Tag Archives: ALJ

If Denial of Licensure is Disciplinary in Nature, Then Agency Must Prove Case by “Clear and Convincing Evidence”

The foregoing case summary was prepared by Mary F. Smallwood, Esquire, of The Administrative Law Section of The Florida Bar.

Davis Family Day Care Home (“Davis”) was issued a license as a family day care home in 2007. Davis applied annually for renewal of that license. In 2011, Davis applied for renewal of its license and also applied for a license as a large family child care home.

The Department of Children and Families (“DCF”) proposed to deny both the renewal application and the application for licensure as a large family child care home. Davis sought an administrative hearing on both denials. After an administrative hearing, the administrative law judge (“ALJ”) issued a recommended order recommending issuance of the renewal on a probationary basis and issuance of the large family child care home application on a provisional basis. The ALJ held that the burden of proof for the license denial was clear and convincing evidence. DCF rejected that conclusion, and provided a substituted conclusion of law that the burden of proof was by competent substantial evidence. DCF adopted the ALJ’s recommendation to renew the family day care home on a probationary basis, but denied the application for a large family child care home license.

On appeal, the court reversed and remanded. It held that DCF had misused the appellate “competent substantial evidence” standard of review as the burden of proof.

With respect to the appropriate burden on DCF, the court held that DCF must establish by clear and convincing evidence that the license should be denied, and not by a preponderance of the evidence. The court opined that the denial of the license for a large family child care home was essentially a disciplinary action since it was predicated on violations allegedly committed under the day care home license. The statute relied on by DCF authorized imposition of “disciplinary sanctions,” including denial or revocation of a license, for violations of the licensing laws. The court noted that DCF itself had acknowledged the disciplinary nature of its action, referring to its initial decision letter as an “administrative complaint.”

While recognizing that the court in Department of Banking and Finance v. Osborne Stern & Co., 670 So. 2d 932 (Fla. 2006), had applied the preponderance of the evidence burden of proof (instead of clear and convincing evidence) to license application proceedings, the court noted that section 120.57(1), Fla. Stat., had been amended since the Osborne decision. Section 120.57(1)(j), Fla. Stat., now provides that the preponderance of the evidence standard applies except in penal or disciplinary actions. In this case, the statute made clear that DCF was taking disciplinary action.

Source:

Davis Family Day Care v. Department of Children and Family Servs., 117 So. 3d 464 (Fla. 2d DCA 2013) (Opinion filed July 17, 2013).

About the Author: The foregoing case summary was prepared by Mary F. Smallwood, Esquire, of The Administrative Law Section of The Florida Bar. It originally appeared in the Administrative Law Section newsletter, Vol. 35, No. 2 (Dec. 2013).

 

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AHCA Expert Not Allowed to “Use His Discretion” in Deciding Claims Were Improper in Medicaid Appeal Hearing

FACTS: The Agency for Health Care Administration’s (“AHCA”) Office of Medicaid Program Integrity audited Dr. Rao, an authorized provider of Medicaid services, for claims between July 1, 2007, and June 30, 2009, and found him to be in violation of certain Medicaid provider policies. AHCA prepared a Final Audit Letter on June 1, 2011, notifying Dr. Rao that he had been overpaid by the Medicaid program by $110,712.09 for services provided during the audit period. Dr. Rao’s administrative hearing challenging AHCA’s overpayment determination was pending before DOAH. On August 17, 2012, Dr. Rao filed an unadopted rule challenge, alleging that AHCA’s overpayment determination was based on unadopted rules regarding the medical necessity of long-term monitored electroencephalograms (LTM EEGs).

OUTCOME: The ALJ found that AHCA’s peer review expert applied certain standards to the Medicaid claims he examined in conducting the Medicaid audit, but “exercised his discretion as to whether to apply them based on the specifics of each patient’s medical records.” The ALJ dismissed the unadopted rule challenge, explaining that “where application of agency policy is subject to the discretion of agency personnel, the policy is not a rule. . . . The medical standards at issue in this case are not self-executing and require the exercise of discretion in their application.” The ALJ noted that “the medical standards of practice must be applied on a case-by-case basis to determine whether the services provided were medically necessary, and provided both an appropriate level of care and standard of care ‘customarily furnished by the physician’s peers and to recognized health care standards” as required by section 409.9131(2)(d), Florida Statutes.

