STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
AGENCY FOR HEALTH CARE )
ADMINISTRATION, )
)
Petitioner, )
)
vs. ) Case No. 02-0683
) HALLANDALE REHABILITATION ) CENTER, )
Respondent. )
) AGENCY FOR HEALTH CARE )
ADMINISTRATION, )
)
Petitioner, )
)
vs. ) Case No. 02-0684
)
G.J.S. HOLDINGS, INC., d/b/a ) HALLANDALE REHABILITATION ) CENTER, )
)
Respondent. )
)
RECOMMENDED ORDER
Robert E. Meale, Administrative Law Judge of the Division of Administrative Hearings, conducted the final hearing in Fort Lauderdale, Florida, on July 31 and August 1, 2002.
APPEARANCES
For Petitioner: Lori C. Desnick
Agency for Health Care Administration 2727 Mahan Drive, Suite 3431
Fort Knox Building No. 3 Tallahassee, Florida 32308
For Respondent: Jay Adams
Jay Adams, P.A. Broad and Cassel
215 South Monroe Street, Suite 400 Post Office Drawer 11300 Tallahassee, Florida 32302
STATEMENT OF THE ISSUES
The issues are whether Respondent's operation of its nursing home was deficient and, if so, whether Petitioner should have imposed an already-lifted admissions moratorium, pursuant to Section 400.121(5)(a), Florida Statutes; and should impose a conditional license, pursuant to Section 400.23(7)(b), Florida Statutes; administrative fines of $95,000, pursuant to Section 400.19(8), Florida Statutes; a survey fee of $6000, pursuant to Section 400.19(3), Florida Statutes; and costs, pursuant to Section 400.121(10), Florida Statutes.
PRELIMINARY STATEMENT
DOAH Case No. 02-0683 and DOAH Case No. 02-0684 involve the same alleged deficiencies at Hallandale Rehabilitation Center.
In DOAH Case No. 02-0683, Petitioner seeks to impose a conditional license, and, in DOAH Case No. 02-0684, Petitioner seeks to impose fines and fees in the amount of $101,000, assess costs, and sustain an already-lifted admissions moratorium.
By letter dated December 13, 2001, Petitioner issued Respondent a conditional license for Hallandale Rehabilitation Center, effective December 4, 2001. A Notice of Intent to
Assign Conditional Licensure Status dated December 14, 2001, explains that a survey completed on December 4, 2001, uncovered several class I and II deficiencies due to violations of Rule 59A-4.1288, Florida Administrative Code, and Section 400.022(1)(l), Florida Statutes, for failing to protect residents from neglect by providing the necessary treatment to avoid physical harm to a resident who sustained a burn, for failing to protect residents who developed pressure sores, and for failing to protect residents who suffered altered skin integrity; Rule 59A-4.1288, Florida Administrative Code, and Section 400.022(1)(n), Florida Statutes, for failing to provide a dignified existence for residents who were double diapered and whose personal care needs were unmet by the failure to trim fingernails and toenails; Rule 59A-4.109, Florida Administrative Code, for failing to review and revise the care plan of a resident who acquired a pressure sore; Rule 59A-4.1288, Florida Administrative Code, for failing to ensure that caregivers met professional standards of care; Rule 59A-4.1288, Florida Administrative Code, and Section 400.022(1)(l), Florida Statutes, for failing to provide the necessary care and services for a resident who sustained a burn on her right thigh, thus diminishing the resident's highest quality of wellbeing; Rule 59A-4.1288, Florida Administrative Code, for failing to ensure that residents who cannot care for their personal needs are
aided by staff, as evidenced by a resident who remained in a saturated incontinent brief for 12 hours; Rule 59A-4.1288, Florida Administrative Code, for failing to ensure that a resident who entered the facility without pressure sores did not develop any pressure sores while in the facility; and Section 400.147(1)(e), Florida Statutes, for failing to have any measures to minimize the risk of adverse incidents to residents, as based on the review of the quality assurance program and observation of wounds.
By amended Administrative Complaint filed February 28, 2002, Petitioner sought a $95,000 administrative fine and a
$6000 survey fee, the costs of the investigation and prosecution, and an order sustaining an already-lifted moratorium at the 141-bed nursing home, Hallandale Rehabilitation Center.
Count I alleges that Respondent failed to prevent the mistreatment or neglect of seven residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. Count I alleges that Respondent thus violated
42 Code of Federal Regulation Section 483.13(c); Rule 59A-4.1288, Florida Administrative Code; and Section
400.022(1)(o), Florida Statutes. Count I alleges that these violations constitute an isolated class I deficiency.
Count II alleges that Respondent failed to provide or arrange for the provision of services that met professional standards of quality for seven residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. Count II alleges that Respondent thus violated
42 Code of Federal Regulation Section 483.20(k)(3)(i) and Rule 59A-4.1288, Florida Administrative Code. Count II alleges that these violations constitute an isolated class I deficiency.
Count III alleges that Respondent failed to provide the necessary care and services for Resident #1 to attain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with her comprehensive assessment and plan of care. Count III alleges that Respondent thus violated
42 Code of Federal Regulation Section 483.25; Rule 59A-4.1288, Florida Administrative Code; and Section 400.022(1)(l), Florida Statutes. Count III alleges that this violation is an isolated class I deficiency.
Count IV alleges that Respondent failed to promote care in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for seven residents: Resident #2 and #8-13.
Count IV alleges that Respondent thus violated 42 Code of Federal Regulation 483.15(a), Rule 59A-4.1288, Florida Administrative Code, and Section 400.022(1)(n), Florida
Statutes. Count IV alleges that these violations constitute an isolated class II deficiency.
