Conclusions Having reviewed the Notice of Intent to Deem Application Incomplete and Withdrawn from Further Review, dated May 12, 2009, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration ("Agency") has entered into a Settlement Agreement (Ex. 2) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows: ORDERED: The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. Each party shall bear its own costs and attorney's fees. The above-styled case is hereby closed. 1 Filed July 10, 2009 2:23 PM Division of Administrative Hearings. DONE and ORDERED this _f_day of _ ,,_of""""--"'"""'"-l""""A-'-t_f , 2cf.i inTallahassee, Leon County, Florida. Holly Benson, ecretary Agency for He th Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Stephen T. Maher Shutts & Bowen LLP 201 $outh Biscayne Boulevard Suite 1500, Miami Center Miami, Florida 33131 Jamie L. Jackson Assistant General Counsel Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS #3 Tallahassee, Florida 32308 (Interoffice Mail) Jan Mills Karen Rivera Agency for Health Care Administration Laboratory Unit Manager 2727 Mahan Drive, Bldg #3, MS #3 Agency for Health Care Administration Tallahassee, Florida 32308 2727 Mahan Drive, MS #28 (Interoffice Mail) Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the _._8:,.._P_day of-=:......-.--=-""-7-·....,,,. '-----' 20 g:- -- Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 To:RS09210158 CHARLIE CRIST GOVERNOR Mi,y 1l, 2009 ADMTNTSTR.ATOR B1HMf HHlth care for.,,Flor'ltlltms MOU.Y BEN50N SECReTARY CEKTlPIBD MAll. / RETURN R.ECEW'r Rl?Q STED 'PETER M WALLACH AND ST·TART F TOP.PER MOS PA 1480 N UNIVERSllY DRIVE COP.AL SPR.INGS, E'L 3307 l LlC:f.NSE NUMBER: 800004917 CAS£ #: 200900.5482 !i()J'JC& a,ViUNT TO pEEM Al'fUCA:rJmr,,lX,COM1"1.V.Il., 'ND wrrlJDBAl»'ll fRQM FURTHER gvur.w or Your tappJIClltlan for license is d.:cmod lncompleto and wlthdrnwn ftom further consideration punnuu,t 10 SQQllon 408,806(3)(b), Plorida St11-Mea, wJii\;b i1litll¢8 that "Tteque vd informition omiHod from an 11ppllc•tk,n for Uccnsure, license renewal, or obnn1io ownership, other than an lnspectjon, must be.fll•d wilh the a cncy within 21 do.y, after the llSCDcy'1 rcqu fi:il' Qmltted inform11tion or tho oppllcadon shall be deemed incomplete and shitll be withdrawn from further oon,idonition llnd the f,ot sh•ll bo forfoi d' '. You were notified by c:orrcq,o"d11m:111 dntod Fobruar)' 28, 2009 to provide furthar infonnat1o11 nddrol\ ing identified appt1rcnt c1Tnr11 or ,'lmlsslont within twenty-one da.)'I trc,m &he rcoelpt of the Agency's correspondence, Our rec:ordl lndlc1110 you received this cornr11pondcncc: by certified mllfl on Murch 09, 2009. A11 this requested Information wa. not timcl)' received by tho Agency, your application is dc:c:mcd Incomplete and withdmwn C'l'oTTI further uonsidcnuion, TI1e ou'tt)IAl\dll\Q h1sue1 rornalnlng for liconsure are: Corrected LIit ofTU!lts Performed: Tbe Pl'Clflclcney TtJstlng Comp ¦11)' Ji11red I• not CLIA approved, ·-·· .. EXPLANAJJOJ! OF RlGWl'S l'ursuant to Section 120.S69, F.S., you h1n1c the rlgt11 to rcquost ,in 1.1dn1iuilllfAtfvc bc:arins, .(n or(J¢r to obtidn a formal proc;aodina before tho Di'lision of Admlnlstrn\.lvo 'Htorin under Section 120.57(1)1 P.S., your rcq1,1 1t for on administrative hearin11 musr i.:onronn to·m requfre1no11t.li in Seotlon 28-106.%0 I, FlorldA MminlNtr'o1tiYC Code (F.A.C), nnd must state tho material fru;ts you dispula. ION AND EXPLANATION OF RICRTS IORMS. Katen Rivera, Manaa r r :.bomtory LicL.'JldUrt: U11it l.)C: Agit,1.;y Cl\lrk, MBil Stop j Legal Lnt ¢ Unit. Mnll Stop '.l T:u1an11111, Plorida 32305 Z7:z7 M11han Oriv,,MS#U Certified Adidti Nun1bcr SENDERS RECORD 111111· 1/lhCI.myflcirld•. i:cim • Vi:rn Ai'iCA !lrtllno II\ EXHIBIT I ( JUN-05-2009 16:40 From: To:9509210158 STATE OF FLOlUl)A AGENCY FOR HEALm CARE ADMlNlSTRATION RE: Pc,tor M Wall11c:h And Shari F Topper Mds P11 CASE NO: 2009005482 El,.RCTION OF RIGHTS Thill Jlh;:cti9n of Rishta form Is attaohed to II proposed Noti of lntont to Dcein Inc:omploio Rlld Withdraw fl-0111 Purther Rt!Vlew of the Agency for Hoslth Care Admi11istration (AHCA). Tua lltlc may be Nottcc ot lnlenc fO Dc:orn Incompluto and Withdraw from P'arthor Rcwlow or ,nmo otbcr notice vr •ntondcd adlon by AJiCA. An £1,sdpp oflUc,ltM muu be rclyrnecl hyJDBll or by fqr \Y.i!Jlln 21 de:m or the dg YOU rn:eh,e lhJ iHtaehefl rfgtlt:e o( Jntent to peom Tnenm111.11,s ¦qd WltLdraw,,.ftpm fynher Reylm or pny nrJ,sr PDIURl d gctJon h,y ARCA. If' an Rleclkn1 g{ Rigg with )'OUI' IClecmtd optJon i, not nctlvccl by ,'\HCA within twenty.one (21) dn)'S from the dato you rocoivcd d1i1 notice of propo_.d ac;t(Qn, you will havo given up your right to t1on1.esr rhe Agenc)''III proposed agtlon amd w ti1111l ordorwfll b,:1,.ued. (PlciU$a n::J)Jy using thi, B)ccti,:1n qf Rjght, fnnn unless you.)'Our attorney er your roprosentBtiv prc:rcr io reply ncc:ordlna to Chapter 120, Florida Statutes (2006) lllld .Rul, :28, Florida Administrative Cod ¦.) Plcase return your EL6C',CIQN 9.FRIQHTS to: Agency for HCA!th Administration AL1QnUon: Agency Clt::rk 2727 Mahnn Drive, Mail Slup N3 T•llahusao, Florida 32308 Phon,:: (8SO) 9ll-:B73 Fax: (850) 921·01S8 'PLM S.W...F-.c:r QNLY 1 op TI:JESE 3 OPTIONS, Ol''l"lON ONE (I.) I admit to tbe aJltptlons of facts and law contutned 11- tbo Notlee ofintcnt to DCIClm lncontpleta abd Withdraw from Furth•.- Rovti!W. o, other notice ot lnte•dod acdun by ABCA aad I waive my rli:bt to object and bavi, a hcnrln1, I 1.tndermnd that by Jiving up my rigbt lO A h•ring, a tlnal order will be 1,,cued that adopts tbc prop0scd agency nction and impoao11 the: proposed pcn11lty, fine= or nction. OP'flON TWO (2) I 11dmit to tha allcuation1 or taotl tOJ1C1ln111d In tbc N1,1Uce ur lnt.:Pt to 0111-,sn lnaompl"to 11.,d.Wllhdraw rrom 11'ut111or Rovlew, or olbcr propoKd aetfoa by AHCA, but I w,,h to be bcurtl at 011 Informal prooeeclln1 (pursuant to Se<:tion 120.57(2), f'luridA Statute:1) where I mtiy submit testimony and wtincn cvld nce to tbc Agency tu shuw t..hat the proposed administrative llC: ion i, too 11cverc or that Lhc floe sbou Id bv roduccd. OPTION 1".l-lltf:E (3) _ - I cU11p11te the ancsatloo» uffatt contained In tho Notice otlntont fo Ocam I11completo •nd Wlthdnn, fmrn Further luview or other proposed acdoo by AHCA, And I r1:q11est a tormal hearing (pursuant to Sc:ctiun 120.57(1). Floridn Statuto1) before an . Adminis1ntlvc Law Judge l\J)pointed by the Divlsil)n of Administrative Hc11rin1:s, fl.,lliASE,.NOTE: Choo11in1 OPTIOii THREE (3), by i oit, l» u9-I tufflclcnt to obtain n f1mr..aJ hcarlni;. Yuu ahm mu t nte II writtan petition in order to obtnin a formal hc11ring before tho ...,... ., · - _,.. -' .. ,- = ••n?:. ,_ U.nr:... ......,4,.,. c:.. 1-..,..,.tfn" 1')0 <i7f1' f.'lnl'l.-fn L'\tUtell. It must be JUN-05-2009 16:41 From: To:8509210158 P.17,,.17 recelv(:d b)' the Agency Clerk ut tha address above within 21 clllys o( receipt or lhls proposed adminislrutivc aotlon. The roqut:u1L for rorrnal h rlng m1Jsl. cottform tc;, thi: requirements of Rule lR- 106.201. Florida Administrntivc Code, which willim lhat it contnin: l. The T!M1\: and addre'5 of coch agi;noy llfl'ect(:d ond each agency's 1tfe or ldi,ntJfielldon nurnbor. If known: Your numc, addn1111, and telephone numoor, 111td th nimc, uddrcs!I, and telephone number of )'Our rcpti,acntativo or l1twyor, If any: An 9pJanation of how yoUl' sub1tantl11I Interests will be affected by Ihc Agency's proposed action; A statement of when and how you rccoivod notice ot'tho Agency's proposed action: A statement of tlll disputed issues of nmwria1 fact, If there arc nunc, you must s111tc that thon:t arc none; _ A concise statement of me ultimate f111:1:S allc9cd. including the specific facts you contend wnmint rav rsJl or modi.flcatlon of the Aaency's proposed nclion; · A 6tati:nient of the spc:oific rules or su.tu.tcs )'OU c;lnlm require ri:,vorsal or modlflcAtion of the Agcn )"I proposed aotlon; and A 1tfttcment of the r¢lli=f yo1,1 are sceklns, stating ex.,ctly what uc.tion you wi1h th Agcnt:-y to take with respeet to It., proposed 11otion. (Medl11tlon under Section 120.S73, Florida. Statutes. may bo avaUablci in thill matter If the Agen y agrees,) License type: clinical laborntocy T..iccr.is= number: 800004917 Lfccn cc Nnme: Peter M Wallach And Shari F Topper Meis Pn Contact l)crson: ·------ Name 'i'itle Ad Ms:. _ Streot and numb(tt' -··· ··clty Zip Code Telephone No. Fax No•. Email (optional). _ 1 hereby eortify that J. pm duly authQTl d ro submit this Notice of Election of Righis to the Agency for Meahh Caro Adrninhitmtlon on behalf of th lictn$eo referred to 11bova. Signed; Dat9; Print Namo:. 'rittc: ·------- USPS -Track & Confirm Page 1 of 1 Hl2trul I t.il.lJI I SlgnJn Track & Confirm Search 'Results Label/Receipt Number: 7180 390198481045 5162 Service(s): Certified Mall"' Status: Delivered Your item was delivered at 12:27 PM on May 18, 2009 in MIAMI, FL 33144. Detailed Results: Delivered, May 18, 2009, 12:27 pm, MIAMI, FL 33144 Notice Left, May 15, 2009, 11:22 am, MIAMI, FL 33144 Jrack & Confirm •!!i_ o.nQp i ..._ _ Track & Confirm by email _ _ _ Get current event information or updates for your Item sent to you or others by email. (oii> ) Return Receipt (Electronic) Verify who signed for your item by email. (iii) ,..,,.,. f.;f<" I:lll!!!ll. Pdyat:y Polk:y Terms of Us uslness customer GatewllV Copyright© 2009 USPS. All Rights Reserved. No FEAH Act EEO Data FOIA { 1\i t1! f. •"ti(:1•:: 1\: "1·'<'• -1 t'. h••'.J. • http://trkcnfrml.smi.usps.com/PTSinternetWeb/InterLabelinquiry.do 05/19/2009 STATE OF FLORIDA
The Issue The issues for consideration are those allegations set forth in an Administrative Complaint brought by the State of Florida Department of Professional Regulation (Department), in which the Respondent, Scarlett Jones, R.N., is accused of various violations of Chapter 464, Florida Statutes. Through Count One it is said that the Respondent transcribed an order for Heparin to be administered to the patient K.W. as 15,000 units when the physician's order quoted the dosage as 5,000 units, and that the patient was given two dosages at 15,000 units as opposed to the required 5,000 units. In an additional accusation against the Respondent, related to patient care, Respondent is said to have failed to indicate in the patient K.W.'s nursing notes, on or about May 16, 1988, that an administration of Aminophylline was to be restarted during the 11:00 p.m. to 7:00 a.m. shift. Further, it is alleged that this substance was not restarted until 8:00 a.m. on the next day as discovered by a subsequent shift employee. As a consequence, Respondent is said to have violated Section 464.018(1) (f), Florida Statutes, related to alleged unprofessional conduct. Count Two to the Administrative Complaint alleges that on or about June 4, 1988, the Respondent who was assigned to care for the patient E.J., was told by a co-worker that the patient had fallen out of bed and soiled himself and that the Respondent failed to respond to the patient's needs after repeated requests. Eventually, it is alleged that the patient's wife assisted him back to bed and the co-worker took care of the patient's hygiene. As a consequence, Respondent is said to have violated Section 464.018(1)(f), Florida Statutes, related to unprofessional conduct and that she violated Section 464.018(1)(j), Florida Statutes, for knowingly violating a rule or order of the Board of Nursing. Finally, the third count of the Administrative Complaint alleges that the Respondent, on or about June 14, 1988, was found asleep while on duty in violation of Section 464.018(1)(f), Florida Statutes, an act of unprofessional conduct, including, but not limited to, the failure to conform to minimum standards of acceptable and prevailing nursing practice. For these alleged violations, the Department seeks to impose disciplinary action which could include revocation or suspension, the imposition of an administrative fine and/or other relief which the Board of Nursing might deem appropriate.
Findings Of Fact During the relevant periods under consideration in this Administrative Complaint the Respondent was licensed by the Department as a registered nurse and subject to the jurisdiction of the Board of Nursing in disciplinary matters. The license number was 1702172. On April 11, 1988, Respondent took employment with Gadsden Memorial Hospital in Gadsden County, Florida, in a position of charge nurse on the Medical-Surgical Pediatrics Unit, also known as "Med-Surg. Ped." That unit provides short term acute care for post-operative patients, acute medical patients, and acute pediatric patients, some of which require 24-hour observation. Response to the needs of the patients is given by three nursing shifts in each day which begins with shifts of 7:00 a.m. to 3:00 p.m., followed by the 3:00 p.m. to 11:00 p.m. and then 11:00 p.m. to 7:00 a.m. on the following morning. Upon hiring, Respondent was assigned to the work the 11:00 p.m. to 7:00 a.m. and was the only registered nurse on duty during that shift. Among the responsibilities of the charge nurse at the time under examination here, was the assessment of patients on the unit as well as an awareness of the abilities of those other employees who were working in this shift. This was in an effort to provide direct supervision of critical care patients and included supervision of activities performed by a Nurse Technician. Respondent was more directly responsible for critical patients. Other duties included making frequent rounds and checking vital signs in an attempt to insure that the patients were stable. Respondent as charge nurse on "Med-Surg. Ped." could not leave the floor without notification of the house supervisor, another registered nurse. This person would replace the Respondent on those occasions where the Respondent would need to vacate the floor. In addition it was expected that the Respondent would notify those personnel who were working with her on the unit, where she intended to go and how long she would be gone. Before departing it was expected that the Respondent would check the stability of patients. physician's Orders were written on March 2D, 1988, in anticipation of the admission of patient K.W. to Gadsden Memorial Hospital to "Med. Surg Ped." The admission was under orders by Dr. Halpren. Among those orders was the prescription of Heparin, 5,000 units, subcutaneously every 12 hours. The Physician's Orders in terms of legibility are not immediately discernible but can be read with a relatively careful observation of the physician's orders. A copy of those may be found at Petitioner's Exhibit No. 5 admitted into evidence. The problem that tends to arise is that on the line which immediately follows the orders related to Heparin 5,000 units, is found the word hysterectomy written in such a fashion that the initial portion of the letter "H" might be seen as being placed on the prior line giving the unit dosage of the Heparin the appearance of being 15,000 units as opposed to 5,000 units. On April 11, 1988, K.W. was admitted to Gadsden Memorial Hospital as anticipated. At the time of admission the Physician's Orders previously described were provided. Surgery was scheduled and the patient file was made on "Med-Surg. Ped." Under the practices within this hospital, the ward clerk was responsible for transcribing physician's orders onto the patient's Medication Administration Record. This was done here by the ward clerk, S. Diggs. This is to be checked for accuracy by the charge nurse, to include Respondent, with the fixing of the signature to this Medication Administration Record verifying the accuracy of the clerk's entries. Respondent initialed the Medication Administration Record for the patient designating that Heparin in the amount of 15,000 units Q-12, meaning to be given every 12 hours was the requirement, and had been administered in that dosage. This may be seen in a copy of the Medication Administration Record which is part of Petitioner's Exhibit No. The patient was to undergo extensive abdominal surgery, to include the possibility of a hysterectomy and the incorrect administration of Heparin might promote problems with bleeding. The incorrect amount of Heparin as a 15,000 unit dosage was given to K.W. on two occasions. Another patient who was admitted to the ward which Respondent was responsible for as charge nurse was the patient A.W. Physician's Orders were written for that patient by Dr. Woodward on May 16, 1988. A copy of the Physician's Orders may be found at Petitioner's Exhibit No. 6 admitted into evidence. Among the substances prescribed was Aminophylline drip 20 milligrams per hour I.V. This patient had been admitted to the pediatric unit with a diagnosis of asthma and prescribed the Aminophylline to aid the patient's breathing. It was expected that patient A.W. was to be administered two dosages of Aminophylline, an intermediate dosage to be given every few hours in a larger quantity, and a continuous drip to run at 20 milligrams per hour. Within Petitioner's Exhibit No. 6 are nursing notes made by Respondent concerning A.W. On May 17, 1988, between the hours of 12:00 a.m. and 2:00 a.m. it is noted that Respondent was having trouble with patient A.W.'s I.V. She states that the I.V. site was assessed and had to be pulled and that she was not able to reinsert due to the uncooperative nature of this child. The I.V. was restarted by the house supervisor nurse. An entry at 6:30 a.m. made by the Respondent describes the I.V. position as acceptable. When the shift changed at 7:00 a.m. the new charge nurse did not find the Aminophylline drip in progress, as called for, and this is noted in a 7:30 a.m. entry made by this registered nurse, Sherry Shiro. Petitioner's Exhibit No. 4 admitted into evidence is a Confidential Incident Report prepared by the Gadsden Memorial Hospital concerning allegations against the Respondent. They have to do with an alleged incident that occurred around 5:00 a.m. and contain the purported observations by Lucinda Mack, a licensed practical nurse on duty at that time, and they were received on June 15, 1988, by Carol Riddle, R.N., Director of Nursing at Gadsden Memorial Hospital, and the person responsible for investigating this matter. The copy of the Confidential Incident Report contained observations about the alleged failure of treatment by the Respondent directed in the matter of the patient E.J. These remarks are hearsay. They do not corroborate competent evidence at hearing concerning any oversight by the Respondent in the treatment of the patient E.J. On or about June 14, 1988, the Director of Nursing, Carol Riddle, called the night supervisor Michelle Warring at 2:00 a.m. to ascertain if the Respondent was on duty. Respondent was working on that date. At 2:15 a.m. Warring advised Riddle that the Respondent could not be found and Riddle went to the hospital at that time. When she arrived at the facility at 3:00 a.m. she went to "Med-Surg. Ped." where she was informed by the communications clerk that Lucinda Mack, LPN, was the only nurse on duty in that unit, and that the clerk did not know where Respondent could be found. Riddle and Warring then looked through the patient rooms in "Med-Surg. Ped." but could not find the Respondent. One and a half hours after commencing the search Riddle located the Respondent in a different wing of the hospital which contains a respiratory therapy manager's office. Respondent was there with her husband asleep, with the door locked and lights off. At that time she was the only registered nurse on duty in "Med-Surg. Ped." which had six patients receiving care on that evening. Respondent was not performing her duties or supervising those other persons who worked with her on the unit. Respondent had been observed asleep at her nurses' station desk on several other occasions by Dale Storey, a registered nurse working at the Gadsden Memorial Hospital. Linda Reed, a nurse technician at Gadsden Memorial Hospital had observed the Respondent asleep on duty. As commented on by nurse Riddle, who is qualified to give expert opinion testimony about the performance of the Respondent in her nursing practice, the conduct set out before in these findings of fact constitutes unprofessional conduct in the practice of nursing, in a situation which the Respondent knew what her duties were as charge nurse and failed to perform them at an adequate level.
