f-lil'll] 1y'eril'led L'i'il'l'eet L'upy ul't Jri pi I'lLli BEFURE THE (IF ADEHNISTRATIVE HEARINGS STATE DIEGGN fer the GREGGN HEALTH IN THE DP AND FINAL 3' . . . and HEALTH SYSTEMS DIVISIUN IHSTIURY (IF THE CASE ?n Geteber Ell-1?, the ?regen. Health Autherity's Health Systems Iliyisien (Authetity) neti?ed elaimant that it had denied a request te autherise payment fer eentinued heusing in a seeured residential treatment faeilitj.r Uri Neyember d, T, the Autimrity a request fer hearing ?nite claimant eballenging the denial. Du Neyember E, the Autherity referred elaimant?s hearing request te the D?iee ef Administra?ye Hearings (BAH). 0n 13, 2131?, the Autherity issued an Amended Netiee ef Denial farther elari?dng its reasen fer denial ef the request ?n January 2, 2013, Administrative Law Judge (ALB Matthew C. Wymer eenyened a telephene hearing. elaimanfs mether, represented elairnatrt. Claimant?s father dents, administrater fer the SRFT Where claimant resides, appeared en elaimant's behalf, but did net testify. Claimant ared' and testi?ed. ?epmsented the Audlerity and testi?ed. PC, an empleyee ef stene Peer Review Urganieatien appeared and testi?ed en behalf ef the Autherity. QMI-EP, an empleyee ef KEPRG, and Chad Seett, Qhe?ii?, an empleyee ef the Autimrity, appeared en behalf af the .?iutherity but did net testify. The hearing eentinued en January 3, Claimant was net present at the resenyened hearing due te illness. and Chad Seett a ed and testi?ed en behalf ef the Autherity. appeared and testi?ed en behalf ef elaimant. The hearing eentinued en January EMS. Claimant appeared and eempleted his testimony. ?appeared and testi?ed. The elesed at the end ef the hearing. Issue ?ether the Authurity must audterine payment fer eentinued heusing in a SRTF. Dregen Administratiye Rules (DARerrmer 39); (T), 1"]111" ot'l h'i giant 1432? CONCLUSIBN LAW The Authority may,r net den],r authorisation ofpavrnent Ter- cont11111ed housing 1n a. secured residential treatmens 111111111 hast-2d on1he tl?tlE-B?- issued on Uetoher 1712201? and December 13, 201 UPDJIDN rIhe sole issue for detcrnunation is whether the Authorityr is required to authorise payment for continued housing in a secured residential treatment facility. states: ?The harden evidence-to support a: fact or- position in-a contested case rests en-the proponent of the fact or position." See also Harris 11 W, 292 Dr 633, 691] [1932} (holding that, as a general rule, the harden of proof is on the proponent of the fact or position). Thus .it- is claimant 111-harden to produce- relishle, suhstaatial, and probative evidencein support of the position that the stuthority' 1s- required:- to authorise payment for continued housing? 1a a- secnred residential treatment facth In the absence of legislation specifying another standard, the standard of proof in an administrative hearing is pmp-enderance of the evidence. Mctcel?f v. MD, 65 Dr App T61, are (1933). Preponderance of the evidence means evidence suf?cient to persuade the fact ?nder that the facts asserted are-?more true than not-true:- Rilay Hill General Conn-actor v. Tiaras}r Corp, 303 or 390, 4021:1987), in its notices, the Authority cited to and DAR specificallyr to BARS and (2), (7), {1 1). Sec Eel-111111115. ?ne of the Authority?s witnesses, Mr. Scott, testi?ed to the criteria used in civil commitments; however, that criteria has net been presented either in the notices to claimant?s guardian or offered into evidence at hearing: Either than these administraiive rules, the Authority has net provided evidence of an}.r ether criteria that it relied upon in making its determination: Therefore, I hase my decision on the documents admitted into the record and the testimonies of the parties. To the extent KEPRD and the surthoritg,F relied on outside criteria to make their decision, I do net rel}.r on these criteria because the}1 were net included in the record, nor even offered for admission into evidence. Under OAR dl?-l the r??tutheritjlr ?shall authorise continued staj,F in residential programs hosed on the medical appropriateness of the request and supporting clinical documentation.? DAR dl?-l?-?em de?nes ?medicallv appropriate? in the area of behavioral - . health services and states in relevant part: (1) In addition to the de?nition of medicallv appropriate in can 4111-1211- for behavioral health services, ?medicallyr rneans the services 3 Former GAR 41 39} de?nes ?medically appropriate? as and medical supplies that are required for prevention, diagnosis, or treatment of a health condition that encompasses physical or mental conditicus or inj cries and that are:- 1?Jeri tied L'opy ol't night-til 25432:] v. i and supports required to diagnose, stabilise, care for, and treat a behavioral health condition. (2) The [Amhority] shall make payment for medically appropriate behavioral health services when the services or supports are: Based on the standards of evidence-based practice, and the services provided are appropriate and consistent with the diagnosis identi?ed in the behavioral health assessment[.] The Authority?s notices simply state that the ?