Source:

Radhakrishna K. Rao et al. v. AHCA, DOAH Case No. 12-2813RU (Final Order Aug. 20, 2013).

About the Author: The forgoing case summary was prepared by and appeared in the DOAH case notes of the Administrative Law Section newsletter, Vol. 35, No. 2 (Dec. 2013), a publication of the Administrative Law Section of The Florida Bar.

Invoking Fifth Amendment by Applicant’s Personnel May Result in Denial of Their Application for a License

The foregoing case summary was prepared by and appeared in the DOAH case notes of the Administrative Law Section newsletter

FACTS: The Agency for Health Care Administration (“AHCA”) denied Avalon Assisted Living III’s (“Avalon III”) application for licensure of an assisted living facility in Orlando. Avalon III challenged the denial, and the case was referred to DOAH for a formal hearing. During AHCA’s attempts to obtain discovery, two people closely associated with Avalon III (Mr. Robert Walker and Mrs. Chiqquittia Carter-Walker) invoked their Fifth Amendment privilege against selfincrimination in response to questions regarding the grounds stated by AHCA in its initial decision to deny the license. These areas of inquiry included alleged unlicensed activity, the ownership and control of Avalon III, and Avalon III’s lease on the facility sought to be licensed. Based on Avalon III’s failure to provide any relevant information during three discovery depositions, AHCA filed a Motion to Dismiss on September 16, 2013. In an Order issued on September 27, 2013, the ALJ stated that dismissal of Avalon III’s petition and denial of its licensure application would be an appropriate sanction. However, in an abundance of caution, the ALJ gave Avalon III one more chance to have the Walkers answer deposition questions without invoking the Fifth Amendment. Avalon III responded to the Order by filing a notice that the Walkers would answer deposition questions regarding ownership and the lease without invoking the Fifth Amendment. Conspicuously absent from the notice was any assurance the Walkers would answer questions about the alleged unlicensed activity.

OUTCOME: The ALJ issued an Order recommending that AHCA deny Avalon III’s application. In contrast to licensure disciplinary cases in which the agency has the burden of proof, Avalon III had the burden of proving entitlement to licensure, and the Walkers were the only people with knowledge of the relevant issues. Accordingly, their refusal to answer deposition questions left Avalon III “in an untenable position,” preventing Avalon III from proving its entitlement to licensure.

Source:

Avalon’s Assisted Living III, LLC v. Agency for Health Care Administration, DOAH Case No. 09-6342 (Recommended Order Oct. 9, 2013).

About the Author: The foregoing case summary was prepared by and appeared in the DOAH case notes of the Administrative Law Section newsletter, Vol. 35, No. 2 (Dec. 2013), a publication of the Administrative law Section of The Florida Bar.

Appeal Court Rules AHCA Was Justified in Withdrawing Home Health Agency’s License Application

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The First District Court of Appeal has ruled that the Agency for Health Care Administration (AHCA) had substantial justification to withdraw a home health agency’s application for licensure in a recent case. To view the opinion, click here.

Home Health Agency Challenged AHCA’s Decision to Withdraw Application.

AHCA withdrew the home health care facility’s license application because the application allegedly contained insufficient information. The application did not provide enough information for AHCA to verify actual ownership of the facility.

The home health agency challenged AHCA’s decision. The administrative law judge (ALJ) ruled that AHCA incorrectly withdrew the application. According to the ALJ, the application was complete, and the home health agency met all the requirements for licensure at the time the application was submitted. To view the recommended order, click here.

Home Health Agency Awarded Attorney’s Fees by ALJ.

After receiving this favorable order, the home health agency moved for attorney’s fees pursuant to section 57.111(4)(a), Fla. Stat. The home health agency argued that AHCA had no justification for withdrawing its license application. At a separate hearing, the ALJ awarded attorney’s fees to the home health care facility.

Appeal Court Reverses ALJ’s Ruling.