Recommendation Based upon the findings of fact and conclusions of law, it is RECOMMENDED: That a final order be entered which fines the Respondent in the amount of $1,000 for the violation related to the care of patient K.W. as set out in Count One and for sleeping on duty as set out in Count Three. And, finds that the violation related to patient A.W. as set out in Count One and the violation alleged in Count Two related to the patient E.J. were not proven. DONE and ENTERED this 19 day of April, 1989, in Tallahassee, Leon County, Florida. CHARLES C. ADAMS Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904)488-9675 Filed with the Clerk of the Division of Administrative Hearings this 19 day of April, 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 88-5719 Petitioner's fact finding is subordinate to the finding in the Recommended Order with exception of paragraph 16 which is not relevant and reference within paragraph 34 to the date June 24, 1988, which should have been June 14, 1988. COPIES FURNISHED: Lisa M. Bassett, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Scarlett Jones 2636 Mission Road, #138 Tallahassee, Florida 32302 Judy Ritter, Executive Director Florida Board of Nursing 111 East Coastline Drive, Room 504 Jacksonville, Florida 32202 Kenneth E. Easley, Esquire General Counsel Department of professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue At issue in this proceeding is whether Petitioner is liable for overpayment of Medicaid claims for the period of January 1, 2000, through December 31, 2001.
Findings Of Fact Based upon the stipulations of the parties and the evidence presented at the hearing, the following relevant Findings of Fact are made: AHCA is the state agency charged with the regulation of the Medicaid program in the State of Florida, and has the authority to perform Medicaid audits and recover overpayments, pursuant to Section 409.913(2), Florida Statutes (2001). Petitioner is a Florida, not-for-profit corporation that was enrolled as a Medicaid provider during the audit period of January 1, 2000, through December 31, 2001. At all times relevant to this proceeding, Petitioner was authorized to provide medical services to Medicaid recipients. The selection of records for and the conduct of the audit was not a matter of controversy between the parties. The records in this case were requested within the five-year window for record retention and agency investigation provided by Section 409.913(8), Florida Statutes (2001). Medicaid pays a per diem rate for inpatient hospital care and treatment. This per diem payment covers all services and items furnished during a 24-hour period. The audit in this case dealt exclusively with inpatient services at Florida Hospital Orlando. Deborah Lynn, a medical health care program analyst for AHCA, reviews the agency's inpatient hospital audits. The agency selects a hospital for audit on a random basis, then selects for review, a random sample of that hospital's patients admitted during the audit period. AHCA sends a demand letter to the hospital, which then sends the relevant patient records to AHCA. Florida Hospital Orlando had to be granted a 30-day extension, but eventually provided, to AHCA, all of the requested patient records. The hospital's records were first provided to a nurse consultant, who reviewed the records and made a suggestion as to the number of days for which Medicaid reimbursement should be denied for each patient. The nurse consultant's suggestions were then calculated into an initial overpayment amount and included in the PAAR that was sent to Petitioner on January 20, 2005. Ms. Lynn acknowledged that the PAAR constituted the first notice to Petitioner that AHCA disputed the length of stay for some patients based on medical necessity. After receipt of the PAAR, Petitioner was given the opportunity to examine the days that AHCA preliminarily questioned and to provide additional information in defense of its Medicaid billings. Petitioner did, in fact, submit additional documentation. The records, the additional documentation, and the nurse consultant's recommendations were then forwarded to a peer reviewer; a physician who uses his or her medical expertise to determine the medical necessity of the services provided. In this case, AHCA employed the services of two peer reviewers. Dr. Laura Machado was the peer reviewer for the inpatient medical cases, and Dr. Rahul Mehra was the peer reviewer for the inpatient psychiatric cases. The peer reviewers prepared reports that offered their opinion as to which days of the patients' stays were medically necessary. Ms. Lynn then calculated the amount of the alleged overpayment and communicated that number to Petitioner in the FAAR on August 20, 2005. General issues regarding patient discharge Ms. Lynn emphasized that the peer reviewer's job is simply to determine medical necessity, not to base coverage decisions on the convenience of the patient or provider. She rejected the suggestion that it was any part of the peer reviewer's task to consider what medical facilities and services are actually available in Orlando, at the time that Florida Hospital Orlando is contemplating the discharge of a Medicaid patient. Ms. Lynn reiterated that hospital services under Medicaid are governed by the Hospital Services Coverage and Limitations Handbook, the January 2001 edition, of which sets forth the following "Service Requirements": Medicaid reimburses for services that are determined medically necessary, do not duplicate another provider's service, and are: individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient's needs; not experimental or investigational; reflective of the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a covered service. Dr. Ross Edmundson, Florida Hospital Orlando's medical director for health care management, agreed that a clinically stable patient can be sent home or to a skilled nursing facility "in the best of all worlds." However, Dr. Edmundson pointed out that a safe discharge plan is the primary consideration for the treating physician, and that a safe discharge plan may render things "medically appropriate" that might not be found "medically necessary" in purely clinical terms. For example, if the Medicaid patient has no home, and the physician knows full well that the patient will be living under a bridge if he is discharged to the street, then it would be grossly negligent to discharge that patient without a plan to get better care. If the patient requires $500.00 worth of medications for the next month, and has no way of obtaining them, it may be grossly negligent for the physician to send that patient out the hospital door. The InterQual Products Group's "ISD" (Intensity of Service, Severity of Illness Discharge Screens) is a nationally recognized set of utilization guidelines that are used by hospitals, Medicare and Medicaid. Dr. Edmundson believed that these discharge guidelines take into account factors beyond the purely clinical: You have to have a discharge treatment plan. If you have a place to follow up, if you have [an] accepting physician, if you have a plan, if you know that they can make it there in the next three days and they require follow up in three days, that is clinically appropriate. If you know that they're going to live in a box and you have no assurance that this patient is going to make it back for any follow up, then that is not a safe discharge plan, it is not medically appropriate. The criteria really has that built in. There are barriers that may prevent the hospital from discharging the patient to an alternative location. Even if the hospital has met the patient's immediate medical needs and the patient's condition is stable, the patient's financial situation may present an obstacle to placement in a skilled nursing facility or to obtaining home health care. Petitioner has access to "a very limited number" of providers who will give follow up care to Medicaid and self-pay patients. Most nursing homes in central Florida have a set number of Medicaid beds for which they will accept patients. Medicaid will not pay a sub- acute facility or a nursing home any additional money for expensive medications, such as intravenous (IV) antibiotics, which further discourages those facilities from accepting patients upon their discharge from the hospital. Florida Hospital Orlando has severe capacity problems. The hospital has about 1,800 beds on its seven campuses, and these beds are almost always full. It is not unusual for the hospital's daytime census to be above 100 percent, with patients backed up in the emergency room waiting for beds to become available. Given the hospital's capacity problems and the low reimbursement rates of Medicaid, there is no motive for Petitioner to keep Medicaid patients in the hospital any longer than is absolutely necessary. Tammy Rikansrud is Florida Hospital Orlando's director of case management, utilization management, and denial management. According to Ms. Rikansrud, the hospital begins discharge planning within 24 hours of a patient's admission, and immediately begins seeking referrals as soon as its knows the patient will be discharged to a sub-acute facility. A major problem is that many facilities limit the number of beds for Medicaid patients, if they accept Medicaid patients at all. Robert Fleener is Petitioner's director of case management. Based on Mr. Fleener's testimony, the impediments to placing a patient in a nursing home from the hospital include rejection of the patient for "payer constraints," meaning that the Medicaid system does not reimburse the nursing home enough to cover its costs. Petitioner seeks placement for its Medicaid patients throughout the state of Florida and beyond, if necessary. Aside from nursing homes, Petitioner uses Shands Teaching Hospital in Gainesville, and long-term acute care hospitals such as those operated by Kindred Healthcare. Petitioner always assesses the practicality of home care for its patients. Petitioner also seeks to place its patients at outpatient clinics when appropriate, but there are few clinics in Orlando, and they are not required to accept Petitioner's discharged patients. The usual practice with ambulatory patients is to discharge them from the hospital, then have them come back on an outpatient basis for follow up treatment. Petitioner always assesses its patients to achieve discharge to the least restrictive setting. If the patient is ambulatory, the hospital will seek to place the patient in an assisted living facility. If the patient is not ambulatory, the hospital will look to a skilled nursing facility that is able to provide the necessary level of service. As also noted by Dr. Edmundson, a patient's need for expensive medicines can make it difficult to place the patient in a nursing home because of reimbursement problems. According to Mr. Fleener, nursing homes look very closely at accepting homeless patients, because they assume that if they accept a homeless person, they will have that patient for the rest of his life. Petitioner has "unavoidable" inpatient days for its Medicaid patients, where the care could have been provided in a nursing home but the hospital was unable to place the patient, due to lack of beds, patient behavior problems, age, or the cost of clinical care. Stephen William Bailey is the clinic coordinator for Petitioner's department of psychiatry. Petitioner has a 76-bed psychiatric inpatient unit and a medical psychiatric unit for patients with a psychiatric diagnosis and co-morbid medical problems. The hospital must obtain state approval to place a psychiatric patient in a nursing home, assuming it is possible to find a nursing home that is equipped to handle psychiatric issues and is willing to take the patient. It is not uncommon for Petitioner to admit a patient with behavior disturbances from a nursing home, stabilize the patient's medications and treatment, then have the nursing home refuse to take the patient back. Petitioner has no incentive to prolong inpatient stays. Patients are waiting to be admitted on a regular basis, and there are, at times, as many as 20 psychiatric patients in the emergency room waiting for admission. Cara Lee Staples is a social worker at Florida Hospital Orlando. She attends treatment team meetings, assesses patients for discharge needs, researches placement availabilities, and meets with families to plan care after discharge. Based on Ms. Staples' testimony, many of Petitioner's Medicaid patients have chronic mental illnesses and often have no involvement with their families. As soon as a patient is admitted, Ms. Staples seeks to obtain a psychosocial history of the patient, which includes where the patient came from and whether the patient can return upon discharge. If the patient cannot return to, for example, the assisted living facility from which he was admitted to the hospital, then Ms. Staples must attempt to find an appropriate placement for the patient so that he may be safely discharged once he is stabilized. According to Ms. Staples, there is a range of alternative placements she may explore, depending on the patient's circumstances. Those persons who do not need structured care may be placed in a boarding home. Those requiring minimal care may be placed in an assisted living facility or a retirement home. The next level of care would be provided by an extended care facility, which Ms. Staples described as an intermediate facility between an assisted living facility and a skilled nursing facility. Other placement options include substance abuse rehabilitation facilities, halfway houses, 28-day programs, and shelters. The hospital faces some placement problems. Assisted living facilities tend not to accept patients with recent histories of drug abuse. Some assisted living facilities will not accept patients who are incontinent and unable to change themselves. Assisted living facilities without locked units will not accept Alzheimer's patients who tend to wander. Nursing homes will often reject young psychiatric patients in need of skilled nursing services because of their age. Nursing homes are generally reluctant to accept Medicaid patients, particularly those who are homeless, because of the difficulty they will face in placing the patient after the need for skilled nursing services has passed. Nursing homes will decline to accept a patient once they learn he is on a psychiatric unit because they "cannot meet their needs," which Ms. Staples described as a global catch-all phrase for their general desire not to accept psychiatric patients. Acute Care Inpatient Hospital Stays By the time of the hearing, the acute care inpatient hospital stays of 16 patients remained at issue. The findings below are set forth in the order that the patients were listed in AHCA Exhibit 6, the recipient spreadsheet indicating the dates of the patients' stays, the dates denied by the peer reviewers, and the amount of claimed overpayment. Patient #1 R.B. R.B. was admitted on March 30, 2001, and was discharged on April 8, 2001. Peer reviewer Dr. Machado determined that two days, April 6 through 8, should be denied due to lack of medical necessity for continued inpatient care.3 Dr. Machado's peer review report stated that R.B. was a 46-year-old female with scleroderma. She was admitted with chest tightness and found to be in near end-stage renal failure. Standard enzyme testing ruled out a heart attack. Her renal function continued to deteriorate and it became clear she would soon need dialysis. R.B. underwent placement of a Tessio catheter on April 3, and arrangements were begun for her to receive dialysis at an outpatient center in her hometown of Pensacola. Dialysis could not be arranged at the outpatient center until after she underwent dialysis at the hospital on April 4 and 5. Dr. Machado agreed that it would not have been safe to discharge her until adequate arrangements had been made for her outpatient dialysis, but that she was medically stable and ready for discharge by April 5 with an outpatient treatment plan in place. The care R.B. received in the hospital after April 5, including two blood transfusions on April 7, could have been provided on an outpatient basis. Petitioner's expert witness, Dr. Yithak Daniel Haim, testified that R.B. was not discharged as scheduled on April 6, because of changes in her mental status. She had nausea and episodes of confusion. On April 7, her medications were reviewed in light of their propensity to cause confusion in persons with poor kidney function. It was thought that her confusion could be due to OxyContin. Dr. Haim also noted that R.B.'s hemoglobin dropped on April 7, and she required a transfusion. Treating physician Dr. Daniel Tambunan confirmed that R.B. was kept in the hospital after April 6 due to her mental status, which developed into hallucinations on April 7. Dr. Tambunan also noted that R.B. had developed tachycardia on April 5 probably due to low hemaocrit, which was measured at 22.3 on April 7. Dr. Haim stated that a normal hematocrit is between 39 and 45. Dr. Haim agreed with Dr. Machado that dialysis can usually be done on an outpatient basis, but that he decided to keep her in the hospital due to the combination of the tachycardia, low hematocrit necessitating a transfusion, and the need to ascertain whether the hallucinations were caused by medications or by the dialysis. The greater weight of the evidence supports Petitioner's position that April 6 through April 8 should not have been denied. Dr. Machado's opinion was supportable regarding the ability of the patient to receive transfusions and dialysis on an outpatient basis. However, Dr. Machado's testimony ignored R.B.'s hallucinations and the reasonableness of keeping her in the hospital until the treating physician could ascertain their cause. Therefore, AHCA offered no evidence to conflict with the testimony of Dr. Haim that it was medically necessary to keep R.B. in the hospital until her discharge on April 8. Patient #2 F.C. F.C. was admitted on March 5, 2001, and was discharged on March 12, 2001. Peer reviewer Dr. Machado determined that the admission should be denied and a 23-hour observation should be approved.4 Dr. Machado's peer review report stated that F.C. was a 43-year-old female smoker with high blood pressure. She was admitted with chest pain for 3 days and by some notes was chronic over the last year. An electrocardiogram (EKG) did not show ischemia, and serial enzyme tests ruled out a heart attack. A spiral computer tomography (CT) scan was negative for a pulmonary embolism, i.e., a blood clot in the lung. Dr. Machado wrote that F.C.'s vital signs were stable, and that an outpatient work-up of her chest pain would have been appropriate. Instead, she had a stress test on March 7. The results were still "pending," according to a note on March 11. She also underwent work-up of abnormal findings on her abdominal CT/ultrasound, all of which could have been accomplished safely in the outpatient setting. Petitioner's physician expert, Dr. Haim, concurred with Dr. Machado's denial of this admission. The treating physician, Dr. Ashok Khanna, offered plausible reasons for keeping the patient in the hospital, including the fact that F.C. was a drug addict who could not be relied upon to comply with testing required to rule out coronary artery disease on an outpatient basis. However, the greater weight of the evidence supports Dr. Machado's denial of the admission. Patient #3 J.C. J.C. was admitted on July 6, 2000, and was discharged on July 12, 2000. Peer reviewer Dr. Machado determined that five days, July 8 through July 12, should be denied due to lack of medical necessity for continued care on the medical ward. Dr. Machado's peer review report stated that J.C. was a 55-year-old male initially admitted to the psychiatric unit due to depression and suicidal gesture. Psychiatric notes indicate that J.C. complained of three weeks of exertional chest pain and fatigue. On July 6, he was transferred to the medical ward for further evaluation. Serial enzyme tests ruled out a heart attack, and he was hemodynamically stable. He underwent a stress test on July 6, with no chest pain and no EKG changes. Dr. Machado concluded that a transfer back to the psychiatric unit or to home would have been appropriate, with follow-up. She believed it was not medically necessary to keep J.C. on the medical ward while awaiting the nuclear images of the stress test, as he was chest pain free and hemodynamically stable after July 7. Treating physician Dr. Luis Allen testified that he was called in on a psychiatric consultation on J.C. while he was in the medical unit. Dr. Allen found that J.C.'s depression was significant and that he would be in need of inpatient psychiatric treatment. Dr. Allen therefore followed J.C. until he was transferred to the inpatient psychiatric unit. The transfer was delayed while the cardiac workup was completed, so that the physicians could be confident that J.C. was medically stable before his transfer back to the inpatient psychiatric unit. Dr. Allen noted that J.C. had a history of depressive disorder and experiencing feelings of helplessness, hopelessness, that his level of depression was significant, and that he had been admitted for a suicidal gesture. Dr. Allen testified that J.C.'s psychiatric symptoms were too marked to be treated on an outpatient basis. Dr. Allen believed that his stay through July 12, was necessary when the combination of the patient's medical and psychiatric conditions are considered. Petitioner's medical expert, Dr. Haim, disagreed with Dr. Machado that J.C. could have been transferred from the medical ward on July 7, because the results of his cardiac stress test did not come back until July 9. Dr. Haim agreed that J.C. could have then been transferred off the medical ward on July 9. However, there was no bed available on the psychiatric floor on July 9. J.C.'s condition indicated a need for acute psychiatric hospitalization, meaning that he could not be discharged home. Thus, he remained on the medical ward until a psychiatric bed became available. Dr. Haim agreed that this was not strictly a medical reason, but contended that the lack of beds constituted a "reality reason" that justified the full admission. Petitioner's expert psychiatrist, Dr. Alan Berns, agreed with Dr. Allen and Dr. Haim that the full stay was