Case 1:16-cv-00303-LJM-TAB Document 1 Filed 02/04/16 Page 1 of 19 PageID #: 1

In the United States District Court

For the Southern District of Indiana
Indianapolis Division
HOME CARE PROVIDERS, INC.;
NIGHTINGALE HOME HEALTH
CARE, INC.; NIGHTINGALE
HOSPICE CARE, INC.; and
DEV A. BRAR,
)
Plaintiffs,
vs.

)
)
)
)

)
)
)
KELLY HEMMELGARN, individually;)
RANDALL SNYDER, individually;
)
INGRID MILLER, individually;
)
SYLVIA MATHEWS BURWELL, in )
her official capacity as Secretary for )
the United States Department of
)
Health and Human Services; and
)
JEROME ADAMS, in his official
)
capacity as Commissioner of the
)
Indiana State Department of Health )
Defendants.
)

Cause No. _______________

Complaint for Damages and Injunctive Relief

The Defendants have used their governmental positions to subject Plaintiffs,
a home healthcare company, a hospice agency, and their owner, a physician, to a
campaign of harassment and retaliation based on race, ethnicity and/or national
origin, and his prior complaints about their discriminatory statements and conduct.
Defendants Burwell and Adams ratified that conduct. The campaign of harassment
culminated in an effort by the Defendants late last year to terminate the Medicare
status of Plaintiffs home health care agency, which would shut the agency down
and deprive 900 patients of medical care. Defendants conduct required the agency
to seek bankruptcy protection and obtain a temporary injunction against the
termination from Bankruptcy Judge Carr. This action seeks further injunctive

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relief and money damages under 42 U.S.C. 1983 against the defendants sued in
their individual capacities. The injunctive relief is sought the defendants sued in
their official capacities under Ex Parte Young, 209 U.S. 123 (1908), and its progeny.
Jurisdiction and Venue
1.

This is an action brought under 42 U.S.C. 1983, Ex Parte Young ,

and Bivens v. Six Unknown Named Agents, 403 U.S. 388 (1971).
2.

This Court has subject matter jurisdiction under 28 U.S.C. 1331

because this action arises under the Constitution or laws of the United States.
3.

The Court further has subject matter jurisdiction under 28 U.S.C.

1343 because this is an action to redress the deprivation, under color of State law of
rights, privileges or immunities secured by the Constitution of the United States
providing for equal rights of citizens or of all persons within the jurisdiction of the
United States and is an action to recover damages or to secure equitable or other
relief under any Act of Congress protecting civil rights.
4.

Venue is proper in this district under 28 U.S.C. 1391(b) because a

substantial part of the events or omissions giving rise to the claim occurred in this
district.
Parties
5.

Plaintiff Dev A. Brar, is a physician licensed in India who resides in

Hamilton County, Indiana. He is also the owner of plaintiff, Home Care Providers,
Inc. (Home Care), an Indiana corporation with its principal place of business in

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Indiana. Through a number of subsidiaries, Home Care provides home healthcare

and hospice services in Indiana and 10 other States.
6.

Plaintiff Home Care is the sole shareholder of Plaintiffs Nightingale

Home Healthcare, Inc. (Nightingale) and Nightingale Hospice Care, Inc.

(Hospice)
7.

Plaintiff Nightingale is an Indiana Corporation with its principal place

of business in Indiana. It is a home health agency licensed under Ind. Code 16-271-8. It also has a Medicare Provider Agreement with the Secretary of Health and
Human Services, through the Center for Medicare and Medicaid Services and a
Medicaid Provider agreement with the Indiana Office of Medicaid Policy and
Planning, through the Indiana State Medicaid Director.
8.

Nightingale is currently operating its business as a debtor in

possession as a result of an emergency voluntary petition that it filed on December

10, 2015 under Chapter 11 of the Bankruptcy Code. Nightingales Chapter 11 case
is pending in this district before the Honorable James M. Carr, as Case No. 1510099-JMC-11.
9.

