() C) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR . HEALTH CARE ADMINISTRATION, Petitioner, vs. _ AHCA No. 2012004729 * LOVING CARE OF ST. PETERSBURG, INC,, Respondent, /- ADMINISTRATIVE COMPLAINT .COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint . against the Respondent, Loving Care of St. Petersburg, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges as follows: NATURE OF THE ACTION This is an action to revoke the Respondent’s assisted living facility license based on the failure to pay administrative fines imposed on it by the Agency by way of final orders, THE PARTIES 1. The Agency is the licensure and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities. Chs. 429, Part I, and 408, Part II, Fla. Stat. Ch. 58A-5, Fla. Admin. Code. 2. The Respondent was issued a license by the Agency (License No. 11357) to operate an assisted living facility located at 1001 9th Street North, St. Petersburg, Florida 33701, and was at all material times required to comply with the statutes and rules governing assisted living facilities, Filed June 26, 2012 3:56 PM Division of Administrative Hearings CY ) COUNTI Failure to Pay Administrative Fines 3. Under Florida law, in addition to any other remedies provided by law, the Agency may deny each application or suspend or revoke each license, registration, of certificate of. entities regulated or licensed by it: If the applicant, licensee, or a licensee subject to this part which shares a common controlling interest with the applicant has failed to pay all outstanding fines, liens, or overpayments assessed by final order of the Agency or final order of the Centers for Medicare and Medicaid Services, not subject to further appeal, unless a repayment plan is _ approved by the Agency. § 408.831(1)(a), Fla. Stat. (2011). 4, On May 20, 2011, the Agency entered a final order against the Respondent requiring it to pay administrative fines in the amount of $15,000.00, fo be paid within 30 days of the date of the final order. Ex. A. 5. On May 23, 2011, the Agency entered a final order against the Respondent requiting it to pay administrative fines in the amount of $1,500.00, to be paid within 30 days of the date of the final order, Ex, B. 6. The Respondent failed to timely pay the administrative fines as required by the terms of the final orders, WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondents license to operate this assisted living facility. COUNT I False Representation of a Material Fact in a License Application 7. Under Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: False representation of a material fact in the license application or omission of any material fact from 2 9 9 ‘the application, § 408.815(1)(a), Fla. Stat. (2011). 8. On April 6, 2012, the Respondent submitted a license renewal application to the Agency with respect to this assisted living facility. Ex. C. 9. In the renewal application, the Facility Administrator swore of affirmed “under penalty of perjury, that the statements in this application are true and correct,” 10. In Section 6 of the Respondent’s renewal application, the Facility Administrator answered “no” to the following question: Pursuant to subsection 408,831(1)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or a licensee which shares a common controlling interest with the applicant if they have failed to pay all outstanding fines, liens, or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless a repayment plan is approved by the agency. Are there any incidences of outstanding fines, liens, or overpayments as described above? 11. Contrary to the Respondent’s answer, the Respondent actually had two unpaid - final orders in the amounts of $15,000.00 and $1,500.00. Ex. A and B, 12. The Respondent’s answer was a false representation to the Agency. 13. The Respondent’s false representation to the Agency was respect to a material fact. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license to operate this assisted living facility. CLAIM FOR RELIEE The Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to impose a Final Order that: 1, Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief against the Respondent as set forth above. ) Y Respectfully submitted on this ©] day of May, 2012. Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: (850) 412-3630 Facsimile: (850) 921-0158 NOTICE The Respondent has the right to request a hearing to be conducted in accordance with. Sections 120.569 and 120,57, Florida Statutes, and to be represented by counsel or other qualified representative. Specific options for the administrative action are set out within the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered, The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights Form were served to the individuals named below by the method designated on this©Q | day of May, 2012, Johi‘E. Bradley, Assist Florida Bar No. 092277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: (850) 412-3644 Facsimile: (850) 921-0158 4 c) Y [Administrator Loving Care of St, Petersburg, Inc. 1001 9th Street North St. Petersburg, Florida 33701 ee Mail — 7004 1160 0003 3739 6527) Shaddrick Haston, Unit Manager Assisted Living Unit Agency for Health Care Administration (Electronic Mail) Patricia Caufiman, Field Office Manager Areas 5-6 Agency for Health Care Administration (Electronic Mail) os C) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re; Loving Care of St. Petersburg, Inc. AHCA No. 2012004729 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency 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 may be ieturned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m, Eastern