justified. The greater weight of the evidence supports AHCA's denial of the last five days of J.C.'s admission. The record established that J.C. ceased to meet the criteria for inpatient admission in the medical unit on July 7. The reason for keeping J.C. on the medical unit after July 7 was administrative convenience, not medical necessity.5 Patient #4 P.C. P.C. was admitted on July 9, 2000, and was discharged on July 17, 2000. Peer reviewer Dr. Machado determined that six days, July 11 through July 17, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that P.C. was a 64-year-old female with a history of leg cellulitis treated with IV antibiotics. She was admitted through the emergency room with increased swelling of her lower left leg, which raised concerns about deep vein thrombosis (DVT), compartment syndrome, or progression of her cellulitis. P.C. also had chronic anemia, which had worsened. DVT was ruled out and she was continued on IV antibiotics. She had a blood transfusion due to her anemia. P.C. declined inpatient gastrointestinal (GI) work for her anemia, so the hospital planned to schedule the GI work after her discharge. Dr. Machado concluded that the remainder of her hospital stay could have been outpatient. She did have one further transfusion of packed red blood cells (PRBCs) on July 12, but she did not need to remain in the hospital for this, as she continued to refuse further workup and was asymptomatic. Dr. Machado testified that the physician's note on July 10 stated that the patient "looks and feels better, no complaints," and that P.C. was sufficiently improved to be discharged on that date. She could have been continued on IV antibiotics at home through home health care, or could have received the treatment at a skilled nursing facility. Dr. Machado acknowledged that the patient received a blood transfusion on July 12, but stated that this could have been provided on an outpatient basis. Blood could have been drawn after the transfusion for lab testing, and there would have been no need to call P.C. back in unless there was a problem with the labs. Dr. Haim testified that P.C. was diabetic, had kidney problems, peripheral vascular disease, and congestive heart failure. As of July 11, the status of her infection had improved, but she was still on IV antibiotics and her hematocrit had dropped. Because P.C. had several chronic medical problems, it was important to raise her hematocrit. She was given the transfusion on July 12, but her hematocrit continued to drop. Dr. Haim testified that this raised intense concerns as to "where is this blood going to." A CAT scan of her abdomen revealed no internal bleeding. Her release was planned for July 15, but blood testing on that date showed that her kidney function had deteriorated. It was feared that one of her IV antibiotics, Vancomycin, was affecting her kidney function. Dr. Haim concluded that her drop in hemoglobin and kidney function necessitated keeping her in the hospital until July 17. J.C.'s treating physician, Dr. Sidiab Elalaoui, testified that he could not have given the patient transfusions in his office. He disagreed with Dr. Machado that J.C. could have been seen in an outpatient setting as of July 11. Dr. Elalaoui noted that J.C. had been getting IV antibiotics at home, but that her condition nonetheless worsened to the point where she had to be brought to the emergency room on July 9. Dr. Elalaoui stated that J.C. did not have a simple infection. She had a bacteremia, a bacteria that went from the skin into the blood of a patient with diabetes and high blood pressure. Dr. Elalaoui could not be sure if her condition was life- threatening, but confidently stated that it was "severe." The greater weight of the evidence supports Petitioner's position that July 11 through July 17 should not have been denied. Dr. Machado's opinion was supportable regarding the ability of the patient to receive a transfusion and IV antibiotics on an outpatient basis. However, Dr. Elalaoui's testimony as the treating physician, in combination with Dr. Haim's expert testimony, credibly established that, whatever the patient's theoretical ability to receive transfusions and IV antibiotics on an outpatient basis, under the actual circumstances, it was medically necessary to keep J.C. in the hospital through July 17. Patient #5 A.F. A.F. was admitted on November 30, 2000, and was discharged on December 7, 2000. Peer reviewer Dr. Machado determined that four days, December 3 through December 7, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that A.F. was a 32-year-old female admitted with a severe headache and apparent new onset seizures. She underwent a CT scan, magnetic resonance imaging (MRI), and an electroencephalogram (EEG), all of which reported negative. She had undergone a lumbar puncture previously for the severe headaches, which was also negative. Dr. Machado concluded that A.F. could have been discharged with oral medications and outpatient follow-up for treatment of her apparent migraine headaches. Instead, A.F. underwent further testing for low back pain, depression, and substance abuse. Dr. Machado believed that the treating physicians allowed the patient's subjective complaints to outweigh the objective clinical findings, noting that A.F. had been seen sitting up and talking on the phone during the time when she was complaining of a severe headache. Petitioner's expert, Dr. Haim, agreed with Dr. Machado that the days denied were redundant. Thus, it is found that the greater weight of evidence supports AHCA's denial of four days of A.F.'s inpatient stay. Patient #6 C.G. C.G. was admitted on May 3, 2001, and was discharged on May 14, 2001. Peer reviewer Dr. Machado determined that eight days, May 5 through May 14, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that C.G. was a 47-year-old female admitted with increasing chest pain and numbness in her left arm. She was found to have a mass in the middle of her chest and possible early superior vena cava (SVC) syndrome. Serial enzymes and a CT scan respectively ruled out heart attack and pulmonary embolism as the cause of her chest pain. She was started on steroids and pain medication, with satisfactory pain relief. Dr. Machado concluded that the remainder of her stay focused on a workup on the mediastinal mass, which could have been done on an outpatient basis. The steroid and pain medications she was receiving through IV, could have been given orally. None of the progress notes documented sufficient evidence for inpatient workup. In her deposition, Dr. Machado explained that the SVC is the large blood vessel that returns blood from the heart to the upper portion of the body. When there is a mass in that area of the chest, it can compress the SVC and cause swelling from the backing up of the blood. Dr. Machado believed that once immediate life-threatening diagnoses such as heart attack and pulmonary embolism were ruled out, and C.G.'s pain was managed with medication, the matter of determining the nature of the mediastinal mass could have been handled on an outpatient basis. Treating physician Dr. Vajihuddin Khan, an internal medicine specialist at Florida Hospital Orlando, testified that he kept C.G. in the hospital until May 14 to complete the workup and perform all the necessary investigations of the mediastinal mass. Dr. Khan noted that C.G. could not have been released and observed daily on an outpatient basis because of transportation or financial problems. The patient lacked outside support. If she had gone out of the hospital with no place to stay and no friends to support her, the workup might never have been completed. C.G. was ultimately diagnosed with Hodgkins lymphoma. Dr. Haim testified that on May 7 the patient was ordered NPO (nothing by mouth) for a biopsy to be performed the next day. She had a swollen face, neck, and arm, with a large, undiagnosed mass in her chest. The chest pain and shortness of breath had not gone away. Dr. Haim believed it would be irresponsible to discharge C.G. in that condition without a diagnosis. The biopsy was performed on May 8 and showed cancer. The pathology report on May 9 was inconclusive, but her physicians knew it was "something bad," either lymphoma or a small cell carcinoma of long standing. Dr. Haim testified that it was important to differentiate the type of cancer because the treatments would be different for each. Therefore, it was necessary to perform surgery to obtain a larger sample of the mass. Dr. Haim noted that the surgery was not performed prior to C.G.'s discharge on May 14, due to the surgeon's unavailability. Dr. Haim agreed that reimbursement for the dates of May 10 through May 14 were "somewhat questionable" because C.G. was, in essence, sitting in the hospital waiting for a surgeon. The record did not disclose why she was forced to wait for a surgeon. The greater weight of the evidence supports AHCA's denial of the last eight days of C.G.'s admission. The record established that C.G. ceased to meet the criteria for inpatient admission in the medical unit on May 5. Patient # 7 C.G. C.G. was readmitted on May 25, 2001, and was discharged on June 3, 2001. Peer reviewer Dr. Machado determined that the last day should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that C.G. was a 47-year-old female admitted for elective mediastinoscopy to diagnose a mediastinal mass. The procedure was attempted but was unsuccessful due to a large goiter. A thoroactomy was performed that diagnosed lymphoma. C.G. did fine postoperatively but her discharge was delayed after an episode of chest pain, determined to be non-cardiac. When the oncologist saw her on May 30, he felt that she had SVC syndrome and called for an urgent radiation oncology consult. She was started on IV Decadron and improved dramatically by June 2, when she received her first radiation treatment. Dr. Machado saw no reason to keep the patient in the hospital for an extra day, until June 3. Dr. Haim testified that it was reasonable to wait for hours after the radiation treatment to note any improvement or adverse reaction. The greater weight of the evidence supports Dr. Haim's opinion that it was medically necessary to keep C.G. in the hospital through June 3. Patient #8 THE. THE. was admitted on April 3, 2001, and was discharged on April 9, 2001. Peer reviewer Dr. Machado determined that three days, April 6 through April 9, should be denied due to lack of clear documentation showing medical necessity for continued inpatient care. Dr. Machado's peer review report stated that THE. was a 21-year-old pregnant patient admitted with dehydration from hyper emesis gravid arum (the nausea and vomiting commonly called "morning sickness"). She had lost 14 pounds in the week prior to admission. This was the only abnormal vital sign, as she was not hypertensive or tachycardia and her electrolytes were not abnormal. No blood urea nitrogen (BUN) or cretonne was documented, indicating normal kidney function. She had two previous admissions for hyper emesis. She received sufficient IV hydration by April 4 for a 10 pound weight gain and was documented by nursing notes as feeling better and tolerating oral medications. She did have an increase in vomiting on April 5, but by April 6 this was much less and her weight was stable. Most of her anti-emetics were switched from IV to oral, and her IV was locked off for the remainder of her hospital stay. Her vital signs remained stable throughout her hospital stay, and there were no new labs to document continuing dehydration. Dr. Machado testified that the record showed no treatment after April 6 that necessitated a hospital stay. She believed THE. could have been discharged on April 6, with outpatient oral anti-nausea medications in a trial to see how she would do. Treating physician Dr. Andre Jakubowski testified that he saw THE. in his office on April 2, for an obstetrical visit. She was about 12 weeks pregnant and complaining of nausea, vomiting and the inability to keep down fluids. At her March 26, visit, she had weighed 134 pounds. On April 2, she weighed 120 pounds, a loss of 14 pounds. Dr. Jakubowksi immediately admitted T.H. to the hospital. For the first few days of T.H.'s hospitalization, Dr. Jakubowski gave her IV hydration in order to correct her electrolytes. On April 6, the IVs were discontinued and T.H. was placed on oral medications and food. Between April 6 and 7, she lost two and one half pounds. Dr. Jakubowski testified that he could not send T.H. home because she was still vomiting and was generally "not in good shape." He started her on IV hydration again and adjusted her medications. She began to eat and was able to go home on April 9. Dr. Jakubowski testified that it is not within the standards of practice to discharge a patient who has been taken off IV hydration without observing for 24 hours to be sure the patient is taking food and/or liquids orally and keeping them down. On April 8, the IV hydration was stopped for the second time. This time, T.H. was able to keep down some oral foods and liquids. Dr. Jakubowski watched her for 24 hours, then sent her home on April 9. Dr. Haim testified that laboratory testing is not necessary to document continued dehydration when the patient continues to vomit. With a weight loss of 14 pounds in a woman who was 12 weeks pregnant, this was clearly more than ordinary morning sickness. T.H. could not be discharged when she could not keep food on her stomach. The greater weight of the evidence supports Petitioner's position that April 6 through April 9 should not have been denied. Dr. Jakubowski's testimony as the treating physician, in combination with Dr. Haim's expert testimony, credibly established that, although T.H. showed some improvement and was taken off IV fluids on April 6, it was reasonable to wait 24 hours to make sure that she could keep down oral nutrition. When she was unable to do so, the IV hydration was resumed and it was reasonable to keep her in the hospital until she was able to keep some food on her stomach. Under all the circumstances, it was medically necessary to keep T.H. in the hospital through April 9. Patient #9 J.H. J.H. was admitted on July 7, 2001, and was discharged on August 7, 2001. Peer reviewer Dr. Machado determined that 21 days, July 17 through August 7, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that J.H. was a 63-year-old female lung transplant candidate with end-stage pulmonary fibrosis. She was admitted with a cough, low-grade fever, and increased shortness of breath. She also appeared to have a postoperative wound infection from recent vascular surgery in the right groin. A CT scan was negative for pneumonia or pulmonary embolism and her respiratory symptoms stabilized and, fairly quickly, returned to their concededly poor baseline. The infected right groin area was the cause for J.H.'s extended stay. The wound was debrided on July 14, following treatment with IV antibiotics and wound care. The infectious disease consultant agreed on July 16 that home IV antibiotics would be appropriate. However, the patient declined a PICC line (peripherally inserted central catheter, a long–term catheter that is inserted into the arm and threaded into central circulation) due to a past poor experience. She therefore, continued to get IV antibiotics in the hospital until July 26, when she was changed to oral Keflex. Dr. Machado found that the reasons for her continued hospital stay were unclear, except for wound care. On August 3, J.H. left the hospital for a few hours on a day pass. During her stay, she underwent other tests that are required for lung transplant evaluation, but weren't necessary during this hospitalization. In her deposition, Dr. Machado testified that J.H.'s lung condition stabilized, but the groin became the problem. The treating physician initially thought the problem was fluid collection, but the increased white blood cell count indicated an infection. J.H. was given proper wound care, but Dr. Machado could not see anything done in the hospital during the last 21 days of J.H.'s stay that required an inpatient stay. Dr. Machado concluded that IV antibiotics and wound care could have been given in a sub-acute skilled nursing facility or with home health. Treating physician Richard Young Feibelman is board certified in internal medicine and pulmonary medicine. He is a pulmonary physician, and was J.H.'s primary physician during this admission. In his deposition, Dr. Feibelman testified that he had followed this patient for some time prior to this admission. J.H.'s primary underlying problem was severe and progressing idiopathic pulmonary fibrosis, a scarring debilitation of the lungs causing progressive shortness of breath and requiring increasing oxygen. It typically results in death within two to three years of the diagnosis. Dr. Feibelman testified that J.H. had recently been evaluated at the University of Miami for a lung transplant, which she desperately wanted despite the high risk of death associated with this surgery. J.H. had been undergoing workup in Miami, about two weeks before this admission, including a carotid artery angiogram and cerebral angiogram. After the angiogram, she developed a pseudo aneurism or partial false leak of the puncture site from the catheter insertion. She then developed a hematoma in that area, with wound infection and fever that made necessary her admission to the hospital. Dr. Feibelman testified that at the time of admission, it was difficult to tell whether the infection came from her groin, or whether it was a superimposed respiratory infection on top of her underlying pulmonary fibrosis. Dr. Feibelman testified that J.H. was extremely sick, near the end stage of chronic fibrotic lung disease. He stated that this was an important hospitalization, because J.H.'s infection had to be under control to ensure she could make it to Miami, and survive the lung transplant. Before her admission, she was on immunosuppressive therapy, which increases the risk of infection. Dr. Feibelman treated her with IV antibiotics, and he described the wound care as "aggressive," an effort to heal the wound before the lung disease killed her. The wound was debrided, and J.H. was seen by an infectious disease consultant and vascular surgery consultant. There was difficulty with her blood pressure, and an episode of arm and leg numbness that required a neurological consultation to rule out a transient ischemic attack or pulmonary embolus. Dr. Feibelman testified that J.H. was still getting IV antibiotics to almost the end of her hospitalization. She was on high flow oxygen. The pain in her wound was such that she required intravenous morphine to change her dressings. Dr. Feibelman concluded that any additional setback for J.H. would have been fatal. Her disease has a fairly rapid stair- step pattern, in which there is a drop-off, then stabilization, then a further drop-off, then stabilization. Dr. Feibelman stated that J.H. could not afford a further drop-off before her lung transplant. Dr. Feibelman testified that J.H. was allowed to leave the hospital for two hours on a day pass. He stated that this was in all likelihood her last chance to go home, and he thought it was worth letting her go. Dr. Haim disagreed that the last 21 days of J.H.'s stay should be denied, but agreed that the last week or two were debatable, depending on the support system she had at home and the possibility of giving her IV antibiotics at home. Dr. Haim stated that she could have had IV antibiotics at home with a PICC line. However, J.H. had prior poor experiences with PICC lines and told her physicians they were not going to "torture" her again. She would also have needed assistance with her oxygen tanks if she went home. Dr. Haim stated that J.H. needed help with all of her activities of daily living (ADLs), as would any patient requiring six liters of oxygen every day. The greater weight of the evidence supports AHCA's denial of the last 21 days of J.H.'s admission. Dr. Machado correctly observed that the patient could have received IV antibiotics, oxygen, and wound care in a skilled nursing facility. She conceded that it would have been correct to keep the patient in the hospital if no skilled nursing facility was available. Petitioner offered no evidence that it attempted to place J.H. in a skilled nursing facility. Dr. Feibelman's concerns about J.H.'s precarious condition are fully credited, but the record as presented established that C.G. ceased to meet the criteria for inpatient admission in the medical unit on July 16. Patient #10 C.J. C.J. was admitted on March 31, 2001, and was discharged on April 9, 2001. Peer reviewer Dr. Machado determined that six days, April 3 through April 9, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that C.J. was a 67-year-old female admitted with abdominal pain, nausea, and vomiting, two days after a colonoscopy. She also had poorly controlled diabetes. The nausea and vomiting resolved quickly after admission, and she was hemodynamically stable throughout her stay. A CT scan of the abdomen and pelvis was performed, which showed a large pelvic mass (likely the recurrence of a previous cancer) with accompanying hydronephrosis (swelling of the kidney caused by obstruction of urine flow). The gastroenterologist cleared C.J. for discharge on April 2. The remainder of her stay involved consultations with urology and oncology specialists regarding the pelvic mass, which could have been accomplished in the outpatient setting. She did not have a ureteral stent (a surgical device implanted to hold the ureter open so that urine can flow freely from the kidneys to the bladder) placed until April 6. Dr. Machado wrote that it was unclear from the notes what was keeping her in the hospital after April 6. In her deposition, Dr. Machado testified that C.J. should have been discharged on April 3 with arrangements for an outpatient workup of the pelvic mass, which was likely a recurrence of the cancer that C.J. had ten years previously. Dr. Machado testified that the placement of the stent was necessary, either during the hospitalization or as an outpatient, and noted that if it had been an emergency, the stent would have been placed sooner in C.J.'s stay. The stent was actually placed one week after C.J.'s admission. Treating physician Dr. Alan Varraux, a specialist in pulmonary medicine, testified that C.J. was