STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

Fit.ED

AHCA

AG EN C Y C LERK

zoo OCT 13 A IQ: 21

v.

HELPING HANDS FOUNDATION OF HAVANA,

Respondent.

----------------'

FINAL ORDER

Fraes Nos. 2008013980

2008013874

2009004203

2009003498

RENDITION NO.: AHCA-09- \ c:o2.. -5-OLC

Having reviewed Administrative Complaint for Case No. 2008013980, dated April 10, 2009 (Ex. 1); Administrative Complaint for Case No. 2008013874, dated April 10, 2009 (Ex. 2); Administrative Complaint for Case No. 2009004203, dated July 16, 2009 (Ex. 3); and Notice of Intent to Deny for Case No. 2009003498, dated March 20, 2009 (Ex. 4); attached hereto and incorporated herein, and all other matters of record, the Agency for Health Care Administration ("Agency") has entered into a Settlement Agreement (Ex. 5) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows:

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. The Respondent shall pay an administrative fine in the amount of ten thousand, five hundred dollars ($10,500.00) and a survey fee in the amount of five hundred dollars ($500.00) for a total of eleven thousand dollars ($11,000.00). The fine and the survey fee are due and payable within sixty (60) days of the rendition of this order.

   
   

   1

   Filed October 13, 2009 4:41 PM Division of Administrative Hearings.

   
   

   
   

3. If the Petitioner is cited for a Class I or Class II deficiency within one year of the date of the final order executing this settlement agreement, then the full amount of the fines sought in the aforementioned administrative complaints will become due.

4. The Agency agrees that it will not impose any further penalty against Petitioner as a result of the surveys conducted on August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008. However, no agreement made herein shall preclude the Agency from imposing a penalty against Petitioner for any deficiency/violation of a statute or rule identified in a future survey of Petitioner, which constitutes a cumulative fine or uncorrected deficiency from the surveys conducted on August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008. The deficiencies from the August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008 surveys will be deemed proved for such future actions. Furthermore, no agreement made herein shall preclude the Agency from using the deficiencies from the August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008 surveys in any decision regarding an application(s) for an assisted living facility license, an extended congregate care license, a limited nursing services license, or a limited mental health license.

1. The Notice of Intent to Deny is deemed superseded and the Agency shall begin processing the Petitioner's application.

2. Checks should be made payable to the "Agency for Health Care Administration." The check, along with a reference to this 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

   
   

3. Unpaid fines pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available.

4. The petitions for formal administrative proceedings are hereby dismissed.

   
   

5. Each party shall bear its own costs and attorney's fees.

   
   

6. The above-styled cases are hereby closed.

DONE and ORDERED this _i!!_ day of all,p/.{,< , 2009, in Tallahassee, Leon County, Florida.

Holly Benson, Secretary

Agency for Health 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:

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 f f:y of

Agency for Health Care Administration 2727 Mahan Drive, Building #3

Tallahassee, Florida 32308-5403

(850) 922-5873

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

Petitioner, ARCA No. 2008013980

vs.

HELPING HANDS FOUNDATION OF HAVANA,

Respondent.

---------------------'/

ADMINISTRATIVE COMPLAINT

COMES NOW the Agency for Health Care Administration (hereinafter "Agency"), by and through undersigned counsel, and files this administrative complaint against HELPING HANDS FOUNDATION OF HAVANA, (hereinafter "Facility" or "Respondent"), pursuant to 120.569 and 120.57, Fla. Stat. (2008).

NATURE OF THE ACTION

1. This is an action to impose an administrative fine in the _amount of eight thousand dollars ($8,000.00) based upon Respondent being cited for two uncorrected Class IT deficiencies (Counts I, III) and two uncorrected Class III deficiencies (Counts II, IV), pursuant to 429.19(b)(c) Fla. Stat.

   JURISDICTION AND VENUE

   
   

2. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 429, Part I, Florida Statutes (2008).

3. Venue lies pursuant to Fla. Admin. Code R. 28-106.207.

   
   

   EXHIBIT

   i ./. _

   
   

   PARTIES

   
   

4. The Agency is the regulatory authority responsible for the licensure of assisted living facilities and the enforcement of all applicable state regulations, statutes and rules, governing assisted living facilities pursuant to Chapter 429, Part I, Chapter 408, Part II, Florida Statutes (2008), and Rule 58A-5, Florida Administrative Code.

5. Respondent operates an assisted living facility located at 186 China Berry Lane, Havana, Florida having been issued license number 7500. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes.

   COUNT!

   
   

   Respondent's facility failed to conduct 2 resident elopement drills each year.

   
   

6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

7. The regulatory provisions of the Florida Law that are pertinent to this alleged violation read as follows:

58A-5.0182(8)(c) Resident Care Standards

(8) ELOPEMENT STANDARDS.

(c) Facility Resident Elopement Drills. The facility shall conduct resident elopement drills pursuant to Sections 429.41(1)(a)3 and 429.41(1)(1), F.S.

429.41(1)(a)3 Rules Establishing Standards

3. Resident elopement requirements.--Facilities are required to conduct a minimum of two resident elopement prevention and response drills per year. All administrators and direct care staff must participate in the drills which shall include a review of procedures to address resident elopement. Facilities must document the implementation of the drills and ensure that the drills are conducted in a manner consistent with the facility's resident elopement policies and procedures.

1. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

   
   

2. Based on record review and administrator interview, the facility failed to conduct 2 resident elopement drills each year. The findings include:

   1. A review of the facility's elopement drills revealed one was completed 3/11/06 and one was completed on 5/12/08. There were no other elopement drills completed.

      
      

3. That the failure to conduct 2 resident elopement drills each year is in violation of

   
   

   law.

   
   

4. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.41 (l)(a) 3 and 58A-5.0182(8)(c), F.A.C.

5. That the Agency provided a mandatory correction date of September 21, 2008.

   
   

6. That on or about November 3, 2008, the Agency conducted a second follow up biennial licensure survey of the facility and found that the violation was uncorrected. The findings include:

   1. an interview was conducted with the Administrator on 11/3/08 at 10:45

      A.M. which revealed that no other elopement drills have been done.

      
      

7. That the Agency determined that this deficient practice directly threaten the physical or emotional health, safety, or security of the facility residents and cited Respondent for an uncorrected State Class II deficiency, in accordance with 429.19(2)(b), Fla. Stat. (2008).

   WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected State Class II violation in the amount of one thousand dollars ($1,000.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(b) Florida Statutes (2008).

   COUNT II

   
   

   Respondent's facility failed to ensure the Administrator participated in 12 hours of continuing education in topics related to assisted living every 2 years.

   
   

8. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

   
   

   
   

9. The regulatory provisions of law that are pertinent to this alleged violation read as follows:

   58A-5.0191(1)(c) Staff Training Requirements and Competency Test

   (1) ASSISTED LNING FACILITY CORE TRAINING REQUIREMENTS AND COMPETENCY TEST.

   (c) Administrators and managers shall participate in 12 hours of continuing education in topics related to assisted living every 2 years as provided under Section 429.52, F.S.

   
   

   429.52(4) Staff Training and Educational Programs; Core Educational Requirement

   (4) Administrators are required to participate in continuing education for a minimum of 12 contact hours every 2 years.

   
   

10. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

11. Based on record review and interview the facility failed to ensure the Administrator participated in 12 hours of continuing education in topics related to assisted living every 2 years. The findings include:

    1. A record review of the administrator's file revealed that 12 hours of continuing education in topics related to assisted living every 2 years was not done. There was evidence of training in long term care MDS/RAPS but this is not related to assisted living continuing education.

       
       

12. That the failure to ensure the Administrator participated in 12 hours of continuing education in topics related to assisted living every 2 years is in violation of law.

13. That the Agency cited Respondent with a Class III deficiency and provided a mandatory correction date of September 21, 2008.

14. That on or about November 3, 2008, the Agency conducted a follow up survey of the facility and found that the violation was uncorrected. The findings include·:

    1. An interview with the administrator on 11/3/08 at 10:45 a.m. revealed that she had not completed 12 hours of continuing education in topics specifically related to assisted living.

       
       

15. That the Agency determined that this deficient practice was related to the care of

    
    

    
    

    the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected State Class III deficiency.

    WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected isolated Class III violation in the amount of one thousand dollars ($1,000.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

    COUNT III

    
    

    Respondent's facility failed to ensure each employee had a background screening for 1 of 3 personnel reviewed (#3).

    
    

16. The Agency re-alleges and incorporates paragraphs one (I) through five (5) as if fully set forth herein.

17. The regulatory provisions of law that are pertinent to this alleged violation read as follows:

58A-5.019(3)(a) Staffing Standards

(3) BACKGROUND SCREENING.