Time, of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency 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, and Chapter 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 Telephone: 850-412-3630 Facsimile: 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 Fee, Notice of Intent to Impose a Late Fine, 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, 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, Notice of Intent to Impose a Late Fine, or Administrative Complaint, 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 Section 120.57(1), Florida Statutes, it must be received by the Agency Clerk at the address above within 21 ays of your receipt of this proposed agency 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. The name, address, telephone number, and facsimile number (if any) of the Respondent, 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if'any) upon whom service of pleadings and other papers shall be made, 3. A statement requesting an administrative heating identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, Licensee Name: Contact Person: Title: a Address; Number and Street City ; Zip Code " Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above, _ Signed: Date: eee a Printed Name: Title: ee — FILED ; STATE OF FLORDA AGE ACA. AGENCY FOR HEALTH CARE ADMINISTRATION KCY CLERK. STATE OF FLORIDA, AGENCY FOR ; 20 KAY 20 A 10: os HEALTH CARE ADMINISTRATION, Petitioner, : CASE NO, 10-336PH AHCA NO, 2010003083 v. AHCA NO, 2010003084 RENDITION NO,: AHCA-11- ©. Spo-FOI-OLc ' LOVING CARE OF ST. PETERSBURG, INC. d/b/a LOVING CARE OF ST. PETERSBURG, Respondent. FINAL ORDER At the specific request of the Respondent, this case was forwarded to a hearing officer (hereafter referred to as the Presiding Officer) for a proceeding to be conducted pursuant to Section 120.57(2), Florida Statutes. The Presiding Officer’s Recommended Order, which was signed on April 28, 2011, and filed with the Agency Clerk’s office on the same day is attached to this Final Order, and incorporated herein by reference, . . FINDINGS OF FACT The Agency adopts the findings of fact set forth in the Recommended Order. CONCLUSIONS OF LAW The Agency adopts the conclusions of law set forth in the Recommended Order, IT IS THEREFORE ADJUDGED THAT: The Agency’s May 6, 2010 Administrative Complaint is hereby upheld. Unless payment has already been made; payment in the amount of $15,000 is now due from the Respondent as a result of the agency action, Such payment shall be made in full within 30 days of the rendition of this Final Order. The payment shalt be made by check payable to Agency for Health Care Administration, and shall be mailed to the Agency for Health Care Administration, Attn. Revenue Management Unit, Office of Finance and Accounting, 2727 Mahan Drive, Fort Knox Building 2, Mail Stop 14, Tallahassee, FL 32308. DONE and ORDERED this Bey of Vay , 2011, in Tallahassee, Florida, BLIZABETH QUDEK, SECRETARY AGENCY FOR/HEALTH CARE ADMINISTRATION EA OTICE OF A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW, WHICH SHALL BE INSTITUTED BY FILING THE ORIGINAL NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A COPY, ALONG WITH THE FILING FEE 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 PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE - FLORIDA APPELLATE RULES, THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF THE RENDITION OF THE ORDER TO BE REVIEWED. | RTIBICA’ F SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has been furnished by U.S. or interoffice mail to the persons named below on this oR of fen. 2011, a oO eee eee RD JS , Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (850) 412-3630 COPIES FURNISHED TO; William H. Roberts Informal Hearing Officer Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 Thomas J. Walsh, Esquire Agenoy for Health Care Administration 525 Mirror Lake Drive North St, Petersburg, Florida 33701 Don Vachon, Administrator ‘Loving Care of St. Petersburg, Inc. 1001 9" Street North St. Petersburg, Florida 33701 Jan Mills . Facilites Intake Unit : Revenue Management Unit Finance & Accounting nnn 0 eee FILED STATE OF FLORIDA ANCA / AGENCY FOR HEALTH CARE ADMINISTRATION AGENGY CLERK .. STATE OF FLORIDA, AGENCY FOR Ul APR 28 Py 18 _ HEALTH CARE ADMINISTRATION, Petitioner, v. ; CASENO, 10-336PH FRAES NO, 2010003083 LOVING CARE OF ST. PETERSBURG, INC. FRAES NO. 2010003084 d/b/a LOVING CARE OF ST. PETERSBURG, Respondent. / STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. CASENO, 10-839PH FRAES NO. 2010009926 LOVING CARE OF ST, PETERSBURG, INC. . FRAESNO. 2010009970 d/b/a LOVING CARE OF ST, PETERSBURG, Respondent, STATE OF FLORIDA, AGENCY FOR . HEALTH CARE ADMINISTRATION, Petitioner, v. CASENO. 11-42PH ; FRAES NO. 2010013244 LOVING CARE OF ST. PETERSBURG, INC. d/b/a LOVING CARE OF ST, PETERSBURG, Respondent. RECOMMENDED ORDER ~ On April 21, 2011 an informal hearing was held in these consolidated matters pursuant to Section 120,57(2), Florida Statutes. Don Vachon, Administrator, and Adrian Goett represented the respondent, Loving Care of St, Petersburg, Inc. (“LC”) by phone, Thomas Walsh, Assistant General Counsel represented the petitioner, the Agency for Health Care Administration (“the Agency”), also by phone, Beverly Buchan was the Agency’s witness,. LC admitted all the material facts contained in the three Administrative Complaints, issued by the Agency on May 6, 2010, November 17, 2010, and December 27, 2010. The three cases were consolidated for purposes of hearing to promote efficiency. Separate recommended orders will issue for each case. Case No. 10-336PH ~ FRAES NO. 2010003083 and 