STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

THE AMBROSIA HOME, )

)

Petitioner, )

)

vs. ) CASE NO. 80-671

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

)

RECOMMENDED ORDER

Final hearing in this case was held pursuant to notice on July 10, 1980, in Tampa, Florida, by Stephen F. Dean, assigned Hearing Officer of the Division of Administrative Hearings. Entry of the Recommended Order in this case was delayed to permit the parties the opportunity to file proposed recommended orders. The proposed recommended orders not having been filed, after consulting with the parties the Recommended Order is herewith entered.

This case arose upon the denial of the Department of Health and Rehabilitative Services (DHRS) of a claim for reimbursement by The Ambrosia Home, Inc. (Ambrosia) for a bed reserved by Ambrosia for a Medicaid recipient.

APPEARANCES

For Petitioner: Willard Roth, Administrator

The Ambrosia Home

1709 Taliaferro Avenue

Tampa, Florida 33602

For Respondent: Janice Sortor, Esquire

Department of Health and Rehabilitative Services

W. T. Edwards Facility 4000 West Buffalo Avenue Tampa, Florida 33614

PROCEDURAL BACKGROUND

The issue in this case is whether Ambrosia, a nursing home, should be reimbursed for 15 days that a bed was reserved for a Medicaid recipient pursuant to Rule 10C-7.48, Florida Administrative Code. The claim was denied by DHRS because Ambrosia failed to complete Paragraph 2 of HRS Form 227.

FINDINGS OF FACT

1. The Ambrosia Home, Inc. is a nursing home approved as a provider of health care to Medicaid recipients.

2. This case involves a claim for the reservation of a bed for Leo LaPorte. LaPorte was an elderly male who was in poor condition and whose application for Medicaid benefits had been pending for some time. After preliminary medical approval, LaPorte was tentatively approved for Medicaid benefits. His placement in Ambrosia was discussed between the caseworker assigned to LaPorte's case and the staff of Ambrosia. LaPorte was admitted to Ambrosia on January 21, 1980, but was hospitalized on January 22, 1980.

   
   

3. An on-site visit of a Medicaid recipient in the provider facility is necessary to the final approval of the recipient's benefits. Final approval of LaPorte's application for Medicaid benefits was impossible due to his hospitalization, and therefore his application was not approved until after his discharge from the hospital, at which time he was placed in Havana Villas Nursing Home.

   
   

4. Upon LaPorte's hospitalization on January 22, 1980, LaPorte's caseworker was notified by telephone of his hospitalization, and the staff of Ambrosia prepared an HRS Form 227 on LaPorte as though he were an approved recipient. This form was forwarded to DHRS and eventually came into the possession of LaPorte's caseworker.

   
   

5. LaPorte's HRS Form 227 was introduced as Exhibit 1. This form addressed to the Social and Economic Services' Assistance Payments Section from Ambrosia, Provider #0200999, advised that Leo LaPorte had been admitted to Brandon Community Hospital on January 22, 1980. The specific portion of the form which was not completed is contained in Paragraph 2 of the form and provides as follows: "...we (a) are ....(b)are not ....reserving a bed."

   
   

6. Subsequent to LaPorte's hospitalization, there were several conversations between the Administrator of Ambrosia who had filled out the HRS Form 227 and LaPorte's caseworker regarding approval of LaPorte's application for Medicaid benefits. These conversations continued until approximately February 26, 1980, two weeks after LaPorte's release from the hospital and placement in Havana Villas Nursing Home. On or about that date LaPorte's caseworker conducted an on-site visit of LaPorte, and his application for Medicaid benefits was approved.

   
   

7. During the conversations between LaPorte's caseworker and the staff member at Ambrosia responsible for completion of the HRS Form 227, the fact that Paragraph 2 of the form was not completed was never raised by the caseworker.

   
   

8. On February 26, 1980, DHRS denied the reimbursement of Ambrosia for the bed reserved for 15 days for Leo LaPorte on the basis that Paragraph 2 of HRS Form 227 had not been completed to indicate whether or not Ambrosia was reserving a bed for LaPorte. Ambrosia controverted the denial of its claim in a timely fashion.

   
   

9. No evidence was presented that the bed reserved by Ambrosia for LaPorte was not reserved.

   
   

   CONCLUSIONS OF LAW

   
   

10. HRS Form 227 is used pursuant to two rules contained in the Florida Administrative Code. Form 227 is used by nursing homes pursuant to Rule 10C- 7.48, Florida Administrative Code, to reserve a bed for a recipient under the following portion of the rule:

    (b) Conditions for Paid Bed Reservation:

    The following conditions will be met when a bed is to be reserved in a long-term care facility because of a recipient's hospitalization for an acute condition

    or a therapeutic home visit:

    1. Notification -- must be promptly made to local office of the Department on Form DHRS-227 provided for that purpose, prior to planned absence. On the weekends and holidays, notification of unplanned absence such as emergency hospitalization will be accomplished

    by phone with the local Department the following working day with simultaneous submitted of DHRS-227.