Plaintiff Hospice is an Indiana corporation with its principal place of

business in Indiana and is a hospice licensed under Ind. Code 16-25-3-1. It also
has a Medicare Provider Agreement with the Secretary of Health and Human
Services, through the Center for Medicare and Medicaid Services and a Medicaid
Provider agreement with the Indiana Office of Medicaid Policy and Planning,
through the Indiana State Medicaid Director.

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10.

Defendant Kelly Hemmelgarn is the Program Director within the

Acute Care Division of the Indiana State Department of Health (sometimes referred
to as ISDH) with responsibility for surveys for State licensing, Medicare Program
Participation, and Medicaid Program Participation for Home Health Agencies;
Hospice providers; Rural Health Centers; and End Stage Renal Disease Clinics. At
all times relevant to this Complaint she acted under color of State law. Ms.
Hemmelgarn is sued in her individual capacity.
11.

Defendant Ingrid Miller is a surveyor within the Acute Care Division

of the Indiana State Department of Health with responsibility for surveys for State
licensing, Medicare Program Participation, and Medicaid Program Participation for
Home Health Agencies; Hospice providers; Rural Health Centers; and End Stage
Renal Disease Clinics. At all times relevant to this Complaint she acted under color
of State law. Ms. Miller is sued in her individual capacity.
12.

Defendant Randall Snyder is the Director of the Division of Acute Care

for the Indiana State Department of Health. He is Ms. Hemmelgarns direct

supervisor. At all times relevant to this Complaint, he acted under color of State
law. Mr. Snyder is sued in his individual capacity.
13.

Defendant Jerome Adams is the Commissioner of the Indiana State

Department of Health. He has final authority for all decisions made by the Indiana
State Department of Health. At all times relevant to this Complaint, he acted
under color of State law. Mr. Adams is sued in his official capacity only, and only
for injunctive relief, as permitted by Ex Parte Young.

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14.

The Defendant, Sylvia Mathews Burwell, is the Secretary for the

United States Department of Health and Human Services. As Secretary, she

administers the Social Security Act, 42 U.S.C. 301, et seq., and in particular the
Medicare Act, 42 U.S.C. 1395, et seq. The Secretary has been named only in her
official capacity, and is sued only for prospective relief.
15.

This Court has personal jurisdiction of all of the defendants except

Burwell because they reside in this state and transact business here.
16.

This Court has personal jurisdiction over Burwell because this is a suit

relating to her actions that are purposefully directed at the State of Indiana and
that are designed to and do have a substantial impact in the State of Indiana.
The Medicare Program
17.

The Medicare program is a program under which the federal

government pays healthcare providers for providing specified healthcare services to

the elderly and other individuals who qualify for the program. Payments to
providers under the program are commonly called reimbursements.
18.

To be eligible for reimbursement under the Medicare program,

providers must agree to and comply with statutory and regulatory conditions of
participation and must enter into a provider agreement.
19.

Under the Medicare program, Secretary Burwell, acting through the

Centers for Medicare and Medicaid Services (CMS), uses the Indiana State
Department of Health to survey healthcare providers for compliance with program
requirements for reimbursement under Medicare (and Medicaid). Such surveys are

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conducted periodically to recertify providers for the program and upon complaints
initiated by or received by the Indiana State Department of Health or CMS.
20.

Under the statute, Secretary Burwell is also authorized to use federal

surveyors from CMS or, in some circumstances, to use surveyors from an

accrediting body that has accredited the provider being surveyed, such as The Joint
Commission, f/k/a the Joint Commission on Accreditation of Health Care
Organizations.
21.

Nightingale and Hospice are accredited by the Accreditation

Commission for Health Care. Secretary Burwell has statutory authority to have
surveys conducted by that accrediting agency.
Plaintiffs Businesses
22.