2010003084 The May 6, 2010 administrative complaint charged LC with three Class IT deficiencies, with a fine of $5000 each, pursuant to Section 429.19, Florida Statutes. The Agency noted the deficiencies in a March 5, 2010 follow-up survey to a December 29, 2009 complaint survey. At the follow-up survey, the Agency found that the medication observation record (MOR) for resident 4 (R4) listed six medications for which R4 had been given no assistance, The MOR contained no notations about this and R4’s doctor had not been notified. Resident 6 (R6) had been prescribed Clonazepam, a controlled substance. The count of doses on the controlled drug record indicated that five doses of Clonazepam had been missed. For several entries, a staff person’s name had been crossed out after the staff person had signed the record. There was no record that R6’s doctor had been notified of this significant change. The Agency charged LC with a - failure to provide care and services appropriate to the needs of a resident, cited as a Class Tl violation, and assessed a fine of $5000.00. The Agency also found that LC had failed fo maintain an accurate and up-to-date MOR for three residents, The MOR had not been annotated as to medications administered, refused or otherwise prescribed in regard to the morning medications for two residents, There were dual entries, absence of entries, or other discrepancies in the entries for R6. The Agency cited LC for a Class II violation of Florida Administrative Code Rule 58A~5,0185(5)(b) and assessed a fine of $5000. The Agency also found that prescriptions for R4 had not been timely filled or refilled, The Agency cited LC for a Class II violation of Florida Administrative Code Rule 58A-5.0185(7)(f) and assessed a fine of $5000, LC argued that the fines were too severe, LC characterized the medicines in question as a deviation from previous prescriptions of the residents. LC had new people in the office who, although they were in contact with the residents’ physicians, did not properly document those contacts. LC argued that the deficiencies were just a failure to keep a proper record. No harm had come to any of the residents, LC has corrected the deficiencies, Shortly after the March survey, it began doing business with a new pharmacy, instituted a computerized pharmacy system, and hired both a nurse and 4 pharmacy consultant to assist with compliance measures. LC pointed out that it serves the poorest segment of society and is a not for profit facility. The Agency stated that the $5000 fines were appropriate because LC had been cited for the same violations in December 2009. The potential for harm to residents was high, as the residents may not have been receiving the appropriate medications. Some of , ee OQ. C) the medicine was for treatment of mental illness, putting the resident's emotional well- being in danger. LC gained some financial benefit ftom not taking corrective measures because the corrective measures, such as hiring new personnel, were costly. LC is a large facility, at 120 beds. Conclusions of law 1. Section 429.19(2), Florida Statutes provides: (2) Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: (a) Class "I" violations are defined in s. 408,813, The agency shall impose an administrative fine for a cited class I violation in an amount not less than’$ 5,000 and not exceeding $ 10,000 for each violation. (b) Class "II" violations are defined in s. 408.813, The agency shall impose an. administrative fine for a cited class II violation in an amount not less than $ 1,000 _ and not exceeding $ 5,000 for each violation. (c) Class "III" violations are defined in s. 408.813, The agency shall impose an administrative fine for a cited class IIT violation in an amount not Jess than $ 500 and not exceeding $ 1,000 for each violation. (d) Class "IV" violations are defined in s. 408,813. The agency shall impose an administrative fine for a cited class IV violation in an amount not less than $ 100 and not exceeding $ 200 for each violation. 2, - Section 408.813, Florida Statutes provides in part: As a penalty for any violation of this part, authorizing statutes, or applicable tules, the agency may impose an administrative fine. (1) Unless the amount or aggregate limitation of the fine is prescribed by authorizing statutes or applicable — tules, the agency may establish criteria by rule for the amount or aggregate limitation of administrative fines applicable to this part, authorizing statutes, and applicable rules. Each day of violation constitutes a separate violation and is subject to a separate fine, For fines imposed by final order of the agency and not subject to further appeal, the violator shall pay the fine plus interest at the rate specified in s. 55,03 for each day beyond the date set by the agency for payment of the fine. (2) Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its ptobable effect on clients, The scope of a violation may be cited as an isolated, patterned, or widespread deficiency. An isolated deficiency is a deficiency affecting one or a very limited number of clients, or involving one or a.very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency in which more than a very limited number of clients are affected, or more than a very limited ° number of staff are involved, or the situation has occurred in several locations, or the same client or clients have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the provider. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the provider or represent systemic failure that has affected or has the potential to affect a large portion of the provider's clients, This subsection does not affect the legislative determination of the amount of a fine imposed under authorizing statutes. Violations shall be classified on the written notice as follows: (a) Class "I" violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation, A fine shall be levied notwithstanding the correction of the violation. (b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations, The agency shall impose an administrative fine as provided by law for a cited class II violation. A fine shall be levied notwithstanding the correction of the violation. (c) Class "III" violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation, A citation for a class III violation must specify the time within . which the violation is required to be corrected. Ifa class III violation is corrected within the time specified, a fine may not be imposed, (d) Class "IV" violations are those conditions or occurrences related to the operation and maintenance of a provider or to required reports, forms, or documents that do not have the potential of negatively affecting clients. These violations are of'a type that the agency determines do not threaten the health, safety, or security of clients. The agency shall impose an administrative fine as provided in this section for a cited class IV violation. A citation for a class IV violation must specify the time within which the violation is required to be corrected. Ifa class IV violation is corrected within the time specified, a fine may not be imposed. 3. Florida Administrative Code Rule 58A-5.0131(33) provides: “Significant change” means a sudden or major shift in behavior or mood, or a deterioration in health status such as unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure sore. Ordinary day-to-day fluctuations in functioning and behavior, a short-term illness such as a cold, or the gradual +o arava pent tin: CY CY deterioration in the ability to carry out the activities of daily living that " accompanies the aging process are not considered significant changes. 4. Florida Adminsitrative Code Rule 58A-5.0182, Resident Care Standards, provides in pertinent part: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility, (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: * * *(d) Contacting the resident’s health care provider and other appropriate party such as the resident's family, guardian, health care surtogate, or case manager if the resident exhibits a significant change; contacting the - resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (c) A written record, updated as needed, of any significant changes.as defined in subsection 58A-5.0131(33), F.A.C,, any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. 5. Florida Administrative Code Rule S8A-5,0185 provides in pertinent part: (5) Medication Records, (b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self- administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider's telephone number; the name, strength, and directions for use of each medication; and a chart for recording cach time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. (7) Medication labeling and orders, (f) The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self- administration of medication or medication administration are filled or refilled in atimely manner. | LC has violated the standards cited in the administrative complaint, and the Agency is required to impose fines as outlined above, 6. Section 429.19(3), Florida Statutes provides: For purposes of this section, in determining if a penalty is to be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rules were violated, (b) Actions taken by the owner or administrator to correct violations, (c) Any previous violations. (d) The financial benefit to the facility of committing or continuing the violation, (e) The licensed capacity of the facility. 1, The Agency appropriately weighed the foregoing factors in deciding to assess the maximum fine of $5000. In the absence of further mitigating circumstances, the fines should not be reduced. 8. “Evidence is mitigating if, in faimess or in the totality of the defendant’s life or character, it may be considered as extenuating or reducing the degree of moral . culpability uP Wickham v. State, 593 So.2d 191, 194 (Fla, 1991), 9. LC did not present any evidence of extenuating circumstances beyond its control that caused or contributed to the deficiencies. Although some of the problems . cited by the Agency include a failure to properly document, some of the residents ended ~ up not receiving their prescriptions. LC has taken substantial measures to correct the violations and prevent future ones; however, these fines were appropriately assessed and should not be reduced. . Recommendation It is recommended that the Agency enter a final order upholding the fines and assessing total fines of $15,000,00, pm _ DONE AND ORDERED this Zf day of April, 2011, in Tallahassee, Leon County, Florida, William H. Roberts Informal Hearing Officer Agency for Health Care Administration Office of the General Counsel 272'1 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 412-3630 Copies furnished to: Thomas J, Walsh, Esq. Assistant General Counsel Agency for Health Care Administration . 