STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION A Y CLERK STATE OF FLORIDA, AGENCY FOR 208 HAY th A & 5§ HEALTH CARE ADMINISTRATION, Petitioner, DOAH Case No. 08-5944 AHCA Case No.: 2008012501 vs. RENDITION NO.: AHCA-09-f¢¢~ -S-OLC GRACEVILLE MEDICAL CLINIC, Respondent. / FINAL ORDER Having reviewed the Notice of Intent to Deem Application Incomplete and Withdrawn from Further Review (NOI), dated November 4, 2008, attached hereto and incorporated herein (Ex. 1), and having received the Respondent's response to the Election of Rights and NOI (Ex. 2) and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Settlement Agreement (Ex. 3) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows: 1. On December 8, 2008, the Agency and the Respondent entered into a Motion to Remand Case back to the Agency (Ex. 4). 2. On December 16, 2008, the Administrative Law Judge entered an Order Relinquishing Jurisdiction and Closing File (Ex. 5). ORDERED: 1. The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. 2. Respondent shall pay an administrative fine in the amount of $50.00. The administrative fine is due and payable within thirty (30) days of the date of rendition of this Order. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to the AHCA case number, should be sent directly to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, MS# 14 Tallahassee, Florida 32308 4. Unpaid fines pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available. 5. Respondent’s petition for formal administrative proceedings is hereby dismissed. 6. Each party shall bear its own costs and attorney’s fees. 7. The above-styled case is hereby closed. DONE and ORDERED this _42-day of yNacy , 2009, in Tallahassee, Leon County, Florida. Holly Benson) Secretary Agency for Hgalth Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. | Copies furnished to: Jimmy Rigsby Lorraine M. Novak Administrator Assistant General Counsel Graceville Medical Center Agency for Health Care 5429 College Drive Administration Graceville, Florida 32440 2727 Mahan Drive, Bldg #3, MS #3 (U. S. Mail) Tallahassee, Florida 32308 (Interoffice Mail) Finance & Accounting Jan Mills Agency for Health Care Agency for Health Care Administration Administration Revenue Management Unit 2727 Mahan Drive, Bldg #3, MS #3 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 ; Tallahassee, Florida 32308 (Interoffice Mail) | (Interoffice Mail) Janet Crain, BSM, BSMT, MT(ASCP) Diane Cleavinger Health Services and Facilities Administrative Law Judge Consultant Division of Administrative Hearings Agency for Health Care The DeSoto Building Administration 1230 Apalachee Parkway Laboratory Unit Tallahassee, Florida 32399-3060 2727 Mahan Drive, MS 32 (U. S. Mail) Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the LY day of Ley , 2009. Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: CHARLIE CRIST HOLLY BENSON GOVERNOR ; SECRETARY NOVEMBER 4, 2008 CERTIFIED MAIL / RETURN RECEIPT REQUESTED THOMAS BIRDWELL MD GRACEVILLE MEDICAL CLINIC LICENSE NUMBER: 800021965 $470 COLLEGE DR GRACEVILLE, FL 32440 : CASE #: 2008012501 NOTICE OF INTENT T0 DEEM APPLICATION INCOMPLETE AND WITHDRAWN_FROM FURTHER REVIEW Your application for Clinical Laboratory Licensure is deemed incomplete and withdrawn from further consideration pursuant to Section 408.806(3)(b), Florida Statutes. Section 408.806(3)(b), F.S. contains the following language: Requested information omitted from an application for licensure, license renewal, or change of ownership, other than an inspection, must be filed with the agency within 21 days after the agency's request for omitted information or the application shall be deemed incomplete and shall be withdrawn from further consideration and the fees shall be forfeited. You were notified by correspondence dated October 01, 2008 to provide further information addressing identified apparent errors or omissions within twenty-one days from the receipt of the Agency’s correspondence. Our records indicate you received this correspondence by certified mail on October 03, 2008. : As the following information was received within required time frames but incomplete, your application is deemed incomplete and withdrawn from further consideration: 1. Properly completed fingerprint card for Background Screening for Laboratory Director (card was not signed) EXPLANATION OF RIGHTS Pursuant to Section 120.569, F.S., you have the right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. Visit AHCA online at 2727 Mahan Drive, MS# 32 http://ahca.myflorida.com Tallahassee, Florida 32308 EXHIBIT : ; SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS. Agency for Health Car€'A By: Karen Rivera, Manager Laboratory Unit ce: Agency Clerk, Mail Stop 3 : Legal Intake Unit, Mail Stop 3 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: GRACEVILLE MEDICAL CLINIC CASE NO: 2008012501 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed Notice of Intent to Deem Incomplete and Withdraw from Further Review of the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Deem Incomplete and Withdraw from Further Review or some other notice of intended action by AHCA. An Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Deem Incomplete and Withdraw from Further Review or any other proposed action by AHCA. ‘ If an Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action, you will have given up . your right to contest the Agency’s proposed action and a final order will be issued. (Please reply using this Election of Rights form unless you, your attorney or your representative prefer to reply according to Chapter. 