From time to time federal regulations covering nursing home quality of care are updated. Thus far, the following updates have been published in May and June of 2024. Updates posted May 10, 2024 42 CFR Part 483 — Requirements for States and Long Term Care Facilities view changes § 483.5 Definitions. view changes § 483.10 […]
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Nursing homes that accept Medicare or Medicaid are required to comply with quality of care regulations. Although we have blogged elsewhere on specific nursing home resident rights, the current federal regulations are linked below. 42 CFR Part 483 — Requirements for States and Long Term Care Facilities § 483.5 Definitions. § 483.10 Resident rights. § […]
In ____ v. Brock, Judge Schwall, Fulton County Superior Court), affirmed an administrative law judge’s Final Decision as supported by the administrative record. Here, the most interesting portion is the language discussing how a Superior Court reviews the appeal of an ALJ decision. The case began when DHS found suspicious transactions on a food stamp […]
In PR v. Division of Medical Assistance and Health Services (NJ. App. Div. 6/8/2023), the State was authorized to recover Medicaid benefits incorrectly paid. It was not, however, authorized to play fast and loose by withdrawing a waiver of a portion of its claim as part of the Commissioner’s review. Peter and Uma, an unmarried […]
The collateral estoppel (issue preclusion) rule is part of the finality doctrine along with Res Judicata (claim preclusion). It general prevents a party from re-litigating the same issue in a second court. In other words, you don’t get a second bite at the apple in another court simply because you were dissatisfied with the result […]
On June 5, 2023, the Centers for Medicare and Medicaid Services (CMS) amended 42 C.F.R. § 483.80 (infection control) and § 483.430 (Condition of participation: Facility staffing) to remove expired COVID-19 provisions. See 88 FR 36485. The specific amendments are: Section 483.80 is amended by removing paragraphs (h) and (i). Section 483.430 is amended by […]
“In general, in order to maintain an action, a party “must establish standing to sue on the ground asserted, which requires showing an injury in fact that was caused by the breach of a duty owed by the defendants to the plaintiffs and that will be redressed by a favorable decision from the court.” Ames […]
In L.U. v. Division of Medical Assistance (N.J. Superior Court Docket A-2937-20, May 23, 2023), the Superior Court affirmed denial of L.U.’s request for a fair hearing. How, you ask? “I thought everyone had a right to a fair hearing!!! Well, apparently not. L.U. was an unrepresented Medicaid recipient. He appealed from a May 11, […]
The following Georgia Medicaid cases were litigated outside the context of an administrative hearing, or were appealed beyond that point. Of course, we are not representing there are no other published decisions on point. United Cerebral Palsy of Georgia v. Ga. Dep’t of Behavioral Health and Dev. Disabilities, 331 Ga. App. 616 (2015). A provider […]
An ALJ may order a prehearing conference to simplify the issues being presented. Conferences may be held in person or by telephone. Ga. R. & Regs. § 616-1-2-.14 is analogous to O.C.G.A. § 9-11-16(a) because it allows ALJs to clear up evidentiary and procedural matters before the hearing. Specifically, Rule 14 provides: (1) Conferences. The […]
All applications for ABD Medicaid require that the applicant’s basic eligibility be verified. See ABD Manual Section 2201-4. Applications for long-term care Medicaid also require verification of income and resources, but caseworkers are instructed to “For ABD Medicaid verification requirements, see the sections pertaining to the specific COA and the Income and Resource Chapters.” ABD […]
Right to a Hearing The right to a hearing is a property right and belongs to the applicant. See Bd. of Regents v. Roth, 408 U.S. 564 (1972) (“Property interests, of course, are not created by the Constitution. Rather, they are created and their dimensions are defined by existing rules or understandings that stem from […]
Taking over a case started by someone else is never my preference. It’s far easier to do something correctly the first time. So what do you do when you’re brought in to fix a case. You pray! First, if someone hires you and no decision has been made, review the file. If there is an […]
Both O.C.G.A. § 49-4-153(b)(1) and 42 C.F.R. § 431.244(g) require that all Medicaid agency decisions be accessible to the public, except that 42 CFR § 431.305(b) requires that the following information must be safeguarded: (1) Names and addresses; (2) Medical services provided; (3) Social and economic conditions or circumstances; (4) Agency evaluation of personal information; […]
Right to Hearing, Generally Medicaid applicants and beneficiaries are entitled to adequate notice of state agency actions and a meaningful opportunity for a hearing to review those decisions whenever their claim for benefits is denied or not acted upon with reasonable promptness. Federal law, at 42 U.S.C. § 1396a(3); 42 C.F.R. Part 431, Subpart E, […]
There are times when formal “legal” communication is necessary. This post addresses several instances regarding how that can be done. It is not meant to be all inclusive and, in many cases, specific communication rules apply. Beginning a lawsuit: When you begin a lawsuit, a summons must be served on the Defendant(s). Generally, Rule 4 […]
In a recent case (Dep’t of Tenncare 4/20/2022), Appellant’s application for nursing home Medicaid was denied due to ownership of a life insurance policy with a cash value of $2,184.66. She had been under a limited conservatorship since June 2, 2021. The Medicaid application was filed on July 21, 2021. Neither Appellant nor the limited […]
In Weeks v. DHS, Division of Family and Children Services, Office of State Administrative Hearings, Docket 2117014 (April 28, 2021), Brian Center Health and Rehabilitation – Canton, purportedly filed a direct appeal on behalf of Marilu Weeks after her Medicaid application was denied. Judge Teate, in Docket No. 2115533, directed Brian Center to provide evidence […]
In 1984, the U.S. Supreme Court decided Chevron v. Natural Resources Defense Council, Inc., 467 U.S. 837 (1984). Chevron concerned an EPA environmental regulation. The amended Clean Air Act required these “nonattainment” States to establish a permit program regulating “new or modified major stationary sources” of air pollution. Generally, a permit may not be issued […]
Appeal Route From Article 6 Probate Court In Spence v. Dep’t of Behavioral Health and Developmental Disabilities, 359 Ga. App. 603 (2021), Jermaine Spense was involuntarily committed as a hospital inpatient. Spence sought review after the Department sought an order of continued hospitalization of Spence pursuant to OCGA § 37-3-83. On April 18, 2019, the […]
In Georgia Department of Community Health v. Medders, 292 Ga. App. 439, 2008 Ga. App. LEXIS 804 (2008) the Court stated the appellate standard of review as follows: “In addressing this appeal, we are mindful of the narrow scope of judicial review applicable to administrative agency matters. A court cannot “substitute its judgment for that […]