525 Mitror Lake Drive North St. Petersburg, Florida 33701 Don Vachon, Administrator Loving Care of St. Petersburg, Inc. 1001 9" Street North St. Petersburg, Florida 33701 } la ; ~eewe re ™ ) —nccrnanece a Fil. ” STATE OF FLORIDA AHCA ED AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY CLERK STATE OF FLORIDA, AGENCY FOR 20 MAY 23 A tt: 275 HEALTH CARE ADMINISTRATION, ; : Petitioner, " CASENO, 10-839PH . AHCA NO. 2010009926 ¥. . AHCA NO, 2010009970 RENDITION NO.: AHCA-11- OS" -FOI-OLC LOVING CARE OF ST. PETERSBURG, INC. d/o/a LOVING CARE OF ST. PETERSBURG, Respondent, / ; FINAL ORDER At the specific request of the Respondent, this case was forwarded to a hearing officer (hereafter referred to as the Presiding Officer) for a proceeding to be conducted pursuant to Section 120.57(2), Florida Statutes. The Presiding Officer’s Recommended Order, which was signed on April 28, 2011, and filed with the Agency Clerk’s office on the same day is attached to this Final Order, and incorporated herein by reference. . FINDINGS OF FACT The Agency adopts the findings of fact set forth in the Recommended Order. CONCLUSIONS OF LAW The Agency adopts the conclusions of law set forth in the Recommended Order. IT IS THEREFORE ADJUDGED THAT: The $1,000 fine imposed in Count 1 of the Agency’s November 17, 2010 Administrative Complaint is hereby upheld; the fine imposed in Count Il is hereby rescinded; and the $500 survey fee imposed in Count III is hereby upheld. Unless payment has already been made; payment in the amount of $1,500 is now due from the Respondent as a result of the agency action. Such payment shall be made in full within 30 days of the rendition of this Final Order. The payment shall be made by check payable to Agency for Health Care Administration, and shall be mailed to the Agency for Health Care Administration, Attn, Revenue Management Unit, Office of Finance and Accounting, 2727 Mahan Drive, Fort Knox Building 2, Mail Stop 14, Tallahassee, FL 32308. DONE and ORDERED this A) day of flay ,2011, in Tallahassee, Florida. BLIZABETH DUDEK, SECRE’ AGENCY FOR PIEALTH CARE ADMINISTRATION ey, & a () _ cae OTI iF CIAL REVIEW A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER JS ENTITLED TO a JUDICIAL REVIEW, WHICH SHALL BE INSTITUTED BY FILING THE ORIGINAL NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A COPY, ALONG WITH THE FILING FEE PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN-THE APPELLATR DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE’A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THB FLORIDA APPELLATE RULES. THE NOTICE OF APPRAL MUST BE FILED WITHIN 30 DAYS . ‘ OF THE RENDITION OF THE ORDER TO BE REVIEWED. RTIFI E 1 HEREBY CERTIFY that a true and correot copy of the foregoing Final Order has’ been furnished by U.S. or interoffice mail to the persona named be isZzrm 2011. < Agenoy for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (850) 412-3630 COPIES FURNISHED TO; William H. Roberts Informal Hearing Officer Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 . Thomas 1. Walsh, Esquire Agency for Health Care Administration _ 525 Mirror Lake Drive North: St. Petersburg, Florida 33701 Don Vachon, Administrator Loving Care of St. Petersburg, Inc. 1001 9" Street North St. Petersburg, Florida 33701 Jan Mills Facilities Intake Unit Revenue Management Unit Finance & Accounting ' F t ED STATE OF FLORIDA _ PLICA , AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY CLERK © 20) APR q . __ STATE OF FLORIDA, AGENCY FOR 28 Pw HEALTH CARE ADMINISTRATION, Petitioner, vy, CASENO, 10-336PHL : FRAES NO. 2010003083 LOVING CARE OF ST. PETERSBURG, INC. FRAES NO, 2010003084 d/b/a LOVING CARE OF ST. PETERSBURG, ; Respondent, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ve . CASE NO. 10-839P AL ; ; . ; FRAES NO. 2010009926 LOVING CARE OF ST. PETERSBURG, INC. FRAES NO. 2010009970 d/b/a LOVING CARE OF ST. PETERSBURG, Respondent. / STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. CASENO. 11-42PH . FRAES NO. 2010013244 LOVING CARE OF ST, PETERSBURG, INC, d/b/a LOVING CARE OF ST. PETERSBURG, Respondent. i) IMMENDED ORDER On April 21, 2011 an informal hearing was held in these consolidated matters pursuant to Seotion 120.57(2), Florida Statutes. Don Vachon, Administrator, and Adrian Gostt represented the respondent, Loving Care of St. Petersburg, Inc. (“LC”) by phone, Thomas Walsh, Assistant General Counsel represented the petitioner, the Agency for ' Health Care Administration (“the Agency”), also by phone. Beverly Buchan was the _ Agency’s witness, LC admitted all the material facts contained in the three Administrative Complaints, issued by the Agency on May 6, 2010, November 17, 2010, and December 27, 2010, The three cases were consolidated for purposes of hearing to promote efficiency. Separate recommended orders will issue for each case, Case No. 10-839PH FRAES NO. 2010000026 and 2010009970 The November 17, 2010 administrative complaint charged LC with two Class II deficiencies, with a fine of $1000 each, pursuant to Section 409, 19, Flotida Statutes. The Agency also assessed a $500 survey fee. The Agency noted the deficiencies in an August 30, 2010 complaint survey. The Agency found that LC had failed to make every reasonable effort to ensure that prescriptions were filled or refilled on a timely basis. Resident 2’s MOR called for Tramadol. At the survey, no ‘Tramadol was available. Six of Resident 3’s prescribed medicines were not available. The Agency charged LC with a Class II violation of Florida Administrative Code Rule 58A-5.0185(7)(f), and assessed a fine of $1000.00. The Agency also found that LC had failed to maintain an accurate and up-to-date MOR for R3, R3 frequently refused scheduled doses or was not available during the “medication pass” two-hour window, R3’s absence was notated on the MOR as “pass ) }-- med window.” This signified that a xesident did not show up or could not be located during the two-hour blocks during which morning, noon and bedtime medications were - handed out. Ifa resident missed these windows, the resident could not get the