The Indiana Family and Social Services Administration has 21 days to arrange home health care for an elderly woman with quadriplegia who has been confined to a hospital or nursing home since February 2016, a federal judge has ruled. The decision comes after the judge ruled previously that the FSSA’s failure to develop a home-based care plan violated the woman’s rights under three federal laws, including the Americans with Disabilities Act.

Karen D. Vaughn again prevailed Wednesday in her case in the Indiana Southern District Court. Vaughn sued three FSSA employees in February 2016 after she was unable to return home following a several-week bout with pneumonia. Before her illness, Vaughn had lived in her home and received in-home care to assist her with basic activities such as eating and bathing, but after her January 2016 hospital stay, the FSSA said it could not find providers to continue her home-based assistance.

Ruling on cross-motions for summary judgment in June 2017, Chief Judge Jane Magnus-Stinson concluded FSSA had violated Vaughn’s rights under the ADA, the Rehabilitation Act and the Medicaid Act. The case then moved to the issue of the appropriate remedy, and Magnus-Stinson rejected the state’s argument that injunctive relief was improper.

“The Court concludes, based on the undisputed evidence, that Ms. Vaughn has suffered and would continue to suffer irreparable injury as the result of continued institutionalization,” the chief judge wrote in a Wednesday order. “Ms. Vaughn has presented undisputed medical testimony as to the dangers that institutionalization poses to her health, and she has already suffered demonstrable physical harm.”

That harm, the judge wrote, includes repeated surgeries for recurrent ulcers. Further, Magnus-Stinson said Vaughn has also suffered “adverse mental and emotional consequences associated with the institutional segregation and isolation that the ADA prohibits.”

In their defense, the FSSA employees have argued throughout the case that they could not find care providers to meet Vaughn’s needs because the Indiana Medicaid plan would not provide sufficient reimbursement. But Magnus-Stinson rejected the notion that FSSA’s efforts to find in-home care for Vaughn were sufficient under the law, finding instead that a “bureaucratic quagmire” resulted in the agency making only “paltry efforts” to coordinate internally to secure care for Vaughn.

Specifically, the judge noted the state agency delegated most of the work of finding in-home care providers for Vaughn to contracted case managers, not agency employees. When those contractors failed to find a healthcare agency willing to meet Vaughn’s needs, Magnus-Stinson said FSSA was “content to stop trying.”

“In choosing this course of action, Defendants appear motivated by two concerns: administrative minimization through contractual delegation, and cost-savings,” the chief wrote. “Notably absent from that list is the concern Defendants have professed during the latter stages of this litigation — a ‘shared’ desire to get Ms. Vaughn out of the institution in which she is being held.

“The irony of Defendants’ recalcitrance is highlighted by FSSA’s purported mission, to ‘develop, finance and compassionately administer programs to provide healthcare and other social services to Hoosiers in need in order to enable them to achieve healthy, self-sufficient and productive lives,’” she wrote.

Magnus-Stinson also pointed to FSSA testimony regarding the Community and Home Options to Institutional Care for the Elderly and Disabled, or CHOICE, program. CHOICE is a state-funded program that provides for home healthcare, but FSSA Division of Aging employee Erin Wright testified that Medicaid programs such as Vaughn’s and the CHOICE program do not interact.

The judge, however, pointed to an administrative statute holding that the Division of Aging “shall” administer CHOICE by developing “policies and procedures for coordinating CHOICE with the Medicaid waivers and other funding sources for in-home and community-based services.”

“At a minimum, and certainly during the pendency of this lawsuit, the Court expected that the officials of different divisions within FSSA would have met to discuss how their various programs (which are often used in combination with one another to provide for the entirety of an individual’s care) could coordinate to solve the problem of providing Ms. Vaughn with care in a non-institutional setting,” the chief judge wrote. “That never happened in Ms. Vaughn’s case … .”

Thus, the court rejected FSSA’s argument that it had undertaken “exhaustive” efforts to enable Vaughn to return home, finding instead that their efforts amounted to just one activity: calling home healthcare providers to ask whether they would care for Vaughn under the established Medicaid funding regime.

“The evidence here has demonstrated that if the Court were to accept Defendants’ position, Ms. Vaughn (and no doubt other similarly situated, ventilator-dependent individuals in Indiana) would be relegated to institutions,” she wrote. “In this court’s view, that is an outcome that the ADA prohibits.”

The permanent injunction entered by the court requires FSSA to arrange for “provision of the home health and attendant care services represented on this summary,” including services such as suctioning, helping to prepare meals, bathing and assisting with medication, among other duties approved by Vaughn’s case manager. The court noted the agency will have to work directly with Vaughn to develop a specific care plan, and further noted that her ruling on injunctive relief complies with the holding in Steimel v. Wernert, 823 F.3d 902 (7^th Cir. 2016).

“Through the tireless efforts of the magistrate judge, the Court attempted to engage the parties to craft a solution, and to allow Defendants to look within or amend their own programs to bring their treatment of Ms. Vaughn into compliance with the Americans with Disability Act, the Rehabilitation Act, and the Medicaid Act,” the judge concluded. “The only response has been bureaucratic intransigence, while a vulnerable citizen of our state has deteriorated as she remains institutionalized.

“If the Defendants will not act to protect Ms. Vaughn and her rights,” Magnus-Stinson wrote, “the Court will.”

The case is Karen D. Vaughn v. John J. Wernert, M.D., et al., 1:16-cv-03257.