Cruz v. Waldman

• Decision Date: 08 April 2005
• Docket Number: 040004
• Citation: 2005 MBAR 139
• Parties: Linic Cruz v. Beth Waldman, in her capacity as Acting Commissioner of the Division of Medical Assistance[1]
• Court: Massachusetts Superior Court

2005-MBAR-139

Linic Cruz v. Beth Waldman, in her capacity as Acting Commissioner of the Division of Medical Assistance^[1]

No. 040004

Superior Court of Massachusetts

April 8, 2005

Opinion No.: 88282

As-is Docket Number: 04-0004

Venue Hampden

Judge (with first initial, no space for Sullivan, Dorsey, and Walsh): McDonald, J.

Opinion Title: MEMORANDUM OF DECISION AND ORDER ON PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT and CROSS MOTIONS BY BOTH PARTIES FOR JUDGMENT ON THE PLEADINGS

The plaintiff, Linic Cruz ("Cruz"), has appealed pursuant to G.L.c. 30A, §14, a decision of the Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid ("MassHealth"), which determined that Cruz is not eligible for a Personal Care Attendant ("PCA") under the MassHealth program. Because the administrative record contains substantial evidence to support MassHealth's decision, the defendant's motion for judgment on the pleadings pursuant to Mass.R.Civ.P. 12(6), is allowed and the plaintiff's motion for summary judgment and motion for judgment on the pleadings are denied. The following facts are taken from the certified administrative record.

BACKGROUND

A. Cruz's Condition

Since May of 2000, Cruz has been home-bound, suffering from paranoid schizophrenia. Cruz is on medication, and the family receives weekly in-home counseling. His aunt, who is his guardian, has always cared for him. When Cruz's aunt returned to part-time employment, Cruz stayed home, alone, during the morning. On January 22, 2003, his physician-psychiatrist completed a patient referral form seeking a PCA for Cruz,^[2] noting that he was "unable to manage daily living," had twice been admitted to Providence Hospital in the preceding six months, and "currently has short-term intensive case management." Cruz's physician submitted the referral form to Stavros, a MassHealth Personal Care Agency.^[3]

Pursuant to regulations, Stavros conducted an in-home assessment^[4] on March 13, 2003. In the assessment, it was noted that Cruz had previously threatened his brother with a knife, heard voices, and had a history of violent outbursts. Stavros requested PCA assistance for Cruz's meals because he was "unsafe with knives," and determined that he would also need a surrogate to manage the PCA for him. In its assessment, Stavros was called upon to describe Cruz's ability to perform various daily activities as "independent," "dependent," or "physical assistance required." Cruz was found to be "independent" for eating, feeding, and toileting but "dependent" for all other activities. None of his activities required physical assistance. The assessment explained that Cruz does not rise, dress, eat, groom himself, or take his medication without prompting and supervision. In addition, Cruz often resists performing these tasks. After completion, Stavros submitted the assessment, referral form, and an application for PCA services to MassHealth on April 4, 2003. Cruz's aunt, physician, and Stavros signed the application, which described the underlying reason for initiating the PCA request as "[c]ondition is worsening."

B. The Decision of the Agency

MassHealth offers several different programs for chronically disabled members with mental impairments. For example, the Day Habilitation Program, under 130 CMR 419.000 et seq., provides supervision, medical care, developmental training and occupational therapy to members with severe, chronic disabilities that are (1) attributable to mental or physical impairments, (2) manifesting prior to age 22, (3) likely to continue indefinitely, and (4) result in functional limitations in such areas as self-care, self-direction, and economic self-sufficiency. Other programs example include the Home Health Agency Services, under 130 CMR 403.000 et seq., which provides skilled nursing and household support; the Medical Assistance Program, under 130 CMR 422.000 et seq., which provides unskilled physical assistance and household support; and the Psychiatric Day Treatment Program, under 130 CMR 417.000 et seq., which provides specialized supervision, care, and therapy.

On May 1, 2003, MassHealth deferred Cruz's application, with the following comments:

PCA not a mental health worker. Not approp[riate] for s[upervision] of medication administration and outcomes. Member is in acute phase. Requires skills of psych[iatric] nurse/VNA daily + HHAs.^[5] Have day-hab services^[6] been considered for oversight and supervision of the member's medical needs? The Assessor's signature is needed on page 5 of the evaluation with regard to the need for a surrogate. The Physician did not complete the limitations section on the Patient Referral Form. The Division requests a letter from the physician stating that the member does not require the skilled services of a nurse for assessment and supervision.