medicine, The MOR key did not allow for this wording as an option for documentation of medication assistance. LC’s medication policies and procedures did not direct staff to document “pass med window” but it was standard practice. The Agency cited LC for a Class II violation of Florida Administrative Code Rule 58A-5.0185(5)(b) and assessed a fine of $1000, | LC argued that the fines were too severe, LC stated that it had scheduled doctor’s appointments for R3 so that R3’s medications could be refilled, but R3 did not show up for them. R3 also-refused to show up for the med passes. Lc had been informed by a physician that if the resident missed the med pass, the resident could not get the medications: LC only found out later that it could have obtained verbal orders from the physician for the medications to be administered outside the med pass time frames. LC ‘ noted that no harm had come to any of the residents, LC has corrected the deficiencies, Shortly after the March survey, it began doing business with a new pharmacy, instituted a computerized pharmacy system, and hired both a nurse and a pharmacy consultant to assist with compliance measures. LC pointed out that it serves the poorest segment of society and is a not for profit facility. The Agency stated that the doctor’s appointments for R3 had been scheduled only for August 24, 25 and 30, 2010. The potential for harm to residents was high, as the residents may not have been receiving the appropriate medications. Some of the medicine was for treatment of mental illness, putting the resident’s emotional well-being - in danger. LC gained some financial benefit from not taking corrective measures because _ the corrective measures, such as hiring new personnel, were costly. LC is a large facility, at 120 beds, Conclusions of law 1. Section 429.19(2), Florida Statutes provides: (2) Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: (a) Class "I" violations are defined in s. 408,813. The agency shall impose an administrative fine for a cited'class I violation in an amount not less than $ 5,000 and not exceeding $ 10,000 for each violation. (b) Class "II" violations are defined in 3,408,813. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $ 1,000 and not exceeding $ 5,000 for each violation. (c) Class "III" violations are defined in s. 408,813, The agency shall impose an administrative fine for a cited class III violation in an amount not less than $ 500 and not exceeding $ 1,000 for each violation. (d) Class "IV" violations are defined in s, 408.813. The agency shall impose an administrative fine for a cited class IV violation in an amount not less than $ 100 and not exceeding $ 200 for each violation. 2. Section 408.81 3, Florida Statutes provides in part: As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. (1) Unless the amount or - aggregate limitation of the fine is prescribed by authorizing statutes or applicable niles, the agency may establish criteria by rule for the amount or aggregate limitation of administrative fines applicable to this part, authorizing statutes, and applicable rules, Each day of violation constitutes a separate violation and is subject to a separate fine. For fines imposed by final order of the agency and not subject to further appeal, the violator shall pay the fine plus interest at the rate specified in s, $5.03 for each day beyond the date set by the agency for payment . of the fine. (2) Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its ptobable effect on clients, The scope of a violation may be cited as an isolated, patterned, or widespread deficiency. An isolated deficiency is a deficiency affecting one or a very limited number of clients, or involving one or a very limited number of staff, or a situation that occurred only occasionally or ina very limited number of locations. A patterned deficiency is a deficiency in which more than a very limited number of clients are affected, or more than a very limited number of staff are involved, or the situation has occurted in several locations, or the same client or clients have been affected by repeated occurrences of the same (}--—------— \ . deficient practice but the effect of the deficient practice is not found to be pervasive throughout the provider. A widespread deficiency i is a deficiency in, ’ which the problems causing the deficiency are pervasive in the provider or represent systemic failure that has affected or has the potential to affect a large portion of the provider's clients, This subsection does not affect the legislative determination of the amount of a fine imposed under authorizing statutes, Violations shall be classified on the written notice as follows: (a) Class "I" violations are those conditions or occurrences related to the operation and: maintenance of a provider or to the care of clients which the agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated of eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class J violation. A fine shall be levied notwithstanding the correction of the violation. (b) Class "II" violations ate those conditions or occurrences related to the operation and maintenance of a provider or to the caro of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an administrative fine as provided by Jaw for a cited: class II violation, A fine shall be levied notwithstanding the correction of the violation, (c) Class "HI" violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of cliénts which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. Ifa class III violation is corrected within the time specified, a fine may not be imposed. (d) Class. "IV" violations are those conditions or occurrences related to the operation and maintenance of a provider or to required reports, forms, or documents that do not have the potential of negatively affecting clients, These violations are of a type that the agency determines do not threaten the health, safety, or security of clients. The agency shall impose an administrative fine as provided in this section for a cited class IV violation. A citation for a class IV violation must specify the time within which the violation is required to be corrected. Ifa class IV violation is corrected within the time specified, a fine may not be imposed. 