weak and somewhat frail, but underwent a colonoscopy because of gastrointestinal symptoms. The procedure caused her much nausea and vomiting. Her complaints and Dr. Varraux' concerns about dehydration led to her hospitalization on March 31. On admission, she was kept NPO and IV fluids were started. She was allowed to start eating on April 1. A GI specialist saw her on April 2 and performed an upper GI endoscopy and a colonoscopy. A consulting oncologist saw the patient on April 3. Dr. Varraux stated that an X-ray showed hydronephrosis, a blockage of the ureter system causing urine to back up into and dilate the kidney. The stent could not be placed on an outpatient basis because C.J. was a debilitated, immuno-compromised cancer patient who could be killed by a urinary tract infection. She was a high risk patient and needed to be cleared by a urological specialist before discharge. The urologist planned to place the stent on April 6, after which C.J. could be discharged if all went well. Dr. Haim testified that the stent was actually placed on April 7 and that C.J. needed to stay in the hospital for an additional 24-to-48 hours to ensure that she had adequate urine output, and that her fever was going down, and that her subjective feelings were improved. After reviewing the depositions of Dr. Varraux and Dr. Haim, Dr. Machado testified that she saw no reason to change her opinion. Dr. Machado stated that the medical record showed C.J.'s cancer was 10 years prior to this admission. This led Dr. Machado to disagree with Dr. Varraux's assumption that C.J. was immuno-compromised and unable to fight infections normally. Dr. Machado also did not see anything in the medical record to support the concerns about a urinary tract infection. C.J.'s urinalysis was normal on admission. There was glucose in her urine, which was consistent with her diabetes. On April 3, her white blood count was normal, indicating that if there was an infection, it had been treated adequately. No culture or urinalysis was performed on that date. Dr. Machado opined that the patient's low grade fever throughout her stay was not a reason to keep her in the hospital, as evidenced by the fact that she was still running a low grade fever on the day she was discharged. She was treated with antibiotics that can be given orally, but that they chose to give via IV. Dr. Machado could find no notes from the primary treating physician from April 6, until his discharge note on April 9. Dr. Machado found nothing in the medical record to support the view that the stent had to be placed in the hospital. The stent certainly needed to be placed, to allow urine to drain properly from the kidney. However, this is not always an inpatient procedure. Dr. Machado noted that the urologist's post-operative orders were written as outpatient orders. The greater weight of the evidence supports AHCA's denial of the last six days of C.J.'s admission. The record as presented established that C.J. ceased to meet the criteria for inpatient admission in the medical unit on April 3. Patient #11 G.M. AHCA Exhibit 6 indicates that G.M. was admitted on July 6, 2000, and was discharged on July 20, 2000. However, Dr. Machado noted that the records provided by the hospital indicate that this patient was admitted directly to a rehabilitation facility, and was never an acute medical admission. Therefore, Dr. Machado determined that the entire 14-day stay should be denied. Dr. Haim testified that his own abbreviated notes show that the patient came into the hospital, was in respiratory failure, had shortness of breath, coded with cardiac arrest, and was intubated. However, the lack of medical records provided by the hospital to AHCA require that Dr. Machado's denial determination be sustained. Patient #12 N.P. N.P. was admitted on January 8, 2000, and was discharged on January 14, 2000. Peer reviewer Dr. Machado determined that two days, January 13 through January 14, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that N.P. was a 46-year-old male with cardiomyopathy and poorly controlled diabetes. He was admitted with increasing shortness of breath, fever, cough, and chest pain. He was started on antibiotics, diuretics, and respiratory treatments, and his symptoms improved rapidly. Serial enzyme tests ruled out a heart attack and his chest pain was not thought to be cardiac in nature. On January 11, his IV medications were changed to oral, and it was felt he was near ready for discharge. Though he felt better, his oxygen saturations were slow to improve and he was still saturating in the high 80's on room air, which was not his baseline. Dr. Machado found it reasonable to monitor him for one more day in the hospital to see if this would improve before sending him home with oxygen. The saturations stayed the same the following day, and he continued to feel better. Dr. Machado concluded that discharge would have been safe on January 12, with home oxygen and close outpatient follow-up. Dr. Haim testified that N.P. could have probably been discharged on January 13 on oxygen, with outpatient follow-up. He noted that N.P. was started on a new medication on January 12, and that it is reasonable to keep the patient for an additional 24 hours to gauge his response. However, Dr. Haim also noted that the medication was a diuretic, not an antibiotic. The greater weight of the evidence supports AHCA's denial of the last two days of N.P.'s admission. The record, as presented, established that N.P. ceased to meet the criteria for inpatient admission in the medical unit on January 13. Patient #13 T.S. T.S. was admitted on September 18, 2001, and was discharged on October 16, 2001. Peer reviewer Dr. Machado determined that 12 days, October 4 through October 16, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that T.S. was a 55-year-old man with cirrhosis and a history of drug abuse and hypertension. He was admitted for treatment of a non-healing venous ulcer that had failed outpatient therapy. T.S. was also experiencing uncontrolled pain despite oral pain medications. He was started on broad-spectrum antibiotics and underwent debridement of the wound on September 21. Plans were made to discharge him to a skilled nursing facility for several weeks of wound care and IV antibiotics. On September 22, his pain continued to be poorly controlled. On September 25, he had a fever of 101 degrees and diarrhea, which prompted further work- up. Cultures of the wound continued to show a polymicrobial infection that also had a fungal component. Oral Sporanox was added to his medications to address the fungal component. On September 27, a pain management consultation was requested due to his continued uncontrolled pain, mostly during dressing changes. T.S. was placed on a Dilaudid PCA (patient controlled analgesic) pump, which did control his pain. During this time, T.S. had waxing and waning mental status due to the pain medications. Because of T.S.' increasing lethargy, the PCA was discontinued on October 3, and T.S. was thenceforth maintained on oral medications. The patient also had chronic anemia on admission that slowly worsened during his stay. He was found not to be acutely bleeding and was transfused PRBCs with improvement in his hematocrit level. Dr. Machado agreed that it would have been difficult to discharge T.S. to a skilled nursing facility for dressing changes and IV antibiotics if he was unable to tolerate dressing changes without a PCA pump for pain. Therefore, she would allow the hospitalization through October 3, when T.S. was switched to oral pain medications and could have gone to a skilled nursing facility. Treating physician Dr. Pradeep Vangala testified that he saw T.S. in his office, prior to his hospital admission. T.S. came in with what appeared to be cellulitis in his legs, and was treated with oral antibiotics. When the condition failed to respond to treatment, Dr. Vangala admitted T.S. to the hospital. Dr. Vangala stated that T.S. was kept in the hospital after October 4 because his cellulitis had not resolved and the patient was not stable enough to be changed to oral antibiotics. Dr. Vangala testified that it was not a simple decision to send T.S. home with IV antibiotics because of complicating issues. Secondary to his cirrhosis, T.S. had significant edema in most of his body in general, and his legs in particular. Dr. Vangala stated that T.S. required close observation of his skin integrity and his cellulitis, and that his cirrhosis was the cause of the edema. Though T.S. had a lot of excess fluid, most of it was in the subcutaneous tissues rather than the blood vessels. This means that his fluid status had to be closely monitored, because of the danger that he might become intravascularly volume depleted, which could affect renal function. Dr. Vangala stated that the cirrhosis had altered T.S.'s mental status for a significant portion of his stay, and that an acutely confused patient is not a candidate for discharge because he is not able to follow discharge instructions. T.S. also had significant anemia, which meant that his hemoglobin had to be watched. Dr. Haim testified that during all 12 days denied by Dr. Machado, T.S. was still running a fever and had a depressed mental status. He was still receiving IV medications, and had a significant swelling of the abdomen that required drainage. His mental status was abnormal, and physicians were having a very difficult time titrating his pain medications. A neurologist was called in on October 4 because of T.S.'s impaired mental status. The gathering fluids in his body were causing swelling and making it difficult for him to breathe. Dr. Haim testified that the IV antibiotics that T.S. was receiving after October 4 had to be closely supervised, though he conceded that a skilled nursing facility could handle their administration. The greater weight of the evidence supports AHCA's denial of the last twelve days of T.S.'s admission. Dr. Machado's opinion that the medications administered via IV after October 4 could have been given outside of the inpatient hospital setting was uncontradicted. Dr. Vangala's concerns were genuine, but mostly consisted of monitoring actions he wished to perform as a precaution, rather than acute care needs. The record as presented established that T.S. ceased to meet the criteria for inpatient admission in the medical unit on October 4. Patient #14 & 15 (two denials) F.T. F.T. was admitted on March 27, 2000, and was discharged on May 13, 2000. Peer reviewer Dr. Machado determined that: March 27 through April 4, should be approved for treatment of coagulopahty, subdural hematoma, and evaluation of the patient's near-syncopal episode; April 14 through May 7, should be approved for chemotherapy and treatment of neutropenic fever; and that April 5 through April 13 (nine days) and May 8 through May 13, (five days) should be denied because the treatment during those periods could have been administered on an outpatient basis. Dr. Machado's peer review report stated that F.T. was a 49-year-old female with metastatic breast cancer admitted with a coagulopathy and near-syncope (almost fainting). She was found to have new subdural hematomas and a new pathologic fracture of the left femur. Her coagulopathy was reversed and she was evaluated by neurosurgery and radiation oncology. No surgery was recommended. She began palliative radiation therapy to the brain and left femur on March 29. She remained hemodynamically and neurologically stable, and neurosurgery signed off on the case on April 4. Her pain responded well to radiation. Between April 4 and April 14, F.T.'s hospital care involved continued radiation therapy and the biopsy of a left auxiliary lymph node (on April 11) to determine the receptor status of the breast cancer, which would enable the oncologist to decide if chemotherapy would be of benefit. Dr. Machado concluded that this evaluation and the radiation therapy could have been done on an outpatient basis. On April 14, F.T. began chemotherapy over two days and very soon began experiencing fever and neutropenia (an abnormally low level of neutrophils, the white blood cells produced in the bone marrow) and then respiratory distress. She was started on IV antibiotics and IV diuretics. She was also started on a feeding tube due to poor oral food intake. The fevers and neutropenia were resolved by April 25, but she continued to decline, with increased shortness of breath requiring more diuresis to clear fluid from the lungs. It became evident she was deteriorating and her feeding tube was discontinued by May 4. By May 8, comfort measures only were initiated, and evaluation for inpatient hospice care was requested. In her deposition, Dr. Machado testified that between April 4 and April 14, F.T. was receiving radiation as her main treatment, as well as further evaluation to determine whether anything more could be done for her cancer. Everything she received during this period, including the lymph node biopsy, could have been done on an outpatient basis. On April 14, she started chemotherapy, which was reasonable to perform in the hospital. By May 8, the medical chart notes indicate the initiation of "comfort only" measures. At that point, she could have been sent home with hospice care or to a hospice house. Dr. Machado conceded that some patients do receive inpatient hospice care, but she testified that this should have been done in a hospice bed, not an acute care medical bed. Dr. Haim testified that during the period of April 5 through April 13 F.T. was receiving radiation to the fractured femur and awaiting a lymph node biopsy. The initial pathology report did not have sufficient material for receptor studies, so a surgical biopsy would need to be performed. On April 5, the hospital social worker was awaiting orders to transfer F.T. back to the nursing home from which she had been admitted. However, F.T. had an episode of nausea and vomiting. Dr. Haim stated that nausea and vomiting in a patient who has metastasis is extremely serious because it could indicate more brain swelling or bleeding in the brain. She was started on IV Decadron, a steroid given to combat nausea and vomiting in chemotherapy patients. Dr. Raul Castillo, F.T.'s oncologist, met with a pathologist on April 7 to discuss the need for an open biopsy of F.T. On April 8, F.T. was receiving radiation and was started on a new chemotherapy drug, IV Aredia. She was monitored closely for side effects. Pain management was a persistent problem. On April 10, she was given the open biopsy under a local anesthetic. On April 13, an orthopedist saw her and ordered a specially fitted brace, because she had difficulty sitting due to her spinal problems. Dr. Haim concluded that, because of all the treatments F.T. was undergoing, including IV chemotherapy, it was mandatory for her to stay inpatient from April 5 through April 13. She could not get the chemotherapy in a non-acute care facility. The hospital was the only place she could get IV Aredia, the brace hadn't arrived until April 13, and she had multiple problems that required monitoring, including advanced cancer and bleeding in the brain. Dr. Haim did not believe that a skilled nursing facility had the capacity to handle F.T. As to F.T.'s second stay, Dr. Haim testified that from May 8 to May 13 F.T. was very weak. Her abdomen was markedly distended, which could have meant that her bowels weren't working well. The abdomen was X-rayed. Her platelet count was dangerously low. An oncology note dated May 9 stated that she was a full code (meaning that all resuscitative efforts must be attempted), by her own choice. Her full code status forced the doctors to plan the performance of tests on her abdomen. On May 10, F.T. voluntarily changed her instructions to DNR (do not resuscitate). Comfort measures were instituted and hospice was consulted. However, when the hospice nurse arrived, F.T. was out having an ultrasound preparatory to having the abdominal fluid drained. The hospice decided not to see her, because she was getting a procedure. The hospice nurse never saw the patient on that day. F.T. was admitted to hospice on May 13. The oncologist, Dr. Castillo, testified that his medical group first saw F.T. in March 2000. F.T. had been diagnosed with breast cancer in 1988, and treated in Puerto Rico, with a left mastectomy and chemotherapy. After she completed the chemotherapy, she had radiation. She indicated that in December 1999, she was told she had metastatic cancer in her bones. In 2000, she developed pain over her hips and legs. She had a fracture over her left femur and a prosthesis over her left leg. She had been taking Coumadin, and Dr. Castillo became involved when F.T. presented with bleeding secondary to Coumadin toxicity. Dr. Castillo described this as a very complex and emotional case in which a few strands of information had to be pieced together to determine the best case management. F.T.'s case history was incomplete because she spoke only Spanish, creating a big language barrier with most of the hospital staff. Dr. Castillo speaks Spanish, and was able to get a "full but scattered history" from F.T. F.T. had metastatic disease. Dr. Castillo testified that it is extremely important to determine if the patient has an estrogen receptor or hormonally positive tumor. Patients who are hormonally sensitive have a much higher probability of responding positively to therapy. To make things more difficult, F.T. developed a subdural hematoma, for which the medical team had to correct her coagulation. Dr. Castillo testified that they felt uncomfortable discharging F.T. while treatment planning was underway. Because of her previous exposure to chemotherapy and radiation, F.T. was at high risk for complications such as the sepsis that eventuated. Dr. Castillo emphasized that this was a complex case, and that the treatment team lacked all the information necessary to make rapid and clear decisions. One event followed another, and the team concentrated on trying to catch up and get the patient somewhat stable. Dr. Castillo stated that a problem with treating a patient this sick on an outpatient basis is the lack of supervision by a specialist. Such a patient will not have access to a site where she is going to get one-to-one care from the oncological standpoint. Dr. Castillo agreed that radiation is commonly done on an outpatient basis, but he noted that this was a patient who had bleeding on the brain and was getting radiation to the brain. If she was in a skilled nursing facility and had a subdural hematoma, she would probably have died on her way to the hospital. Dr. Castillo stated this his group's philosophy is to discharge a patient when they consider the patient stable, and not to leave a patient in the hospital for a mere workup. However, this was a patient who could become a neurosurgical emergency case at any moment. Dr. Castillo concluded that he would not have done anything different in the management of this patient. The greater weight of the evidence supports Petitioner's position that April 5 through April 13 and May 8, through 13 should not have been denied. Dr. Castillo's testimony as the treating oncologist, in combination with Dr. Haim's expert testimony, credibly established that F.T.'s condition was so precarious that her entire inpatient stay was medically necessary. Patient #16 J.Y. J.Y. was admitted on March 3, 2001, and was discharged on March 21, 2001. Peer reviewer Dr. Machado determined that five days, March 16 through March 21, should be denied due to lack of medical necessity for continued inpatient care. Dr. Machado's peer review report stated that T.S. was a 39-year-old female admitted due to swallowing a dental appliance that had become lodged in her esophagus. She underwent an endoscopy on March 3, and the foreign body was removed with some difficulty. Her esophagus was perforated due to the foreign body. She began having fever and pain. A CT scan on March 6 showed extensive edema and air tracking compatible with esophageal perforation. She was kept NPO, hyperalimentation (feeding tube) was started, and IV antibiotics were continued. Clinically, she improved and conservative treatment was continued, as the patient wished to avoid surgery. Dr. Machado believed that it was still prudent to monitor and treat the patient in the hospital, due to the possibility of serious complications from this type of injury. A barium swallow was performed on March 12, which showed that a leak persisted in the esophagus. Because she was clinically so much better, it was decided to repeat the CT scan of the neck on March 14 to check for improvement. The scan showed that soft tissue gas and swelling had decreased considerably. By March 16, her IV antibiotics were discontinued and it was decided to give her a trial of fluids by mouth. She was hemodynamically stable and afebrile. Dr. Machado concluded that she should have been discharged with home health and hyperalimentation, with an outpatient swallowing study and close follow-up, rather than waiting in the hospital until March 19. Dr. Haim testified that the March 12 barium swallow results led to J.Y.'s being kept on no food by mouth and total parenteral nutrition (TPN, another term for a feeding tube). On March 16, J.Y. was noted to be clinically stable, but her liver function tests were noted to be high. Dr. Haim noted that the TPN itself could be causing the liver problems, so there was a GI consult. The gastroenterologist recommended a change of antibiotics as a possible solution to the increase in her liver enzymes. Contrary to Dr. Machado's statement, no trial of fluids by mouth was done on March 16. As of March 17, J.Y.'s orders were still nothing by mouth and TPN, and her liver enzymes continued to rise. On March 18, there were no major interventions and J.Y. was scheduled for a swallow study. Her liver enzymes were noted to be decreasing for the first time. Her swallow study results were pending on March 19. Also on March 19, a pulmonary note indicated phlebitis in J.Y.'s arm, in the area of the IV feeding. An order to replace the PICC line was written. On March 20, J.Y. was started on an oral diet and her PICC line was replaced. The gastroenterologist recommended a liquid diet for several weeks. On March 21, the patient was discharged home on IV TPN and a liquid diet. Dr. Haim concluded that the acute care setting was required for the