   a

nursing assistant, that the nursing assistant’s actions may have

been    punitive         and    retaliatory,          and    that   the     rough    handling

resulted in obvious injury.                  It was not error for either CMS or

the ALJ to find the potential for serious harm in Robinson’s

continued interaction with Beverly’s residents.

                                                 C.

                Beverly next claims that the CMPs imposed by CMS are

unreasonable.        Again, the Secretary’s findings (via CMS) must be

upheld     if    “supported        by      substantial        evidence      on   the    record

considered as a whole.”                42 U.S.C. § 1320a-7a(e).               Further, when

a reviewing court concludes that the basis for imposing a CMP

exists, it “may not . . . [r]eview the exercise of discretion by

CMS    .   .    .   to    impose       a   civil      money       penalty.”      42     C.F.R.

§ 488.438(e)(2).               Nor may a reviewing court reconsider any of

the    factors      taken       into    account       by    CMS   with    respect      to   “the

amount of the penalty.”                Id. at § 488.438(e)(3).

                                                 18
             CMS can impose a CMP, not to exceed $10,000, for every

day   that    a      facility       is    found      not    to     be     in    substantial

compliance. 42 U.S.C. § 1395i-3(h)(2)(B)(ii).                             The appropriate

CMP is split into two ranges depending on the severity of non-

compliance.         When immediate jeopardy is present, the daily CMP

can range from $3,050-$10,000.                      42 C.F.R. § 488.438(a)(1)(i).

When there is no immediate jeopardy, but the deficiencies have

either caused actual harm or have the potential for more than

minimum harm, the daily CMP can range from $50 - $3,000.                             Having

found the three deficiencies listed above, CMS imposed a CMP of

$3,050 a day for April 9-14, 2005 -- the period for which it

found immediate jeopardy -- and a CMP of $1,000 a day for April

15-August 4, 2005.               The ALJ changed the $3,050 CMP so that it

only ran from April 9 through April 11, 2005, based on his

finding      that     immediate          jeopardy      ended      when     Robinson       was

suspended.

             Because the $3,050 CMP for April 9 through April 11 is

the minimum penalty under the immediate jeopardy classification,

the   CMP    is     reasonable      as    a    matter      of    course    once    we   have

concluded     that         the    “immediate        jeopardy”          classification      is

appropriate.          It    is    also    reasonable       in    duration       because    it

covers only the period during which Robinson remained at work at

Beverly.      We also conclude that the $1,000 CMP for April 12

through     August     4,        2005,    is    reasonable        in     both   scope     and

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duration.      The burden of proving that the CMP was unreasonable

fell on Beverly,       Coquina Ctr. v. Ctrs. for Medicare & Medicaid

Servs., DAB 1860 at 32-33 (2002), yet Beverly made no specific

argument on this point.           Even if it had, however, the CMP still

appears to be reasonable.               It falls at the lower end of the

allowable range for violations that have caused harm or threaten

more than minimum harm, and we agree with the ALJ that the

amount “served the purpose of driving the facility back into

compliance.”       J.A. 312.      Further, it was reasonable for this CMP

to extend to August 4 because it was not until that day that CMS

could   say    with   certainty      that     Beverly’s    employees    had    been

properly      “in-serviced”       and    that    there     were   no   additional

unreported allegations of abuse.                Accordingly, the CMPs imposed

by CMS were reasonable.

                                         D.

              Finally, Beverly argues that the DAB erred when it

upheld CMS’s conclusions by overlooking the fact that Surveyor

Campbell completed his investigation at Beverly and testified

before the ALJ despite a clear conflict of interest.                          While

there   is    no   doubt   that   Surveyor      Campbell    ignored    an   obvious

conflict of interest in proceeding with the survey that resulted

in the citations at issue, see 42 U.S.C. § 1395i-3(g)(1)(E)(2),

this does not affect our analysis.                 First, “inadequate survey

performance by a state does not -- (1) Relieve a [facility] of

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its     obligation      to        meet     all     requirements       for      program

participation;         or        (2)     Invalidate      adequately         documented

deficiencies.”         42 C.F.R. § 488.318(b).                 Further, as the DAB

decision noted, the ALJ knew of the conflict of interest and

could   weigh    the    credibility        of    Surveyor      Campbell’s    testimony

accordingly.       In fact, the ALJ explicitly stated that he was

relying    on    evidence        other    than    Campbell’s      testimony.       Had

Campbell been the government’s only witness, perhaps the ALJ’s

decision would be in doubt, but under the circumstances there

was substantial evidence to support the decision.

                                          III.

            In   sum,       we    conclude      that   CMS’s    determination     that

Beverly violated 42 C.F.R. §§ 483.13(b), (c), and (c)(2), (3)

was supported by substantial evidence.                  We further conclude that

CMS’s finding of immediate jeopardy (as subsequently modified by

the ALJ) was also reasonable, as were the CMPs imposed for the

violations.      Beverly’s petition for review is therefore

                                                                               DENIED.

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