3. Florida Administrative Code Rule 58A-5.0185 provides in pertinent part: (5) Medication Records. (b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self- administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider's telephone number; the name, strength, and directions for use of each medication; and a chart O— OD for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. (7) Medication labeling and orders. (f) The facility shalt make every reasonable effort . to ensure that prescriptions for residents who receive assistance with self- administration of medication or medication administration are filled or refilled in atimely manner, LC has violated Florida Administrative Code Rule 58A-5.0185(7)(f). It is not clear that ‘LC violated Florida Administrative Code Rule 58A-5.0185(5)(b). ” 4, Rule 58A-5.0185(5)(b) does not require standardized language for "documentation of the MOR. The term “pass med window” may be cryptic to anyone who has not encountered it before, but LC’s staff knew it meant the resident had not received his-or her medication during the scheduled two hout blocks, It therefore documents a missed dosage or refusal. The Agency did not allege that the use of this ". term on the MOR led to any confusion on the part of LC’s staff or the residents’ physicians, Without more, the allegations do not clearly establish a violation of the rule based solely on the use “pass med window” and no fine should be assessed. 5. Section 429,19(3), Florida Statutes provides: For purposes of this section, in determining if a penalty is to be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rules were violated. (b) Actions taken by the owner or administrator to correct violations. (c) Any previous violations. (d) The financial benefit to the facility of committing or continuing the violation. () The licensed capacity of the facility. 6. The Agency appropriately weighed the foregoing factors in deciding to assess the minimum fine of $1000. In the absence of further mitigating circumstances, the remaining fine should not be reduced, 7. “Evidence is mitigating if, in fairness or in the totality of the defendant’s life or character, it may be considered as extenuating or reducing ihe degree of moral culpability [.)” Wickham vy. State, 593 So.2d 191, 194 (Fla. 1991). 8. LC did not present any evidence of extenuating circumstances beyond its control that caused or contributed to the deficiency regarding failure to timely fill prescriptions. R3’s history of refusing medication or not appearing for doctot’s appointments does not relieve LC of its duty to assure that prescriptions are timely filled and the medication is available. LC has taken substantial measures to correct the violations and prevent future ones; however, the fine was appropriately assessed and. should not be reduced. 9. Section 429.19(7), Florida Statutes provides: In addition to any administrative fines imposed, the agency may assess a survey | fee, equal to the lessor of one half of the 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 undes g. 429.28(3)(¢) to verify the correction of the violations. The violation here was found pursuant to a complaint investigation and therefore a survey fee may be assessed. Recommendation Itis recommended that the Agency enter a final orderftescinding oh fine based onFlorida Administrative Code Rule 58A-5.0185(5)(b), upholding the fine based on 58A- 5.0185(7)(), and assessing a $500 survey fee, for a total of $1500.00. DONE AND ORDERED this 6? day of April, 2011, in Tallahassee, Leon County, Florida. William H. Roberts Informal Hearing Officer Agency for Health Care Administration _ Office of the General Counsel _ 2727 Mahan Drive, MS. #3 Tallahassee, Florida 32308 (850) 412-3630 Copies furnished to: Thomas J. Walsh, Esq. Assistant General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Don Vachon, Administrator. Loving Care of St, Petersburg, Inc, 1001 9" Street North St. Petersburg, Florida 33701 RECEIVED APR 06 2012 _ SRIDAAGENGY TORENT CAEADVINISTRA - Central Systems Health Care Licensifij"ANMNGdn J ASSISTED LIVING FACILITIES u cher the euthorty af Chapters 406 Pert I and 420 Florida Statutes 8) ond Chapters 604-35 and 884-5, Flords Aciministrative . Code (FAG) anaplcon shmby nae sprt as Ses Chat Ba 25 a 1. Provider / Licensea tnfonnation 727-823-2008 Malling Address or Bd Same a8 above (Al mal wil be sont to thie J ACA Fann 3110-4008, Revised August 2011 . rath -38.080(1), Florkda Administrative Code Section 59A, Page 1 0f6 Form avallable at: http. Jaher snytloncta.convPubtcations ONNSIA Q- 9 2. Application Type, Number of Beds and Fees Indicate the of splcatn vit on" Applcationa wil act be processed ll appcabe foe ae st cluded, Al tean Fon Renewal and Change of must be recelved 60 days pvlor tothe exptation ofthe license ere . f applications ropcased effective date of the change to avoid a late fine. if the renews! application is received the Agency less than 60 dar {0 the epation ote subjest tra la ee on The tinker wee zoe ac cine Part of the application process