Nightingale is a provider of home healthcare services. Home

healthcare services allow patients who would otherwise require hospitalization or

admission to a nursing home, such as for a course of IV drugs or antibiotics, to
receive such care in their homes. The delivery of home healthcare not only permits
patients to be in their homes, but also results in care that costs less and for which
outcomes are as good, and often better, than similar care delivered in an
institutional setting.
23.

Nightingale serves many patients that cannot obtain such care from

other home health agencies due to geography or the difficulty, expense, or lack of
profitability of providing care to those patients.

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24.

Hospice provides hospice care to patients in residential settings,

including assisted living facilities, other licensed facilities, and private homes.
25.

Hospice serves many patients that cannot obtain such care from other

hospice agencies due to geography or the difficulty, expense, or lack of profitability

of providing care to those patients.
26.

Nightingale has operated in Indiana for almost twenty years, and

Hospice has operated in Indiana for nine years. Neither has ever had a malpractice
claim or lawsuit brought against it.
27.

If Nightingale had to discontinue operations, many patients it serves

could not find another provider, and many new patients Nightingale would
otherwise serve could not find a provider. As a result, Indiana residents would
either be deprived of needed care or would be forced to seek that care in
substantially more expensive institutional settings, i.e., hospitals and nursing
homes.
28.

If Hospice had to discontinue operations, many patients to whom it

provides hospice care could not find another provider, and many new patients that
Hospice would otherwise serve could not find a provider.
29.

Home healthcare agencies and hospice providers are periodically

surveyed for State licensure purposes and for certification or recertification for
participation in the Medicare or Medicaid program and because of complaints
received by or initiated by the Indiana State Department of Health or CMS.

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Defendants Conduct
30.

Defendants, and particularly Hemmelgarn and Snyder, have abused

the survey process to subject Dr. Brar, Home Care, Nightingale, and Hospice to a
continuing campaign of harassment, discrimination, intimidation, and retaliation
based on race, Plaintiffs exercise of their First Amendment rights, and personal
dislike or disapproval of Dr. Brar and his companies.
31.

Defendants Hemmelgarn and Snyder have issued harsher survey

reports and findings to Nightingale and Hospice than they have to similarly
situated providers for similar conditions, with no rational basis for doing so.
32.

Hemmelgarn and Snyder have directed Department of Health

surveyors to conduct an inordinate number of surveys of Nightingale and Hospice

compared to similarly situated providers, with no rational basis for doing so.
33.

Hemmelgarn and Snyder have initiated an inordinate number of their

own complaints against Nightingale and Hospice compared to similarly situated

providers, with no rational basis to do so.
34.

Hemmelgarn and Snyder have instructed Indiana State Department of

Health surveyors to find deficiencies in the care Nightingale and Hospice provide,
without regard to whether such findings are justified, and have directed surveyors
to find that patients are in immediate jeopardy, without regard to whether the
facts justify such findings.

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35.

They have also instructed Indiana State Department of Health

surveyors to disregard survey guidelines that CMS publishes. CMS publishes those
guidelines to ensure that surveys of healthcare providers are consistent and fair.
36.

Snyder and Hemmelgarn have also taken actions that are

extraordinary for government officials at their level of seniority. For example,

Hemmelgarn made an anonymous complaint via a government website concerning
Dr. Brars use of the title Dr. on the ground that it was misleading because he
does not have a medical license in Indiana. That action violated guidelines from the
Attorney General of Indiana that officials at her level are to communicate
regulatory complaints directly to the Attorney Generals office, rather than via
anonymous complaints. In an effort to conceal her conduct, Hemmelgarns
complaint asked that her name not be disclosed. Dr. Brar responded to the
complaint, and no further action was taken on it. Dr. Brars use of the title Dr. is
not misleading because he is a trained physician licensed in India, who practiced
there for several years
37.

Snyder, in assessing the permissibility of a branch office location, took

the extraordinary step of personally driving the distance between Plaintiffs parent
headquarters in Carmel and the proposed branch office location in Merrilville,
finding that it was just outside permissible limits. Branch locations at the same or
greater distances have been approved for other providers.
38.

