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UNITED STATES DISTRICT COURT FOR THE
EASTERN DISTRICT OF PENNSYLVANIA

UNITED STATES OF AMERICA, Plaintiff
v.
THE CITY OF PHILADELPHIA; EDWARD G. RENDELL, MAYOR OF THE CITY OF PHILADELPHIA; ESTELLE B. RICHMAN, COMMISSIONER, HEALTH DEPARTMENT; EPISCOPAL LONG TERM CARE, AS OPERATORS OF THE PHILADELPHIA NURSING HOME, Defendants

COMPLAINT

1. The Attorney General of the United States brings this action on behalf of the United States of America, pursuant to the Civil Rights of Institutionalized Persons Act of 1980 ("CRIPA"), 42 U.S.C. § 1997, to enjoin the named Defendants from depriving persons residing at the Philadelphia Nursing Home ("PNH") of their legal rights, and of rights, privileges or immunities secured or protected by the Constitution of the United States and federal statutes.

2. The United States of America, through the United States Attorney for the Eastern District of Pennsylvania, also brings this civil action under the False Claims Act, 31 U.S.C. §§ 3729 et seq., and alleges that the City of Philadelphia, PNH, and Episcopal Long-Term Care, submitted or caused the submission of false or fraudulent claims to the United States for payment for care that was not adequately rendered to elderly individuals, to individuals with developmental disabilities, and to individuals with mental illness residing at PNH.

JURISDICTION, STANDING AND VENUE

3. This Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331, 1345 and 31 U.S.C. §§ 3729 et seq.

4. The United States has standing to maintain this action pursuant to 42 U.S.C. § 1997a and 31 U.S.C. §§ 3730 and 3732.

5. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein.

6. Venue is proper in the United States District Court for the Eastern District of Pennsylvania pursuant to 28 U.S.C. §§ 1391(b) and (c). All claims set forth in the Complaint arose in said District.

PARTIES

7. Plaintiff is the UNITED STATES OF AMERICA acting for itself, and on behalf of the Department of Health and Human Services, Office of Inspector General, the Medicare Trust Fund, the Medical Assistance Program, and the beneficiaries thereof.

8. Defendant CITY OF PHILADELPHIA ("City") owns PNH, a nursing home housing individuals with special needs including the elderly, those with developmental disabilities, and those with mental illness, located in Philadelphia, Pennsylvania.

9. Defendant EDWARD G. RENDELL is the Mayor of the City of Philadelphia, and in this capacity heads the Executive Branch of the City's government and, among other duties, reviews and approves budget requests submitted by Executive Branch agencies. He selects and appoints the Commissioner of the City's Health Department.

10. Defendant ESTELLE B. RICHMAN is the Commissioner of the City's Health Department and, in this capacity, exercises administrative control of, and responsibility for, PNH.

11. Defendant EPISCOPAL LONG TERM CARE ("ELTC") is the operator of PNH pursuant to a contract with the City, and is responsible for the day-to-day operations of PNH.

12. The individual Defendants named in ¶¶ 9 and 10 above are officers of the Executive Branch of the City of Philadelphia and are sued in their official capacities.

13. PNH is an institution as that term is defined in 42 U.S.C. §§ 1997(1)(A), (1)(B)(i) and (1)(B)(v).

14. Defendants are legally responsible, in whole or in part, for the operation of and conditions at PNH, as well as for the care and treatment of persons residing at that institution.

15. At all relevant times, Defendants have acted or failed to act, as alleged herein, under color of state law.

NURSING HOME REFORM ACT

16. The Nursing Home Reform Act (the "Act") mandates that nursing facilities comply with federal requirements relating to the provision of services. 42 U.S.C. §§ 1396r et seq. See also 42 U.S.C. §§ 1395i-3 et seq. Specifically, in terms of the quality of life for residents of nursing facilities, the Act states that: "A nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident." 42 U.S.C. § 1396r(b)(1)(A). See also 42 U.S.C. § 1395i-3(b)(1)(A); 42 C.F.R. § 483.15.

17. In addition, the Act mandates that a nursing facility:

provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care which --

(A) describes the medical, nursing, and psychosocial needs of the resident and how such needs will be met;...

42 U.S.C. § 1396r(b)(2)(A). See also 42 U.S.C. § 1395i-3(b)(2)(A); 42 C.F.R. § 483.25.

18. A duty is placed on the nursing facility to fulfill the residents' care plans by providing, or arranging for the provision of, inter alia, nursing and related services and medically-related social services that attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, pharmaceutical services, and dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident, and treatment and services required by residents with mental illness and/or mental retardation. 42 U.S.C. §§ 1396r(b)(4)(A)(i-vii). See also 42 U.S.C. §§ 1395i-3(b)(4)(A)(i-vii).

19. The Act mandates that nursing homes that participate in the Medical Assistance Program ("Medicaid") and the Medicare Program meet certain specific requirements in order to qualify for such participation. These requirements are set forth at 42 C.F.R. §§ 483.1 et seq. and "serve as the basis for survey activities for the purpose of determining whether a facility meets the requirements for participation in Medicare and Medicaid." 42 C.F.R. § 483.1(b).