Count V alleges that Respondent failed to revise, as needed, Resident #2's comprehensive care plan; failed to assure that a team of qualified persons reviewed and revised
Resident #2's comprehensive care plan after each assessment; and failed to assure that an interdisciplinary team, including the attending physician, appropriate registered nurse, other appropriate staff, and the resident or his family or legal representative, prepared Resident #2's comprehensive care plan. Count V alleges that Respondent thus violated 42 Code of Federal Regulation Section 483.20(k)(2)(ii) or (iii), and Rules
59A-4.1288 and 59A-4.109(1) and (2), Florida Administrative Code. Count V alleges that this violation is an isolated class II deficiency.
Count VI alleges that Respondent failed to ensure that Resident #2, who was unable to perform the activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Count VI alleges that Respondent thus violated 42 Code of Federal Regulation Section 483.25(a)(3) and Rule 59A-4.1288, Florida Administrative Code. Count VI alleges that this violation is an isolated class II deficiency.
Count VII alleges that Respondent failed to ensure that Resident #2, who entered the facility without pressure sores, did not develop pressure sores, unless his clinical condition demonstrated that pressure sores were unavoidable, and failed to ensure that Resident #2 received the necessary treatment and services to promote healing, prevent infection, and prevent new sores. Count VII alleges that Respondent thus violated 42 Code of Federal Regulation Section 483.25(c)(1) and (2) and Rule
59A-4.1288, Florida Administrative Code. Count VII alleges that this violation is an isolated class II deficiency.
Count VIII alleges that Respondent failed to develop appropriate measures to minimize the risk of adverse incidents to residents, such as by training all nonphysician staff in risk management and risk prevention. Count VIII also alleges that Respondent failed to implement any risk management program.
Count VIII alleges that Respondent thus violated Section 400.147(1)(e), Florida Statutes. Count VIII alleges that this violation is a widespread class II deficiency.
Count IX alleges that Petitioner cited Respondent for one class I deficiency during a survey that took place on December 3 and 4, 2001. Count IX alleges that, pursuant to Section 400.19(3), Florida Statutes, Respondent was thus subject to inspections every six months and was subject to a survey fine of
$6000. The amended Administrative Complaint seeks fines
totaling $95,000 for the three isolated class I deficiencies alleged in Counts I-III, four isolated class II deficiencies alleged in Counts IV-VII, and one widespread class II deficiency alleged in Count VIII. In Count IX, Petitioner does not seek a fine for the acts and omissions described in that count, but seeks to rely on the proved citation to justify doubling the fines proved in the preceding counts.
By Order of Immediate Moratorium filed December 11, 2001, Petitioner alleged that it had licensed Respondent to operate Hallandale Rehabilitation Center as a 141-bed facility and, as of December 11, 2001, Respondent was serving 75 residents.
Alleging substantially the same allegations that are contained in the amended Administrative Complaint, the Order alleges that Petitioner has concluded that conditions at the facility present a threat to the health, safety, or welfare of the residents, so as to require the imposition of an immediate admissions moratorium.
Respondent timely requested formal hearings in both cases.
By Motion to Consolidate filed March 6, 2002, Respondent requested the consolidation of DOAH Case Nos. 02-0683 and 02-0684. The Administrative Law Judge granted the motion.
At the hearing, Petitioner called seven witnesses and offered into evidence 24 exhibits: Petitioner 1-2, 5, 8, 12-29, and 31-32. Respondent called two witnesses and offered into
evidence three exhibits: Respondent Exhibits 1-3. All exhibits were admitted except Respondent Exhibit 2, which Respondent withdrew by notice filed August 15, 2002, and Respondent Exhibit 3, which Respondent did not file post-hearing.
The court reporter filed the transcript on August 30, 2002.
The parties filed their proposed recommended orders by
October 22, 2002.
FINDINGS OF FACT
Respondent owns and operates Hallandale Rehabilitation Center (Hallandale), which is a 141-bed nursing home located at 2400 East Hallandale Beach in Hallandale. Licensed as a skilled nursing facility, Hallandale holds license number SNF11920961, effective April 25, 2001, through December 31, 2001.
Petitioner's surveyors conducted an inspection of Hallandale on December 3 and 4, 2001. The inspection lasted four to five hours on the first day and twelve and one-half hours on the second day. As a result of the inspection, Petitioner found numerous deficiencies in resident care, as discussed below.
At the time of the incident described below, Resident #1 was 84 years old. She had been admitted to
Hallandale on September 11, 2001, having suffered a stroke with aphasia, hemiplagia, hypertension, and cardiac arrhythmia. She
was totally dependent upon staff for all of her needs, which she was unable to communicate.
On October 25, 2001, one of Respondent's staff discovered a large reddened area on the right anterior thigh of Resident #1. The area measured 14 cm by 8 cm and was raised and hard. A licensed practical nurse and registered nurse, both employed by Respondent, examined the wound. The registered nurse spoke to the certified nursing assistants to learn what she could about the wound, but no one was aware of its cause.
Without delay, the nurse on duty contacted the advanced registered nurse practitioner, who was employed by the physician who supervised Resident #1's care. After listening to an accurate description of the wound, the advanced registered nurse practitioner opined that the reddened area might be cellulitis, possibly due to a bug bite. At 6:45 a.m., the advanced registered nurse practitioner ordered the application of warm compresses to the wound several times a day. Respondent's staff promptly implemented these orders. Respondent's staff also contacted Resident #1's husband and informed him of the situation.
The wound quickly deteriorated. When Respondent's staff informed the advanced registered nurse practitioner later the same day that the reddened area had begun to blister and opened blisters had begun to seep clear fluids, the advanced
registered nurse practitioner ordered that staff discontinue the warm compresses and clean the wound with saline solution, apply triple antibiotic ointment, and cover the wound with Telfa.