denied days. Treating surgeon Dr. Stephen Huber testified J.Y. came in having swallowed her partial plate, which had become lodged in her esophagus. The emergency room physicians could not get it out, and so J.Y. was taken to surgery. Dr. Huber kept her NPO because he was afraid she might have torn her esophagus. He placed her on IV antibiotics and ordered a swallow study, which revealed a small leak. Dr. Huber called in an infectious disease specialist to manage J.Y.'s antibiotics because he was worried about contamination from the leak spreading into her neck. She was started on IV feedings and the medical team watched for an abscess to develop in her neck. A few days later, another swallow study was performed, which indicated the leak was smaller but still persistent. J.Y. was kept NPO and kept on IV antibiotics. A third swallow study showed the leak had resolved, and she was started on regular food the next day. Once she was cleared by all her specialists, she was discharged from the hospital. Dr. Huber testified that he kept J.Y. in the hospital after March 16 mainly to watch her. Even after the last swallow study, there was still a small leak in the esophagus. J.Y. had not eaten for a couple of weeks, but she was getting better clinically, and Dr. Huber decided to feed her. He started with clear liquids, then advanced her diet slowly over the next few days. Dr. Huber testified that J.Y. had to be watched for fevers and neck swelling caused by her eating, and that he could not evaluate her progress if she was at home. J.Y. did not speak English, and there would have been difficulty monitoring her condition if she were not under direct observation. Seeing her on an outpatient basis might prove harmful if she developed an abscess in her neck, or sepsis. J.Y. remained on IV antibiotics until she was discharged. The greater weight of the evidence supports AHCA's denial of the last five days of J.Y.'s admission. Dr. Huber's concerns were genuine, but mostly consisted of monitoring actions he wished to perform as a precaution, rather than acute care needs. The record as presented established that J.Y. ceased to meet the criteria for inpatient admission in the medical unit on March 16. Psychiatric Inpatient Hospital Stays By the time of the hearing, the psychiatric inpatient hospital stays of 13 patients remained at issue. The findings below are set forth in the order that the patients were listed in AHCA Exhibit 6. Patient #1 H.A. H.A. was admitted on February 20, 2001, and was discharged on February 26, 2001. Peer reviewer Dr. Rahul Mehra determined that three days, February 23 through February 26, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that H.A. was a 57-year-old female with a diagnosis of schizophrenia. She was admitted, involuntarily, under the Baker Act on February 20, for reasons unclear in the medical record. As of February 23, the patient was not actively suicidal, homicidal, manic, or in complicated withdrawal. The patient's psychotic symptoms may have persisted, but these symptoms appeared to be baseline. As of February 23, she did not need 24-hour nursing care. She was discharged on the same dose of anti-psychotic medication she was taking upon admission. Dr. Mehra concluded that, as of February 23, outpatient was the appropriate level of care. Generally the Medicaid standards for whether a patient requires an inpatient psychiatric bed are as follows: whether the patient is actively suicidal or homicidal; whether the patient is so acutely psychotic that her ability to care for herself is impaired; whether the patient is physically aggressive or manic; and whether the patient is having a "complicated withdrawal" from alcohol or drugs that might cause a seizure or other acute health problem. Dr. Mehra testified that it was appropriate to admit H.A. because of her family's concerns that she might have a handgun and was threatening self-harm. At admission, she was having some psychotic symptoms, displaying disorganized thoughts. However, as of February 23, she was no longer actively suicidal or homicidal, which was the reason she was admitted. She did have psychiatric symptoms, such as visual and auditory hallucinations, but these seemed to be her baseline level of functioning. No changes were made to her medications. Dr. Mehra's recommendation would have been to transfer H.A. to an outpatient setting or a nursing home. Petitioner's psychiatric expert, Dr. Alan S. Berns, testified that H.A. was admitted through the emergency room for increasing auditory hallucinations and religious preoccupation. She had a history of non-compliance with her outpatient treatment, mood swings, and unpredictable impulse control. She denied hallucinations, but was noted to talk to herself as a religious preoccupation. The diagnostic impression was of acute exacerbation of chronic undifferentiated schizophrenia, and rule out schizoaffective disorder. The psychosocial note on admission stated that the patient is talking to God and dead relatives. The emergency room nursing notes stated that the patient wanted to hurt an unidentified person with a handgun. She was labile, crying and laughing. H.A. had been admitted to Lifestream, a mental health center in Lake County, three times since November 2000. She had a history of "cheeking" her medications. She required assistance with her ADLs and ate poorly. The social worker reported that she did not attend group therapy sessions, and that she heard God talking to her all the time. By February 24, H.A. showed an improved mood and affect, with no overt agitation. She was observed talking to herself and appeared to be responding to internal stimuli. She also demonstrated some looseness of association. On February 25, she denied auditory or visual hallucinations and any suicidal or homicidal ideations. However, she remained seclusive, with pressured speech and a depressed, blunted affect. She refused to participate in groups. She was discharged on February 26 with improved mood and affect, no evidence of delusions, and denied hallucinations and suicidal or homicidal ideations. She was diagnosed with schizoaffective disorder and discharged with prescribed Seroquel and Paxil, the same medications she was taking on admission. Dr. Berns concluded that H.A. warranted another day or two past the February 23 discharge authorized by Dr. Mehra. The nursing notes from February 23 show the patient alert and oriented times three (time, place and person), and indicate that she was cooperative, pleasant, and denied suicidal ideation. However, H.A. also stated that God talks to her and she sees the Holy Spirit. On February 24, she was still exhibiting some looseness of association, indicating that her thinking was not organized, which could in turn affect her ability to perform her ADLs. At this point, she did not appear a danger to herself in terms of intentionally inflicting harm. Dr. Mehra agreed that the symptoms cited by Dr. Berns, such as looseness of association, loose thoughts and disorganization, can be indicative of the need for a longer inpatient stay. However, loosening of associations is a common finding in a patient with schizophrenia, which is a lifelong disorder. Looseness of association in a schizophrenic patient does not, in and of itself, invoke the Medicaid guidelines that the patient is acutely and gravely psychotic. Dr. Mehra reasoned that if her acute condition had been such a great concern, then her antipsychotic medication could have been increased to effect a change in the observed loosening of associations. Her subtherapeutic dosage was never changed during her inpatient stay. Dr. Mehra concluded that just having loosening of associations is not sufficient, under the Medicaid guidelines, to continue an inpatient level of care. The greater weight of the evidence supports AHCA's denial of the last three days of H.A.'s admission. The record as presented established that H.A. ceased to meet the criteria for inpatient admission in the psychiatric unit on February 23. Patient #2 T.E. T.E. was admitted on March 19, 2001, and was discharged on March 27, 2001. Peer reviewer Dr. Mehra determined in his report that three days, March 25 through March 27, should be denied due to lack of medical necessity for continued inpatient care. However, in his deposition, Dr. Mehra testified that he now agreed with the hospital that the entire stay should be approved.6 Patient #3 S.G. S.G. was admitted on October 25, 2001, and was discharged on November 1, 2001. Peer reviewer Dr. Mehra determined in his report that four days, October 28, through November 1, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that S.G. was a 42-year-old male with diagnosis of schizophrenia admitted, involuntarily under the Baker Act from Orange County Jail, for psychotic symptoms and homelessness. The patient had a previous admission to Florida Hospital Orlando's psychiatric unit, having been discharged on October 8, 2001. Dr. Mehra found that as of October 28, the patient was not actively suicidal, homicidal, manic, or in complicated withdrawal. The patient's psychotic symptoms were still present but improved. The patient was cooperative, directable, and interacting with some peers. His delusions appeared to be chronic. He did not require seclusion or restraints and was not a management problem on the unit. His vital signs, appetite, mood and sleep were stable. Placement became an issue during his inpatient stay. Dr. Mehra concluded that the appropriate level of care as of October 28, was outpatient, with closely supervised living arrangements. In his deposition, Dr. Mehra testified that S.G. was admitted with auditory hallucinations and delusions, reaching the level of psychotic behavior. During his stay, S.G.'s speech and thought became more organized. His psychotic symptoms became less intrusive. By October 28, he was not a danger to himself or others and was ready to move into a sub-acute setting. Dr. Mehra conceded that S.G. was probably still delusional on October 28, but noted that his delusions were probably chronic and at this time were not interfering with his ability to perform his ADLs. Treating physician Dr. Rex A. Birkmire testified that S.G. was initially very psychotic, delusional, and disorganized. He had not been taking his prescribed medications. S.G. thought that one of the his nurses was the Queen of England. He heard voices and had a religious preoccupation about Satan, aliens and dragons. Staff at the jail believed S.G. needed a higher level of care, and therefore had him admitted to the hospital under the Baker Act. Dr. Birkmire testified that as late as October 31, S.G. was still so psychotic, he thought the medication Artane was a "gasoline pill." His conversation continued to be irrelevant and rambling. He said that "people see the smell but they don't see me." On October 31, S.G. was so disorganized that he could not identify the medications he would need to stay stable, and hospital staff felt he could not maintain his basic ADLs. Dr. Birkmire noted that by October 28, S.G. was "passively compliant" with his medications, meaning that he would take them when the nurses gave them to him. Dr. Birkmire stated that S.G. could have been managed in a skilled nursing facility with a 24-hour nursing staff. Dr. Berns testified that S.G.'s prior admission on October 8 raised questions as to the adequacy of his prior treatment, his compliance upon discharge, and his stress level during the interval between admissions. The notes for the current admission stated that S.G. was readmitted due to medication noncompliance. The admission note stated that the patient was psychotic and disorganized, with jumbled thoughts, and had ideas of reference as to the television, i.e., that it was sending him special messages. S.G. was reported to be hyper-religious, and carried a Bible. He had a history of hearing voices and was diagnosed with chronic undifferentiated schizophrenia. A note from Dr. Luis Allen stated that on October 28 the patient was still "very loose," meaning his thoughts were disorganized and psychotic. Hospital staff reported that S.G. remained delusional, and there was concern from the social worker that he might be responding to internal stimuli. On October 29, a note reported that S.G. was psychotic and manic, though starting to make more sense. On October 30, the notes stated that S.G. was still rambling and tangential, and that his ADLs were not good. Staff was concerned that S.G. was not committed to taking medication as an outpatient. Dr. Birkmire recommended the decanoate form of antipsychotic medicine, a long-acting intramuscularly administered form. Dr. Berns stated that some of these medications can be injected such that a dose can last from two- to-four weeks, which can improve patient compliance. A November 2 note from an advanced registered nurse practitioner stated that the patient seemed confused when given discharge instructions to follow up at Lakeside Alternatives. Dr. Berns testified that such confusion can be a red flag that the patient is not ready for discharge. Dr. Berns stated that S.G.'s chronic schizophrenic condition could deteriorate if he were discharged without being well stabilized and not committed to following through with his medications. Dr. Berns concluded that the length of stay was appropriate, and that he might have kept S.G. in the hospital even longer if he appeared confused on the day of discharge. In response, Dr. Mehra testified that the psychotic symptoms, including delusions that his nurse was the Queen of England, did not mean that S.G. must remain in the hospital. Dr. Mehra stated that the note in the chart that the patient believed Artane was a "gasoline pill" was not necessarily a delusion, but could have been an uneducated patient's way of saying that the pill peps him up. Dr. Mehra argued that if the medical concern was persistent psychotic symptoms so severe that he needed hospitalization, then the medical team needed to make dosage adjustments. However, no such adjustments were made after October 26. Dr. Mehra's opinion remained that S.G. did not meet Medicaid guidelines as of October 28. The patient was cooperative on the unit, not a management problem. He could live outside the hospital and still have delusions that someone was the Queen of England. Dr. Birkmire testified that S.G. was rambling, disorganized, and thought the nurse was Queen even after October 28, but that does not necessarily mean he should be in the hospital. Dr. Mehra pointed out that plenty of people walking the street have schizophrenia, are psychotic, and ramble. Dr. Mehra stated that one possible reason S.G. was kept in the hospital was concern as to where he would go upon discharge, because he came from jail and was homeless. Dr. Mehra testified that Medicaid does not cover the period of time when someone is needing placement. Dr. Mehra agreed that S.G. showed psychotic symptoms, but stated that the psychotic symptoms should affect the patient's ability to function in order to justify inpatient treatment. This patient was taking his medications, eating, participating in activities on the unit, and was directable. He did not require any means of seclusion or physical restraints and did not demonstrate aggressive behavior. Dr. Mehra agreed with Dr. Berns that it is a concern any time a patient is readmitted, because it speaks to the chronic nature of schizophrenia and psychoses, and how the symptoms persist over a period of time. "Loose" symptoms probably continued until the day he left. Dr. Mehra also agreed with Dr. Berns that schizophrenics can stabilize and have their thoughts become more organized, depending on the patient and his response to medications. One patient can be loosely organized and live on the street, and another may regain full control of his thoughts. However, Dr. Mehra saw no reason to amend his original opinion. A patient with loose thinking, who is psychotic and disorganized, may need hospitalization, if he is not taking his medicine, not eating, not sleeping appropriately, or is being aggressive. Otherwise, those symptoms may be as good as things are going to get for this patient, given that he has been in jail, has had frequent inpatient hospitalizations, and is homeless. Again, Dr. Mehra noted that S.G. remained in the hospital for several days with no changes to his medications. The greater weight of the evidence supports AHCA's denial of the last four days of S.G.'s admission. The record as presented established that S.G. ceased to meet the criteria for inpatient admission in the psychiatric unit on October 28. Patient #4 C.M. C.M. was admitted on March 2, 2001, and was discharged on March 10, 2001. Peer reviewer Dr. Mehra determined in his report that four days, March 6 through March 10, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that C.M. was a 16-year-old male admitted, involuntarily, under the Baker Act from the Orange County jail, where he was banging his head on the wall. Hospital records indicated concerns by hospital staff that C.M. was malingering in an effort to avoid his pending legal woes. Dr. Mehra found that, as of March 6, C.M. was not actively suicidal, homicidal, grossly psychotic, manic, or in complicated withdrawal. Dr. Mehra concluded that the patient should have been discharged to the juvenile detention center, with psychiatric consultation. In his deposition, Dr. Mehra testified that the hospital had a range of diagnoses for this patient, from "malingering," meaning that he was intentionally inventing his symptoms, to a concern about schizophrenia. Dr. Mehra's review of the hospital records led him to conclude that C.M. was malingering, based primarily on C.M.'s statement to his grandmother that he would get himself placed in the psychiatric unit anytime he went to jail. The record stated that C.M. said the devil was telling him to kill himself, but the physician and staff all thought C.M. was malingering. C.M.'s statement about killing himself led to no increase in precautions, and his medications were not increased until the next day. By the end of C.M.'s hospitalization, the physician was talking about tapering the boy completely off of Respiradol, an anti- psychotic, and was convinced that C.M. was feigning his symptoms. Attending physician Scott D. Farmer7 contended that C.M. remained very dangerous on March 6, because he was still complaining of command hallucinations. "Command hallucinations" cause the patient to believe there are voices telling him to act in a dangerous way, and are recognized as a "unique risk factor" justifying inpatient care. On March 6, C.M. was hearing the voice of his grandfather reassuring him, but he was also hearing the voice of the devil telling him to kill himself. Dr. Farmer testified that patients have been known to kill themselves when they have persisting command hallucinations, and this was a patient who bangs his head against a brick wall. This was an indication that his medications had not been properly adjusted, and that they could not be so adjusted on an outpatient basis. Dr. Farmer's opinion was that it was "ludicrous" to think this patient could be placed in a more complex environment and get better. To discharge C.M. on March 6, would have constituted "abandonment." Dr. Farmer contended that it is a "glib assumption" to say that C.M. was faking his illness, and it is not within the spirit of psychiatry to prejudge that a patient is falsifying his expressed distress. The tradition in medicine is to compassionately adjust medication to remedy the symptom complex, which in this case pointed toward schizophrenia. Dr. Farmer stated that the faking allegation is "a reflection of the lowest form of psychiatric practice. It is a departure from the Hippocratic oath to do no harm. It is an assumption that you can climb inside of somebody else's head and then make conclusions that are a distinct departure from what the patient is saying." Dr. Farmer pointed out that C.M. had been treated at least once for a prior suicide attempt. He also pointed out that a "first break" psychotic episode is the best opportunity for treatment to have a favorable impact in the case of a patient with command hallucinations. Subsequent episodes require more aggressive treatment and higher doses of medications. C.M. was being treated with antipsychotic and antidepressant medications. On March 6, he was taking Wellbutrin, an antidepressant that has the lowest likelihood of triggering manic-type symptoms, and Risperdal. His medications were increased on March 6 and March 7. On March 8, C.M. was still responding to internal stimuli, carrying on a conversation with an internal voice. Dr. Farmer agreed that C.M. was stabilized by March 9 and should have been discharged on that date rather than on March 10. Dr. Berns noted the suspicions of malingering, but also considered that jail staff could not handle C.M., that he appeared to be in imminent danger of harming himself, and he had been treated for at least one suicide attempt in the past. These factors raised concerns as to how much of C.M.'s behavior was malingering and how much indicated genuine illness. Dr. Berns was influenced by the fact that C.M. requested an increase in his dosage of Risperdal, which is not a medication that can be abused or used for intoxication. Dr. Berns acknowledged that C.M. lost some credibility with his statement that he would continue getting Baker Acted if incarcerated. He also acknowledged that C.M.'s age and impulsiveness made it harder to determine the extent of his malingering, but that there was undoubtedly some malingering present in this case. Dr. Berns concluded, as did Dr. Farmer, that C.M. could have been discharged a day or two earlier than March 10. Dr. Mehra replied that it was the treating physician, Dr. Birkmire, who concluded that C.M. was malingering. The auditory hallucinations on March 6 were not sufficient to keep him in the hospital where the treating physician and the medical team believed he was making up the symptoms. Nothing in the testimony of Dr. Farmer or Dr. Berns caused Dr. Mehra to change his opinion. Both doctors referred to this patient's having a diagnosis of schizophrenia. Dr. Mehra called this a "serious and unusual diagnosis" for a 16-year-old, similar to a diagnosis of cancer in that the patient will have to live with it for the rest of his life. Dr. Mehra would expect that