AHCA appealed this decision. On its license application, the home health agency had allegedly claimed that one person had sole ownership of the facility. However, a letter informing AHCA of litigation contesting the sole ownership claim was included with the license application. According to the court of appeal, given the uncertainty the home health agency created concerning its ownership, there was substantial justification for AHCA’s action. The ALJ’s ruling was reversed by the court of appeal.

Contact Health Law Attorneys Experienced in Home Health Agency Cases.

The Health Law Firm and its attorneys represent home health agencies and home health agency employees in a number of different matters including incorporation, preparing contracts, defending the facility against malpractice claims, licensing and regulatory matters, administrative hearings, and routine legal advice.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources Include:

Agency for Health Care Administration v. MVP Health, Inc. 74 So. 3d 1141 (Fla. 1st DCA 2011)

Smallwood, Mary F. “Attorney’s Fees.” Administrative Law Section Newsletter. (Apr. 2012).

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

Orlando-based Assisted Living Facilities Appeal ALJ Decision, Win Case Against AHCA

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Two related assisted living facilities (ALFs) based in Orlando won a case against the Agency for Health Care Administration (AHCA) on appeal. The First District Court of Appeal heard the case and filed an opinion in favor of the ALFs on November 30, 2011.

 To view the opinion in this case, click here.

Appeals Court Dismissed Three Complaints Made by AHCA.

On appeal, the ALFs challenged a final order issued by AHCA. The amended final order revoked the ALFs’ licenses, denied their licensure renewal applications, and imposed administrative fines. 

After conducting an investigation, AHCA filed a four count administrative complaint. The court of appeal dismissed AHCA’s conclusion that the first three counts were proven. The appeal court dismissed these counts because they consisted of uncorroborated hearsay.

AHCA Alleged ALFs’ Owners Operated Third Facility Without a Valid License.

The fourth count against the ALFs alleged that the ALFs’ owners/administrators operated a third Florida facility without obtaining a valid license or qualifying for a license exemption. The ALFs argued that AHCA failed to present any witness at the administrative hearing who had first-hand knowledge that the facility in question was providing personal services “for a period of 24 hours to one or more adults who are not relatives of the owner or administrator.” These are material elements of the statutory definition of assisted living facility that AHCA was required to prove.

AHCA Offered Testimony from the ALFs’ Employees at Administrative Hearing.

At the administrative hearing, AHCA offered testimony from an employee who worked at the third facility from 8:00 A.M. to 8:00 P.M. She testified that the facility had five or six residents when she worked there for six weeks in Summer 2009. She said that she never saw a resident leave the facility at the end of the day or arrive in the morning.

In the recommended order, the administrative law judge (ALJ) found that there was no evidence presented by the ALFs that the residents were transported to another location at night. Click here to view the recommended order.

Court of Appeal Rules ALJ Improperly Shifted the Burden of Proof, Reverses Final Order.

The First District Court of Appeal ruled that the ALJ improperly shifted the burden of proof to the ALFs. The burden was misplaced when the ALJ suggested that the ALFs should have provided proof that the residents were transported out of the facility during the night. According to the court of appeal, it was AHCA’s burden to establish that the facility was an unlicensed ALF. Furthermore, the court ruled that the testimony offered by AHCA did not foreclose the possibility that these residents were at the facility for periods less than 24 hours. Therefore, the court ruled that AHCA did not meet its burden of proof. The final order was reversed.

Contact Health Law Attorneys Experienced in Representing Assisted Living Facilities.

The Health Law Firm and its attorneys represent assisted living facilities (ALFs) and ALF employees in a number of different matters including incorporation, preparing contracts, defending the facility against malpractice claims, licensing and regulatory matters, administrative hearings, and routine legal advice.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources Include:

Smallwood, Mary F. “Adjudicatory Proceedings.” Administrative Law Section Newsletter. (Apr. 2012).

LeadingAge Florida. “Florida Supreme Court Requested to Hear ALF Case.” LeadingAge Florida. (2012). From: http://www.fahsa.org/displaycommon.cfm?an=1&subarticlenbr=96

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.