Acting on the directions of Defendants Snyder and Hemmelgarn,

Defendant Miller engaged in an unlawful search and seizure by entering into

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Hospices closed former business premises, which were no longer open to the public
because Hospice had relocated its office from Fort Wayne to Crown Point, and by
rummaging through desks, boxes and filing cabinets in a general search for which
there was neither probable cause nor a warrant. On information and belief,
Defendant Miller was acting on instructions from Hemmelgarn and/or Snyder.
39.

The extraordinary regulatory scrutiny to which Defendants have

subjected Plaintiffs has its genesis, in part, in racially tinged remarks that a
colleague of Snyders made, and which were recorded because Snyders colleague
failed to disconnect a call after leaving a voice message for Nightingale.
Nightingales voicemail system recorded additional comments the colleague made to
another ISDH official who was in her office at the time of the call.
40.

Dr. Brar complained about the racially tinged remarks to higher level

officials at ISDH, and the employee was disciplined.

41.

Since that time, and in retaliation for Dr. Brars and Nightingales

protected activity in complaining about mistreatment by ISDH personnel, Snyder

and Hemmelgarn have subjected Nightingale to multiple complaint surveys.
Nearly all surveys found that the complaints were not substantiated, and until
recently none of them resulted in action against either Nightingales license or
Medicare status.
42.

Snyder and Hemmelgarn have continued their campaign of

harassment. In 2015, Hospice decided to close its office in Fort Wayne, where it had
only a single patient on service nearby. After initially indicating that Hospice could

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do so and it was only a simple matter of paperwork, Hemmelgarn and Snyder

initiated a complaint survey and then a license revocation proceeding, causing
Nightingale to incur extensive legal expenses just to close the facility. ISDH
likewise attempted to have CMS de-certify Hospices Fort Wayne office.
43.

The complaint survey referred to in the previous paragraph was the

result of an ISDH initiated complaint based on the unlawful search and seizure
conducted by Defendant Miller.
44.

In October and November of 2015, Hemmelgarn and ISDH directed

that Nightingale be surveyed for fifteen days.

45.

Both Hemmelgarn and Snyder started with the preconceived judgment

that Nightingales Medicare and Medicaid status and provider agreements should
be terminated and its license to provide home healthcare services should be revoked
and instructed surveyors acting under their direction that the surveyors should find
deficiencies and find instances of immediate jeopardy that would justify such
actions.
46.

Surveyors acting under the direction of Snyder and Hemmelgarn made

statements to Nightingale that we are going to shut you down before the survey
was even completed.
47.

The surveyors were antagonistic, bullying and adversarial, falsely

accusing Nightingales employees of lying and altering or falsifying documents,

resulting in extraordinary distress to Nightingales employees.

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48.

On November 2, 2015, surveyors acting under the direction of Snyder

and Hemmelgarn purported to verbally find that a Nightingale patient was in

immediate jeopardy but refused to provide Nightingale with any information
about the conditions allegedly creating the immediate jeopardy or even the name of
the patient, as required by CMSs surveyor manual, so Nightingale could remove
the immediate jeopardy.
49.

Both orally and in writing on November 2, 2015 and in writing again

on November 6, 2015, Nightingale asked for adequate information on the alleged

immediate jeopardy so Nightingale could address the issues and remove the
jeopardy.
50.

However, none of Snyder, Hemmelgarn, and the surveyors acting at

their direction responded to Nightingales request, instead citing Nightingale for a

continuing immediate jeopardy on November 9, 2015.
51.

At a November 9, 2015 exit conference, surveyors acting at

Hemmelgarns and Snyders direction again refused to provide any specific

information regarding the immediate jeopardy determination.
52.

Surveyors acting at Snyders and Hemmelgarns direction also refused

to provide Nightingale with a list that would permit Nightingale to identify patients
designated solely by number on Defendants survey reports, in violation CMSs
survey manual, so Nightingale could correct and remove any deficiencies that
pertained to particular patients.