1. All staff, who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S., and meet the screening standards of Section 435.03, F.S. A packet containing background screening forms and instructions may be obtained from the Agency Background Screening Unit, 2727 Mahan Drive, Tallahassee, FL 32308; telephone (850)410-3400. Within ten (10) days of an individual's employment, the facility shall submit the following to the Agency Background Screening Unit:

   1. A completed Level 1 Criminal History Request, AHCA Form 3110-0002, July 2005, which is incorporated by reference and may be obtained in the screening packet referenced in paragraph (3)(a) of this rule; and

   2. A check to cover the cost of screening.

2. The results of employee screening conducted by the agency shall be maintained in the employee's personnel file.

3. Staff with the following documentation in their personnel records shall be considered to have met the required screening requirement:

   1. A copy of their current professional license, proof that a criminal history screening has been conducted, and an affidavit of current compliance with Section 435.03, F.S.;

   2. Proof of continuous employment in an occupation which requires Level 1 screening without a break in employment that exceeds 180 days, and proof that a criminal history screening has been conducted within the previous two (2) years; or

      
      

      5

      
      

   3. Proof of employment with a corporation or business entity or related entity that owns, operates, or manages more than one facility or agency licensed under Chapter 400, F.S., that conducted Level 1 screening as a condition of initial or continued employment.

429.174 Background Screening; Exemptions.--The Owner or Administrator of an Assisted Living must conduct level 1 background screening, as set forth in chapter 435, on all employees hired on or after October 1, 1998, who perform personal services as defined in s. 429.02(16). The agency may exempt an individual from employment disqualification as set forth in chapter 435. Such persons shall be considered as having met this requirement if:

(2) The person required to be screened has been continuously employed in the same type of occupation for which the person is seeking employment without a breach in service which exceeds 180 days, and proof of compiiance with the level 1 screening requirement which is no more than 2 years old is provided. Proof of compliance shall be provided directly from one employer or contractor to another, and not from the person screened. Upon request, a copy of screening results shall be provided by the employer retaining documentation of the screening to the person screened.

1. That on October 1, 2008 the Agency conducted a survey of the Respondent facility.

2. Based on record review and interview the facility failed to ensure each employee had a background screening for 1 of 5 personnel reviewed (#3) the findings include:

   1. During the survey on 10/1/08 at 10:15 A.M. requested the personnel file for the employee #3. The Administrator stated was unable to locate the personnel file. The Administrator was unsure of the employees date of hire.

   2. The employee was observed in the kitchen at 11:30 A.M. assisting with the preparation of lunch. The employee stated serves meals and assists the residents with personal care.

   3. After the completion of the survey the manager delivered the personnel file to the AHCA office on 10/1/08. The employee file did not contain a background screening.

   4. A review of the information provided revealed conflicting dates in August and/or September as the date of hire. The majority of the information provided contained the date of 9/8/08 or 8/10/08 and 9/8/08 was determined to be the date of hire.

      
      

3. That the failure to comply with background screening requirements is in violation

   
   

   oflaw.

   
   

4. That the Agency cited Respondent with a Class III deficiency and provided a

   
   

   
   

   mandatory correction date of November 1, 2008.

   
   

5. That the Agency conducted a follow up survey on November 3, 2008.

   
   

6. Based on record review and interview the facility failed to ensure each employee had a background screening for 1 of 3 personnel reviewed (#3). The findings include:

   1. The employee file did not contain a background screening.

   2. An interview with the facility administrator on 11/3/08 at 10:45 a.m. revealed that employee #3 has not had a background screen done. The administrator stated that the employee has not been working since the last survey, but when the surveyor requested a copy of the schedule employee #3 was noted to be on the schedule for the entire month of October. The administrator admitted that the employee did actually work, the days she was on the schedule to work, for the month of October.

      
      

7. That the Agency determined that this deficient practice directly threatens the physical or emotional health, safety, or security, of the facility residents and cited Respondent for an uncorrected State Class II deficiency.

   WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected State Class II violation in the amount of five thousand dollars ($5,000.00) against the Respondent, an assisted living facility, pursuant to Chapter 429. l 9(2)(b) Florida Statutes (2008).

   COUNT IV

   
   

   A review of employee #3's personnel file revealed that there was no verification that employee #3 was free from communicable disease.

   
   

8. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

9. The regulatory provisions oflaw that are pertinent to this alleged violation read as follows:

58A-5.024(2)(a) Records

(2) STAFF RECORDS.

1. Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. fu addition, records shall contain the

   
   

   following, as applicable:

   1. Documentation of compliance with all staff training required by Rule 58A- 5.0191, F.A.C.;

   2. Copies of all licenses or certifications for all staff providing services which require licensing or certification;

   3. Documentation of compliance with level 1 background screening for all staff subject to screening requirements as required under Rule 58A-5.019, F.A.C.;

   4. A copy of the job description given to each staff member pursuant to Rule 58A- 5.019, F.A.C., for facilities with a licensed capacity of seventeen (17) or more residents; and

   5. Documentation of facility direct care staff and administrator participation in resident elopement drills pursuant to paragraph 58A-5.0182(8)(c), F.A.C.

      
      

      429.275 Business practice; Personnel Records; Liability Insurance.--The Assisted Living Facility

      (4) The department may by rule clarify terms, establish requirements for financial records, accounting procedures, personnel procedures, insurance coverage, and reporting procedures, and specify documentation as necessary to implement the requirements of this section.

      
      

      1. That on October 1, 2008 the Agency conducted a survey of the Respondent facility.

      2. Based on record review and interview the facility failed to ensure employees personnel files contained verification of freedom from communicable disease for 3 of 5 personnel files reviewed. (#3, 4, 5) the findings include:

         1. During the survey on 10/1/08 at 10:15 A.M. requested the personnel file for the employee #3. The Administrator stated was unable to locate the personnel file. The Administrator was unsure of the employees date of hire.

         2. The employee was observed in the kitchen at 11:30 A.M. assisting with the preparation of lunch. . The employee stated serves meals and assists the residents with personal care.

         3. The manager delivered the employee file to the AHCA office on 10/1/08 after the completion of the survey. The employee file did not contain verification of freedom from communicable disease.

         4. A review of the information provided revealed conflicting dates in August and/or September as the date of hire. The majority of the information provided contained the date of 8/9/08 or 8/10/08 and was determined as the date of hire.

         5. The personnel files for employee #4 and #5 did not contain a statement of freedom from communicable disease including tuberculosis.

         6. An interview with the Administrator on 10/1/08 at 11:05 A.M. stated was

            
            

            
            

            unable to obtain statements of freedom from communicable disease on the new employees because the local Physician did not have the vaccine to administer the PPD for the TB test and refused to sign freedom from communicable disease statements. The Physician stated there were too many diseases to certify someone was free of communicable disease.

            
            

      3. That the failure to ensure employees personnel files contained verification of freedom from communicable disease for 3 of 5 personnel files reviewed. (#3, 4, 5) is in violation oflaw.

      4. Agency cited Respondent for a Class III deficiency and provided a mandatory correction date of November 1, 2008.

      5. That on or about November 3, 2008, the Agency conducted a follow up survey of the facility and found that the violation was uncorrected.

      6. Based on record review and interview the facility failed to ensure employees personnel files contained verification of freedom from communicable disease for 1 of 3 personnel files reviewed. (#3) the findings include:

         1. A review of employee #3's personnel file revealed that there was no verification that employee #3 was free from communicable disease.

         2. An interview was conducted on 11/3/08 at 10:45 a.m. with the facility administrator which revealed that employee #3 is scheduled to see the doctor on 11/5/08 but does not have a statement right now. The Administrator also stated that the employee has not been working since the last survey. The surveyor asked to see a copy of the schedule for the month of October and employee #3 was noted to be on the schedule. The Administrator stated that employee #3, did in fact work the days she was scheduled for the month of October. The last survey was done on October 1, 2008.

            
            

      7. That the Agency determined that this deficient practice was related to the care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected State Class ill deficiency.

      WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected State Class III violation in the amount of one thousand dollars ($1,000.00) against the

      9

      
      

      
      

      Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

      
      

      CLAIM FOR RELIEF

      
      

      WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court:

      1. Make factual and legal findings in favor of the Agency on Counts I through N;

         
         

      2. Recommend administrative fines against Respondent in the amount of $8,000.00 for Counts I through N;

      3. Assess attorney's fees and costs; and

         
         

      4. Grant all other general and equitable relief allowed by law.

      
      

      Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873.

      If you want to hire an attorney, you have the right to be represented by an attorney in this

      
      

      matter.