20. Federal regulations, when addressing quality of care concerns, mandate that "[e]ach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care." 42 C.F.R. § 483.25.

21. As a pre-requisite to enrollment as a provider in the Medicaid Program, PNH entered into a provider agreement and agreed to the following provisions:

1. That the submission by, or on behalf of, the Facility of any claim, either by hard copy or electronic means, shall be certification that the services or items from which payment is claimed actually were provided to the person identified as a medical assistance resident by the person or entity identified as the Facility on the dates indicated.

*******

5. That the Facility's participation in the [Medicaid] Program is subject to the laws and regulations effective as to the period of participation, including all of those that may be effective after the date of the agreement and that the Facility has the responsibility to know the law with respect to participation in the [Medicaid] Program.

22. At all times relevant to this action, PNH was a "provider" with a valid provider agreement with the Pennsylvania Department of Public Welfare.

FACTUAL ALLEGATIONS

COUNT I: CIVIL RIGHTS OF INSTITUTIONALIZED PERSONS ACT

23. The above paragraphs are incorporated herein by reference as if fully set forth.

24. Defendants have failed to ensure the reasonable safety and personal security of the PNH residents. Defendants have failed to adequately supervise, monitor and protect the residents from harm and risk of harm.

25. Defendants have failed to provide adequate basic care and related services to PNH residents.

26. Defendants have failed to provide residents with adequate, appropriate and meaningful activities.

27. Defendants have failed to ensure that PNH residents are free from undue or unreasonable restraint and that restraints are administered to PNH residents by appropriately qualified professionals in keeping with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff.

28. Defendants have failed to provide adequate mental health care and services to PNH residents.

29. Defendants have failed to provide adequate medical and health care and services to PNH residents and to ensure that medications are prescribed and administered to PNH residents by appropriately qualified professionals in keeping with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff.

30. Defendants have failed to provide adequate nursing care and services to PNH residents.

31. Defendants have failed to provide adequate physical and occupational therapy services to PNH residents.

32. Defendants have failed to provide a sufficient number of adequately trained professional and direct care staff to render the essential care and treatment outlined above in paragraphs 24 through 31.

33. Defendants have failed to ensure that PNH residents are evaluated by appropriate professionals for placement in the most integrated setting and appropriately placed into the most integrated setting according to their individualized needs.

34. Defendants have failed to meet the requirements of the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C. §§ 12101 et seq., and the regulations promulgated pursuant thereto, by excluding the PNH residents, by reason of their disability, from participation in or by denying them the benefits of the services, programs, or activities of the City, or by subjecting them to discrimination, and by failing to administer services, programs, and activities in the most integrated setting appropriate to their needs. For purposes of Title II of the ADA, the Defendants are a "public entity," and the residents of PNH are "qualified individual[s] with a disability."

35. Defendants have failed to meet the requirements of the Medicaid Program established under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396r et seq., and the regulations promulgated pursuant thereto.

36. Defendants have failed to meet the requirements of the Medicare Program established under Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395i-3 et seq., and the regulations promulgated pursuant thereto.

37. The acts and omissions alleged in paragraphs 24 through 36 infringe upon the PNH residents' legal rights and substantive liberty interests and constitute resistance to their full enjoyment of rights, privileges or immunities secured or protected by the Constitution or laws of the United States, and deprive the PNH residents of such rights, privileges or immunities.

38. Unless restrained by this Court, Defendants will continue to engage in the conduct and practices set forth in paragraphs 24 through 36 that deprive residents of PNH of their legal rights under law and the rights, privileges, or immunities secured or protected by the Constitution of the United States, and cause irreparable harm to PNH residents.

COUNT II: FALSE CLAIMS ACT

39. The above paragraphs are incorporated herein by reference as if fully set forth.

40. The United States charges that the Defendants submitted or caused the submission of false or fraudulent claims to the United States for payment for care that was not adequately rendered to elderly individuals, to individuals with special needs, to individuals with developmental disabilities, and to individuals with mental illness residing at PNH.

41. PNH is a licensed long-term care (nursing) facility under federal and state law and is certified to participate in the Medicaid and Medicare Programs.

42. A synopsis of the factual basis for which this cause of action is based is incorporated herein and is attached hereto as Exhibit A.

43. The provision of adequate medical care, nursing care and psychiatric care, pertaining to the appropriate use of psychotropic drugs for PNH residents and monitoring for side-effects of these medications, was the responsibility of PNH medical and nursing staff.

44. The provision of adequate wound care to PNH residents was the responsibility of the PNH nursing and medical staff.

45. The provision of adequate nutrition to PNH residents was the responsibility of not only the PNH nutritionists and dietary staff but included the PNH nursing and medical staff as well.

46. The provision of a safe environment in which PNH residents were free from any abuse, included all PNH disciplines, including but not limited to PNH medical, nursing, and facility management staff.