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53.

Snyder, Hemmelgarn, and surveyors acting at their direction refused

to review and respond to Nightingale's Plans for Removal of the immediate jeopardy
situations in a consistent and timely manner, leaving Nightingale without fair
notice of what conditions the Defendants believed placed patients in immediate
jeopardy, and without information on which patients were allegedly in jeopardy.
That action deprived Nightingale of the ability to promptly remove any such
conditions, as required by State and federal regulations and survey procedures.
54.

Then, having made it virtually impossible for Nightingale to even

know what conditions allegedly created immediate jeopardy, the ISDH surveyors
submitted the survey reports to CMS and Defendants purported to use those
reports to justify termination of Nightingales Medicare status and provider
agreement.
55.

Nightingale has followed proper administrative procedures in seeking

review of the Defendants erroneous findings, and therefore need not further
exhaust administrative remedies before invoking the Courts power to grant relief.
56.

In addition to challenging the basis for the termination of its Medicare

provider agreement in the administrative process, Nightingale will apply for

readmission to the Medicare program which requires it to undergo and pass two
surveys months apart in order to demonstrate to CMS that it is in compliance with
Medicare conditions of participation for home health agencies. That reapplication
process makes it particularly important that unbiased, impartial surveyors assess
Nightingales compliance.

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57.

Defendants are continuing their campaign of harassment, bullying and

discrimination against Nightingale and have now directed the same tactics and
conduct at Hospice, with the preconceived intent to shut down Hospice.
58.

As a matter of due process, Plaintiffs are entitled to impartial

surveyors and decision makers who do not come to the survey process with a
preconceived intent to find Plaintiffs out of compliance and take punitive actions
against them.
59.

Despite multiple requests for impartial surveyors and decision makers,

Defendants have refused to permit surveys of Plaintiffs to be done fairly and

impartially.
Claims for Relief
60.

Plaintiffs incorporate paragraphs 1 through 59 above, as if fully stated

in this paragraph.
61.

All defendants other than the Secretary have, under color of State law,

subjected and continue to subject Dr. Brar, Home Care, Nightingale, and Hospice to
a deprivation of rights secured by the Constitution and laws of the United States.
62.

The Secretary has, under color of federal law, subjected and continues

to subject Dr. Brar, Home Care, Nightingale, and Hospice to a deprivation of rights
secured by the Constitution and laws of the United States.
63.

Plaintiffs have suffered, and continue to suffer, grievous and

irreparable harm as a proximate result of Defendants misconduct.

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64.

The particular rights of which Defendants have deprived Plaintiffs are

set forth in the Counts below:

Count I Equal Protection (Race Discrimination)
65.

Plaintiffs incorporate paragraphs 1 through 64 above, as if fully stated

in this paragraph.
66.

The Defendants other than the Secretary have discriminated against

Dr. Brar and his businesses on the basis of race, ethnicity and/or national origin, in
violation of the equal protection clause of the Fourteenth Amendment to the
Constitution of the United States.
67.

By ratifying the other Defendants actions, the Secretary has

discriminated against Dr. Brar and his businesses on the basis of race, ethnicity,
and/or national origin, in violation of the equal protection component of the due
process clause of the Fifth Amendment to the Constitution of the United States.
Count II Equal Protection (Class of One)
68.

Plaintiffs incorporate paragraphs 1 through 67 above, as if fully stated

in this paragraph.
69.

The Defendants other than the Secretary have discriminated against

Dr. Brar and his businesses by treating them more harshly than other hospice and
home healthcare providers, with no rational basis to do so, in violation of the equal
protection clause of the Fourteenth Amendment to the Constitution of the United
States.

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70.

