STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No.: 2011002526 Return Receipt Requested: ANA HOME CARE, INC. d/b/a ANA HOME 7009 0080 0000 0586 1152 CARE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Ana Home Care, Inc. d/b/a Ana Home Care (hereinafter “Ana Home Care”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2010), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $10,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2010), for the protection of public health, safety and welfare, and a survey fee in the amount of $500.00 pursuant to 429.19(7), Florida Statutes (2010). Filed June 22, 2011 3:19 PM Division of Administrative Hearings JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2010), and Chapter 28-106, Florida Administrative Code (2010). 3. Venue lies pursuant to Section 120.57, Florida Statutes (2010), and Rule 28-106.207, Florida Administrative Code (2010). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2010), and Chapter 58A-5 Florida Administrative Code (2010). 5. Ana Home Care operates a 6-bed assisted living facility located at 20555 S. W. 187 Avenue, Miami, Florida 33187. Ana Home Care is licensed as an assisted living facility under license number 6. Ana Home Care was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I ANA HOME CARE EXCEEDED LICENSED CAPACITY SECTION 408.806(1) (d)&(4), FLORIDA STATUTES RULE 58A-5.0131(7), FLORIDA ADMINISTRATIVE CODE (GENERAL LICENSURE STANDARDS) CLASS II VIOLATION 6. AHCA re~alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Ana Home Care was cited with two (2) Class II deficiencies as a result of a complaint investigation survey conducted on February 4, 2011. 8. A complaint investigation survey was conducted on February . 4, 2011. Based on observation, record review, and interview, it was determined that the facility failed to ensure the number of residents at the facility does not exceed their licensed capacity of 6 and their ability to provide appropriate housing and care. The facility's current census is 11. The findings include the following. 9. On 02/05/2011 at 8:45 AM, 11 individuals were observed at the facility. Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, & #11. Resident's #1-#4 were observed in the day room. Residents #5-#11 were observed in various bedrooms. A garage like shed was observed in the backyard. Inside the shed there was a kitchen area and a living room. There was a room partitioned off with a mattress and a wheel chair in it. There was a bathroom and another room with a bed. 10. On 02/05/2011 at 10:30 AM staff stated that resident #12 left the facility on 02/04/2011. Record review of the facility license found the licensed capacity was 6. Record review documents that resident #12 was admitted to the facility 11/25/2010 with a discharge date of 02/04/2011. Resident #5, #6 & #10 are listed on the admission discharge log. Resident #7, #8, #9 & #11 are not listed on the admission discharge log. 11. On 02/05/2011 at 10:30 AM resident #9 stated she lives at the facility and there are over 10 residents currently at the facility. Resident #1 stated he has been at the facility for over 2 weeks. Resident #1's family was contacted by phone at 12:25 PM. The family member stated that the resident has been living at the facility for over 2 months. 12. On 02/05/2011 at 1:40 PM resident #12 and family members were interviewed at the rehabilitation facility were the resident is currently located. The resident's brother stated that resident #12 had to stay in the shed behind the house because there was no room for him in the house. The brother stated that resident #12 is confined to a wheel chair. The brother stated that the facility would leave resident #12 in his wheelchair all night to sleep. 13. The brother stated that on 01/11/2010 resident #12 was in the shed and tried to reach for his urinal and fell out of the wheelchair on to the concrete floor. Resident #12 stated he hit his head when fell and was unable to get off the cold floor all night as no staff was available in the shed to assist residents. The brother stated that the following morning a 2nd resident called him and told him resident #12 was on the floor. 14. Based on the foregoing facts, Ana Home Care violated Section 408.806(1) (d)&(4), Florida Statutes, and Rule 58A- 5.0131(7), Florida Administrative Code, herein classified as a Class .II violation, which warrants an assessed fine of $5,000.00. The factors set out in Section 429.19(3), Florida Statutes, have been considered in imposing the administrative fine. COUNT IT ANA HOME CARE FAILED TO ENSURE THAT RESIDENTS LIVED IN A SAFE AND DECENT LIVING ENVIRONMENT. SECTION 429.28(1), FLORIDA STATUTES (RESIDENT CARE STANDARDS) CLASS II VIOLATION 15. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16. A complaint investigation survey was conducted on February. 4, 2011. Based on observation, record review, and interview, it was determined that the facility failed to honor resident's right to live in a safe and decent living environment for 1 (#12) of 12 sampled residents. The findings include the following. 17. On 02/05/2011 at 8:45 AM, 11 individuals were observed at the facility. Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 & #11. Resident's #1-#4 were observed in the day room. Residents #5-#11 were observed in various bedrooms. A garage like shed was observed in the backyard. Inside the shed, there was a kitchen area and a living room. There was a room partitioned off with a mattress and a wheel chair in it. There was a bathroom and another room with a bed. 18. On 02/05/2011 at 10:30 AM staff stated that resident #12 left the facility on 02/04/2011. Record review of the facility license found the licensed capacity was 6. Record review documents that resident #12 was admitted to the facility 11/25/2010 with a discharge date of 02/04/2011. Resident #5, #6, & #10 are listed on the admission discharge log. Resident #7, #8, #9, & #11 are not listed on the admission discharge log. 19. On 02/05/2011 at 1:40 PM, resident #12 and family members were interviewed at the rehabilitation facility where the resident is currently located. The resident's brother stated that resident #12 had to stay in the shed behind the house because .there was no room for him in the house. The brother stated that resident #12 is confined to a wheel chair. The brother stated that the facility would leave resident #12 in his wheelchair all night to sleep. 20. The brother stated that on 01/11/2010 resident #12 was in the shed and tried to reach for his urinal and fell out of the wheelchair on to the concrete floor. Resident #12 stated he hit his head when fell and was unable to get off the cold floor all night as no staff was available in the shed to assist residents. The .brother stated that the following morning a resident called him and told him resident #12 was on the floor. 21. Based on the foregoing facts, Ana Home Care violated Section 429.28(1), Florida Statutes, herein classified as a Class II violation, which warrants an assessed fine of $5,000.00. The factors set out in Section 429.19(3), Florida Statutes, have been considered in imposing the administrative fine. SURVEY FEE Pursuant to Section 429.19(7), Florida Statues (2010), AHCA May assess a survey fee in the amount of $500.00 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. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Ana Home Care on Counts I and ITI. 2. Assess an administrative fine of $10,000.00 against Ana Home Care on Counts I and II for the violations cited above. 3. Assess a survey fee of $500.00 against Ana Home Care on Counts I and II for the violations cited above. 4, Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2010). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER Lourdes A.. Naranjo, Esq. f” Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53°¢ Street Suite 300 Miami, Florida 33166 Copies furnished to: Field Office Manager Agency for Health Care Administration 8333 N. W. 53° Street - Suite 300 Miami, Florida 33166 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Armando Hidalgo, Administrator, Ana Home 3 Jae Care, 20555 S, W. 187 Avenue, Miami, Florida 33187 on this day of Ph eee , 2011. Lourdes A. Naranjo, Esq. 10 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Ana Home Care, Inc. d/b/a Ana Home Care AHCA No.: 2011002526 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 Chapter 120, 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: 850-412-3630 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)____—S— 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: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby 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. Signed: Date: Print Name: Title: Late fee/fine/AC 7009 0080 o000 0586 1L5¢ ay seam i ‘US: Postal eyeValitetcean N SENDER: COMPLETE THIS SECTION CERTIFIED MAILin.R (Doniestic Mail Only; No.insuran For delivery information ‘our:wel fOFFICI Postage js Certified Fee Return Recelpt Feo (Endorsement Required) Restricted Delivery Feo (Endorsement Required) Total Postage & Fees $ (Weanster Horns sawied | i | PS Form 9811, February 2004 has: Fortin 3800; ‘August 2006: COMPLETE THIS SECTION ON DELIVERY

Docket for Case No: 11-003149

Orders for Case No: 11-003149