Respondent's staff promptly implemented these orders.
Respondent's staff initiated an investigation into the cause of Resident #1's wound and completed adverse incident reports. In retrospect, the most plausible explanation is that a heated metal plate warmer, which is under the food plate on which residents are served their food, may have somehow slipped out of its protective enclosure and burned Resident #1. But this explanation appears to have emerged later, partly due to the fact that the facility had never previously had a resident burned by a plate warmer and partly due to the belated identification of the wound as a burn.
The day after the discovery of the wound, the advanced registered nurse practitioner visited the facility and intended to examine Resident #1's wound. However, Resident #1 was out of the facility at a neurologist's appointment, and the advanced registered nurse practitioner did not see her on that day.
Four days after the discovery of the wound, the advanced registered nurse practitioner ordered the discontinuation of the triple antibiotic ointment and the application of Silvadene. It is unclear what prompted this change in orders.
Six days after the discovery of the wound, the advanced registered nurse practitioner visited the facility and examined the wound, but was unable to conclude the source of the injury. Satisfied with the present treatment, the advanced registered nurse practitioner ordered the continuation of the Silvadene and a follow-up visit in one week.
On November 2, which was eight days after the discovery of the wound, Respondent's staff notified the advanced registered nurse practitioner that the wound was not progressing. The advanced registered nurse practitioner ordered a consultation with a wound care physician, with whom an appointment was made for November 6. In the meantime, Respondent's staff continued to implement the orders of the advanced registered nurse practitioner.
On November 4, the advanced registered nurse practitioner re-examined the wound and did not change the treatment order. Two days later, the wound care physician, who is a dermatologist, examined the wound and ordered Santal ointment, which is a debriding agent, and an outpatient debridement, but Resident #1's husband declined the surgical procedure on behalf of his wife.
Eight days later, on November 14, a plastic surgeon examined Resident #1's wound. Testifying that he did not know who summoned him to the facility, the physician visited the
facility and found that Resident #1's wound was actually a third-degree burn, which was now 16 cm by 9 cm and exhibiting areas of necrosis. Continuing the order for Santal, the plastic surgeon ordered a surgical debridement to remove the nonviable tissue that were impeding healing.
Based on the plastic surgeon's testimony, the application of warm compresses, although contraindicated for a burn wound, did not exacerbate the injury because all of the damage was done at the moment of the initial incident. Also, the Silvadene, triple antibiotic, and Santal were appropriate treatments. From the moment of the initial incident,
Resident #1 would have required surgical treatment regardless of the diagnosis and nonsurgical treatment of the wound. However, the passage of six days before a physician (or presumably an advanced registered nurse practitioner) examined the wound was unreasonable; at most, two days would be reasonable.
On November 18, Resident #1 was admitted to the hospital for an unrelated condition. During this admission, on November 23, the plastic surgeon performed the debridement. The wound healed nicely after the procedure.
The three allegations concerning Resident #1 involve mistreatment and neglect, the failure to provide services meeting professional standards of quality, and the failure to provide the services necessary for Resident #1 to attain her
highest practicable physical, mental, and psychosocial wellbeing. Petitioner has focused on Respondent's acts and omissions after discovering the wound and not on any acts or omissions possibly resulting in the wound.
These issues turn on the failure of the physician or at least advanced registered nurse practitioner to examine the wound for six days. Ultimately, it is unimportant that the advanced registered nurse practitioner was at the facility the next day, but was unable to examine the injury due to the absence of the resident. The fact remains that Resident #1 was not examined by a physician or an advanced registered nurse practitioner for six days after the injury was discovered.
However, when the advanced registered nurse practitioner examined Resident #1 on October 31, he did find that the condition of the wound demanded a change in treatment or immediate intervention. As noted by the plastic surgeon, the Silvadene then being administered was appropriate.
The failure of the advanced registered nurse practitioner to diagnose Resident #1's burn would have been material, if timely diagnosis would have resulted in materially different treatment that could have obviated the need for surgical debridement. However, the plastic surgeon established that, from the moment of the burn, Resident #1 was destined to
undergo a surgical debridement of the wound. Significantly, the wound healed shortly after the surgery.
The failure of the advanced registered nurse practitioner to diagnose Resident #1's burn would also have been material, if a timely diagnosis would have materially shortened the healing process or materially reduced the amount of pain produced by the wound. However, the evidence describing Resident #1's reaction to the pain of the wound prior to debridement is scant. And no evidence suggests timely diagnosis would have meant that a surgical debridement would have taken place earlier than the one actually performed--about one month after the burn occurred. In general, the evidence fails to show that the delayed diagnosis materially affected Resident #1's physical, mental, or psychosocial wellbeing.
The question whether Respondent mistreated or neglected Resident #1 requires an assessment of the reasonableness of its reliance upon the nonemployee health care professionals who cared for Resident #1 prior to the intervention of the plastic surgeon. Respondent timely notified these professionals, as well as Resident #1's husband, of the initial injury, as well as subsequent developments. Petitioner has not shown that any shortcomings in diagnosis and treatment by those professionals had a material bearing on the course or outcome of Resident #1's case.
In general, Petitioner has not proved that Respondent's care for Resident #1 after discovery of the injury constitutes mistreatment or neglect, a failure to provide services meeting professional standards of quality, or a failure to provide the services necessary for Resident #1 to attain her highest practicable physical, mental, and psychosocial wellbeing.
At the time of the incident described below, Resident #2 was 61 years old. He had been admitted to Hallandale on October 9, 2001, with a right-leg amputation below the knee a day or two prior to the admission to Hallandale, diabetes, cardiovascular disease, and dehydration, but not pressure sores.