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) > Please return your ELECTION OF RIGHTS to: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS: OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review, or other notice of intended action by AHCA and I waive my right to object and have a hearing. | understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the proposed penalty, fine or action. OPTION TWO (2) | I admit to the allegations of facts contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review, or other proposed action by AHCA, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. EXHIBIT i 3 OPTION THREE ot I dispute the allegations of fact contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review or other proposed action by AHCA, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Subsection 120.57(1), Florida Statutes. It must be received by the Agency Clerk-at the address above within 21 days of receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, which requires that it contain: 1. The name and address of each agency affected and. each agency’s file or identification number, if known; 2. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any; 3. An explanation of how your substantial interests will be affected by the Agency’s proposed action; 4. A statement of when and how you received notice of the Agency’s proposed action; 5. A statement of all disputed issues of material fact. If there are none, you must state that there are none; 6. A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency’s proposed action; 7. A statement of the specific rules or. statutes you claim require reversal or modification of the Agency’s proposed action; and 8. A statement of the relief you are seeking, stating exactly what action you wish the Agency to take with respect to its proposed action. (Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees.) License type: CLINICAL LABORATORY License number: 800021965 Licensée Name: GRACEVILLE MEDICAL CLINIC Contact person: Dude, Fuck n, Fidmin. Ase . Name ~ Title . . ; Address: SURG Cathe Keeye “De Voree CracegWe, iF ion ABYYUO Street and number City Zip Code Telephone No. ¥50-7ip2-Ud3 L_ Fax No 450-263-3312 Email (optional) yausii a@pon handle v7 .com I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. ; a | \ Se weiss | Aes Date: WM OF Print Name: | Gom A v tagby 4. Title: fd wen 8 ¥ cotor i) .. . : CAMPBELLTON-GRACEVILLE HOSPITAL 5429 COLLEGE DRIVE GRACEVILLE, FLORIDA 32440 TELEPHONE (850) 263-4431 FAX (850) 263-3312 November 11, 2008 BE CEIVED Agency for Health Care Administration AGENCY CLERK Attn: Agency Clerk \ £ 2008 2727 Mahan Drive, Mail Stop #3 - NOV £4 a ate Tallahassee, FL 32308 Agency tor Healt Care Acministvationt Re: Graceville Medical Clinic — License 4800021965 Denial of Clinical Laboratory License Renewal Application Case# 2008012501 This letter is written is in response to the NOTICE OF INTENT TO DEEM APPLICATION INCOMPLETE AND WITHDRAWN FROM FURTHER REVIEW, which we received on November 6, 2008. Upon reviewing the reason the application was denied the only action available was to choose Option 3 and request an Administrative Hearing. However, in an attempt to resolve this issue my Assistant did contact Mrs. Crane at the Laboratory License Unit to find out if there was anything the hospital could do to avoid the Administrative Hearing, as the reason for denial was based on the determination that the Level 2 Background Screening Card submitted by the Laboratory Director, Dr. Birdwell was not signed, when in actuality it was. We were informed that because the matter had already been turned over to the legal department we would have to proceed with the request for an Administrative Hearing. : So therefore, in compliance with the requirements of Rule 28-106.201, Florida Administrative Code, we submit the following information. 1. The name and address of each agency affected and each agency’s file or identification number, if known; Graceville Medical Clinic Campbellton-Graceville Hospital 5470 College Drive Owner of Graceville Medical Clinic Graceville, FL. 32440 5429 College Drive License# 800021965 Graceville, FL 32440 Case# 2008012501 2. The name, address, and telephone number, of the person requesting the administrative hearing and the mame, address, and telephone number of the representative or lawyer, if any; Jimmy Rigsby, Administrator Frank Baker, PA Campbellton-Graceville Hospital Baker, Mercer and Young 5429 College Drive 4431 Lafayette Street Graceville, FL 32440 Marianna, FL 32446 (850) 263-4431 ext. 2012 (850) 526-3633 An explanation of how our substantial interests will be affected by the Agency’s proposed action; If the hospital’s clinic Graceville Medical Clinic is denied their Clinical Laboratory License they will be unable to effectively meet all the needs of the patients. Additionally, it is the goal of the hospital to convert Graceville Medical Clinic to a Rural Health Clinic to maximize profitability and the Clinical Laboratory License is a requirement of an RHC. In the long run failure to convert the Graceville Family Medicine clinic would result in lack of profitability and force to hospital to consider closing the clinic. A statement of when and how we received notice of the