      
      

      RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY

      OF A FINAL ORDER BY THE AGENCY.

      Respectfully submitted this toay of April, 2009.

      
      

      
      

      Vikram Mohan, Semor Attorney Florida Bar No. 49402

      Agency for Health Care Administration

      
      

      2727 Mahan Drive, Mail Stop #3

      Tallahassee, Florida 32308

      850.922.4347 (office)

      850.921.0158 (fax)

      
      

      
      

      CERTIFICATE OF SERVICE

      
      

      I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by

      U.S. Certified Mail, Return Receipt No. 7000 0520 0024 8388 2478 to: Karen L. Goldsmith, Esq. Jonathan S. Grout, Es,51_; Goldsmith and Grout, P.A. 2160 Park Ave. North, Winter Park, Florida 32789 on April l0 009.

      
      

      Vikram Mohan, Esquire

      Copy furnished to:

      Barbara Alford, FOM

      
      

      STATE OF FLORIDA

      AGENCY FOR HEALTH CARE ADMINISTRATION

      
      

      RE: HELPING HANDS FOUNDATION OF HAVANA CASE NO: 2008013980

      
      

      ELECTION OF RIGHTS

      
      

      This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint.

      
      

      Your 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 Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint.

      
      

      If your 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 by AHCA, you will have given up your right to contest the Agency's proposed action and a final order will be issued.

      
      

      (Please use this form unless yo.u, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.)

      
      

      PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS:

      
      

      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 Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I 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 penalty, fine or action.

      
      

      OPTION TWO (2) I admit to the allegations of facts contained in the Notice of

      Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, 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.

      
      

      0 0

      
      

      
      

      OPTION THREE (3) I dispute the allegations of fact contained in the Notice of

      Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 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 Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain:

      
      

      1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any.

      2. The file number of the proposed action.

      3. A statement of when you received notice of the Agency's proposed action.

      4. A statement of all disputed issues of material fact. If there are none, you must state that there are none.

      
      

      Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees.

      
      

      License type: Assisted Living Facility

      
      

      Licensee Name: License number:

      
      

      Contact person: _

      
      

      	Name	Title
      	City	Zip Code

      Address:

      Street and number

      
      

      Telephone No. Fax No. Email (optional) _

      
      

      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.

      
      

      Sie:ned: Date:

      
      

      Print Name: Title:

      
      

      0 0

      STATE OF FLORIDA

      AGENCY FOR HEALTH CARE ADMINISTRATION

      
      

      STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

      
      

      Petitioner, AHCA No. 2008013874

      
      

      VS.

      
      

      HELPING HANDS FOUNDATION OF HAVANA,

      
      

      Respondent.

      !

      
      

      ADMINISTRATNE COMPLAINT

      
      

      COMES NOW the Agency for Health Care Administration (hereinafter "Agency"), by and through undersigned counsel, and files this administrative complaint against HELPING HANDS FOUNDATION OF HAVANA, (hereinafter "Facility" or "Respondent"), pursuant to § 429, Part I, 408, Part II, 120.569 and 120.57, Fla. Stat. (2008).

      NATURE OF THE ACTION

      
      

      1. This is an action to impose an administrative fine in the amount of five thousand dollars ($5,000.00) based upon one (1) isolated Class II deficiency (Count VII), one (1) pattern Class II deficiency (Count VIII), two (2) uncorrected pattern Class III deficiencies (Counts III, VI), and four (4) uncorrected isolated Class III deficiencies (Counts I, II, N, V), pursuant to 429.19(b)(c) and in addition to impose a survey fee in the amount of five hundred dollars ($500.00) pursuant to 429.19(7) Fla. Stat. (2008).

         JURISDICTION AND VENUE

         
         

      2. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 429, Part I, Florida

         
         

         Statutes (2008).

         
         

         EXHIBIT

         I

         
         

         ' ... 0

         
         

      3. Venue lies in Gadsden County, pursuant to Fla. Ad.min. Code R. 28-106.207.

         
         

         PARTIES

         
         

      4. The Agency is the regulatory authority responsible for the licensure of assisted living facilities and the enforcement of all applicable state regulations, statutes and rules, governing assisted living facilities pursuant to Chapter 408, Part II and Chapter 429, Part I, Florida Statutes (2008), and Rule 58A-5, Florida Administrative Code.

      5. Respondent operates an assisted living facility located at 186 China Berry Lane, Havana, Florida having been issued license number 7500. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes.

         COUNT!

         
         

         Respondent's facility failed to maintain an up-to-date admission and discharge log.

         
         

      6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

      7. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

      58A-5.024(1)(b) F.A.C. Records

      (1) FACILITY RECORDS. Facility records shall include:

2. An up-to-date admission and discharge log listing the names of all residents and each resident's:

   1. Date of admission, the place from which the resident was admitted, and if applicable, a notation the resident was admitted with a stage 2 pressure sore; and

   2. Date of discharge, the reason for discharge, and the identification of the facility to which the resident is discharged or home address, or if the person is deceased, the date of death. Readmission of a resident to the facility after discharge requires a new entry. Discharge of a resident is not required if the facility is holding a bed for a resident who is out of the facility but intends to return pursuant to Rule 58A- 5.025, F.A.C.

8. That on August 21, 2008 the Agency conducted a re-licensure survey of the

0

1. Venue lies in Gadsden County, pursuant to Fla. Ad.min. Code R. 28-106.207.

   
   

   PARTIES

   
   

2. The Agency is the regulatory authority responsible for the licensure of assisted living facilities and the enforcement of all applicable state regulations, statutes and rules, governing assisted living facilities pursuant to Chapter 408, Part II and Chapter 429, Part I, Florida Statutes (2008), and Rule 58A-5, Florida Administrative Code.

3. Respondent operates an assisted living facility located at 186 China Berry Lane, Havana, Florida having been issued license number 7500. Respondent was at all times material

   hereto a licensed :eunieg facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes.

   COUNT!

   
   

   Respondent's facility failed to maintain an up-to-date admission and discharge log.

   
   

4. The Agency re-alleges and incorporates paragraphs one {1) through five (5) as if fully set forth herein.

5. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

58A-5.024(1)(b) F.A.C. Records

(1) FACILITY RECORDS. Facility records shall include:

1. An up-to-date admission and discharge log listing the names of all residents and each resident's:

   1. Date of admission, the place from which the resident was admitted, and if applicable, a notation the resident was admitted with a stage 2 pressure sore; and

   2. Date of discharge, the reason for discharge, and the identification of the facility to which the resident is discharged or home address, or if the person is deceased, the date of death. Readmission of a resident to the facility after discharge requires a new entry. Discharge of a resident is not required if the facility is holding a bed for a resident who is out of the facility but intends to return pursuant to Rule 58A- 5.025, F.A.C.

      
      

      1. That on August 21, 2008 the Agency conducted a re-licensure survey of the

         
         

         0

         
         

         Respondent facility.

         
         

      2. Based on record review and interview, the facility failed to maintain an accurate admissions and discharge log. A new admission from January 2008 was not on the log, and the reason and location for discharge was not indicated on several discharged residents, the findings include:

         1. A review of the admissions and discharge log revealed that Client #3, a current resident at the facility, was not on the admission and discharge log. Also the reason for discharge and the discharge location was left blank for several discharged residents.

            
            

      3. The Agency provided a mandatory correction date of September 21, 2008.

         
         

      4. That on October 1, 2008 the Agency conducted a follow up to re-licensure survey of the Respondent facility.

      5. Based on record review and interview the facility failed to maintain an up-to-date admission and discharge log. The findings include:

         1. On 10/1/08 at 10:05 A.M. the surveyors arrived at the facility. The staff member present stated there were currently 20 residents, with one resident Baker Acted and iq a Psych unit.

         2. On 10/1/08 at 10:10 requested the current admission/discharge log. The Administrator stated her son had the log. The son was at his home and could not be reached by phone. The Administrator stated there were currently 21 residents in the facility.

         3. After the completion of the survey the son presented at the AHCA offices on 10/1/08 and provided an admission/discharge log. A review of this log revealed 19 residents.

         4. The log did not include the resident #2 which was admitted on 7/30/08.

            
            

      6. That the failure to maintain an up-to-date admission and discharge log is in violation of law.

      7. That the Agency determined that this deficient practice was related to the care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected isolated Class III deficiency.

         
         

         3

         
         

         0

         
         

         WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected isolated Class III violation in the amount of five hundred dollars ($500.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

         COUNT II

         
         

         Respondent's facility failed to conduct 2 resident elopement drills each year.

         
         

      8. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

      9. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

      58A-5.0182(8)(c) F.A.C. Resident Care Standards

      (8) ELOPEMENT STANDARDS.