While at the facility, Resident #2 mostly remained in his room. Resident #2 had recently been living in a homeless shelter. When he used his wheelchair, Resident #2 propelled himself with his arms, not his foot.
On October 31, about three weeks after his admission, Respondent's staff found a "stage II" open wound measuring 2 cm by 3 cm on the sole of Respondent's foot. Respondent contends that the wound was a vascular ulcer. This contention is supported by the diabetes, peripheral vascular disease, and recent amputation.
On the other hand, Petitioner's surveyor examined the wound during the survey and found a stage II pressure sore the
size of a quarter or half-dollar. Several facts support Petitioner's classification of the wound as a pressure sore; these include the fact that it healed later in December, that some of Respondent's records identify the wound as a pressure sore, various risk factors for pressure sores, and Respondent's haphazard maintenance of medical records for this resident-- featuring one admittedly incorrect record of the inception of the wound and treatment records that Respondent claims are missing.
A stage II pressure sore is defined by the presence of opened area through the epidermis and possibly the dermis. A stage I pressure sore is defined by a reddened area. A stage III pressure sore is defined by the exposure of subcutaneous tissue, and a stage IV pressure sore is defined by the exposure of the fascia, muscle, or bone. A pressure sore results from pressure to an area over an extended period of time, so that an area loses blood circulation and suffers tissue breakdown.
It is impossible to find sufficient factual bases for mistreatment or neglect of Resident #2 strictly in the development of the pressure sore. His various physical problems predisposed him to this condition. His means of movement in the wheelchair was his hands, not his foot, so that the source of pressure on the foot is not obvious.
However, Respondent's response to the pressure sore was inadequate. First, Respondent provided Resident #2 no treatment for the pressure sore for the first three weeks after its discovery; under these circumstances, this absence of treatment was mistreatment and neglect and a failure to provide services meeting professional standards of quality. During this period, Respondent likewise failed to make the necessary revisions in any care plan that it maintained for Resident #2.
On November 20, Respondent's staff applied duoderm to the pressure sore and continued to provide effective treatment, including hydrogel, that resulted in the speedy resolution of the condition. However, the period during which Resident #2 suffered with an untreated pressure sore on his foot occurred during a crucial period of his life, as he tried to recover from the amputation of part of his right leg.
While his pressure sore remained symptomatic and untreated, Resident #2 suffered a decline in his level of participation in physical therapy. For instance, progress notes from the occupational therapist dated October 17 and 24 report "excellent progress"; the latter note reports "max[imum] motivation" and the therapist's expectation that Resident #2 will make "cont[inued] progress." By November 19, Resident #2 was refusing to participate in physical therapy, citing "drainage pain in foot." He refused physical therapy again the
next day for the same reason. One week later, the physical therapist discontinued Resident #2's physical therapy due to his noncompliance.
Interestingly, Resident #2's urinary continence also changed for the worse during the same period that his painful foot remained untreated. On October 22, Respondent completed a minimum data set for Resident #2 and determined that he was continent. However, the minimum data set that Respondent completed six weeks later revealed that he was now occasionally incontinent. The interdisciplinary care plan confirms declines during this time in behavior and continence.
If Resident #2 reacted poorly to the untreated and painful pressure sore in his left foot, it can perhaps be explained by, not only the fact that this was his sole remaining foot, but also by the circumstances surrounding the loss of the right foot. A week prior to his admission to Hallandale, Resident #2 had been admitted to the hospital complaining of a draining ulcer at the base of his right foot, which resulted in the amputation of his right leg below the knee a few days later.
Two other allegations involve Resident #2. One involves the discovery of the resident by a surveyor in a urine- soaked condition. The other involves the presence of excessively long toenails on Resident #2, suggestive of a lack of attention to his grooming needs.
During the survey, a surveyor found Resident #2 in his bed soaked in urine up to his armpits. She found his sheets and clothing totally soaked in urine and the smell "unbelievabl[y]
. . . strong." When the surveyor contacted the Director of Nursing, he told her that staff had last changed Resident #2's incontinence brief 12 hours ago.
The evidence concerning the condition of Resident #2's toenails does not establish any deficiency. The surveyor who noted the condition of the toenails had to rely on her report, rather than an independent recollection. The evidence generally does not describe the circumstances surrounding this situation.
Although Petitioner did not prove that Respondent unreasonably failed to avoid the development of the pressure sore, Petitioner proved that Respondent's failure to treat the pressure sore promptly was mistreatment and neglect and a failure to provide services meeting professional standards of quality. Similarly, Petitioner proved that Respondent failed to revise Resident #2's comprehensive care plan during this period of nontreatment.
Although Petitioner did not prove that Respondent failed to promote care to maintain Resident #2's dignity in terms of any failure to timely trim his toenails, Petitioner proved that Respondent's failure to change Resident #2's briefs for 12 hours, at the end of which time he was totally soaked in
urine, constituted a failure to provide those services necessary to maintain personal hygiene to a resident in need of assistance in his activities of daily living.
The prompt healing of the pressure sore, once it was treated, is a mitigating factor. However, the effect of the delay in treatment upon Resident #2 is a serious aggravating factor. Having recently undergone the amputation of his lower right leg following a similar sore on his right foot, Resident #2 began the difficult transition period with a worrisome pressure sore on his remaining foot. The period during which Respondent failed to treat this pressure sore corresponds with the period during which Resident #2 suffered declines in urinary continence and therapeutic progress following the leg amputation. Allowing Resident #2 to lie in bed totally soaked in his own urine literally added insult to injury.
At the time of the incident described below, Resident #3 was 45 years old. He was quadriplegic and incontinent. Due to decreased bed mobility and bowel incontinence, Resident #3 was at increased risk of developing pressure sores.
