Appeal from the Order of the Department of Public Welfare in case of Sylvester Sutton, Case No. 106436.
Nancy Schuster, for petitioner.
Gary Goldman, Assistant Counsel, for respondent.
Judges Rogers, Craig and MacPhail, sitting as a panel of three. Opinion by Judge Rogers. This decision was reached prior to the resignation of Judge Mencer.
[ 66 Pa. Commw. Page 461]
The appellant, Sylvester Sutton, is an 80-year-old resident at Centennial Springs Health Care Center, a skilled care nursing home located at Warminster, Pennsylvania. He was admitted to Centennial in August, 1979. In June or July of 1980, he was hospitalized for surgery and the placement of a pacemaker and afterwards readmitted to Centennial in July, 1980. His care at Centennial is paid by his Social Security allotment and by contributions of the Department of Public Welfare through the Medical Assistance Program, the costs of which program is shared by the Federal and State governments.
In October, 1980 Centennial's Utilization Review Committee recommended that the level of nursing care provided Mr. Sutton should be reduced from skilled to intermediate. As required by regulation, the Bucks County Board of Assistance, as agent for the appellee State Department of Public Welfare, reviewed Centennial's recommendation and on November 12, 1980 notified Mr. Sutton that his level of care would be changed from skilled to intermediate on November 24, 1980. On November 19, 1980, Centennial sent to Jean Davis, Mr. Sutton's daughter and the person acting in his behalf, written notice of the change in the level of care to be provided to her father, from skilled to intermediate. This latter notice also reminded Ms. Davis that Centennial was a skilled nursing facility which did not accept Intermediate Medical Assistance patients, with the obvious, although not expressly stated, consequence that Mr. Sutton's residence would have to be changed.
Ms. Davis, in behalf of Mr. Sutton, filed an appeal from action of the County Board of Assistance changing
[ 66 Pa. Commw. Page 462]
the level of her father's classification of care. A hearing was thereupon conducted by a Department of Public Welfare Hearing Examiner at which Jean Davis appeared for her father, with legal counsel. The Hearing Examiner dismissed the appeal and the Department of Public Welfare by final administrative action affirmed. This appeal by Mr. Sutton followed.
The evidentiary hearing consisted for the most part of the admission of Mr. Sutton's case records at Centennial, consisting in the main of his medical records. Mr. Sutton's counsel made it clear at the hearing that an important ground of her client's appeal was the contention that Centennial, the skilled nursing facility (referred to in Federal regulation as the SNF), had not maintained a Discharge Plan for Mr. Sutton and that its Utilization Review Committee had not, therefore, reviewed his Discharge Plan -- both requirements of Federal law; and that his imminent discharge to intermediate care without reference to a Discharge Plan was contrary to law.
If a state chooses to participate in the Medical Assistance program, as Pennsylvania has, it must follow the Federal Medical Assistance statutes and applicable Federal regulations. White v. Beal, 555 F.2d 1146 (3rd Cir. 1977).
The statute in question is Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396m (1976 & Supp. III 1979). The Act requires a State Plan for Medical Assistance to provide methods and procedures to prevent unnecessary utilization and to promote economy in the Medicare program, 42 U.S.C. §§ 1396a(a)(28) and 1396a(a)(30).
The regulations concerning utilization control are found at Part 456 of Title 42 of the Code of Federal Regulations. Included within Part 456 is a topic "Discharge Plan" at 42 C.F.R. §§ 456.346-456.348 ...