47. Defendants' agents and/or employees were responsible for the provision of medical care, nursing care, psychiatric care, appropriate medications and monitoring thereof, wound care, nutritional services, and safe conditions for all of the PNH residents.

48. Defendants' agents and/or employees billed the United States (through the Pennsylvania Department of Public Welfare) for care provided to the PNH residents for reimbursement by the Medicaid Program. Defendants' agents and/or employees billed the United States for care provided to the PNH residents for reimbursement by the Medicare Program.

49. Defendants' agents and/or employees submitted or caused to be submitted false or fraudulent claims to the Medicaid and Medicare Programs for payment or approval of the provision of medical care, nursing care, psychiatric care, appropriate medications and monitoring thereof, wound care, nutritional services, and safe conditions that were not adequately rendered to PNH residents for the time period January 1995 through December 1996.

50. Defendant City of Philadelphia, as licensee for PNH, was responsible for the care rendered to residents at PNH and submitted or caused to be submitted the repeated submission of false or fraudulent claims for payment or approval to the Medicaid and Medicare Programs, for the provision of medical care, nursing care, psychiatric care, appropriate medications and monitoring thereof, wound care, nutritional services, and safe conditions that were not adequately rendered to PNH residents for the period January 1995 through December 1996. 31 U.S.C. § 3729.

51. Defendants knowingly did not ascertain the truth or falsity of the claims for services submitted or caused to be submitted to the Medicaid and Medicare Programs, for payment or approval on behalf of PNH residents, all of whom were Medicaid recipients and/or Medicare beneficiaries. 31 U.S.C. § 3729.

52. Defendants acted in reckless disregard and/or deliberate ignorance of the care and services ordered and actually provided to PNH residents when billing the Medicaid and Medicare Programs. 31 U.S.C. § 3729.

53. Upon information and belief, the United States alleges that the care rendered to the residents identified in Exhibit A was representative of the care rendered to residents of PNH. The claims for reimbursement for the care of these residents would thus constitute false claims actionable under the False Claims Act to the same extent as the claims for the individuals identified in Exhibit A.

54. The United States was damaged as a result of the conduct described above.

COUNT III: UNJUST ENRICHMENT

55. The above paragraphs are incorporated herein by reference as if fully set forth.

56. The conduct described in the foregoing paragraphs caused all Defendants to receive, directly or indirectly, benefits from the United States.

57. Under the circumstances described in the foregoing paragraphs, as between the United States and each Defendant in this Count, retention by each Defendant of the benefits conferred by the United States would be unjust.

PRAYER FOR RELIEF

WHEREFORE, Plaintiff, the United States of America, prays, with regard to Count I of this Complaint, that this Court enter an order permanently enjoining Defendants, their agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, practices and omissions at PNH set forth in paragraphs

24 through 36 above, and to require Defendants to take such action as will provide legal and constitutional conditions of care to persons who reside at PNH. The United States further prays that this Court grant such other and further equitable relief as it may deem just and proper.

WHEREFORE, Plaintiff, the United States of America, demands and prays, with regard to Count II of this Complaint, that judgment be entered in its favor and against the Defendants, jointly and severally, as follows:

a. an amount equal to the number of false or fraudulent claims that will be proven at trial, multiplied as provided for in 31 U.S.C. § 3729(a), and imposition of $10,000.00 per claim;

b. three times that total amount of damages sustained by the United States because of the acts complained of;

c. costs of this action;

d. such other and further relief as the Court shall deem proper.

WHEREFORE, Plaintiff, the United States of America, demands and prays, with regard to Count III of this Complaint, that judgment be entered in its favor and against the Defendants, jointly and severally, as follows:

a. an amount equal to the gain to the Defendants as a result of the activities complained of;

b. interest according to law;

c. costs of this action; and

d. such other and further relief as this Court may deem proper.

Respectfully submitted,

__________________________
JANET RENO, Attorney General of the United States
BILL LANN LEE, Acting Assistant Attorney General, Civil Rights Division
MICHAEL R. STILES, U.S. Attorney, Eastern District of Pennsylvania

STEVEN H. ROSENBAUM, Chief, Special Litigation Section
ROBINSUE FROHBOESE, Deputy Chief, Special Litigation Section
RICHARD J. FARANO, Senior Trial Attorney, Special Litigation Section
Civil Rights Division
U.S. Department of Justice
P.O. Box 66400
Washington, DC 20035-6400
(202) 307-3116

JAMES G. SHEEHAN, Assistant U.S. Attorney, Chief, Civil Division, Eastern District of Pennsylvania
DAVID R. HOFFMAN, Assistant U.S. Attorney
Eastern District of Pennsylvania
615 Chestnut Street
Suite 1250
Philadelphia, PA 19106
(215) 451-5337

General Information Special Litigation Section
 
Leadership
Jonathan M. Smith
Chief
Contact
Special Litigation Section
(202) 514-6255
toll-free at (877) 218-5228

FAX - (202) 514-0212
Alt. FAX - (202) 514-6273
Email - Special.Litigation@usdoj.gov
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