The surveyor directed that staff remove dressings of wounds, so that she could examine the condition of the wounds. In removing a dressing covering a stage II pressure sore at the sacrum, a nurse either tore the epidermis at the distal end of Resident #3's buttock or a previously reddened area had been
masked by the tape used to secure the dressing for the pressure sore at the sacrum.
There is little evidence in the record concerning Resident #3. With respect to either of his pressure sores, Petitioner failed to prove any mistreatment or neglect or any failure to provide services meeting professional standards of care.
At the time of the incident described below, Resident #4 was 77 years old. She was incontinent and dependent on staff for all of her needs.
During the survey, a surveyor discovered a severe excoriation of the perineal area extending to Resident #4's groin and right upper thigh. At the time, Respondent's staff was treating the excoriated area with zinc oxide to provide a barrier between the skin and external moisture. The treatment was appropriate, and Respondent's standing orders duly authorized the use of zinc oxide for this condition without obtaining a physician's order to do so.
Petitioner failed to prove any mistreatment or neglect or failure to meet professional standards of quality in Respondent's care of Resident #4.
At the time of the incidents described below, Resident #5 was 87 years old and Resident #7 was 57 years old. Both
residents had been admitted to Hallandale less than one month prior to the survey.
During the survey, the surveyor noticed that each of these residents had stage II pressure sores without dressings. The Director of Nursing, who was pregnant at the time and unable to remove dressings herself, had directed staff to remove the dressings of a number of residents at the same time, shortly before the wound inspection, to facilitate the surveyor's examination of wounds. Staff did so with respect to Resident #5 and Resident #7, and the surveyor wrongly inferred that Respondent did not maintain the necessary dressings for these residents.
As to Resident #5 and Resident #7, Petitioner failed to prove any mistreatment or neglect or any failure to meet professional standards of quality.
At the time of the incident described below, Resident #6 was 90 years old.
During the survey, the surveyor found a dressing on a wound on Resident #6's left lateral ankle. The date written on the dressing was two days prior to the date of the survey, but the physician's order was to change the dressing and treat the wound daily.
The treatment record documents that Respondent's staff changed the dressing on the day prior to the survey, even though
this date was not noted on the dressing itself. Absent any evidence of harm to the resident, the evidence does not establish that Respondent's staff failed to change the dressing on the prior day.
As to Resident #6, Petitioner has failed to prove any mistreatment or neglect or any failure to provide services meeting professional standards of quality.
At the time of the incident described below, Resident #8 was 47 years old. He had been admitted to Hallandale with diagnoses of heart failure, HIV, neuropathy, and psychosis. Fortunately, Resident #8 required minimal assistance with his activities of daily living because he was intractably abusive toward staff, yelling insults and throwing furniture and dishes.
During the survey, a surveyor noticed that Resident #8's fingernails were long and yellowed. The resident claimed that Respondent's staff ignored his frequent pleas that they trim his nails. According to Respondent's staff, Resident #8 refused to allow anyone to trim his fingernails.
It is impossible to credit Resident #8's claims.
Petitioner cited excessively long nails for only two of about 75 residents. The other situation was discussed above. The most likely explanation for Resident #8's long fingernails was his disruptive lack of cooperativeness and psychotic behavior.
Petitioner failed to prove any failure to promote care to maintain Resident #8's dignity.
There is little evidence concerning Resident #9, whom Petitioner alleges suffered from excoriated buttocks and delays in changing wet briefs. In its proposed recommended order, Petitioner did not mention the latter allegation, which consisted of hearsay in this record, but restated the observation of excoriated buttocks. There is also little evidence concerning Resident #10, whom Petitioner alleges suffered from delays in responses to her call bell to be assisted in toileting. In its proposed recommended order, Petitioner did not mention this allegation, which consisted of hearsay in this record. Absent evidence of the circumstances surrounding the excoriation or the other alleged deficiencies omitted from the proposed recommended order, Petitioner has failed to prove any failure to promote care to maintain either resident's dignity.
As for Resident #11, Resident #12, and Resident #13, Respondent's staff double-diapered all of them at the time of the survey. Resident #11 and Resident #13 had requested double diapering. As to these residents, Petitioner failed to prove any failure to promote care to maintain their dignity.
Resident #12 had not consented to double diapering.
However, according to her minimum data set completed about three
weeks before the survey, Resident #12 suffers from dementia, has a poor memory, and is completely incontinent of bladder and bowel. Absent additional evidence of Resident #12's response to the double diapering, it is impossible, on this record, to infer sufficient insight on her part as to justify a finding of loss of dignity in this otherwise-benign practice, as evidenced by the fact that some residents request double diapering. Although Respondent had reminded staff not to double diaper residents who had not requested such extra protection, language barriers likely contributed to the unrequested double diapering of Resident #12.
As to Resident #12, Petitioner has failed to prove any failure to promote care to maintain her dignity.
At the time of the incident described below, Resident #14 was 49 years old. She had been admitted to Hallandale on November 22, 2000, with diagnoses of acute respiratory failure, status--post subarachnoid hemorrhage, status--post cerebral aneurysm, seizure disorder, and percutaneous endoscopic gastrostomy tube and tracheostomy placement.
Respondent was aware that Resident #14 repeatedly pulled at both tubes, without which she would expire. Respondent was aware that Resident #14 was agitated and restless. On January 16, 2001, Resident #14 succeeded in pulling out her tracheotomy tube, and, after onsite
resuscitation, she was transported by ambulance to the hospital for treatment.
Three days later, Resident #14 was readmitted to Hallandale with wrist restraints, pursuant to her physician's order. The order required that Respondent's staff check the restraints every 30 minutes to assure that they would effectively prevent Resident #14 from pulling out her tubes. The order required that Respondent's staff release the wrist restraints every two hours for ten minutes. Five hours after her readmission to Hallandale, Resident #14 was found with her wrists unrestrained, her tracheotomy tube removed, and not breathing. She was in a coma from which she never recovered, and Resident #14 later died. Petitioner cited Respondent for a class II deficiency in connection with this incident.