2. Facility Resident Elopement Drills. The facility shall conduct resident elopement drills pursuant to Sections 429.41(1)(a)3 and 429.41(1)(1), F.S.

429.41(1)(a)3 F.S. Rules Establishing Standards

3. Resident elopement requirements.--Facilities are required to conduct a minimum of two resident elopement prevention and response drills per year. All administrators and direct care staff must participate in the drills which shall include a review of procedures to address resident elopement. Facilities must document the implementation of the drills and ensure that the drills are conducted in a manner consistent with the facility's resident elopement policies and procedures.

1. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

2. Based on record review the facility failed to conduct 2 resident elopement drills each year, the findings include:

   1. A review of the facility's elopement drills revealed one was completed 3/11/06 and one was completed on 5/12/08. There were no other elopement drills completed.

      
      

3. The Agency provided a mandatory correction date of September 21, 2008.

   
   

4. That on October 1, 2008 the Agency conducted a follow up to the re-licensure

   
   

   0

   
   

   survey of the Respondent facility.

   
   

5. Based on record review the facility failed to conduct 2 resident elopement drills each year. The findings include:

   1. A review of the facility's elopement drills revealed one was completed 3/11/06 and one was completed on 5/12/08. There were no other elopement drills completed. The Administrator on 10/1/08 at 11:15 A.M. stated the drill wasn't completed unless her son had the form or hadn't written it up.

   2. On 10/1/08 the Administrator's son presented to the AHCA offices a copy of the elopement drill from 5/12/08. There were no other drills completed.

      
      

6. That the failure to conduct 2 resident elopement drills each year is in violation of

   
   

   law.

   
   

7. That the Agency determined that this deficient practice was related to the care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected isolated Class III deficiency.

   . WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected isolated Class III violation in the amount of five hundred dollars ($500.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

   COUNT III

   
   

   Respondent's facility failed to ensure that resident contracts were included in the resident records for 3 of 7 records reviewed. (#2,3,4).

   
   

8. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

9. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

   58A-5.025 (1) F.A.C. Resident Contracts

   1. Pursuant to Section 429.24, F.S., each resident or the residents legal representative, shall, prior to or at the time of admission, execute a contract with the facility which contains the following provisions:

      
      

      1. A list of the specific services, supplies and accommodations to be provided by the facility to the resident, including limited nursing and extended congregate care services if the facility is licensed to provide such services.

      2. The daily, weekly, or monthly rate.

      3. A list of any additional services and charges to be provided that are not included in the daily, weekly, or monthly rates, or a reference to a separate fee schedule which shall be attached to the contract.

      4. A provision giving at least 30 days written notice prior to any rate increase.

      5. Any rights, duties, or obligations of residents, other than those specified in Section 429.28, F.S.

      6. The purpose of any advance payments or deposit payments and the refund policy for such advance or deposit payments.

      7. A refund policy which shall conform to Section 429.24(3), F.S.

      8. A written bed hold policy and provisions for terminating a bed hold agreement if a facility agrees in writing to reserve a bed for a resident who is admitted to a nursing home, health care facility, or psychiatric facility. The resident or responsible party shall notify the facility in writing of any change in status that would prevent the resident from returning to the facility. Until such written notice is received, the agreed upon daily, weekly, or monthly rate may be charged by the facility unless the resident's medical condition, such as the resident's being comatose, prevents the resident from giving written notification and the resident does not have a responsible party to act in the resident's behalf.

      9. A provision stating whether the organization is affiliated with any religious organization, and, if so, which organization and its relationship to the facility.

      10. A provision that, upon determination by the administrator or health care provider that the resident needs services beyond those the facility is licensed to provide, the resident or the resident's representative, or agency acting on the resident's behalf, shall be notified in writing that the resident must make arrangements for transfer to a care setting that has services needed by the resident. In the event the resident has no person to represent him, the facility shall refer the resident to the social service agency for placement. If there is disagreement regarding the appropriateness of placement, provisions as outlined in Section 429.26(8), F.S., shall take effect.

   
   

   58A-5.024(3)(i) F.A.C. Records

   The facility shall maintain the following written records in a form, place and system ordinarily employed in good business practice and accessible to Department of Elder Affairs and Agency staff.

   1. RESIDENT RECORDS. Resident records shall be maintained on the premises and include:

      1. A copy of the resident's contract with the facility, including any addendums to the contract, as described in Rule 58A-5.025, F.A.C.

         
         

         429.24(1) F.S. Contracts

         1. The presence of each resident in a facility shall be covered by a contract, executed at the time of admission or prior thereto, between the licensee and the resident or his or her designee or legal representative. Each party to the contract shall be provided with a duplicate al thereof, and the licensee shall keep on file in the facility all such

   
   

   contracts. The licensee may not destroy or otlJ_erwise dispose of any such contract until 5 years after its expiration.

   
   

10. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

11. Based on record review, the facility failed to obtain client signatures on contracts for 2 of 7 clients reviewed, #4 and #7, the findings include:

    1. Record review for Client #4 revealed a contract dated 1/2/08. The client's name was printed on the contract. The contract had not been signed by either the client or the facility representative.

    2. Record review for Client #7 revealed a contract dated 1/2/08. The client's name was printed on the contract, and the contract was signed by the administrator. The contract had not been signed by the client.

    3. The manager of the facility was unavailable for interview.

       
       

12. The Agency provided a mandatory correction date of September 21, 2008.

    
    

13. That on October 1, 2008 the Agency conducted a follow up to the re-licensure survey of the Respondent facility.

14. Based on record review and interview the facility failed to ensure the resident's contract was included in the resident's record for 3 of7 records reviewed. (#2, 3, 4). The findings include:

    1. A review of the resident record for resident #2 revealed the resident was admitted on 7/30/08. The record did not contain a resident contract. An interview with the Administrator on 10/1/08 at 11:00 A.M. stated her son had the contracts at his home. The son/manager was not able to be contacted by phone during the survey.

    2. A review of the resident record for resident #3 revealed the resident was admitted on 3/1/08. The record did not contain a resident contract.

    3. A review of the resident record for resident #4 revealed the resident was admitted on 3/8/03. The record did not contain a resident contract.

       
       

15. That the failure to ensure the resident's contract was included in the resident's record for 3 of7 records reviewed. (#2, 3, 4) is in violation oflaw.

16. That the Agency determined that this deficient practice was related to the care of

    
    

    the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected pattern Class III deficiency.

    WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected pattern Class III violation in the amount of five hundred dollars ($500.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

    COUNT IV

    
    

    Respondent's facility failed to ensure the Administrator participated in 12 hours of continuing education in topics related to assisted living every 2 years.

    
    

17. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

18. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

    58A-5.0191(1)(c) F.A.C. Staff Training Requirements and Competency Test

    (1) ASSISTED LIVING FACILITY CORE TRAINING REQUIREMENTS AND

    COMPETENCY TEST.

    (c) Administrators and managers shall participate in 12 hours of continuing education in topics related to assisted living every 2 years as provided under Section 429.52, F.S.

    
    

    429.52(4) F.S. Staff Training and Educational Programs; Core Educational Requirement

    (4) Administrators are required to participate in continuing education for a minimum of

    12 contact hours every 2 years.

    
    

19. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

20. Based on record review and interview the facility failed to ensure the Administrator participated in 12 hours of continuing education in topics related to assisted living every 2 years, the findings include:

    1. A review of the Administrator's personnel file revealed the last training was completed 6/5/06.

    2. An interview with the Administrator on 8/21/08 at 10:55 A.M. stated she

       
       

       was a Registered Nurse and had completed 12 hours of training. The Administrator stated would have to locate the information. The information was not provide during the course of the survey to verify the total hours and content to be specific to assisted living facilities.

       
       

21. The Agency provided a mandatory correction date of September 21, 2008.

    
    

22. That on October 1, 2008 the Agency conducted a follow up to the re-licensure survey of the Respondent facility.

23. Based on record review and interview the facility failed to ensure the Administrator participated in 12 hours of continuing education in topics related to assisted living every 2 years. The findings include:

    1. On 10/1/08 at 12:00 P.M. the Administrator presented a certificate of 12 hours of continuing education. The course content was for "The Federal MDS: Procedures for Completing the Resident Assessment Protocols (RAP's)" for Long Term Care. The Administrator was questioned if any courses were completed specific to Assisted Living Facilities, as ALF's do not complete MDS/R.APs. The Administrator stated she had not completed any other continuing education courses.

    2. After the completion of the survey the Administrator's son presented to the ARCA offices on 10/1/08 and provided a copy of a website Long Term Care Education.com. The son indicated the course completed was approved for ALF Administrators. The web site was reviewed and it was noted the courses offered are for Long Term Care and ALF Administrators. The site stated each user must review their specific State requirements. The site contained many courses specific to ALF's but the MDS/RAP was not one of these courses specific to ALF's.

       
       

24. That the failure to ensure the Administrator participated in 12 hours of continuing education in topics related to an assisted living every 2 years is in violation oflaw.

25. That the Agency determined that this deficient practice was related to the care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected isolated Class Ill deficiency.

    WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected isolated Class Ill violation in the amount of five hundred dollars ($500.00) against the

    
    

    Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

    
    

    COUNTY

    
    

    Respondent's facility failed to ensure the Administrator received 2 hours of annual education in nutrition and food service in an ALF.

    
    

26. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

27. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

    SSA-5.0191(6) F.A.C. Staff Training Requirements and Competency Test

    (6) NUTRITION AND FOOD SERVICE. The administrator or person designated by the administrator as responsible for the facility's food service and the day-to-day supervision of food service staff must obtain, annually, a minimum of 2 hours continuing education in topics pertinent to nutrition and food service in an assisted living facility. A certified food manager, licensed dietician, registered dietary technician or health department sanitarians are qualified to train assisted living facility staff in nutrition and food service.

    
    

    429.5 F.S. Staff Training and Educational Programs; Core Educational Requirement

    (6) Other facility staff shall participate in training relevant to their job duties as specified

    by rule of the department.

    
    

28. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

29. Based on record review and interview the facility failed to ensure the Administrator or the person designated for food service (#3 and #4) received 2 hours of annual education in nutrition and food service in an ALF, the findings include:

    1. A review of the personnel files revealed the Administrator's last training in nutrition was 3/13/06. The employee #3 and 4's personnel file contained a job description for cook. The employee #3's last nutrition training was 4/13/07. The employee #4's last nutrition training was 2004. The manager had received nutrition training in 1996.

    2. An interview with the Administrator on 8/21/08 at 1:00 P.M. stated she had attempted to attend a training but it was canceled. The employee #3 is the main cook and was recently sent to training. The Administrator was notified the training for employee #3 was over 1 year.

       
       

30. The Agency provided a mandatory correction date of September 21, 2008.

    
    

31. That on October 1, 2008 the Agency conducted a follow up to the re-licensure survey of the Respondent facility.

32. Based on record review and interview the facility failed to ensure the

    
    

    Administrator received 2 hours of annual education in nutrition and food service in an ALF. The findings include:

    1. A review of the personnel file revealed the Administrator's last training in nutrition was 3/13/06.

    2. An interview with the Administrator on 8/21/08 at 1:00 P.M. stated she

       had attempted to attend a training but it was canceled. The Administrator stated had registered for a class. The other staff had not attended nutrition update training.

       
       

33. That the failure to ensure the Administrator received 2 hours of annual education in nutrition and food service in an ALF is in violation oflaw.

34. That the Agency determined that this deficient practice was related to the care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an uncorrected isolated Class Ill deficiency.

    WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected isolated Class ID violation in the amount of five hundred dollars ($500.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

    COUNT VI

    
    

    Respondent's facility failed to ensure the resident's community living support plan was signed and dated and updated annually for 3 of 5 re-licensure residents sampled. (#1, 4, 5).

    
    

35. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

36. The regulatory provisions of Florida Law that are pertinent to this alleged

violation read as follows:

58A-5.029(2)(3a, viii) F.A.C. Re-licensure

1. RECORDS.

   1. A Community Living Support Plan.

   a. Each mental health resident and the resident's mental health case manager shall, in consultation with the facility administrator, prepare a plan within 30 days of the resident's admission to the facility or within 30 days after receiving the appropriate placement assessment under paragraph (c), whichever is later, which:

   (viii) Is updated at least annually;

   
   

   1. That on August 21, 2008 the Agency conducted a re-licensure survey of the Respondent facility.

   2. Based on interview and record review, the facility failed to ually update the community living support plan for Resident #4, the findings include:

      1. A record review for client #4 showed that the community living support plan was updated on 3/28/06 and again on 3/19/07. The plan had not been updated in 2008.

      2. An interview was conducted with the administrator on 8/21/08 at approximately 11:00a.m. The administrator stated that several mental health records were at the facility's managers home, and were unavailable for review.

         
         

   3. The Agency provided a mandatory correction date of September 21, 2008.

      
      

   4. That on October 1, 2008 the Agency conducted a follow up to the re-licensure survey of the Respondent facility.

   5. Based on interview and record review the facility failed to ensure the resident's community living support plan was signed and dated to and updated annually for 3 of 5 re­ licensure residents sampled. (#1, 4, 5). The findings include:

      1. A review of the medical record for the resident #5 revealed a Community Support Plan which was signed but was not dated. An interview with the Administrator on 10/1/08 at 11:15 A.M. stated all the Community Support Plans had been updated. Unable to verify the date of the update.

      2. A review of the medical record for the resident #1 the last Community Support Plan was completed on 10/12/2004.

      3. A review of the medical record for the resident #4 the last Community Support Plan was completed on 3/18/04.

         
         

   6. That the failure to ensure the resident's commW1ity living support plan was signed and dated to and updated annually for 3 of 5 re-licensure residents sampled is in violation of law.

   7. That the Agency determined that this deficient practice was related to the care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for an W1corrected pattern Class III deficiency.

      WHEREFORE, the Agency intends to impose an administrative fine for an W1corrected pattern Class III violation in the amoW1t of five hW1dred dollars ($500.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

      COUNT VII

      
      

      Respondent's facility failed to ensure each employee had a background screening for 1 of 5 personnel reviewed (#3).

      
      

   8. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

   9. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

   58A-5.019(3) F.A.C. Staffing Standards

2. BACKGROUND SCREENING.

1. All staff, who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S., and meet the screening standards of Section 435.03, F.S. A packet containing backgroW1d screening forms and instructions may be obtained from the Agency BackgroW1d Screening Unit, 2727 Mahan Drive, Tallahassee, FL 32308; telephone (850)410-3400. Within ten (10) days of an individual's employment, the facility shall submit the following to the Agency BackgroW1d Screening Unit:

   1. A completed Level 1 Criminal History Request, AHCA Form 3110-0002, July 2005, which is incorporated by reference and may be obtained in the screening packet referenced in paragraph (3)(a) of this rule; and

   2. A check to cover the cost of screening.

2. The results of employee screening conducted by the agency shall be maintained in the employee's personnel file.

3. Staff with the following documentation in their personnel records shall be considered to have met the required screening requirement:

   
   

   13

   
   

   1. A copy of their current professional license, proof that a criminal history screening has been conducted, and an affidavit of current compliance with Section 435.03, F.S.;

   2. Proof of continuous employment in an occupation which requires Level 1 screening without a break in employment that exceeds 180 days, and proof that a criminal history screening has been conducted within the previous two (2) years; or

   3. Proof of employment with a corporation or business entity or related entity that owns, operates, or manages more than one facility or agency licensed under Chapter 400, F.S., that conducted Level I screening as a condition of initial or continued employment.

429.174(2) F.S. Background Screening; Exemptions

The owner or administrator of an assisted living facility must conduct level 1 background screening, as set forth in chapter 435, on all employees hired on or after October 1, 1998, who perform personal services as defined ins. 429.02(16). The agency may exempt an individual from employment disqualification as set forth in chapter 435. Such persons shall be considered as having met this requirement if:

(2) The person required to be screened has been continuously employed in the same type of occupation for which the person is seeking employment without a breach in service which exceeds 180 days, and proof of compliance with the level 1 screening requirement which is no more than 2 years old is provided. Proof of compliance shall be provided directly from one employer or contractor to another, and not from the person screened. Upon request, a copy ofscreening results shall be provided by the employer retaining documentation of the screening to the person screened.

1. That on October 1, 2008 the Agency conducted a follow up to the re-licensure survey of the Respondent facility.

2. Based on record review and interview the facility failed to ensure each employee had a background screening for 1 of 5 personnel reviewed (#3). The findings include:

   1. During the survey on 10/1/08 at 10:15 A.M. requested the personnel file for the employee #3. The Administrator stated was unable to locate the personnel file. The Administrator was unsure of the employee's date of hire.

   2. The employee was observed in the kitchen at 11:30 A.M. assisting with the preparation of lunch. The employee stated serves meals and assists the residents with personal care.

   3. After the completion of the survey the manager delivered the personnel file to the AHCA office on 10/1/08. The employee file did not contain a background screemng.

   4. A review of the information provided revealed conflicting dates in August and/or September as the date of hire. The majority of the information provided contained the date of 9/8/08 or 8/10/08 and 9/8/08 was determined to be the date of hire.

      
      

3. That the failure to ensure each employee had a background screening for 1 of 5

   
   

   personnel reviewed (#3) is in violation oflaw.

   
   

4. That the Agency determined that this deficient practice directly threatens the physical or emotional health, safety, or security of the facility residents and cited Respondent for an isolated Class II deficiency.

   WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected isolated Class II violation in the amount of one thousand dollars ($1,000.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(b) Florida Statutes (2008).

   COUNT VIII

   
   

   Respondent's facility failed to ensure new employees received the 4 hour medication training course before assisting with the self-administration of medications to residents for 2 of 2 new employees assisting with medications. (#4 and 5).

   
   

5. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

6. The regulatory provisions of Florida Law that are pertinent to this alleged violation read as follows:

SSA-5.0191(5) F.A.C. Staff Training Requirements and Competency Test

(5) ASSISTANCE WITH SELF-ADMINISTERED MEDICATION AND MEDICATION MANAGEMENT. Unlicensed persons who will be providing assistance with self-administered medications as described in Rule 58A-5.0185, F.A.C., must meet the training requirements pursuant to Section 429.52(5), F.S., prior to assuming this responsibility. Courses provided in fulfilment of this requirement must meet the following criteria:

1. Training must cover state law and rule requirements with respect to the supervision, assistance, administration, and management of medications in assisted living facilities; procedures and techniques for assisting the resident with self-administration of medication including how to read a prescription label; providing the right medications to the right resident; common medications; the importance of taking medications as prescribed; recognition of side effects and adverse reactions and procedures to follow when residents appear to be experiencing side effects and adverse reactions; documentation and record keeping; and medication storage and disposal. Training shall include demonstrations of proper techniques and provide opportunities for hands-on learning through practice exercises.

2. The training must be provided by a registered nurse or licensed pharmacist who shall issue a training certificate to a trainee who demonstrates an ability to:

   
   

   1. Read and understand a prescription label;

   2. Provide assistance with self-administration in accordance with Section 429.256, F.S., and Rule 58A-5.0185, F.A.C., including:

      1. Assist with oral dosage forms, topical dosage forms, and topical ophthalmic, optic and nasal dosage forms;

      2. Measure liquid medications, break scored tablets, and crush tablets in accordance with prescription directions;

      3. Recognize the need to obtain clarification of an "as needed" prescription order;

      4. Recognize a medication order which requires judgment or discretion, and to advise the resident, resident's health care provider or facility employer of inability to assist in the administration of such orders;

      5. Complete a medication observation record;

      6. Retrieve and store medication; and

      7. Recognize the general signs of adverse reactions to medications and report such reactions.

429.52(5) F.S. Staff Training and Educational Programs; Core Educational Requirement

1. Staff involved with the management of medications and assisting with the self­ administration of medications under s. 429.256 must complete a minimum of 4 additional hours of training provided by a registered nurse, licensed pharmacist, or department staf£ The department shall establish by rule the minimum requirements of this additional training.

   
   

   1. That on October 1, 2008 the Agency conducted a follow up to the re-licensure survey of the Respondent facility.

   2. Based on record review and interview the facility failed to ensure new employees received the 4 hour medication training course before assisting with the self-administration of medications to residents for 2 of 2 new employees assisting with medications. (#4 and 5). The findings include:

      1. A review of the personnel files for #4 and #5 revealed the employees had not received the 4 hour initial medication training. An interview with the Administrator on 10/1/08 at 11:30 A.M. stated the employee #5 had received the training but didn't write the training certificate. The Administrator stated the employees did not administer medications. A review of the facility's Medication Observation Logs (MOR) revealed the 2 employees had initialed the MOR in September 2008. This staffs initials provided evidence of the assistance with self­ administered medications to residents.

         
         

   3. That the failure to ensure new employees received the 4 hour medication training

      
      

      course before assisting with the self-administration of medications to residents for 2 of 2 new employees assisting with medications. (#4 and 5) is in violation oflaw.

   4. That the Agency determined that this deficient practice threaten the physical or emotional health, safety, or security of the facility residents and cited Respondent for an uncorrected pattern Class II deficiency.

      WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected pattern Class II violation in the amount of one thousand dollars ($1,000.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.l 9(2)(b) Florida Statutes (2008).

      COUNT IX

      
      

   5. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

   6. That pursuant to Section 429.19(7), Florida Statutes (2008), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2008), to verify the correction of the violations.

   7. That pursuant to the provisions of law, the Petitioner agency must conduct a monitoring survey the next year of Respondent facility, Sec. 429.428(3)(c), Florida Statues (2008).

   8. That said fee must be assessed though the survey will occur in the future. See, Agency for Health Care Administration v. Luz Home for the Elderly, Inc., d/b/a/ Luz Home for the Elderly, Case No. 02-263PH (Agency for Health Care Administration).

   9. That Respondent is therefore subject to a monitoring fee of five hundred dollars

   
   

   0

   
   

   
   

   ($500.00), pursuant to Section 429.19(7), Florida Statutes (2008).

   
   

   CLAIM FOR RELIEF

   
   

   WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court:

   1. Make factual and legal findings in favor of the Agency on Counts I through VIII;

      
      

   2. Recommend administrative fines against Respondent in the amount of $5,000.00 for Counts I through VIII and a survey fee of $500.00;

   3. Assess attorney's fees and costs; and

      
      

   4. Grant all other general and equitable relief allowed by law.

   
   

   Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873.

   If you want to hire an attorney, you have the right to be represented by an attorney in this

   
   

   matter.

   
   

   RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY.

   Respectfully submitted this i) ay of April, 2009.

   jh

   Vikram Mohan, Senior Attorney Florida Bar No. 49402

   Agency for Health Care Administration

   
   

   0 0

   2727 Mahan Drive, Mail Stop #3

   Tallahassee, Florida 32308

   850.922.4347 (office)

   850.921.0158 (fax)

   
   

   CERTIFICATE OF SERVICE

   
   

   I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by

   WM

   U.S. Certified Mail, Return Receipt No. 7000 0520 0024 8388 2461 to: Karen L. Goldsmith, Esq. Jonathan S. Grout, Esq. Goldsmith and Grout, P.A. 2160 Park Ave. North, Winter Park, Florida 32789 on April 2009.

   
   

   Vi Esquire

   Copy furnished to: Barbara Alford, FOM

   
   

   STATE OF FLORIDA

   AGENCY FOR HEALTH CARE ADMINISTRATION

   
   

   STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

   
   

   Petitioner, AHCA No. 2009004203

   
   

   vs.

   
   

   HELPING HANDS FOUNDATION OF HAVANA,

   
   

   Respondent.

   !

   
   

   ADMINISTRATIVE COMPLAINT

   
   

   COMES NOW the Agency for Health Care Administration (hereinafter "Agency"), by and through undersigned counsel, and files this administrative complaint against HELPING HANDS FOUNDATION OF HAVANA, (hereinafter "Facility" or "Respondent"), pursuant to 120.569 and 120.57, Fla. Stat. (2008).

   NATURE OF THE ACTION

   
   

   1. This is an action to impose an administrative fine in the amount of one thousand dollars ($1,000.00) based upon Respondent being cited for one uncorrected Class III deficiency, pursuant to 429.19(c) Fla. Stat.

      JURISDICTION AND VENUE

      
      

   2. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 429, Part I, Florida Statutes (2008).

   3. Venue lies pursuant to Fla. Admin. Code R. 28-106.207.

      
      

      PARTIES

      
      

      EXHIBIT

      I

      
      

   4. The Agency is the regulatory authority responsible for the licensure of assisted living facilities and the enforcement of all applicable state regulations, statutes and rules, governing assisted living facilities pursuant to Chapter 429, Part I, Chapter 408, Part II, Florida Statutes (2008), and Rule 58A-5, Florida Administrative Code.

   5. Respondent operates an assisted living facility located at 186 China Berry Lane, Havana, Florida having been issued license number 7500. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes.

      COUNT!

      
      

      Respondent's facility failed to maintain minimum weekly staffing hours for 2 of 2 sampled weeks.

      
      

   6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein.

   7. The regulatory provisions of the Florida Law that are pertinent to this alleged

      
      

      violation read as follows:

      
      

      58A-5.019 Staffing Standards.

      1. STAFFING STANDARDS.

         1. Minimum staffing:

1. Facilities shall maintain the following minimum staff hours per week:

1. That on December 18, 2008 the Agency conducted a survey of the Respondent

   
   

   2

   
   

   
   

   facility.

   
   

2. Based on observation, record review and staff interview, the facility failed to maintain minimum weekly staffing hours for 2 of 2 sampled weeks. The findings include:

   1. Interview with the administrator at approximately 9:15 am on 12/18/08, revealed the census for 12/18/08 was 18. For a census of 16-25 residents minimum staffing hours are 253 per week.

   2. Record review at approximately 9:45 am on 12/18/08 revealed that scheduled hours for the week of December 1-7 were 234 hours. The administrator was scheduled to work for 24 hours on multiple days during the weeks of December 1-7 and 8-14, when only 3 employees, including the administrator, were scheduled to work. The maximum numbers of employees scheduled during most shifts during those two weeks were two and duties include food preparation and service.

      
      

3. That the failure to maintain minimum weekly staffing hours for 2 of 2 sampled weeks is in violation of law.

4. That the Agency cited the Respondent for a Class III violation in accordance with 58A-5.019(4)(a)l F.A.C.

5. That the Agency provided a mandatory correction date of January 19, 2009.

   
   

6. That on or about March 9, 2009, the Agency conducted a follow up survey of the facility and found that the violation was uncorrected. The findings include:

   1. Week 1 of 2: Resident census of 18 for February 22, 2009 - February 28, 2009 required minimum of 253 staffing hours. Work Schedule and time cards on which employees punch in and punch out when at work were compared. Time cards correlated with Work Schedule. Employee time was calculated and documented on the time card by owner/administrator. Hours for the week totaled 197.90.

   2. Owner/Administrator is listed on the Work Schedule for February 22, 2009 thru February 28, 2009 to work 86 hours. Owner/administrator states she does not keep a time card, time sheet, or any other documentation of hours she worked.

   3. Week 2 of 2: Resident census of 18 for March 1, 2009 - March 7, 2009 required minimum of 253 staffing hours. Employee time was calculated and documented on the time card by owner/administrator. Time card entries correlated with Work Schedule. Hours for the week totaled 208.5.

   4. Owner/Administrator is listed on Work Schedule for March 1, 2009 - March 7, 2009 to work 56 hours. There is no documentation on a time

      
      

      3

      
      

      0

      sheet. Administrator confirmed there is no record of her/his hours staffing the facility.

      
      

7. That the Agency determined that this deficient practice indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and cited Respondent for an uncorrected State Class III deficiency, in accordance with 429.19(2)(c), Fla. Stat. (2008).

WHEREFORE, the Agency intends to impose an administrative fine for an uncorrected State Class III violation in the amount of one thousand dollars ($1,000.00) against the Respondent, an assisted living facility, pursuant to Chapter 429.19(2)(c) Florida Statutes (2008).

CLAIM FOR RELIEF

WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court:

1. Make factual and legal findings in favor of the Agency on Count I;

   
   

2. Recommend administrative fines against Respondent in the amount of $1,000.00 for Count I;

3. Assess attorney's fees and costs; and

   
   

4. Grant all other general and equitable relief allowed by law.

Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the

attached Election of Rights form. All requests for hearing shall be made to the attention of

I..

1. Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS

   
   

   #3, Tallahassee, Florida 32308, (850) 922-5873.

   
   

   I

   If you want to hire an attorney, you have the right to be represented by an attorney in this

   
   

   matter.

   
   

   RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY.

   Respectfully submitted this \ b11aay of July, 2009.

   
   

   Vikram Mohan, Senior Attorney Florida Bar No. 49402

   Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3

   Tallahassee, Florida 32308

   850.922.4347 (office)

   850.921.0158 (fax)

   
   

   CERTIFICATE OF SERVICE

   
   

   I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by facsimile to Jonathan S. Grout, E uire, Counsel for Respondent, 2160 Park Avenue North, Winter Park, Florida 32789 on \ uly, 2009. / 4 _

   - t1/

   Vikram Mohan, Esquire

   Copy furnished to: Barbara Alford, FOM

   
   

   STATE OF FLORIDA

   AGENCY FOR HEALTH CARE ADMINISTRATION

   
   

   RE: HELPING HANDS FOUNDATION OF HAVANA CASE NO: 2009004203

   
   

   ELECTION OF RIGHTS

   
   

   This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint.

   
   

   Your 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 Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint.

   
   

   If your 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 by AHCA, you will have given up your right to contest the Agency's proposed action and a final order will be issued.

   
   

   (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.)

   
   

   PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS:

   
   

   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 Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I 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 penalty, fine or action.

   
   

   OPTION TWO (2) I admit to the allegations of facts contained in the Notice of

   Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, 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.

   
   

   OPTION THREE (3) I dispute the allegations of fact contained in the Notice of

   Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 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 Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain:

   
   

   1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any.

   2. The file number of the proposed action.

   3. A statement of when you received notice of the Agency's proposed action.

   4. A statement of all disputed issues of material fact. If there are none, you must state that there are none.

Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees.

License type: Assisted Living Facility

Licensee Name: License number:

Contact person: _

Name Title

Address:

Street and number City Zip Code

Telephone No. Fax No. Email (optional) _

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.

l

l Signed: Date:

l Print Name: Title:

!

l 8

I

CHARLIE CRIST GOVERNOR

CERTIFIED MAIL

FLORIDA AGENCY FOR HEAIJH C'.ARE ADMINISTRATION

Better Health Care for all Floridians HOLLY BENSON SECRETARY

Certified Article Number

RETURN RECEIPT REQUESTED

March 20, 2009

REC· r, :' rtn•. .:rt:;;'¼:!,t•if.\J#'

GENERAL cc· . set.

71b0 3 01 984S b974 30&4

SENDERS RECORD

2009

Earnestine Platt MAR 2 L)

Helping Hands Foundation of Havana ~

186 China Berry Lane gency ior He iJ;h

Havana, FL 32333 Cwre AdmlnDstrat,oo

RE: CC# 2009003498

NOTICE OF INTENT TO DENY

Dear Ms Platt:

It is the decision of this Agency that Helping Hands Foundation of Havana renewal application for (an/the) assisted living facility to be DENIED.

The Specific Basis for this determination is the applicant's demonstrated pattern of deficient performance pursuant to Chapters 408, Part II and 429, Part I, Florida Statutes, (F.S.). On August 21, 2008 the field office conducted the biennial survey. During the survey there were twenty-one class III deficiencies cited in the areas of facility/records standards, community living support plan, cooperative agreement, staffing standards, facility records standards, resident records standards, emerg.ency management, physical plant standards, and staff records standards.

On October 1, 2008 the first follow to the biennial survey up was conducted. The first follow up survey yielded nine new class II and class III deficiencies in the areas of staffing standards, staff records standards, resident care standards, and emergency management. Eight class III deficiencies remained uncorrected from the biennial survey.

On November 3, 2008 a second follow up survey for the biennial was conducted, one class II and four class III deficiencies remained uncorrected.

On December 18, 2008 the complaint survey 2008013527 and third follow up to the biennial survey were conducted. All five remaining deficiencies for the biennial survey were corrected. One new class III survey was cited in the area of staffing standards for the complaint survey.

2727 Mahan Drive, MS#30 Tallahassee, Florida 32308

Visit AHCA online at

1111••••11111••1://ahca.myflorida.com

EXHIBIT

I

Helping Hands Foundation Of Havana March 20, 2009

Page 2

On March 9, 2009 a follow up to complaint survey 2008013527 was conducted, one class III deficiency remained uncorrected.

EXPLANATION OF RIGHTS

Pursuant to Section 120.569, Florida Statutes, (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.

SEE ATTACHED ELECTION OF RIGHTS FORM

Sincerely,

er, Manager Assisted L ving Unit

Bureau of Long Term Care Services AG/ps

Copy to: Tallahassee Field Office - 02

LTCOC District 02

Jan Mills, General Counsel Office

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

RE: Helping Hands Foundation Of Havana CASE NO: 2009003498

ELECTION OF RIGHTS

This Election of Rights form is attached to a proposed Notice of Intent to Deny of the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Deny 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 Deny 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 Deny, or other notice of intended action by AHCA and I waive my right to object and have a hearing. I 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 Deny, 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.

OPTION THREE (3) I dispute the allegations of fact contained in the Notice of

Intent to Deny 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: assisted living facility License number: 7500 Licensee Name: Helping Hands Foundation Of Havana

   Contact person:

   Name Title

   Address: Street and number City Zip Code

   
   

   Telephone No. Fax No. Email (optional) _

   
   

   of

   I hereby certify that I am duly authorized to submit this Notice of Election ' Rights to the Agency for Health Care Administration on behalf of the licensee referred to ab?ve.