Agency’s proposed action; The hospital received the NOTICE OF INTENT TO DEEM APPLICATION INCOMPLETE AND WITHDRAWN FOR FURTHER REVIEW on November 6, 2008 by USPS Certified Mail. The letter from the Agency was dated November 4, 2008. A statement of all disputed issues of material fact; In the letter received from the Agency it states the information was received within the required time frame but was deemed incomplete because the fingerprint card for Background Screening for the Laboratory Director was not signed. The fingerprint card submitted by the laboratory Director (Thomas Birdwell, M.D.) was in fact signed, though I concede the signature is not legible and appears to be a squiggly line. However this is the way Dr. Birdwell signs his name as in evidenced in the renewal application sent to the Laboratory Unit wherein Dr. Birdwell’s signature is notarized. - A concise statement ef the ultimate facts alleged, including the specific facts we contend warrant reversal of modification of the Agency’s proposed action; As previously stated the hospital request the administrative hearing based on the notice received from the Agency wherein it states the information was received within the required time frames but was deemed incomplete because the fingerprint card for Background Screening for the Laboratory Director was not signed. The hospital contends the fingerprint card submitted by the Laboratory Director (Thomas Birdwell, M.D.) was in fact signed, though the signature is not legible. However, this is the way Dr. Birdwell signs his name as in evidenced in the renewal application sent to the Laboratory Unit wherein Dr. Birdwell’s signature is notarized. Iam enclosing for your review a copy of the fingerprint card (which was sent back to us by the Agency) and a copy of the page from the Clinical Laboratory renewal application containing Dr. Birdwell’s notarized signature. Based on these facts the hospital is requesting the Agency reverse it’s decision to deem the Clinical Laboratory Renewal Application incomplete. 7. A statement of the specific rules or statutes we claim require reversal or modification of the Agency’s proposed action; The hospital is requesting that the Agency’s decision to deem the Clinical Laboratory Licensure renewal application incomplete and withdrawn from further consideration, pursuant Section 408.806(3)(b), Florida Statutes, be reversed based on the information submitted in this request. 8. A statement of the relief we are seeking, stating exactly what action we wish the Agency to take with respect to its proposed action; As previously indicated the action taken by the Agency could potentially cause profitability issues for Graceville Medical Clinic and affect the level of care provided to the patients of the clinic. Because of this and the fact that the background screening card submitted by the Laboratory Director, Dr. Birdwell was in fact signed the hospital is requesting the Agency reverse its decision to deem the Clinical Laboratory Application incomplete. In the interim the hospital has resubmitted a fingerprint card for Background Screening of the Laboratory Director in an effort to expedite the process should the Agency grant the hospital’s request to reverse its decision concerning this matter. If agreeable to the Agency the hospital request Mediation available under Section 120.573, Florida Statutes to resolve this matter. . Thank you for your consideration, gens evan Jimmy Rigsby Administrator Enclosed: Copy of fingerprint card submitted to the Agency Copy of a page from the application with Dr. Birdwell’s notarized signature Copy of Notice received from Agency. Lia MED RECURS ree oo AGENCY + EALTH CARE ADMIN BSQ 921 8158 Pe STATE OF FLORIDA AGENCY FOR FIEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ve. Case No.: 2008012501 GRACEVILLE MEDICAL CLINIC, Respondent, / SET (LEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”), through Its undersigned representatives, and Respondent, Graceville Medical Clinic (hereinafter “Respondent’), pursuant to Section 120.57(4), Florida Ste tutes, each Individually, a “party,” collectively as “parties,” hereby enter into this Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, the Respondent is a clinicat laboratory licensed pursuant to Chapter 483, Part I, Florila Statutes and the Chapter 59A-7, Florida Administrative Code; and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over licensure of Respondent; and EXHIBIT ues cuud YO. 4 42059420 Lan FIED RELURDS PAGE 64 FER-23-2009 13°25 AGENCY FEALTH CARE @DMIN 956 921 9158 PU WHEREAS, the Agency served the Respondent with a Notice of Intent to Withdraw Application, notifyiig the Respondent of its intent to withdraw its application from further review; and WHEREAS, the partie; have agreed that a fair, efficient, and cost effective resolution of this di:pute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the partie; stipulate to the adequacy of considerations exchanged; and WHEREAS, the parties have negotiated in good faith and agreed that the best Interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending t> be legally bound, agree as follows: 1. All recitais are true and correct and are expressly incorporated herein. 2. Both parties agree: that the “whereas” clauses incorporated herein are binding findings of the par‘les. 3. Upon full executlo 1 of this Agreement, Respondent agrees to waive any and al! proceedings and