On April 25, 2001, one of Petitioner's surveyors conducted a complaint-investigation survey concerning Respondent's care of Resident #14 and concluded that Respondent had failed to provide Resident #14 with adequate supervision. In its proposed recommended order, Respondent concedes that it was unable to demonstrate that the citation from this incident had been improperly issued.
Petitioner has alleged that Respondent never developed a risk management plan or trained its staff in the management and prevention of risk. Although Petitioner alleges in the
alternative that Respondent did not implement a presumably developed risk management plan, the amended Administrative Complaint cites only Section 400.147(1)(e), Florida Statutes, which is not the subsection covering implementation, but is the subsection covering the development of a plan and the training of staff in risk management and prevention.
Although Respondent lacked a written risk management plan at the time of the survey, it maintained a program that included the reporting of all adverse incidents, investigation of all adverse incidents, development of plans to avoid the repetition of adverse incidents, and training of staff on avoiding adverse incidents. Additionally, Respondent conducted monthly quality assurance meetings and required the weekly assessment of wounds.
Undoubtedly, Respondent's care for Resident #14 was gravely deficient, and its care for Resident #2 was seriously deficient. Resident #2 was not the only resident who was the victim of poor recordkeeping, although he seems to have been the only resident who was the victim of materially false recordkeeping. Respondent's care for Resident #1 was marginally adequate. Notwithstanding obvious shortcomings in staff competence, the record in this case does not portray a facility replete with care problems--from which an inference of risk management deficiencies would be easier. Respondent's
nontreatment of Resident #14 and mistreatment of Resident #2 seem isolated, Respondent's treatment of Resident #1--although not without its flaws--reflects a dogged persistence to obtain competent care for her wound, and Respondent's handling of the other residents is either adequate or not materially inadequate. Petitioner has failed to prove any failure to develop a risk management program or to train staff in risk management and prevention.
Petitioner has sought a $6000 survey fee, based on the existence of a class I deficiency. Ignoring Petitioner's argument that the citation alone of a class I deficiency satisfies the statutory requirement, as discussed in the Conclusions of Law below, it is necessary to consider the status of the matters proved as to Resident #2.
As to Resident #2, Petitioner cited Respondent for an isolated class I deficiency with respect to the following: mistreatment or neglect and a failure to provide services meeting professional standards of quality. The remaining citations were for isolated class II deficiencies.
However, in its proposed recommended order, Petitioner refers to the mistreatment or neglect as a class II deficiency. Assuming that this is a typographical error, it remains necessary to consider all aspects of Respondent's mishandling of
the care of Resident #2 to determine if it constitutes a class I deficiency.
As discussed above, Respondent's mistreatment or neglect of Resident #2 and failure to provide him with services meeting professional standards of quality interfered with his ability to rehabilitate following the amputation of part of his right leg. As such, these deficiencies are class II deficiencies. These deficiencies were not so grave as to meet the class I criterion of causing, or likely to cause, serious injury, harm, impairment, or death.
Petitioner has failed to prove that Respondent committed a class I deficiency during the December 2001 survey and thus has failed to prove that Respondent is liable for the
$6000 statutory survey fee.
The amount of the fines is based on the classification of the deficiencies and whether they are isolated or widespread. As already noted, the deficiencies of mistreatment or neglect and failure to provide services meeting professional standards of quality are class II deficiencies, not class I deficiencies as alleged. The failure to revise the comprehensive care plan and the failure to provide services in the form of changing urine-soaked sheets and clothes to maintain personal hygiene are also class II deficiencies, as alleged. The care plan relates closely to the other deficiencies concerning the delayed
treatment of the pressure sore, and the failure to alleviate Resident #2's urine-soaked condition compromised his ability to maintain or reach his highest psychosocial wellbeing. As alleged, these deficiencies are isolated because they affect only one resident.
In calculating the amount of fines, it is necessary to treat the mistreatment or neglect and failure to provide services meeting professional standards of quality as a single deficiency because they are proved by the same facts. However, the failure to revise the care plan is a separate deficiency, as is obviously the failure to provide services to maintain personal hygiene. The fine for each isolated class II deficiency is $2500 for a total of $7500. However, the citation six months earlier of a class II deficiency in the failure to supervise Resident #14 requires the doubling of the fine to
$15,000.
On December 11, 2001, Petitioner issued a moratorium on admissions, which Petitioner lifted eight days later. Respondent's mistreatment and neglect of Resident #2 following its recent citation in connection with the death of Resident #14 constitute adequate grounds for Petitioner to have found, at the time of the December 2001 survey, or even a few days later, that the care provided by Hallandale was so inadequate as to present a threat to the health, safety, or welfare of its residents.
Based on the facts then known or presently found in this recommended order, an eight-day admissions moratorium was a prudent action.
Based on the findings of class I and II deficiencies, Petitioner, by letter dated December 14, 2001, imposed upon Respondent a conditional license, effective December 4, 2001. This license expired on December 31, 2001.
Lastly, Petitioner seeks the costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes. Absent evidence of such costs, the Administrative Law Judge shall retain jurisdiction of the case solely for the purpose of entering a supplemental recommended order awarding these costs, if the parties cannot agree to such costs within a reasonable time. The Administrative Law Judge will set a hearing for this purpose on the request of either party.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter. Section 120.57(1), Florida Statutes. (All references to Sections are to Florida Statutes, unless preceded by "CFR." All references to CFR are to Title 42, Code of Federal Regulations. All references to Rules are to the Florida Administrative Code.)