   
   

   _Signed: Date:

   
   

   Print Name: Title:

   
   

   
   

   APR-08-2009 15:53 AGENCY HEALTH CARE ADMIN

   Apr 8 2009 14:41

   850 921 0158 P.14

   
   

   
   

   Track & Confirm

   
   

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   Status: Deliventd

   Your item was deliveratt at 2:14 PM on March 25, 2009 in HAVANA, FL

   32333. .

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   cationOptions

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   Copyrigtite, 1!199-i!007 USPS. All R.lghtt eservecl, No FEAR Act E;EO O.ta FOIA

   TerrnHfUte

   
   

   http://trkcnfrml.smi.usps.com/PTSlnternetWeb/InterLabellnquiry.do 03/26/2009

   TOTAL P.14

   
   

   STATE OF FLORIDA

   DlVISION OF ADMINISTRATIVE BEARINGS

   
   

   
   

   HELPING HANDS FOUNDATION

   OFHAVANA,

   
   

   Petitioner,

   v.

   AGENCY FORHBALnI CARE

   ADMINISTRATION,

   
   

   CASE NOS.: 09-1785

   09-2333

   09-2334

   09-419S

   
   

   .•i Respondent

   --I -.:'

   SE'[[LJVNT AGREEMENT

   l>etition 1 HELPING HANDS FOUNDATION OF HAVANA (''Petitioner") 4nd Respondent, AGENCY FOR HEALffi CARE ADMINISTRATION ("Ageney"), through their undemgned xepresentatives, pursuant to Section 120.S7(4), Florida St.rtutcs, each individually a

   ..party" collectively as "parties," hereby enter into thls Stipulation and Settlement Agreement (•.Agreement») and agree as follows:

   WHEREAS, Petitioner, an assisted living facility pursuant t.o Chapter 429, Patt t Florida

   Statutes, is located at 186 China Berry Lan Ravena, Florida 32333; and

   WHEREAS, tho Agency has jurisdiction by vjrtue of being the (e8Ulato,:y and licensing authority over assist.ed livjng facilities pursuant to Cha.pt.er 429 Part l Florida Statutes and 58.A-­ '• Florida Administrative Code; and

   WHEREAS, the Agency served Petitioner with three Administrative Complaints (.AIICA Nos.: 2008013874, 2008913980, 2009004203) :notifying the party of its intent to unpose fines and sun,ey fees; and

   
   

   1

   
   

   EXHIBIT

   I

   
   

   WHEREAS, the Agency provided Petitlo.ner W11.S a NQtice oflntent to Deny its Hoen.sure

   renewal application; and

   WHEREAS. Petitioner requested formal administrative hearings in petitions to the

   Agency; and

   WJIB.lWAS, the parties haw agreed that a fair, efficient and cost effective lution of

   this dispute would avoid the e7q>enditure of substantial SWWJ to litigate the dispute; and WHEREAS. the parties have negotiated and agreed that the best interests of all the

   parties will be served by a settlement of this proceed.ins;

   NOW TBEREFORE, in consideration of the mutual promises and recitals herein, the

   parties intending to ho legally bound, agree as follows:

   l. All recitals arc tme and correct 81"e e,q,ressly incorporated herein.

   .2. Both parties agree that the ''whereas" clauses inco1porated herein. are binding

   ftmlings of the parties.

   1. Upon full execution of this .Agreement, Petitioner aarees to a withdrawal of ita Petitions f01: Form.al Administrative Hearing; agrees to waive any and all appeals and proceedings; agrees to waive compliance with the form of the Final Order (findings of fact and

      cor,.clusions of law) to. which it may be entitled inoludmg, but not limited to, an informal pro under Subsection 120.57(2). a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any eourt or quasi-court (DO.AH) of competent jurisdiction.

   2. Upon full execution of this Agreement, the parties agree to the followmg:

      
      

      1. Petitioner agrees to pay Ten Thousand Five-Hundted Pollara ($10,500.00) m administrative fines and $500.00 in survey fees to the Agency within 60 days of the cnt(y of the Final Order.

      2. The Notice of Intent to Deny is deemed superseded.

         
         

      3. Upon the full execution of this Agreement, the Agency shall begin

         
         

         processing Petitioner's application.

      4. If'the Petitioner is cited for a Class I or Class Il deficiency within one year of the date of the £na1order executing this settlement agreement, then the full amount of the fines sought in the aforementioned Administrative Complaints will become due.

S. Venue for any action brought to enforce the terms of this Agreement or the Final

Order entered pursuant hereto shall lie in the Circuit Court inLeon County, Florida,

1. By elreCUtiog this agreement, Petitioner does not admit. and the Agency asserts the validity of the allegations raised in the administ1'ative com.plaints and Notice of Intent to Deny referenced herein. The Agency agrees that it will not impose any further penalty against Petitioner as a result of the surveys oondueted on August 21, 2008, October 1, 2008, November 3, 2008, Dcc;ember 18, 2008 and March 9, 2008. However, no agreement made herein shall preclude the Agency from unposmg a penalty agai1¥t :Petitione.r for any deficiency/violation of a statute or rule identified in a future swvey of Petitioner. which constitutes a cumulative fine or

   uncorrectt.d deficiency ftom the surveys conducted on Ausust 21, 20081 October 1, 2008,

   November 3, 2008, December 18, 2008 and March 9, 2008. The deficiencies :&om the August

   21, 2008, October 1, 2008, November 3, 2008, December 18, 2008 and March 97 2008 surveys

   will he deemed proved for such &turo aciions. Furthormol'6, no agreement made heroin shall

   
   

   preclude the Agency from using the deficiencies ftom the August 21, 2008, October 1, 2008, Novembe,: 3, 2008, December 18, 2008 and March 9, 2008 swveys in any decision regarding an apptication(s) for an assisted living flwility license, an mended congregate c;are license, a limited nursing services license, ora limited mental health license.

2. Upon :full execution of this Agreement, the Agency shall enter a Final Order

   adopting and incorporating the ten:ns of this .Agreement and dismissing the above-styled case,

3. Each party shall bear its own costs and attorneys fees.

4. This Agreement shall become effective on the date upon which it is fully executed

   by all the parties.

5. Petitioner, for itself and for its related or resulting organi7.ation its successors or transferees, attorneys, heirs and executors or adminifltrators, do hereby discharge the Agency fur Health Care Administration. and its agents, representatives and attorneys of and from all claims. demands, actions, causes of action, suits, damages, losses and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the .Agency's actions, including, but not limited to. any claims that were or may be asserted inany federal or state court or administrative fomm, including any c.laim.s arising out of this Agreement, by or on behalf of Petition.er of related facilities.

6. In the event that Petitioner was a Medicaid provider at the subjcd: time, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject .issues.

7. This Agreement is bindins upon all parties herein and those identified in the aforementioned paragraph ten (10) oftbis Asreement.

   
   

8. The undersigned have read and understand this Agreement and have authority to

   
   

   bind their respective principals to it.

9. This.Agreement contains the entire understandings and agKeements Qf the parties.

   
   

   
   

   parties.

10. This Agreement supe,rsede.s any prior oral or written agreements between the

    
    

11. This Agreement may not be amended except in writing. .Any attempted

assigmnent of this .Agreement shall be void.

Tbis space i"'8IIJll>nJJIJy left bhmk.

The following representatives hereby acknowledge that they are duly authorized to enter

into this Agreement:

DBPUTYSECRETAR.Y AGBNCY FOR. HBALIB CARE ADMINISTRATION

2727 Mahan.Drive

Tallahassee, FL 32308

Date, signed: Ll'j/¢,

MST-INSEjffem, ESQU]RB.

Florida Bar II: 79741

GENERAL COUNSEL

1 ATIIAN S. GROUT,

orida Bar #:296066

GOLDSMITII, GROUT & LEWJS, P.A

Post OfliceBox20U Winter Park. FL 32790 (407) 740-0144

Date signed: 1-dd--t?J'I

VIKRAM MOHAN, ESQUllW

Florida Bar# 49402

AGENCY FOR HEALTH CARE

5

. . '

AGHNcY FOR.HEALTH CARE

ADMINISTRATION

2727 Mahan Drive

Tallahassee, FL 32308

Date signed: 1 /h/4f/

,►.1 - _,,-._ (J/J

y

BARNEsTINE PLAIT ADMINISTRATOR.

Bl3UING HANDS FOUNDATION OFHAV.ANA

186 Olina Beny Lane

Havana, Florida 32333

Date signed: tJ-:J ;i - 0 CJ

ADMINISTRATION

2727 Mahan Drive. MS if3

Tallahassee, FL 32308

DatesJgned:

e

Docket for Case No: 09-004195

Orders for Case No: 09-004195