[d]ocun1entation demonstrates claimant is su?iciently stabilised andlor has developed the skills necessary to support transition to a less restrictive-level of the clinical documentation does not-support continued stay at claimant?s current level of care. See Exhibit Afar l. To-the -'entent that the documentationsubmitted with the request and. the KEPRU PCP may be considered as ?clinical doctunentation," the preponderance of the evidence is that the documentation does not supportthe assesses decision. It appears the Authority based its decision to deny the request on the doeummtation submitted with the prior authorisation request and the PCP completed by after interviewing claimant and _is a Quali?ed Mental Health Professional and is intimately acquainted with claimant?s mental health issues. ?ts such, she is most quali?ed to assess claimant?s mental health status, including the ssibili of transitioning him to a RTF with a lower level of secm'ity. Du March 22, El??ompleted a Comprehensive "Mental Health Assessment Dn March 201?, she completed a Residential Service Assessment. {to September Bull?, she evaluated claimant, using the Lovel of Care Utilisation System (LDCUS) assessment tool and completed a service plan for claimant. Each of those evaluations goes into much detail on claimant?s condition, noting his history of suicide attempts. The common theme that emerges from those various evaluations is that, while the intent is to move claimant to a less restrictive housing situation in the mono, claimant?s current condition and history of suicide attempts and substance abuse mean that he needs the structured, secure environment provided by a SRTF. I also note that Judge Tennyson?s limited judgement, which found that claimant was a danger to hireself and others and required 24-hour supervised care, has not been rescinded or amended, and, by all appearances, remains in force. Dn the other hand, the PCP prepared by KEPRD is much less detailed and includes subjective answers from claimant. The answers elicited from _liltewise appear to contain much less detail. Even in answers on the KEPRD PCP, while she ?thinks Consistent with the of a health condition or neauncnt of a health condition; Appropriate with regard to standards of good health practice and generally recognized by the relevant scienti?c eomrmniity, evidence-based medicine, and professional standards of care as effective; . . it} Not solely for the convenience of an UHF client or a provider of the service or medical supplies; and The most cost effective of the alternative levels of medical services or medical supplies that can be safely provided to [an Authority] client or CED member in the Division or judgment. - tilled L'et'teel {Jetty til i lngi uul 2543] that [elaimant] is ready te transitien he a lewer leyel ef here,? _still expresses eeneern about making sueh a ehange ?at this time ef year heeause at [elaiinant?s] histery." I de nut idle thatelaimant has guali?ed fer edntinued residence at the heweyer, the prependeranee ef' the eyidenee in the dees net support the Antherity?s deeiSien te {fl-y the request. The Anthn?ty?e'd?eeisien?te deny the request-fer 'eeutinned stay at the SRTF must he disa?inned. - GREEK The Deteher this and December sets decisiens-denyingantheriaatien at payment fer eantinued heusing in a seeured residential treatment faeility are DISHFIRMED. Matthew C. Wymer Administrative Law Judge G?iee ef Administrative Hearings APPEAL PRDUEDURE This is the Administrative Law Judge?s Prupused Order. If the Prepesed Order is adverse te yen, yen may: Egg L4 KCEPTEUNS. Yen have the right te tile written eneeptiens er present argument -te he-eensidered- lay the Administrater in issuing the Final Grdet.-- Year enaeptiuns must he received by the itltil werltday frern the date ef mailing ef this erder. GAR 41DL12ll-l Send them te: - Adrninistrater ?regen Health Antharity Health Systems Diyisinn 3rd Fleet, Suite E49 Silt} Street NE Salem, UR If yen de net file any timely. written eaeep?ens te this Prep-need Drder, it will the Final Drder at the elese afhnsiness en the In? wed-{day frem the date at mailing. If yen de ?le timely written exceptiens tn the Prepesed ?rder, the Amherity may eunsider yenr written eneeptiens in issuing a Final Drder. The Antherity may alse disagree with the Prepesed Drder and ?le its ewn written eaeeptiens, in whieh ease, the Antherity will issue an Amended Prepesed Under. Lt?the Antherity issues a Final Drderl it will preyide yen with an explanatien ef the Appeal in the Final Drder. If the Prepesed Greer heeumes a Final Drder by nperatian ef law at the elese ef husiness en the day aiter mailing ef the Prepesed IDrder and yen are net satis?ed with the Final Greer, yen may: