Health Law Daily Wrap Up, ADMINISTRATION OF MEDICARE/MEDICAID PROGRAMS—DAB DECISIONS: Board upholds exclusion for caregiver convicted of abuse of vulnerable person, (Sep 18, 2025)

By WK Editorial Staff

Individuals who participate in deferred adjudication where judgment of conviction has been withheld are “convicted” within the meaning of the statute.

The HHS Departmental Appeals Board has upheld the exclusion of a caregiver from federal health care programs due to a conviction for abuse. Although the court acknowledged that the caregiver had successfully completed the terms of the deferred adjudication program, the caregiver was still “convicted” of an offense related to neglect or abuse of patients in connection with the delivery of health care, mandating a five-year exclusion (Labat, DAB No. CR6505, Doc. No. C-24-296 (July 15, 2024)).

Background. The case involved a caregiver who worked at a specialized treatment facility in Gulfport, Mississippi. The caregiver was charged with misdemeanor abuse after an incident where he pulled a resident across a room by the hair. This action was captured on video. The caregiver was charged with one count of misdemeanor abuse of a vulnerable person, leading to a guilty plea under Mississippi law. Despite the state court's subsequent order of non-adjudication, which held the guilty plea in abeyance and dismissed the charges upon successful completion of probation, the Inspector General (IG) enforced a five-year exclusion from Medicare, Medicaid, and all federal health care programs.

Conviction. The caregiver asserted that he was not convicted of a crime because the case was not adjudicated but was ultimately dismissed. However, section 1128(a)(2) of the Social Security Act mandates the exclusion of any individual convicted of a criminal offense related to the neglect or abuse of patients in connection with the delivery of health care services. The statute's definition of "conviction" encompasses deferred adjudication and similar arrangements where judgment is withheld, ensuring that exclusions are not subject to variations in state criminal justice policies.

Broad definition. This broad definition is intended to protect the beneficiaries of health care programs and federal funds. While criminal law aims at punishment and rehabilitation, exclusions imposed by the IG are civil sanctions designed to prevent individuals whose conduct raises concerns about integrity and trustworthiness from participating in federal programs. Congress intentionally crafted this definition to prioritize the safety and well-being of health care beneficiaries over potential leniencies in state legal systems.

Program integrity. The caregiver's exclusion underscored the agency's approach. It highlighted the principle that involvement in the criminal system, even without traditional criminal sanctions, can warrant exclusion if it poses a risk to program integrity. This approach aligned with the remedial nature of exclusions, focusing on safeguarding health care beneficiaries rather than punishing offenders.

Access to benefits. Noting the caregiver’s concerns, the board reiterated that the exclusion does not impact personal entitlement to health care benefits. The IG notice clarified that the exclusion only restricted participation as a provider in federal programs, not as a beneficiary.

Five-year exclusion. The decision affirmed the mandatory five-year exclusion period stipulated by section 1128(c)(3)(B) of the Act.

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