Avante at Lynchburg, Inc. v. Teefey

• Decision Date: 11 August 1998
• Docket Number: Record No. 2457-97-3.
• Citation: 502 S.E.2d 708,28 Va. App. 156
• Court: Virginia Court of Appeals
• Parties: AVANT… AT LYNCHBURG, INC. v. Joseph M. TEEFEY, Director, Virginia Department of Medical Assistance Services.

502 S.E.2d 708

28 Va. App. 156

AVANT… AT LYNCHBURG, INC. v. Joseph M. TEEFEY, Director, Virginia Department of Medical Assistance Services.

Record No. 2457-97-3.

Court of Appeals of Virginia, Salem.

August 11, 1998.

Jeannie A. Adams (Peter M. Mellette; Crews & Hancock, P.L.C., on briefs), Richmond, for appellant.

Brian E. Walther, Special Counsel (Mark L. Earley, Attorney General; Ashley L. Taylor, Jr., Deputy Attorney General; Siran S. Faulders, Senior Assistant Attorney General, on brief), for appellee.

Present: BRAY, OVERTON and BUMGARDNER, JJ.

BUMGARDNER, Judge.

The Director of the Department of Medical Assistance Services (DMAS) refused to pay AvantÈ at Lynchburg, Inc. for specialized medical care provided to Patient H.¹ AvantÈ appealed the Director's refusal to the Circuit Court of the City of Lynchburg. The trial court affirmed the Director's decision, finding substantial evidence to support the decision that Patient H no longer required specialized care after June 14, 1994.

Patient H was admitted to AvantÈ's specialized care facility following release from surgery at Danville Regional Medical Center where a tracheostomy was performed. She was admitted with multiple diagnoses, the most relevant being Down's syndrome and obstructive sleep apnea, which is the inability to breathe effectively while asleep. She had a life expectancy of six months. When admitted on March 4, 1994, DMAS had approved her for specialized care at AvantÈ.

Pursuant to the DMAS Nursing Home Provider Manual, a nursing home will be reimbursed for providing specialized care when a patient requires weekly physician visits, twenty-four-hour-a-day nursing supervision, and a coordinated multi-disciplinary team approach to treatment. In addition, the individual must require one of three specific patient care categories: (1) rehabilitative services, (2) special equipment, or (3) special services, such as ostomy care or ongoing administration of medication or nutrition. Patient H met the basic specialized care criteria and needed specialized equipment. Her physician ordered that she be monitored with a pulse oximeter twenty-four hours a day. The pulse oximeter measures oxygen in the blood. If the level of saturation drops below a designated level, special actions would be taken to correct the deficiency.

On June 13-14, 1994, DMAS's Utilization Review Team conducted a review of the treatment provided Patient H by AvantÈ. Pamalia Hollenbach, a registered nurse, reviewed the patient's records and observed Patient H and her surroundings. Ms. Hollenbach reviewed her findings with the other members of the review team, which was composed of two additional registered nurses. The team determined that Patient H no longer needed specialized care. After proceeding through the administrative appeal channels, the determination by the review team was approved by the Director. He ruled that ample evidence supported the findings (1) that the patient did not need specialized care because weekly nursing summaries never reflected that the patient experienced respiratory distress, (2) the patient's goal of not experiencing any seizure had been met, (3) the physician's progress notes did not reflect any respiratory distress and as of June 2, 1994 described the patient as stable, (4) the patient was observed without a pulse oximeter and without any staff observing her, and (5) no order had been written for defined monitoring by a pulse oximeter or directing the response if saturation levels reached a certain point. The Director found that the specialized care was not necessary based on the review of the records and the observation of Patient H made by the review team even though AvantÈ may have provided the specialized care. AvantÈ appealed the decree of the circuit court which upheld the Director's denial of reimbursement for specialized care from June 24 to December 1, 1994. After December 1, 1994, AvantÈ agrees the specialized care was no longer needed.

The standard of review of an agency's factual findings on appeal to a circuit court is limited to determining whether substantial evidence in the agency record supports its decision. See Code ß 9-6.14:17; Turner v. Jackson, 14 Va.App. 423, 429-30, 417 S.E.2d 881, 886 (1992). On appeal, we do not disturb factual findings if credible evidence supports them. See James v. Capitol Steel Constr. Co., 8 Va.App. 512, 515, 382 S.E.2d 487, 488 (1989). The reviewing court can reject an agency decision "`only if, after considering the record as a whole, it determines that a reasonable mind would necessarily come to a different conclusion.'" Virginia Real Estate Comm'n v. Bias, 226 Va. 264, 269, 308 S.E.2d 123, 125 (1983) (quoting B. Mezines, Administrative Law ß 51.01 (1981)).

The Director accepted the opinion of the review team that the specialized treatment was unnecessary. The team's opinion was based on a review of the patient's records and the observations made of the patient herself. The...