The assessor's signature was subsequently provided on May 23, 2003, along with a letter from Stavros stating "[a]dditional information was requested from this consumer. We have not received anything. Please process the application as it is submitted."

MassHealth denied Cruz's application for PCA services on May 30, 2003. Cruz appealed the decision. An appeal hearing was conducted on October 15, 2003 with Cruz's aunt, her attorney, an interpreter, Cruz's uncle, and the hearing officer in attendance. MassHealth and Stavros representatives participated via telephone. The MassHealth representative restated and explained the agency's denial, concluding "[i]t was the decision of this reviewer that Services of the PCA Program should be denied, and the member requires and is entitled to a higher level of service than the personal care attendant is able to provide." The agency representative further explained, "... [MassHealth] feels that the member would benefit from the Skilled Services of a skilled psychiatric nurse for the needs he has, with his worsening condition, that a home - a PCA cannot provide." The agency representative expressed an additional concern that "[t]he physician did not complete the limitations of his psychiatric needs. There was no Letter of Medical Necessity, as was requested, stating that he did not require Skilled Services, and there was no response on the question of medical day-hab." The agency representative noted, "I'd like the doctor to explain... because all this documentation tells us his condition is worsening... A lot of times doctors use PCA and Home Health Aide back and forth to replace the way people use a nursing agency and a VA. They don't always know the difference." After listening to the concerns of Cruz's representatives, the hearing officer further explained, "A PCA is not somebody who is sort of guiding the person to do something he doesn't want to do... the member must be able to be self-directing... A PCA is unlicensed and [the] member must be able to self-direct a PCA." The hearing officer agreed to leave the record open for three weeks, to allow Cruz's physician to provide the missing letter of medical necessity. Three weeks later, Cruz, through his attorney, wrote to the hearing officer that no additional evidence would be submitted. The decision of the agency was affirmed on December 2, 2003. Cruz then filed the instant action for judicial review of the agency's decision pursuant to G.L.c. 30A, §14, alleging that the decision was not supported by substantial evidence, was contrary to agency regulations, and violated federal law.^[7] Cruz seeks reversal of the administrative decision and moves for Summary Judgment on his claim under the ADA.

DISCUSSION

Cruz asserts that MassHealth's decision to deny PCA services as inappropriate in his circumstances is unsupported by the evidence, which he argues clearly establishes his need for home services. He further asserts that, even if the regulations were correctly applied, they are contrary to law in that they violate the integration mandate of the ADA and the Rehabilitation Act of 1973 which seek to avoid institutionalization whenever possible. MassHealth counters that its decision is supported by substantial evidence that unskilled PCA services would be an inadequate, inappropriate level of professional care, given Cruz's resistance argumentative, and occasionally violent behavior toward caregivers, and his inability to self-direct the attendant. MassHealth asserts that skilled psychiatric nursing services, along with the accompanying home services in that program rather than the untrained PCA program, are necessary and constitute the proper standard of care for Cruz.

A party appealing an administrative decision bears the burden of demonstrating the decision's invalidity. Massachusetts Assoc. of Minority Law Enforcement Officers v. Abban, 434 Mass. 256, 263 (2001); Coggin v. Massachusetts Parole Bd., 42 Mass.App.Ct. 534, 587 (1997); Boston v. Outdoor Advertising Bd., 41 Mass.App.Ct. 775, 782 (1996), citing Merisme v. Bd of Appeals on Motor Vehicle Liab. Policies & Bonds, 27 Mass.App.Ct. 470, 474 (1996). A party can demonstrate a decision's invalidity by showing, among other things, that it is contrary to law or is unsupported by substantial evidence. G.L.c. 30A, §14(7)(a)-(g). In reviewing the agency decision, the court is required to give due weight to the agency's expertise, technical competence, specialized knowledge, and the discretionary authority conferred upon it by statute. G.L.c. 30A, §14(7); Flint v. Commissioner of Public Welfare. 412 Mass. 416, 420 (1992). See Iodice v. Architectural Access Bd., 424 Mass. 370, 375-76 (1997); Foxboro Harness, Inc. v. State Racing Comm'n., 42 Mass.App.Ct. 82, 87 (1997), rev. denied 424 Mass. 1107 (1997). The reviewing court may not substitute its judgment on questions of fact for that of the agency. Southern...