By ratifying the other Defendants actions, the Secretary has

discriminated against Dr. Brar and his businesses by treating them more harshly
than other hospice and home healthcare providers, with no rational basis to do so,
in violation of the equal protection component of the due process clause of the Fifth
Amendment to the Constitution of the United States.
Count III First Amendment
71.

Plaintiffs incorporate paragraphs 1 through 70 above, as if fully stated

in this paragraph.
72.

The Defendants other than the Secretary have retaliated against Dr.

Brar and his businesses for protected speech and protected efforts to petition the
government for redress of their grievances, in violation of the First Amendment to
the Constitution of the United States, as incorporated into the due process clause of
the Fourteenth Amendment to the Constitution of the United States.
73.

By ratifying the other Defendants actions, the Secretary has retaliated

against Dr. Brar and his businesses for protected speech and protected efforts to
petition the government for redress of their grievances, in violation of the First
Amendment to the Constitution of the United States.
Count IV Procedural Due Process
74.

Plaintiffs incorporate paragraphs 1 through 73 above, as if fully stated

in this paragraph.
75.

The Defendants other than the Secretary have ignored and violated

required procedures for Medicare surveys, depriving Dr. Brar and his businesses of

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liberty and/or property interests in their Medicare status and/or provider

agreements, in violation of the due process clause of the Fourteenth Amendment to
the Constitution of the United States.
76.

By ratifying the other Defendants actions, the Secretary has ignored

and violated required procedures for Medicare surveys, depriving Dr. Brar and his
businesses of liberty and/or property interests in their Medicare status and/or
provider agreements, in violation of the due process clause of the Fifth Amendment
to the Constitution of the United States.
Count V Unlawful Search and Seizure
77.

Plaintiffs incorporate paragraphs 1 through 76 above, as if fully stated

in this paragraph.
78.

Defendants Hemmelgarn, Snyder and Miller conducted or directed an

unlawful search of Plaintiffs business premises of Plaintiffs business records, in

violation of the Fourth Amendment to the Constitution of the United States, as
incorporated into the due process clause of the Fourteenth Amendment to the
Constitution of the United States.
Relief Sought
Because of Defendants' misconduct and violation of Plaintiffs' rights,
Plaintiffs seek the following relief:
1.

Plaintiffs have no adequate remedy at law because Defendants

misconduct will put Plaintiffs out of business. Therefore, they seek preliminary and
permanent injunctive relief :

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a. That Defendants other than the Secretary be enjoined from

conducting further surveys of Plaintiffs and that independent
surveyors be put in place to conduct surveys, except that
Defendants may conduct surveys in case of a bona fide, third-party
complaint alleging facts likely to constitute an immediate threat to
the health and well-being of patients;
b. That the Secretary be enjoined from using the Indiana State
Department of Health to conduct further surveys of Plaintiffs and
that independent surveyors be put in place to conduct surveys,
except that Defendants may conduct surveys in case of a bona fide,
third-party complaint alleging facts likely to constitute an
immediate threat to the health and well-being of patients;
c. That the Secretary be mandatorily enjoined to use the services of
surveyors independent from the Indiana State Department of
Health and CMS for all future surveys of Plaintiffs except those
emergency surveys referred to in paragraphs (a) and (b).
d. That the other Defendants be mandatorily enjoined to withdraw the
survey reports they have submitted to CMS since January 1, 2015.
2.

Plaintiffs also seek money damages in an amount sufficient to

compensate them for their losses proximately caused by Defendants unlawful

conduct.

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3.

Plaintiffs also seek an award of costs, including reasonable attorneys

fees, under 42 U.S.C. 1988.

4.

Plaintiffs also seek all other relief that is just and proper.
Respectfully submitted,
/s/ Arend J. Abel. #10763-49
Irwin B. Levin, # 8786-49
Arend J. Abel, #10763-49
Takeena M. Thompson, #28807-53
COHEN & MALAD, LLP
One Indiana Square, Suite 1400
Indianapolis, Indiana 46204
Phone: 317-636-6481
Fax: 317-636-2593

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