Rule 59A-4.1288 requires Respondent to conform to the requirements of 42 CFR Section 483.
As for Count I, CFR Section 483.13(c) provides in part: "The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents "
As for Count II, CFR Section 483.20(k)(3)(i) provides: "The services provided or arranged by the facility must [m]eet professional standards of quality."
As for Count III, CFR Section 483.25 provides in part: "Each 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."
As for Count IV, CFR Section 483.15(a) provides in part: "The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality."
As for Count V, CFR Section 483.20(k)(2)(ii) and (iii) provides:
A comprehensive care plan must be--
Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in
disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and
Periodically reviewed and revised by a team of qualified persons after each assessment.
As for Count V, Rule 59A-4.109(1) and (2) provides:
Each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of:
Physician's orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential.
A preliminary nursing evaluation with physician's orders for immediate care, completed on admission.
A complete, comprehensive, accurate and reproducible assessment of each resident's functional capacity which is standardized in the facility, and is completed within 14 days of the resident's admission to the facility and every twelve months, thereafter. The assessment shall be:
Reviewed no less than once every 3 months,
Reviewed promptly after a significant change in the resident's physical or mental condition,
Revised as appropriate to assure the continued accuracy of the assessment.
The facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and social well-being. The care plan must be completed
within 7 days after completion of the resident assessment.
As for Count VI, CFR Section 483.25(a)(3) provides:
(a) Activities of daily living. Based on the comprehensive assessment of a resident, the facility must ensure that--
A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
As for Count VII, CFR Section 483.25(c)(1) and (2) provides:
Pressure sores. Based on the comprehensive assessment of a resident, the facility must ensure that--
A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and
A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
As for Count VIII, Section 400.147(1)(e) provides:
Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include:
The development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not
limited to, education and training in risk management and risk prevention for all nonphysician personnel, as follows:
Such education and training of all nonphysician personnel must be part of their initial orientation; and
At least 1 hour of such education and training must be provided annually for all nonphysician personnel of the licensed facility working in clinical areas and providing resident care.
As for Count IX, Section 400.19(3) provides:
The agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class II deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be
$6,000, one-half to be paid at the completion of each survey. The agency may adjust this fine by the change in the Consumer Price Index, based on the 12 months immediately preceding the increase, to cover the cost of the additional surveys. The agency shall verify through subsequent inspection that any deficiency identified during the annual inspection is corrected.
However, the agency may verify the correction of a class III or class IV deficiency unrelated to resident rights or
resident care without reinspecting the facility if adequate written documentation has been received from the facility, which provides assurance that the deficiency has been corrected. The giving or causing to be given of advance notice of such unannounced inspections by an employee of the agency to any unauthorized person shall constitute cause for suspension of not fewer than 5 working days according to the provisions of chapter 110.
As for Count X, CFR Section 483.25(h)(2) provides:
(h) Accidents. The facility must ensure that--
Each resident receives adequate supervision and assistance devices to prevent accidents.
As for Count X, Rule 59A-4.106(1)-(3) provides:
Admission, retention, transfer, and discharge policies:
Each resident will receive, at the time of admission and as changes are being made and upon request, in a language the resident or his representative understands:
A copy of the residents' bill of rights conforming to the requirements in Section 400.022, F.S.;
A copy of the facility's admission and discharge policies; and
Information regarding advance directives.
Each resident admitted to the facility shall have a contract in accordance with Section 400.151, F.S., which covers:
A list of services and supplies, complete with a list of standard charges, available to the resident, but not covered by the facility's per diem or by Title XVIII and Title XIX of the Social Security Act and the bed reservation and refund policies of the facility.
When a resident is in a facility offering continuing care, and is transferred from independent living or assisted living to the nursing home section, a new contract need not be executed; an addendum shall be attached to describe any additional services, supplies or costs not included in the most recent contract that is in effect.
No resident who is suffering from a communicable disease shall be admitted or retained unless the medical director or attending physician certifies that adequate or appropriate isolation measures are available to control transmission of the disease.
Residents may not be retained in the facility who require services beyond those for which the facility is licensed or has the functional ability to provide as determined by the Medical Director and the Director of Nursing in consultation with the facility administrator.
Residents shall be assigned to a bedroom area and shall not be assigned bedroom space in common areas except in an emergency. Emergencies shall be documented and shall be for a limited, specified period of time.
All resident transfers and discharges shall be in accordance with the facility's policies and procedures, provisions of Sections 400.022 and 400.0255, F.S., this rule, and other applicable state and federal laws and will include notices provided to residents which are incorporated by reference by using AHCA Form 3120-0002, 3120-0002A, Revised May 2001, "Nursing Home Transfer and Discharge Notice," and 3120- 0003, Revised May 2001, "Fair Hearing Request For Transfer or Discharge From a Nursing Home," and 3120-0004, Revised May 2001, "Long-Term Care Ombudsman Council Request for Review of Nursing Home Discharge and Transfer." These forms may be obtained from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive, MS 33, Tallahassee, FL 32308.
The Department of Children and Family Services will assist in the arrangement for appropriate continued care, when requested.
Each nursing home facility shall adopt, implement, and maintain written policies and procedures governing all services provided in the facility.
All policies and procedures shall be reviewed at least annually and revised as needed with input from, at minimum, the facility Administrator, Medical Director, and Director of Nursing.
As for Count XI, Section 400.23(8)(a)-(c) provides:
The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows:
A class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency,
$12,500 for a patterned deficiency, and
$15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency.
A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency.
A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of
$1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed.
Section 400.121(5)(a) provides: "The agency may impose an immediate moratorium on admissions to any facility when the agency determines that any condition in the facility presents a threat to the health, safety, or welfare of the residents in the facility."