such a diagnosis would have led the treatment team to meet with C.M.'s family to offer the appropriate treatment planning and education regarding schizophrenia, but the record indicated that no such meeting occurred. Dr. Mehra believed that there was cause to admit C.M. for evaluation, because he was only 16 years old. Even if it turned out he was malingering, it was prudent to admit him for four days to evaluate him. The greater weight of the evidence supports AHCA's denial of the last four days of C.M.'s admission. The record as presented established that C.M. ceased to meet the criteria for inpatient admission in the psychiatric unit on March 6. Patient #5 L.M. L.M. was admitted on May 16, 2001, and was discharged on May 22, 2001. Peer reviewer Dr. Mehra determined in his report that three days, May 20 through May 22, should be denied due to lack of medical necessity for continued inpatient care. Florida Hospital Orlando did not contest Dr. Mehra's denial of three days for this admission. Patient #6 H.P. H.P. was admitted on March 7, 2001, and was discharged on March 14, 2001. Peer reviewer Dr. Mehra determined in his report that four days, March 10 through March 14, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that H.P. was a 34-year-old female admitted, involuntarily, under the Baker Act for "suicidal ideation and auditory hallucinations." As of March 10, H.P. was not actively suicidal, homicidal, psychotic, manic, or in complicated withdrawal. Her sleep, vital signs, and appetite were stable. Dr. Mehra concluded that the patient no longer needed 24-hour psychiatric nursing care and could have gone back to the skilled nursing facility on March 10. Outpatient was the appropriate level of care. In his deposition, Dr. Mehra testified that H.P.'s improvement was such that she could have been discharged on March 10. There was no deterioration in her condition after March 10. She denied suicidal or homicidal ideations, hallucinations, and delusions throughout the day. Dr. Mehra noted that H.P. was HIV-positive and obese, and would therefore chronically be at risk for suicidal ideation. She had been hospitalized many times for suicidal ideation and auditory hallucinations. H.P. claimed to have jumped from a five-story building when she was 18 years old. Dr. Mehra did not think H.P. was schizophrenic, though her attending physician was concerned about major depression with psychotic features. Attending physician Dr. Luis Allen testified that H.P. was admitted from a skilled nursing facility. She had had multiple psychiatric hospitalizations, and on this admission was presenting with psychotic symptoms, hearing voices and having suicidal thoughts. Dr. Allen conceded that there was one day during her stay when H.P. reported not having suicidal thoughts, but he added that these thoughts resumed the next day. Given that H.P.'s history made her a higher risk for suicide, Dr. Allen felt that he had to ensure she was stable psychiatrically before she could return to the skilled nursing facility. Dr. Berns testified that the March 7 admission note indicated that H.P. had a history of depressive disorder and multiple psychiatric admissions to Florida Hospital Orlando. H.P. reported insomnia and auditory hallucinations, which were mostly command and derogatory hallucinations, voices calling the patient "stupid" and a "dummy" and saying that she should kill herself. H.P. had a history of several suicide attempts and had been taking Risperdal, Prozac, and Remeron. She reported suicidal thoughts, but no plan, and was alert times three. The admitting diagnosis was major depressive disorder, recurrent with psychotic features, and rule out mood disorder secondary to medical condition with depressive-like features. Dr. Berns agreed that the March 10 notes showed that H.P. was depressed with blunted affect, and that she denied suicidal ideation. On March 11, the notes indicated that H.P.'s mood was improved, that she slept better during the night, that her suicidal thoughts were significantly decreased, and that she was compliant with her medications and reported no auditory hallucinations or delusions. However, the attending physician continued to note that she was depressed and hopeless, and the social worker reported that H.P. discussed having no desire to live any more and be a burden to her children. On March 13, her behavior was improved, she had a very good appetite, and she had no hallucinations, delusions, or suicidal thoughts. On March 14, she denied suicidal ideation and hallucinations and was discharged back to the skilled nursing facility. Dr. Berns testified that H.P.'s stay was necessary, and disagreed that she could have been discharged to a skilled nursing facility on March 10. She had a previous suicide attempt, and she had suicidal thoughts and heard voices telling her to harm herself. Dr. Berns agreed that many people express thoughts such as those H.P. expressed to the social worker on March 11, but Dr. Berns pointed out that many people do not also have previous attempts or voices telling them to kill themselves. H.P. was showing improvement by March 11, but her symptoms were still present. Dr. Berns did not agree with Dr. Mehra that suicidal ideation, without the means to carry out a plan, is never sufficient to keep a patient in the hospital. Dr. Berns stated that if the patient is having thoughts of suicide and staff is documenting that the patient is helpless and hopeless, the suicide risk may be sufficient to hospitalize the patient, particularly where there have been previous hospitalizations and suicide attempts. After reviewing the testimony of Dr. Allen and Dr. Berns, Dr. Mehra maintained his opinion that H.P. should have been discharged on March 10. Dr. Mehra pointed out that no physician saw the patient on March 10, probably because it was a Saturday.8 Regardless of the day of the week, if the patient's condition is so acute that it is necessary to hospitalize her with a risk factor of attempted suicide, then she should be seen by a doctor. The unit notes for March 10 indicate she was showing no evidence of psychoses or suicidal ideation. Dr. Mehra noted that even H.P.'s mental status exam at the time of admission showed no active suicidal plan. If the patient is sick enough to be in the hospital, then she should have been seen by a physician. Dr. Mehra concluded that there appeared no need for H.P. to be seen by a doctor on March 10. The greater weight of the evidence supports AHCA's denial of the last four days of H.P.'s admission. The record as presented established that H.P. ceased to meet the criteria for inpatient admission in the psychiatric unit on March 10. Patient #7 J.R. J.R. was admitted on March 2, 2001, and was discharged on March 15, 2001. Peer reviewer Dr. Mehra determined in his report that ten days, March 5 through March 15, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that J.R. was a 46-year-old female admitted from a skilled nursing facility under the Baker Act for being "suicidal." As of March 5, the patient was not actively suicidal, homicidal, psychotic, manic, or in complicated withdrawal. She needed intensive outpatient treatment to address her depressive symptoms, eating issues, and possible addiction to narcotics. J.R. refused to see a chronic pain specialist while in the hospital. Dr. Mehra's report also raised a "serious quality of care concern" in the fact that the patient was immediately referred for electroconvulsive therapy ("ECT") treatment based on "unclear, poorly documented reasons." The physician's decision to use ECT was based purely on the patient's report, without documentation, of failed past treatments. The patient reported that she had not had psychotherapy in years. In his deposition, Dr. Mehra testified that the admitting concern was that the patient was suicidal in her skilled nursing facility, and Dr. Allen had her Baker Acted into the hospital. Dr. Farmer performed the psychiatric evaluation on admission and stated that the patient was not actively suicidal, not psychotic, and was angry with Dr. Allen for Baker Acting her. Dr. Farmer diagnosed J.R. with major depression and anorexia nervosa. Dr. Mehra concluded that J.R. should have been discharged on March 3, because the initial admission evaluation did not establish medical necessity for an inpatient psychiatric hospitalization. Dr. Mehra testified that it was difficult to determine why the patient was at this level of care because Dr. Farmer found that J.R. was not suicidal, actively suicidal with a plan, or psychotic, had no form of auditory or visual hallucinations, and was not manic or involved in a complicated withdrawal. Dr. Mehra stated that, while he did not come out and say that J.R. should not have been Baker Acted, Dr. Farmer did repeatedly note the patient's anger at being Baker Acted, which is highly unusual in a psychiatric evaluation report. Dr. Mehra also observed that the Baker Act documents were not dated, and, thus, there was no way of saying they were completed on the day of J.R.'s admission. A Baker Act is an involuntary commitment of a patient, and it involves a patient's rights. Dr. Mehra stated that because the papers must be completed within a specified period of time of having face-to- face contact with the patient, they must note the date and time. The failure to fill out the papers completely causes a concern about the appropriateness of the patient's admission. Dr. Mehra believed that the indication for ECT was not clear. There are specific criteria to initiate a patient on ECT, and the medical record here did not support it. One of the ECT criteria is that the patient must have failed a minimum of three antidepressants at adequate doses for an adequate length of time. The only documentation in the record was the patient's own report that medications had not worked. There was no objective data in the record regarding her medication history. Dr. Mehra found it very significant that J.R. had no prior psychiatric hospitalizations, especially in the context of her being given ECT. There was not adequate medical confirmation that she had failed previous antidepressant therapy. Dr. Mehra noted that J.R. had a history of a cervical spinal fusion and issues of lumbar back pain, which should have raised concerns about inducing a grand mal seizure by way of ECT. Dr. Mehra saw no MRI or CAT scan of the brain, which is usually done prior to the administration of ECT in order to rule out a mass in the brain. Dr. Allen testified that J.R. had a history of recurrent depression with psychotic features and an eating disorder. During her initial visit to the skilled nursing facility, she was found to be anxious, depressed, and experiencing some suicidal thoughts, and was referred for inpatient treatment. She had experienced significant weight loss and had issues of untreated depression. ECT was initiated and performed three times a week. Dr. Allen conceded that ECT may sometimes be done on an outpatient basis, but stated that J.R.'s history of psychiatric symptoms and the low level of support she had in the community necessitated inpatient placement. She was at a nursing home and would have had to be transported at 5:30 every morning for the treatment. There was no transportation available for her to come in as an outpatient. Dr. Allen also felt that she needed to remain inpatient because of the confusion and disorientation that she was developing with each treatment. Dr. Allen stated that the primary reason for keeping J.R. as an inpatient was to give the ECT treatment. He decided to complete the course of ECT treatment and discharge her back to the nursing home. Dr. Farmer was the second opinion doctor who actually performed the ECT treatment. Dr. Allen stated that ECT is usually reserved for patients who are considered treatment intolerant or "refractory" to treatment, with a history of failing different trials of medications or having developed side effects, or patients who had a very high risk of suicide. With J.R., it was not clear how much the eating disorder was playing into her depression, but Dr. Allen believed that her inner functions were clearly deteriorating, as evidenced by the fact that she was in a nursing home at age 45. The ECT was to address her primary mood symptoms and appetite. At the nursing home, she was only eating percent of her meals. She was eating 50 percent of her meals when she left the hospital, and she continued to show improvement at the nursing home. Dr. Berns testified that J.R. showed a history of cervical spinal cord injury. J.R. was a nurse, and an aggressive patient had caused her injuries when she worked in the emergency room. She had a history of anorexia, depression, and alcohol abuse. She was agitated in the emergency room during admission. J.R. claimed she had had trials on all available antidepressants, which were only partially helpful or failed. She had insomnia and took Klonopin for restless legs. On admission, she was also taking OxyContin, Wellbutrin, Flomax, Trazedone, and Zofran. Her mental status examination indicated lethargy and monotone speech. She was depressed, helpless, and hopeless, but denied suicidal ideation. J.R. stated that she had an overdose of medications at age 16. On March 5, she was withdrawn, depressed, and complained of anergia (lack of energy) and anhedonia (inability to experience pleasure). She also complained of dizziness. She showed the same symptoms on March 6, hopeless and helpless but denying suicidal thoughts. She again complained of feeling weak and dizzy, and she had low blood pressure, 73 over 53. Because of concerns that her medications may have been the cause of her medical complaints, the treatment team decided to withhold all psychiatric medicines and initiate ECT. J.R.'s first ECT treatment was on March 7. On that date, she was depressed, withdrawn, had anergia, but no suicidal thoughts. Her dose of Klonopin was lowered. On March 8, her mood was depressed and she showed anergia, anhedonia, and a variable appetite. A trial of a new anti-depressant, Remeron, was commenced, and J.R. was given an Ambien sleeping pill at bedtime. Her blood pressure was still low, 70 over 50, and the treatment team decided to withhold the OxyContin. J.R. refused to see the psychiatrist and stayed secluded in her room. By the second ECT treatment on March 9, J.R.'s mood was improving and her blood pressure was up to 90 over 57. ECT was scheduled for three days during the next week. On March 10, J.R. complained of depression and suicidal thoughts, and stayed alone in her room most of the day. On March 11, she again stayed secluded in her room, depressed and with flat affect. On March 12, she slept fairly well and ate 75 percent of her meals. Her mood was improving and suicidal thoughts decreased. She had ECT in the morning then rested in bed most of the day. She was depressed and anxious, with poor insight and judgment. On March 13, her mood was improving and she denied suicidal ideation. J.R. was more goal oriented and showed less psycho- motor retardation. She was scheduled for discharge on March 14, after her ECT treatment. She had the treatment, but her discharge was placed on hold because the skilled nursing facility did not want to accept her. Dr. Berns was not sure why the facility did not want to take J.R. back, unless they considered her a problem patient or didn't want to handle a depressed patient. Such problems can hold up discharge. Dr. Berns testified that it would not be acceptable to discharge this patient to the street, and that the length of stay was medically necessary. Dr. Mehra countered that feeling depressed, helpless and hopeless is not enough to justify an inpatient admission. On J.R.'s mental status exam upon admission, Dr. Farmer documented no suicidal ideation, no psychotic symptoms, and patient anger at being Baker Acted. She was given ECT for reasons that Dr. Mehra thought were not very well documented in the medical record. Dr. Mehra stated that it is a complex question as to whether giving her the ECT treatment is reason enough for an inpatient admission. J.R. was taking a heavy narcotic medication, OxyContin, which can make one depressed, withdrawn, and isolative. Dr. Mehra could find in the medical record no real theory as to why J.R. was still taking these medications. For reasons unclear to Dr. Mehra, there seemed to be an immediate desire to give her ECT. Dr. Mehra believed that March 2, should be authorized just to see what was going on with her, given that she had been Baker Acted by a physician. However, as far as the record indicated, J.R. had no history of inpatient psychiatric treatments. Dr. Mehra found it very unusual that ECT treatments would be given on a patient's first inpatient stay. ECT is routinely performed on an outpatient basis. Dr. Mehra acknowledged that where patient compliance is a problem, it may be proper to keep the patient in the hospital. However, this did not seem to be the case with J.R. One of the cornerstones of the decision process leading to ECT is a documented failure of past antidepressant therapy, and Dr. Mehra found no such documentation in the medical record. Lack of support in the community or transportation problems are not reason enough, standing alone, to keep someone in the hospital. The greater weight of the evidence supports AHCA's denial of the last ten days of J.R.'s admission. The record as presented established that J.R. ceased to meet the criteria for inpatient admission in the psychiatric unit on March 3. Patient #8 J.R. J.R. was admitted on March 16, 2001, and was discharged on March 27, 2001. Peer reviewer Dr. Mehra determined in his report that six days, March 21 through March 27, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that J.R. was a 24-year-old male with a diagnosis of schizoaffective disorder, who was admitted for symptoms of agitated, psychotic behavior. As of March 21, the patient was not actively suicidal, homicidal, manic, or in complicated withdrawal. J.R. may have still been psychotic, but the symptoms had improved. The patient's vital signs, sleep, and appetite had stabilized. He no longer needed 24-hour psychiatric nursing care. Dr. Mehra concluded that sub-acute treatment was the appropriate level of care as of March 21. In his deposition, Dr. Mehra testified that J.R. met discharge criteria on March 21, and could have gone into a sub- acute setting such as a skilled nursing facility or group home. Dr. Mehra could not recall whether there was a problem with bed availability in the skilled nursing facility, but added that after a patient meets discharge criteria, it is not Medicaid's responsibility to pay for a longer hospital stay while the patient awaits placement. Once the schizophrenic's acute crisis is resolved, he no longer meets the criteria for medical necessity. Dr. Birkmire was the treating physician, and his notes indicated compliance and improvement on March 20, and 21. J.R. was having some religious preoccupation, which was probably a baseline issue for him. Religious preoccupations in people with schizophrenia are sometimes chronic and never go away. Dr. Mehra testified that being psychotic and having auditory hallucinations do not alone establish grounds for remaining inpatient. Such symptoms are consistent with a diagnosis of schizophrenia, which is chronic. Dr. Mehra stated that J.R. would probably display these symptoms no matter how long he was kept in the hospital. Dr. Mehra testified that there is a vast difference between J.R.'s having an auditory hallucination and his having a command auditory hallucination to harm himself or someone else. Treating physician Dr. Birkmire testified that J.R. was very disorganized on admission, with a grandiose religious preoccupation that indicated he was in a manic stage. J.R. was also sexually inappropriate with some of the other patients and staff. On March 21, he was inappropriate, grandiose, and sexually preoccupied. On March 22, he was still very psychotic, hearing the voice of Britney Spears, with whom he had delusions of being married. He had sexually explicit conversations with other patients and staff. On March 23, he was severely agitated, requiring staff intervention. He was illogical and bizarre, talking to himself in the hallway, reporting that he heard voices and remaining delusional. He was hearing the voice of the devil and having paranoid thoughts about people around him. On March 24, he was unchanged, still delusional and still hearing voices, though they were becoming less intense and he was becoming less manic. Dr. Berns testified that schizoaffective disorder is an illness with symptoms of psychosis in the absence of symptoms of a mood disorder such as mania or depression. It is a chronic mental illness. Dr. Berns agreed with Dr. Mehra that the presence of a chronic illness is not grounds for hospitalization. It is only when the condition becomes acute, where the patient presents a danger to himself or others, that an inpatient psychiatric hospital may be the option. J.R.'s admission note stated that he was previously hospitalized in January 2001, for agitation, bizarre delusions, and concerns about violent behavior. He stated dead people were talking to him. On March 17, the psychiatrist noted marked auditory hallucinations, grandiosity, paranoid delusions, and tangential thought processes. The plan was to keep him on Risperdal, an antipsychotic, and Lithium, which is a mood stabilizing, anti-manic medication. Dr. Berns testified that the usual practice with these medications is to start with a low dose and build it up slowly and gradually. If the patient is in the hospital, the physician can be more aggressive because he can closely monitor blood work and vital signs. Lithium takes seven to ten days to build up to a therapeutic level. The medical notes from March 22 showed that J.R. remained psychotic, had auditory hallucinations, had delusional thoughts regarding Britney Spears and Judy Garland, was responding to internal stimuli, and was sexually preoccupied. On March 23, he was agitated and illogical with bizarre ideation. On March 24, he continued to report auditory hallucinations and was labile and agitated about his upcoming discharge. On March 25, he was still having auditory hallucinations, but less of the manic behavior. On March 26, there was some improvement in his mood and his auditory hallucinations were