Appeal from the Order of the Department of Public Welfare in case of Appeal of Robert Brown, dated September 15, 1977.
Michael J. Campbell, with him Dana M. Breslin, for petitioner.
Betty F. Perry, Assistant Attorney General, for respondent.
Judges Crumlish, Jr., Wilkinson, Jr. and Mencer, sitting as a panel of three. Opinion by Judge Crumlish, Jr.
Robert Brown appeals a Department of Public Welfare (DPW) decision which reduced his level of care under the State Medical Assistance Program from "skilled" to "intermediate" care. We affirm.
Does Mr. Brown qualify under the definition and intent of federal and state law for skilled care in a State Medical Assistance Program; must non-medical needs be considered in determining a level of care; did the fair hearing violate due process?
This 76-year old male patient received skilled care benefits at the Mercy Convalescent Home for ten years. He is epileptic (for which he takes Dilantin), has lost the toes on his right foot, has occasional recurring ulcers on his right foot, is occasionally confused and occasionally incontinent. He is without family or outside friends who are able to care for him and is said to be an alcoholic. At the same time he walks without aid, is free to come and go as he pleases, needs no assistance with meals, dressing, shaving, etc., desires to leave the home, is quite sociable and makes friends easily. His attending physician described his general state of health as fairly good.
The Office of Medical Programs consisting of doctors and nurses made on-site visits and redetermined
that Mr. Brown required intermediate care. A staff doctor, nurse and administrator disagreed, and so testified at a fair hearing. The hearing examiner concluded that daily skilled care was not required and DPW affirmed the adjudication.
State benefits for skilled and intermediate medical assistance are authorized by Section 443.1 of the Public Welfare Code.*fn1 The level of care required is to be based on an individualized determination which takes into account both health and social problems of the patient.*fn2
Skilled care benefits are skilled nursing and rehabilitative services needed by the patient on a daily basis, which are practical to provide only in a skilled nursing facility.*fn3 Skilled care patients generally fall into two categories: the short term convalescent recovering from serious accident, operation or illness, or the long term chronically ill.*fn4 Examples of skilled care services include administration of medication with known dangerous side effects; restrictive procedures ...