Section 400.121(10) provides: "In addition to any other sanction imposed under this part, in any final order that imposes sanctions, the agency may assess costs related to the investigation and prosecution of the case. Payment of agency costs shall be deposited into the Health Care Trust Fund."
Section 400.23(7) provides:
The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home.
A standard licensure status means that a facility has no class I or class II deficiencies and has corrected all class III deficiencies within the time established by the agency.
A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class II, or class III deficiencies at the time of the followup survey, a standard licensure status may be assigned.
Section 400.121(9) provides: "Notwithstanding any other provision of law to the contrary, agency action in an administrative proceeding under this section may be overcome by the licensee upon a showing by a preponderance of the evidence to the contrary." The reference to "this section" is to Section
400.121. Because Section 400.121(9) imposes the burden of proof on the licensee--here, Respondent--it is necessary to delineate
the issues as to which Respondent, by statute, bears the burden of proof.
By referring to proceedings "under this section," Section 400.121(9) allocates the burden of proof to Respondent only concerning those issues governed by Section 400.121. For the most part, Section 400.121 does not govern this case. As noted in Section 400.121, the section authorizes Petitioner to revoke or suspend a license or impose a continuing fine of $500 per violation per day in certain events, such as a pattern of "defiance," failure to pay fines, exclusion from the Medicare or Medicaid program, or certain adverse regulatory actions. Section 400.121 also authorizes Petitioner to revoke a license if the operator has suffered certain findings, such as two moratoria within 30 months or conditional licensure for at least
30 consecutive days. Section 400.121 also authorizes the immediate suspension or revocation of a license if Petitioner determines that a facility poses a danger to the health, safety, or welfare of its residents. None of these provisions applies to the present case because Petitioner is not seeking these remedies and Respondent did not commit the acts or omissions warranting these remedies, assuming that the danger required to be proved for immediate suspension or revocation is greater than the danger required to be shown for an eight-day admissions moratorium.
The two situations described in Section 400.121 that apply to the present case are the imposition of the moratorium and costs. In an abundance of caution, the Administrative Law Judge has found that Petitioner would prevail on these issues even if it bore the burden of proof by clear and convincing evidence; of course, Petitioner would also prevail on these issues if Respondent bore the burden of proof by a preponderance of the evidence.
Section 400.121 does not govern the remaining issues.
Most prominently, the alleged deficiencies are governed by Section 400.23, which classifies these deficiencies into classes and types and sets fines accordingly. As to these issues, Petitioner bears the burden of proof, and it must prove the material allegations by clear and convincing evidence.
Department of Banking and Finance v. Osborne Stern and Company, Inc., 670 So. 2d 932 (Fla. 1996) and Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987). As to those matters concerning Resident #2 on which it has prevailed, Petitioner has proved the required elements of each deficiency by clear and convincing evidence.
As to the remaining matters on which Petitioner has not prevailed, the same result would follow if Petitioner were only required to prove the required elements of each alleged deficiency by a preponderance of the evidence.
The existence of the three separate, isolated class II deficiencies concerning Resident #2 justifies the imposition of the conditional license and the imposition of a total of
$7500 in fines. The existence of a class II deficiency in the preceding inspection or complaint investigation justifies the doubling of the fines to $15,000. And the nature of the proved deficiencies, especially when considered in conjunction with the recent deficiency that resulted in the death of Resident #14, justified the imposition of an eight-day admissions moratorium.
However, the failure to prove that the deficiencies concerning Resident #2 were class I deficiencies precludes the imposition of the $6000 survey fee. Petitioner's argument that the mere citation of a class I deficiency, even if unproved, justifies the imposition of the survey fee under the statute unnecessarily raises due process issues with the statute. The more reasonable reading of the statute is that, if a licensee timely contests a cited class I deficiency, it remains a tentative or proposed class I deficiency, on which Petitioner may not base the imposition of a survey fee, unless and until Petitioner proves that the deficiency is a class I deficiency.
It is
RECOMMENDED that the Agency for Health Care Administration enter a final order finding Respondent guilty of three separate,
isolated class II deficiencies with respect to Resident #2, imposing a fine of $7500 for these violations, doubling the fine to $15,000 due to the existence of a class II deficiency in the preceding complaint investigation, imposing a conditional license, sustaining the already-lifted admissions moratorium, and imposing costs for the investigation and prosecution (if the parties can agree on an amount; if not, remanding the issue of costs to the Administrative Law Judge for the issuance of a supplemental recommended order on the amount of these costs).
It is further
RECOMMENDED that the Agency for Health Care Administration enter a final order dismissing the remainder of the amended Administrative Complaint.
DONE AND ENTERED this 11th day of December, 2002, in Tallahassee, Leon County, Florida.
ROBERT E. MEALE
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675 SUNCOM 278-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 11th day of December, 2002.
COPIES FURNISHED:
Lealand McCharen, Agency Clerk
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop No. 3 Tallahassee, Florida 32308
Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive
Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
Lori C. Desnick
Agency for Health Care Administration 2727 Mahan Drive, Suite 3431
Fort Knox Building No. 3 Tallahassee, Florida 32308
Jay Adams
Jay Adams, P.A.
Broad and Cassel
215 South Monroe Street, Suite 400 Post Office Drawer 11300 Tallahassee, Florida 32302
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions within
15 days from the date of this recommended order. Any exceptions to this recommended order must be filed with the agency that will issue the final order in this case.
| Issue Date | Document | Summary |
|---|---|---|
| Apr. 08, 2003 | Agency Final Order | |
| Dec. 11, 2002 | Recommended Order | $7500 fine (doubled due to Class II violation within prior year) for three isolated Class II deficiencies; costs; downgrade of license to conditional; and sustaining of eight-day admissions moratorium. |