    
    

11. Form 227 is used by facilities caring for the mentally retarded to report any absence of a resident pursuant to Rule 10C-7.49 Florida Administrative Code, which provides in pertinent part as follows:

    
    

    (c) Absences and Readmissions. The facility will be responsible for advising the local office within 24 hours of any absence from home of any resident for

    whom the Program has assumed responsibility. All absences are to be reported on form

    HRS 227. Local offices are to distribute forms to the facility. On weekends and holidays, notification of absence will

    be made the following working day. When the facility care is interrupted by hospitalization, the bed may be reserved for the resident up to 15 days with vendor payments continuing through the 15th day. ...

    
    

12. The provisions of Rule 10C-7.49, Florida Administrative Code, affirmatively require the completion of Form 227 whenever a resident is absent, and permit the facility to reserve a bed up to 15 days at its option. Rule 10C-

    7.48 would require the filing of Form 227 only when a bed is to be reserved. The filing of a Form 227 by a nursing home pursuant to Rule 10C-7.48 indicates the nursing home is reserving a bed, notwithstanding completion of Paragraph 2.

    
    

13. The facts reveal that LaPorte's caseworker received the HRS Form 227 form Ambrosia and afterwards had conversations with the individual at Ambrosia who filled out the form concerning the status of LaPorte's application for Medicaid benefits. Although the caseworker was on notice of Ambrosia's reserving a bed for LaPorte, the incompleteness of Paragraph 2 was never raised in these conversations. DHRS made no decision regarding LaPorte's Medicaid application and Ambrosia's claim for the reserved bed until February 26, 1980, and more than one month after LaPorte's admission to Ambrosia and nearly two weeks after the reservation expired. At that time DHRS denied Ambrosia's claim for the bed reservation because Paragraph 2 of the form was incomplete. DHRS asserted that it had no basis to assume Ambrosia did reserve the bed because Paragraph 2 was incomplete. This decision is contrary to the provisions of Rule 10C-7.48, Florida Administrative Code, which provides that DHRS be notified when

    a bed is to be reserved in a long-term care facility because of a recipient's hospitalization for an acute condition on Form 227. DHRS having received the incomplete Form 227 from Ambrosia was on notice and under a duty to inquire if it had a question whether or not, in fact, Ambrosia had reserved a bed for LaPorte.

    
    

14. DHRS argues that Ambrosia did not present proof that in fact it did reserve a bed for LaPorte, and that this is fatal to its claim. However, Rule 10C-7.48 establishes that a nursing home advises DHRS of the fact that it is reserving a bed by filing the Form 227. Ambrosia perfected its claim by substantially complying with this rule and is entitled to reimbursement in the absence of a showing by DHRS that the bed was not reserved. If DHRS had reason to believe that Ambrosia did not reserve the bed for LaPorte it should have questioned the matter when it received the Form 227. After the controversy arose, DHRS had the opportunity through discovery to determine whether the bed was reserved. The burden does not lie on the claimant to prove its claim beyond the requirements contained in Rule 10C-7.48, Florida Administrative Code.

    Having substantially shown its compliance with the rule, the burden passes to DHRS to support its denial of the claim.

    
    

15. It should be noted that based upon Ambrosia's filing of HRS Form 227, DHRS could have enforced its right to place LaPorte back in Ambrosia. Similarly, should a review of the records of Ambrosia reveal that the bed was not reserved, this would be grounds for an administrative action to recover the monies paid and to penalize Ambrosia for Medicaid fraud.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends that the agency head approve the claim of The Ambrosia Home, Inc. for reimbursement for 15 days of benefits for a bed reservation for Leo LaPorte.

DONE AND ORDERED this 3rd day of October, 1980 in Tallahassee, Leon County, Florida.

STEPHEN F. DEAN

Hearing Officer

Division of Administrative Hearings Oakland Building

2009 Apalachee Parkway

Tallahassee, Florida 32301

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 3rd day of October, 1980.

COPIES FURNISHED:

Janice Sortor, Esquire Department of HRS

W. T. Edwards Facility 4000 W Buffalo Avenue Tampa, Florida 33614

Willard Roth, Administrator The Ambrosia Home, Inc.

1709 Taliaferro Avenue

Tampa, Florida 33602

Docket for Case No: 80-000671

Orders for Case No: 80-000671