resolving, but he was still having problems in a group situation. Dr. Berns noted that on March 17, J.R. tried to kiss a nurse, then called her a "bitch with an attitude." There were concerns about his impulse control and potential for committing a sexual offense if released before he was fully stabilized. Dr. Berns agreed with the length of hospitalization, because J.R. had shown poor impulse control and sexually inappropriate behavior on admission, had been admitted two months earlier, and there were concerns about psychosis and violent behavior. The greater weight of the evidence supports AHCA's denial of the last six days of J.R.'s admission. The record as presented established that J.R. ceased to meet the criteria for inpatient admission in the psychiatric unit on March 3. Patient #9 N.R. N.R. was admitted on March 4, 2001, and was discharged on March 16, 2001. Peer reviewer Dr. Mehra determined in his report that three days, March 13 through March 16, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that N.R. was a 21-year-old female admitted, involuntarily, under the Baker Act for psychotic agitation and delusions. The authorization was based on the patient's presenting symptoms, diagnosis of intrauterine pregnancy, and a positive test for syphilis. As of March 13, the patient was not actively suicidal, homicidal, manic, or in complicated withdrawal. Her vital signs, sleep, and appetite were stable. She was taking prescribed medications and following unit rules. Her psychosis had decreased and she was not an immediate danger to herself or others. She appeared to have support from her mother. Dr. Mehra concluded that outpatient was the appropriate level of care. In his deposition, Dr. Mehra testified that the physician's note of March 13 stated that N.R. had no recent episodes of bizarre behavior, and no episodes of agitation or aggressive behavior. The physician progress notes for March 14 say the same thing. N.R.'s initial evaluation was for a psychotic disorder, and she was diagnosed with schizophrenia, a chronic condition. Dr. Mehra noted that the hospital did not obtain N.R.'s previous psychiatric history and that her mother could have been contacted about N.R.'s medical records. The treating physician, Dr. Allen, testified that N.R. was psychotic and grandiose on admission, and was noted at the jail to be head-banging, smearing feces, and playing in the toilet. She was pregnant with an unknown gestational age, and had a positive Rapid Plasma Reagin ("RPR") test for syphilis. She needed a lumbar puncture to determine if she had some form of neurosyphilis or another disorder that could influence her psychiatric behavior. Dr. Allen testified that she lacked the social network for the lumbar puncture to be done on an outpatient basis. He conceded that on March 13 she was compliant with her medication, but stated that she was still disorganized. The initial RPR was performed on March 4, but it took an additional ten days for the lumbar puncture to be successfully performed. One puncture was performed on March 10, but the specimen was not good, so another puncture was performed on March 14. Dr. Allen testified that the lumbar puncture requires the patient to remain very quiet in a hunched position as the needle is going through her back. An agitated, restless patient could cause problems. N.R. needed to be stabilized before the puncture could be performed. N.R. was found positive for syphilis and was discharged to her mother's home rather than to the jail. A visiting nurse went to the home to give the treatments. Dr. Allen explained that N.R. was not released to her mother between lumbar punctures because the mother had a history of depression, according to the history provided by N.R., which Dr. Allen conceded may not have been accurate. Dr. Allen also noted that N.R.'s mother was very difficult to contact. Dr. Berns testified that N.R. was psychotic on admission. At the jail, she was stripping off her clothing and hearing voices telling her that her husband was messing around with other women. She was hitting her head against the wall to get rid of the voices. Dr. Berns concluded that the length of stay was medically necessary and reasonable. N.R. was a pregnant female from the jail, psychotic, with self-destructive behavior. Her physician wanted to be extra careful in view of N.R.'s being pregnant. She was placed on antipsychotic medication. N.R. was eventually going back to the jail, and they wanted to stabilize her condition as much as possible, because the jail is a very stressful place to be. Dr. Berns agreed that, as of March 13, N.R.'s psychosis had decreased and she was not an immediate danger to herself or others. The greater weight of the evidence supports AHCA's denial of the last three days of N.R.'s admission. The record as presented established that N.R. ceased to meet the criteria for inpatient admission in the psychiatric unit on March 13. Patient #10 R.S. R.S. was admitted on May 19, 2001, and was discharged on May 30, 2001. Peer reviewer Dr. Mehra determined in his report that nine days, May 22 through May 30, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that R.S. was a 38-year-old female diagnosed with schizophrenia who was admitted, involuntarily, under the Baker Act for worsening of her psychotic symptoms. As of May 22, the patient was not actively suicidal, homicidal, manic, or in complicated withdrawal. The patient was still psychotic but the symptoms were not worsening and appeared to be at baseline, given that they remained unchanged even at discharge. After May 22, the record disclosed no evidence that R.S. required seclusion or emergency treatment orders to force her to take medications. She voluntarily took medications and followed unit rules, and no longer needed 24-hour nursing care. Dr. Mehra concluded that sub-acute treatment was the appropriate level of care as of May 22. Dr. Mehra testified that his main concern with the length of R.S.'s stay was that she persisted with active psychotic symptoms even up to the day of discharge. There was not much difference in her symptoms between May 22 and May 30. After May 22, she received no medication on an "as needed" ("PRN") basis and required no seclusion or restraints. Despite her other noted symptoms, if she was not having command hallucinations telling her to hurt herself, she could have been treated as an outpatient. Dr. Mehra agreed that if she expressed a desire to hurt herself after May 22, then any such days should be authorized. Dr. Mehra did not have the benefit of R.S.'s past medical records and stated this made it difficult to determine if R.S. was a patient whose baseline level of functioning is so low that she could never care for herself. He agreed that the attending physician had the advantage of having seen the patient in person. Attending physician Dr. Birkmire testified that R.S. had just been discharged from a medical psychiatric unit but had to be readmitted on a Baker Act because she was not taking her medications and was psychotic again, hearing and responding to voices and unable to communicate in a meaningful manner to staff. On May 22, she was noted as unchanged from admission, still psychotic, disorganized, hearing voices, depressed, and oriented only to person and place, not date and time. She was secluded in her room, not going to any treatment groups. Dr. Birkmire testified that his greatest concern was that R.S. was so psychotic and disorganized that she would probably not take her medications and would not be not able to care for herself. On May 23, she remained regressed, bizarre and psychotic. She was "dirty and careless" in her ADLs, and was complaining of suicidal command ideations, voices telling her to hurt herself by taking an overdose. On May 24, she was showing mild signs of improvement and was a little less reclusive and bizarre. She was still hearing voices and claimed they were telling her to be a friend to everybody, but she also admitted to suicidal ideations. On May 25, R.S. was still psychotic with suicidal ideations, disorganized, and paranoid. By this time, the voices were telling her to do more good things than bad, but she needed more time to stabilize on her medications. She was still dirty and careless in her appearance, and depressed with a flat affect. On May 26, she showed further mild improvement, was less paranoid, and reported that the voices were less intense. She remained in her room most of the time, and her ADLs were still careless. On May 27, R.S. was now oriented to person, place and time. The treatment team still thought she would stop taking medications on release, and made, further, two more medication changes. On May 28, the hallucinations had resolved. She was more logical and organized and less paranoid, though her ADLs were still poor. By May 29, she was safe to go home, but her appearance was still disheveled, she had poor concentration and hygiene, still heard voices, and was depressed and anxious. She went to group therapy, but was distracted by auditory hallucinations. Dr. Birkmire believed that May 29 or May 30, would be an appropriate discharge date. Dr. Berns testified that R.S.'s diagnosis was schizophrenia. He acknowledged that R.S.'s suicidal ideations on May 22 did not indicate a plan. However, in the hospital setting, a patient may not always reveal her plans for fear of prolonging the hospitalization. On May 23, she was having command auditory hallucinations to hurt herself with a plan to overdose. Dr. Berns found this very serious, because patients have been known to hoard medications in the hospital in order to take an overdose. After reciting the same day-by-day review conducted by Dr. Birkmire, Dr. Berns concluded that he concurred with the length of stay. Noting that she was still psychotic, mumbling and hallucinatory at the time of discharge, Dr. Berns testified that he did not necessarily agree that R.S. should have been released even on May 30. In response, Dr. Mehra testified that he agreed with many of the concerns expressed by Dr. Birkmire, but did not see them evidenced in the medical record. Dr. Birkmire testified that as of May 22, R.S. was so psychotic and disorganized that she would probably not take her medications after discharge. Dr. Mehra agreed this is grounds for keeping someone in the hospital, but did not see this concern noted in the medical record. Dr. Mehra also found nothing in the medical record to indicate she was having command auditory hallucinations to hurt herself with a plan to overdose. Dr. Mehra stated that the record did show that on May 23 she was regressed, bizarre and psychotic, but he noted that those symptoms were also present at the time of R.S.'s discharge. However, the psychiatry unit patient notes do indicate that R.S. told a student nurse on May 23, that "she was having suicidal ideations and a plan to overdose." The other notations cited by Dr. Birkmire, with the exception of the May 22 notation regarding staff's suspicions regarding R.S. medication compliance, were all found in the psychiatry unit patient notes. It must be concluded that Dr. Mehra simply overlooked this section of the record, and that if he had seen that the record supported Dr. Birkmire's concerns, Dr. Mehra would have authorized the full stay for R.S. The greater weight of the evidence supports Petitioner's position that May 22 through May 30, should not have been denied. Dr. Mehra's reason for denying these days was not that he disagreed with Dr. Birkmire's concerns regarding the patient, but that he could not find those concerns reflected in the record. In fact, the record supported Dr. Birkmire's concerns and rendered R.S.'s entire inpatient stay medically necessary. Patient #11 D.T. D.T. was admitted on May 9, 2001, and was discharged on May 21, 2001. Peer reviewer Dr. Mehra determined in his report that nine days, May 12, through May 21, should be denied due to lack of medical necessity for continued inpatient care.9 Dr. Mehra's peer review report stated that R.S. was a 14-year-old female with an extensive psychiatric history who was voluntarily admitted from a community mental health center for mood swings, violent tendencies, and a report of auditory hallucinations. As of May 12, the patient was not actively suicidal, homicidal, grossly psychotic, manic, or in complicated withdrawal. The patient was taking her medications, following unit rules, and participating in activities. The patient's sleep, vital signs, and appetite were stable. Dr. Mehra concluded that she did not require 24-hour nursing care as of May 12 and that outpatient was the appropriate level of care. Dr. Mehra testified that D.T. was admitted for mood swings, a history of violence, and some personality issues. She was diagnosed as bipolar, though Dr. Mehra was not clear as to what features led to that diagnosis. She was also diagnosed with post traumatic stress disorder. Further, she was diagnosed under Axis II of the DSM-IV, which includes personality disorders. Dr. Mehra found this significant because personality disorder symptoms are treated differently than bipolar disorder. Dr. Mehra found no indication in the record that D.T.'s history records were ordered or reviewed for purposes of continuity of care and current treatment. She was admitted and served on the inpatient unit, and her medications were continued: such as Wellbutrin, Topamax, and Risperdal. She was started on Geodan, an antipsychotic, which was then changed to Seroquel, and then back to Risperdal. Dr. Mehra concluded that D.T. met discharge criteria as of May 12. Nothing remarkable happened between May 12, and the date of her discharge. She continued to have some difficulties on the unit, but nothing that warranted inpatient care. She could have been sent to outpatient and returned to foster care. Given her documented history, return to a stable group home or foster home would be appropriate to help her engage with her symptoms. For someone with a personality condition to be on an inpatient psychiatric unit can worsen the symptoms. Dr. Mehra believed that D.T. needed an environment with a lot less stimulation and less potential for her to become agitated and act out. Dr. Mehra acknowledged that the records do show serious medication side effects on May 15, such as akathisia, but he stated that people have these symptoms frequently as outpatients. Dr. Mehra was curious as to why D.T. was on three different antipsychotic drugs. Three different psychotropic medications is a concern because there is insufficient clinical and medical data to use them in children when the diagnosis is not clear. They have potential long-lasting side effects, such as tardive dyskinesia, where the patient develops permanent tic- like movements of the lips, mouth and jaw. Cogentin is a medication for side effects from antipsychotics, and its use caused Dr. Mehra to question whether research was done as to whether this child had been on such medications before. Dr. Mehra stated that such research is essential, especially when the patient starts showing side effects. Treating physician Dr. Scott Farmer testified that all of the denied dates represented necessary periods of care to stabilize D.T. and make her discharge safe. On May 15, she was still experiencing severe mood swings and dissociative symptoms, which Dr. Farmer described as "a watershed between normal and neurotic." In a spectrum moving toward psychosis, dissociative thinking has features of both psychotic and neurotic thinking. Dr. Farmer explained that if a physician has a patient in his office who is disassociating, the physician must watch the patient until the patient has demonstrated several hours of improved functioning. If a patient drifts into a dissociative state during psychotherapy and becomes agitated, the patient requires hospitalization. Dr. Farmer stated that D.T. could not have been released on May 15. She was still requiring Haldol due to episodes of anger, and due to her inability to recognize people who are caring for her and distinguish them from threats. Her agitation was so extreme that Dr. Farmer had to change the dose of Haldol. This was complicated by the fact she was having side effects of the antipsychotic medication. Akathisia is an acute dystonia, a side effect of these powerful medications. It is a restlessness, an inability to sit still. The patient wants to stretch her legs and flex her muscles to relieve tension that feels like an unrelenting, very slowly developing cramp. Dr. Farmer testified that akathisia is not as dramatic as other side effects because it looks like the disease itself: the patient is restless, can't sit still, and wants to walk around. There is a ramping up in the intensity of treatment for akathisia, culminating in Propranolol, which itself causes 40 percent of users to have a new onset of major depression within a year. Dr. Farmer stated that D.T. was so resistant to taking medications that at times intramuscular medications were required. Geodon was the medicine initially chosen to treat D.T.'s psychotic features because it has the least likelihood of causing weight gain. By May 15, Dr. Farmer had deemed it a failure and was in the process of replacing it with Seroquel. On May 16, D.T. remained actively psychotic with visual and auditory hallucinations, side effects of the medication. Dr. Farmer testified that the dosages of medicine that could possibly make the hallucinations go away, had the side effect of incapacitating her. D.T. could not sit in group and match her mood and comments to the group process. She was too lethargic to function. Dr. Farmer believed that as of May 16, D.T. could not be anywhere but an acute care setting, with nurses and physicians monitoring her response to medications. On May 17, D.T. reported seeing what she described as flashing lights. She moved out of her lethargy into accelerated speech. She was irritable and paranoid, different from the day before when she appeared overdrugged and lethargic. On May 18, she had a severe reaction to the Seroquel, active symptoms of delusional, confused and agitated behavior. Seroquel was discontinued and a new antipsychotic, Restoril, was introduced. On that day, D.T. was noted to be crying and hallucinating. She saw a man in her room and held so fast to the idea of being in danger that she required additional medication, Ativan PRN, to make her relax. On May 19, her Risperdal had to be further adjusted because she was overly sedated. She was disheveled, easily agitated, and still required PRN medications in addition to her standard medicines. On May 20, she remained labile, easily upset and crying. Dr. Farmer concluded, by stating, that this case involved a very complex juggling of medications to get control of auditory hallucinations with other medications striving to compensate for side effects. Dr. Berns testified that D.T. had an extensive psychiatric history and was admitted for mood swings, violent tendencies, and report of auditory hallucinations. The admissions note stated that D.T. was depressed and angry, "ready to kill everybody." She was having problems with flashbacks regarding her history of fights with her father, and was fearful that her mood changes and lability would cause her to lose her foster placement. She had been in foster care since January 2001. D.T. had a history of arrests for fighting, breaking and entering, grand theft auto, and battery. She had a decrease in appetite with a four-pound-weight-loss in the past week. She said that she felt paranoid a lot, and she overreacted to intrusions into her physical space. She heard voices with command features telling her to cut her arms instead of battering her father, and admitted to some prior plans of killing her father. The May 15 notes showed severe mood swings and unspecified dissociative symptoms. She received Haldol for anger episodes. Dr. Farmer discontinued Geodon and began Seroquel, another antipsychotic also used in the treatment of bipolar disorder. She was also given Cogentin intramuscularly, because she had tremors and akathasia. On May 16, D.T. was anxious with sleep disturbance, undescribed auditory and visual hallucinations, and said she was lethargic. On May 17, she was reporting flashbacks about "angel trumpet," which may have been a psychedelic drug. She was observed to have accelerated speech, irritable, perseverant and loquacious. Dr. Farmer raised the level of the Seroquel. D.T. was incoherent from midnight to 6:30 a.m., with auditory and visual hallucinations. She was seeing people, carrying on conversations, making and unmaking her bed, trying to open a window, and mumbling. At times she was manic, hyper-verbal, crying and laughing. She said she was high on her medications. The Cogentin was discontinued. They raised the Seroquel and put her on intramuscular injection of Ativan. On May 18, she had a severe reaction to Seroquel. She was delusional, confused and agitated, but showed no aggression. Dr. Farmer stopped the Seroquel and started Risperdal. She hallucinated seeing a man in her room. On May 19, she was anxious and irritable, having non-command hallucinations. Her Risperdal dosage was increased. On May 20, she was upset and emotional. She requested Haldol and Ativan to calm herself down. On May 21, she was organized, with no flight of ideas or loose associations, and was discharged. Dr. Berns noted that Dr. Mehra found that by May 12, D.T.'s sleep, vital signs and appetite were stable, that she was following unit rules of participating in activities, and that she was not actively suicidal, homicidal, psychotic, manic or in withdrawal. Dr. Berns disagreed with this assessment. On May 16, D.T. still had active psychotic symptoms. On May 17, she was paranoid and irritable, carrying on conversations with unseen people. On May 18, she had visual hallucinations. On May 19, she was disheveled and easily agitated. On May 20, she was labile, and very easily upset. Dr. Berns agreed with Dr. Farmer that the entire stay was medically necessary. In response, Dr. Mehra testified that he was aware of Dr. Farmer's statement that on May 15 D.T. was still experiencing severe mood swings and disassociative symptoms, "which are a watershed between normal and neurotic." Dr. Mehra did not know what that means in terms of the issues in this case, because disassociation is not sufficient to warrant keeping her in the hospital. Visual and auditory hallucinations, in and of themselves, are not sufficient to keep her in the hospital unless they are command hallucinations. Dr. Mehra pointed out that the treating physician's own discharge summary stated that D.T. has personality issues of concern. "Personality issue" means that a lot of the symptoms do not necessarily indicate a major, Axis I diagnosis such as schizophrenia or major depression, but are more about the patient's character and how she relates to people. Dr. Farmer noted on May 16 that, due to side effects of medication, D.T. was lethargic and could not function. Dr. Mehra stated that this might be sufficient to keep her in the hospital, though, again, the treating physician must keep the treatment options in mind and distinguish between someone with a personality disorder who is experiencing hallucinatory symptoms and someone who is schizophrenic. Dr. Mehra was concerned that the physicians were injecting this 14-year-old child with potent anti-psychotic medications and that she was having an adverse reaction. He was further concerned that she was not having much of a response to the medications, which Dr. Mehra found would not be unusual if the diagnosis were inaccurate. Based on the documentation in the record, Dr. Mehra could not be sure that D.T. had a true psychotic disorder that would respond to anti-psychotic medications. Because D.T. was in the custody of the Department of Children and Family Services, Dr. Mehra believed there was "a great likelihood" that she had been physically and/or sexually abused. Many of her symptoms would be easier to understand in the context of past abuse rather than as a diagnosis of schizophrenia. Dr. Mehra found the record confusing as to the rationale for this hospitalization. In the admission mental status exam, the physician documented no well formulated plan for the patient to harm herself. No psychotic symptoms were noted in the admission mental status exam. However, because the patient was presenting with symptoms such as auditory hallucinations, Dr. Mehra authorized and approved a three-day evaluation period. Dr. Mehra stated that he would authorize less time for an adult, but with a child it is important to take sufficient time to obtain a good history. What confused Dr. Mehra was that the medical record showed no clear documentation of collateral information regarding D.T.'s past to understand why she may be disassociating or having mood swings. The greater weight of the evidence supports AHCA's denial of the last six days of D.T.'s admission. The record as presented established that D.T. ceased to meet the criteria for inpatient admission in the psychiatric unit on May 12. However, as stated in note 10, AHCA's recovery is limited to May 14 through May 21. Patient #12 S.T. S.T. was admitted on March 7, 2001, and was discharged on March 17, 2001. Peer reviewer Dr. Mehra determined in his report that eight days, March 9 through March 17, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that S.T. was a 34-year-old female admitted, involuntarily, under the Baker Act for violent, agitated, self-harming behavior in a community services van. The patient had a history of moderate mental retardation, cerebral palsy, seizure disorder, and abnormal EEGs. The patient was prescribed Haldol PRN, but required none on March 9, 10, or 11. As of March 10, the patient was not actively suicidal, homicidal, grossly psychotic, or manic. Later in her hospitalization, the patient did require Haldol/Ativan PRN on several days, though no adjustments were made to her routine antipsychotic doses. Dr. Mehra noted that the only adjustment made to S.T.'s psychotropic dosing was on March 8, when her Depakote was increased. Dr. Mehra also noted that the patient was allowed to sign a voluntary consent for treatment, when her legal guardian should have been involved in the consent process. Dr. Mehra found in the record no informed consent for psychotropic medications. Dr. Mehra found that the diagnostic studies performed on S.T. could have been done on an outpatient basis. Dr. Mehra concluded that, as of March 10, outpatient treatment with a return to the group home setting was the appropriate level of care. Dr. Mehra testified that S.T. was admitted through the emergency room under the Baker Act when she became violent and agitated in a van operated by Spectrum Community Services, the group home where S.T. lived. Her admitting diagnosis was mental retardation in the moderate range, as well as organic mood disorder. Dr. Mehra found no physician's notes in the record for March 8 or 9, which indicated that S.T. must not have many problems. The nurse's notes for March 9 indicated that S.T. was sleeping through the night. The unit notes from three different shifts on March 9 indicated that her behavior was under control and that she denied hallucinations. All of the above findings in the record, coupled with a lack of physician notes, led Dr. Mehra to conclude that S.T. should be discharged. Dr. Mehra stated that everything relative to making a medical decision must be documented in the record. If something is not in the record, then a peer reviewer must assume it did not happen. In this connection, Dr. Mehra noted there was no indication in the record that the hospital contacted S.T.'s group home for a treatment history and status before initiating invasive diagnostic procedures. On March 8, S.T. had a fall on the unit, hitting and cutting her head on the cinderblock wall. Dr. Mehra stated that a patient with cerebral palsy and mental retardation, who is having acute psychological problems and has fallen, is a grave concern, yet he could find no record that she was seen by a physician on March 9. He did find a March 9, note calling for a consultation with Dr. Henry Comiter regarding S.T.'s fall, but no actual physician's visit on that date. The record indicated that S.T. was placed in restraints on March 13 and engaged in threatening behavior on March 14. However, Dr. Mehra noted there had been no such incidents on March 11 through 12. He testified that, if a patient with these underlying medical and psychiatric conditions is kept long enough, she will probably act out. The incident on March 13, alone, was not enough to keep her without getting a legal guardian involved to continue her voluntary legal status in the hospital. This was a great concern to Dr. Mehra because the hospital appeared to be relying on a voluntary consent form signed by S.T. on March 10. S.T. was mentally retarded and possibly incompetent to admit herself to the hospital. Treating physician Dr. Farmer described S.T. as a 34- year-old mild-to-moderately retarded woman living in a group home. The incident that led to her admission was her deteriorated impulse control, agitation, and aggression directed toward the van and toward the staff and other peers during a van ride on an outing. She struck at her peers and the van driver, bit herself on the hands and arms, and stated that she wanted to hurt herself. S.T. was already scheduled to have an outpatient neurology consultation in late March with Dr. Comiter, out of concern for a seizure disorder that was not adequately managed. Because of her agitation, S.T. was sent to the psychiatric unit, which began the process of adjusting her medications. The adjustments were ongoing on March 8. She was seen by Dr. Comiter on March 8, as indicated by a consultation note in the record.10 Dr. Comiter ordered an EEG and CT scan of the head. The CT brain scan was scheduled for March 9, but S.T. was too agitated to undergo the procedure. On March 10, S.T. remained agitated. She refused a shower and was generally careless with regard to her ADLs. On March 11, Dr. Farmer reduced S.T.'s dosage of Ativan in order to calm her and make her more manageable for the CT scan. On March 12, she was less agitated, but not calm enough for the CT and EEG to be completed. She was too agitated to go for the CT study, but too fatigued from the medications to be functional on the psychiatric unit. The reduction in her Ativan dosage did enable her to respond more promptly to questions. On March 13, staff attempted to transport S.T. in the van for her EEG, but she began swinging her arms and had to be placed in seclusion and restraints. On March 14, Dr. Farmer characterized S.T. as naïve regarding her manic grandiosity, unable to recognize that her reactions are disproportionate to the circumstances. Her vocal volume was threatening and her intrusiveness was with ominous import, but she believed she was justified in her reactions. She was paranoid and misreading the likelihood of danger and pain, and so was attempting to intimidate people away from her. By this time, Dr. Farmer believed that she was reacting well to the adjusted medications. However, when the medications got her to the point at which she was not threatening others, she began having balance problems and falling again. On March 15, the medications had slowed S.T.'s psychomotor skills, and she was not assaultive. She was taking her medicines by mouth. S.T. was beginning to return to baseline and Dr. Farmer began considering discharging her back to the group home. She was denying any suicidal or homicidal ideation and denying hallucinations. She was able to be redirected from biting her hand, which was a continuing problem for S.T. She was able to participate in group therapy without disruption, though her ADLs remained careless. On March 16, she remained restless, distractable, impulsive, and aggressive, though the hospital did manage to complete the EEG on that date. The EEG showed no evidence of a seizure disorder. On March 17, S.T. was discharged back to the group home. Dr. Farmer concluded that it was in the best interest of S.T.'s care to keep her through March 17. It was best to accomplish all the needed adjustments to her anticonvulsant medications on an inpatient basis, especially since there were no EEG results until March 16. Those results could have required further adjustments, and Dr. Farmer believed that relying on the group home to make the changes in her medications might not work and could result in her readmission. Dr. Berns agreed with the length of stay because the attending physicians were not only trying to make sure that S.T. was no longer suicidal, they were trying to decrease her agitation and aggression while completing important diagnostic tests. Dr. Berns thought that authorizing her stay only through March 10 would be premature. The greater weight of the evidence supports Petitioner's position that March 10 through March 17, should not have been denied. Dr. Mehra's opinion in this instance was at least partly based on a misreading of the record, i.e., that S.T. was not seen by a physician on March 8 or 9. Dr. Mehra's concerns regarding S.T.'s consent to treatment are serious, but cannot be resolved on this record and do not appear relevant to the question of the medical necessity of S.T.'s hospital stay. Dr. Farmer's testimony as the treating psychiatrist credibly established that S.T.'s entire inpatient stay was medically necessary. Patient #13 W.W. W.W. was admitted on June 17, 2001, and was discharged on June 28, 2001. Peer reviewer Dr. Mehra determined in his report that five days, June 23 through June 28, should be denied due to lack of medical necessity for continued inpatient care. Dr. Mehra's peer review report stated that W.W. was a 43-year-old female admitted to the psychiatric unit after an intentional overdose of psychotropic medications. Dr. Mehra wrote that his authorization was based on continued documentation of the patient's having command auditory hallucinations to hurt herself. As of June 23, the patient was not actively suicidal, homicidal, psychotic, manic, or in complicated withdrawal. Her sleep, appetite, and vital signs were stable. She was not a management problem on the unit. Dr. Mehra concluded that, as of June 23, the patient no longer required 24-hour nursing care and that outpatient treatment was the appropriate level of care. In his deposition, Dr. Mehra testified that W.W. was on the medical floor, then transferred to the psychiatric floor after two days. On discharge, her Axis I diagnosis was alcohol abuse, history of cocaine abuse, and rule-out schizoaffective disorder. The hospital's discharge summary stated that the reason for admission was severe depression, no psychotic features, and having suicidal thoughts. She was integrated into the milieu of the inpatient psychiatric unit and prescribed antidepressant medication. Dr. Mehra believed W.W. should have been discharged on June 23. He stated that, even on the psychiatric unit's admission mental status exam, dated June 17, Dr. Allen noted that W.W. was slightly more cooperative than on the previous day's consult, meaning that Dr. Allen probably saw her on the medical floor after her overdose. Dr. Allen noted there was no active suicidal ideation with a plan. Dr. Mehra testified that this admission psychiatric exam, standing alone, would indicate that W.W. did not need to be admitted at all. However, the totality of her presentation and history showed numerous overdoses on psychotropic medications. Based on her history and the mental status exam showing her mood was still depressed, her admission through June 22 was approved. Attending physician Dr. Birkmire testified that, in the weeks before the overdose, W.W. described becoming increasingly depressed with feelings of helplessness and hopelessness. Her history showed at least eight or nine other psychiatric hospitalizations. She indicated a history of being sexually abused by her father at age 12. Her admitting diagnosis was schizoaffective disorder, depressed, subtype provisional, depressive disorder not otherwise specified, alcohol abuse and history of cocaine abuse. W.W.'s global assessment of functioning ("GAF") upon admission was 35. Dr. Birkmire testified that a GAF below 50 indicates that a patient should be in a residential program, at least, and that a GAF below 40-to-45 indicates the patient should be on an inpatient unit. On June 23, the medical notes show she was still somewhat confused. Her mood had improved but she still had suicidal ideations. The hospital was holding her in part to see if the blood test for syphilis was negative. She felt better but complained about mood swings. On June 24, a Sunday, there were no notes. Dr. Birkmire explained that the physicians who take rounds on the weekends are required to see each patient on either Saturday or Sunday, but not both days. On June 25, W.W. was less psychotic. Her auditory hallucinations were present but decreased, and she was taking her medications. On June 26, she continued to have auditory hallucinations. She was disorganized, paranoid, and isolating herself. She reported fear in being released because she might make another suicide attempt. She was given Ativan PRN to treat reported anxiety. On June 27, her mood was euthymic (normal, neither depressed nor highly elevated in mood). She showed no psychotic symptoms, denied suicidal ideations, and felt safe for discharge. However, hospital staff said that W.W. still seemed to be responding to voices. Dr. Birkmire stated that he had reservations about releasing W.W. on June 27 because she seemed to be telling the staff she was doing better than she really was. The voices had played a role in her suicide attempt, and, thus, the knowledge that she was still hearing them would be a strong factor in deciding to keep W.W. hospitalized. In Dr. Birkmire's opinion, W.W.'s problems could not be addressed in a skilled nursing facility. Dr. Birkmire testified that, with the exception of psychiatrists who perform peer reviews and medical authorizations, there is not one psychiatrist in the country who would say that a patient should not be in an acute care setting unless she has a definite plan for suicide or the means to complete the plan. Dr. Birkmire stated that no doctor is going to risk his license in that fashion. Whole books are written on how to perform a suicide assessment, and the assessment is based on much more than what the patient tells the physician. It is based on the patient's history, her degree of hopelessness, degree of disorganization, degrees of psychosis, and her access to the means of doing the suicide. Dr. Birkmire stated that one of the best predictors of suicidality is past attempts. Dr. Berns testified that W.W.'s history of multiple psychiatric hospitalizations indicated a probability of chronic illness. He stated that the number of prior hospitalizations automatically raises the question of past suicide attempts, and noted that her history indicated three attempts prior to this one. She was diagnosed with "depressive disorder" but not otherwise specified, as well as alcohol and cocaine abuse. She took an overdose of Haldol, Cogentin, and Sinequan. Dr. Berns explained that Sinequan is an older antidepressant, a tricyclic, with which a higher number of suicides occur. Thus, an overdose of this medication is more serious than overdoses of other medicines. There were concerns about neurosyphilis because she had a positive RPR. Her physicians were concerned that inadequate treatment for this condition would complicate her psychiatric course as well as cause physical complications leading to dementia and death. Dr. Berns concluded that W.W.'s stay was medically necessary. Her physicians were trying to stabilize her condition and treat a gradual illness that can become fatal. In response, Dr. Mehra testified that the evaluation for neurosyphilis on June 23 and 24, was not, standing alone, a ground for keeping the patient in the hospital. Dr. Mehra also stated that the suicidal thoughts, hallucinations, and psychotic disorganized paranoia are not grounds to keep the patient in the hospital, unless she was actively suicidal with a plan and unless her psychoses were causing imminent danger to herself or others, or she was aggressive or noncompliant. W.W. was taking her medications, eating, and sleeping and was not requiring seclusion or restraints on the unit, which meant that she was, at some level, functioning. Dr. Mehra was adamant that Medicaid and InterQual guidelines require more than a suicidal ideation; they require a plan. The greater weight of the evidence supports Petitioner's position that June 23 through June 28, should not have been denied. Dr. Birkmire's testimony as the treating psychiatrist, as well as Dr. Berns' expert testimony, credibly established that W.W.'s entire inpatient stay was medically necessary. Summary of Findings At the time of the hearing, AHCA sought from Petitioner overpayments in the amount of $198,582.54 for 29 patients who stayed at Florida Hospital Orlando between January 1, 2000, through December 31, 2001. The findings of fact above upheld AHCA's denial of days for the following: Acute Care Inpatient Hospital patients 2, 3, 5, 6, 9, 10, 11, 12, 13, and 16; and Psychiatric Inpatient Hospital patients 1, 3, 4, 5, 6, 7, 8, 9, and 11. The findings of fact above found that the greater weight of the evidence supported Petitioner's position that AHCA should not have denied the days for the following: Acute Care Inpatient Hospital patients 1 (2 days x reimbursement rate of $1,168.38 = $2,336.76), 4 (6 days x $1,206.42 = $7,238.52), 7 (1 day at $1,168.38), 8 (3 days x $1,168.38 = $3,505.14), 14 (9 days x $919.27 = $8,273.43), and 15 (5 days x $919.27 = $4,596.35); and Psychiatric Inpatient Hospital patients 10 (9 days x $1,168.38 = $10,515.42), 12 (8 days x $1,168.38 = $9,347.04), and 13 (5 days x $1,168.38 = $5,841.90). The total dollar figure for days that should not have been denied is $52,822.94, reducing the total overpayment due AHCA from Petitioner to $145,759.60.
Recommendation Based on the foregoing Findings of Facts and Conclusions of Law, it is RECOMMENDED that: Respondent, Agency for Health Care Administration, enter a final order revising its Final Agency Audit Report as directed herein. DONE AND ENTERED this 5th day of March, 2007, in Tallahassee, Leon County, Florida. S LAWRENCE P. STEVENSON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 5th day of March, 2007.
Findings Of Fact The PROVIDER received the Final Audit Report that gave notice of PROVIDER'S right to an administrative hearing regarding the alleged Medicaid overpayment. The PROVIDER filed a petition requesting an administrative hearing, and then caused that petition to be WITHDRAWN and the administrative hearing case to be CLOSED. PROVIDER chose not to dispute the facts set forth in the Final Audit Report dated August 15, 2013. The facts alleged in the FAR are hereby deemed admitted, including the total amount of $14,569.69, which includes a fine sanction of $2,419.26. The Agency hereby adopts the facts as set forth in the FAR including the amount of $14,569.69 which is now due and owing, from PROVIDER to the Agency.
Conclusions THIS CAUSE came before me for issuance of a Final Order on a Final Audit Report (“FAR”) dated August 15, 2013 (C.1. No. 13-1386-000). By the Final Audit Report, the Agency for Health Care Administration (“AHCA” or “Agency”), informed the Respondent, Amwill Assisted Living, Inc., (hereinafter “PROVIDER’), that the Agency was seeking to recover Medicaid overpayments in the amount of $12,096.28, and impose a fine sanction of $2,419.26 pursuant to Sections 409.913(15), (16), and (17), Florida Statutes, and Rule 59G- 9.070(7)(e), Florida Administrative Code, and costs of $54.15 for a total amount of $14,569.69. The Final Audit Report provided full disclosure and notice to the PROVIDER of procedures for requesting an administrative hearing to contest the alleged overpayment. The PROVIDER filed a petition with the Agency requesting a formal administrative hearing on or about September 5, 2013. The Agency forwarded PROVIDER'S hearing request to the Division of Administrative Hearings (Division) for a formal administrative hearing. The Division scheduled a formal hearing for November 22, 2013. On November 12, 2013, the PROVIDER filed a Motion with the Administrative Law Judge, requesting AHCA vs. Amwill Assisted Living, Inc. (AHCA C.I, No.: 13-1386-000) Final Order Page 1 of 4 Filed January 2, 2014 10:59 AM Division of Administrative Hearings withdrawal of their Petition for Formal Hearing, and the Administrative Law Judge issued an Order Closing File on November 12, 2013, relinquishing jurisdiction of the case to the Agency.