or by separate notice. : A. TYPROF APPLICATION APR 06 2012 (J Initial Loénaure Central Systems Was this entity previously jicensed as an Asslated Living Faclity in Florida?” YESS Oo NO (1 Management Unit yee, planse provide the name ofthe agency (ferent), the EIN and the year the por Icense expired or closed a oc Renewal Ucensure CJ Change of Ownership Proposed Effective Date: £7 Change during tiensure period Proposed Effective Date: (C] Add Speciaty License . ia] increase/Decrenge in number of Roensed beds (see Section 2E) (2 Facility Name Change to: \ C] Other (plnase speciy) . terres resis B. TYPEOF LICENSE : Standard - (2 Limited Nursing Services (LNS) LY) Limited Mental Health (LMA) CO) Extended Cangregate Care (ECC) {f applying for an LNG or ECG license, has the facility maintained @ standard license for the past two calendar years, of since initially licensed If licensed less than two years? . OYES [1 No(StoP- You are not Biigible; please skip to Section Cc) it applying for an LNS or ECC license, has the facility been sanctioned uring the past two calendar years? CT YES (€} No if applying for an ECC tloonse, list the total number of ECC beds requested: ——o Identify the buliding, wing, floor, and rooms Geeignated for ECC services: If applying for a LMH Hoarnae, dose the fackty currently hold a Standard Woenee and have no uncorrected deficiencies? : DO yes No tent pteneensae C. NUMBER OF BEDS Please enter the Number of Bate (current Koensod or proposed fri! eopants): If this Is @ renewal application, did you admit a private pay resident into a designated OSS Bed? C] YES 6% No if yes, please remit the fee for the OSS beds used for private poy residents ($62,00 x #of beds converted =$ wore: To request an inoreesatiecroase in the number of becis please see Section 2E. Do not inchide the incressettecrease number of buds in this OSS Bede: 115 + Private Pay Beds:5 = Tota! Beds (OSS and Private Pay Bects): 420 Number of LNS Beds (tanpicabie): 0 Number of ECC Beds (# appiicabie): 0 AHCA Fam 3110-1006, Revised August 2011 Section S9A-25.060(1), Florida Adminvabrative Code Page Form avaidehis at; bltlahca myforida.com/PublcatonsFoonscA he C) ) RECEIVED: APR 06 2012 Dd. RMENSURE FEES -Htthis pplication | fo request en increase decrease in the number of lloansed beds oy Fetewal or change of omerahio) pleate ee section 2D. “ " “ ‘ eiiagtome TOTAL $62.00 per private pay bed x5 number of beds + $371.00 (notte exceed $13,844.00) $523.00 + $10:00 per bed x ____#of beds Spectatly License - Specialty Uicense - Limiad Nursing Service (LNS) mie CA CREAREDECREASE In PAGIT) ~ Hf requesting an increase or decrease in the current number of lloensed bede {not for an inital, renewal or change of ownership) please complete this section, Total number of currentty licensed beds: —. Total number of beds tobe (] Increasedor [) Decreased: ee ADD A SPECIA ‘. 4 SENSE RENE If the facitity Guirently holds a Standard license, and this epplication is to add an LNS oF E Hoonse betwee biennial Hoanse renewal periods: $523.00 + $10.00 per bed x —. # of beds, + Extended ECC 46 the # of Specialty License Congregate Care (ECC) trae wl fe hor per month x A Specially License - Limited Nursing Service (LNS) Specially License ~ Limited Mental Health (LMH) 3 +$10.00p AHCA Fann 3190-1008, Revised August 2011 : a Adminiatran 10.00 ie p $10.00 per hed) | No fee required for increase of beds, $25.00 fae to $0.00 .00 + $10.00 perbed x ___# of beds (lee is prorated at 12,68 per month x the # of months unél + $10.00 Section S9A-36.060(1), Fiorda Adminiatretive Cove Page 30! Form available at hijo-darcamyitorts const ° the PPrabelrsadttnes Orn ned Ws. J RECEIVED APR 06 2012 3. Controlling Interests of Licenses Manageme nt Hin AUTHORITY: Woensure, Howeve effort 'o protect all personal information, do not inchacke Bociel Secusity numbers on thao neve AN Social Security numbers mi: t be ented on the Health Care Licenaing Application Addendunni, AHCA Form 3110-10ae, , . us eee ne a DEFINMONS: Conérotiog intereeta, ex defined in eubtocton 408.803(7), Florida Statutes, ee the applicant or loensee: & pereon oF ity that . Dereon or ont Het nar ae oon rectors Of, oF has a percent oF greater annareipiteest nthe epploat oF econ or a na perenne ents 26 20 officer of, a on the board of diractors of, or hae a B-percent or groater oknoranip Wipro one tert 0008 nt lee a a only, related or unrelated, with which the eppllcant or Roane contracts fo manage the ern The - Somoreten orem, ws defined in subescton 408.8051), pride § Statutes, ea anand ember oF OCA of w not for-profit OF organization who serves 8 , 0t receive any remuneration Or her services on the . Sone dices onan cate aoe ' : et erg In Sections A and B below, provide the information for each Individual or (corporation, partnership, association) with 6% or greater ownership Interest in the licensee. Attach additional shente If phen has ‘ . ; +e pee eP ey by iV tet amenity s+ A. _ Individual and/or Entity Ownership of Licensoe a = Loving Care of St Petersburg | 1001 Martin Luther King Jr North 727-823-1625 B. Board Members and Officers of Licensee ki poms |e | PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER | OWNERSHIP INTEREST DirectoiCEO | Marina Shoit 1004 Martin Luther King Jr North 727-823-1625 100 [Present [ Vice s a A a ~~ OWNERSHIP INTEREST 2 AHA Form 3110-1008, Revised August 2071 Section S9A-36,080(1), Florida Admi Page 4 of 8 Form avaliable at: pip aha mytanue com-Pul 9 oO - RECEIVEp - C. Voluntary Board Members and Officers of Licensee APR:06 2012 Of the licenses is & not-for-profit corporation/organization, provide the requested information for each individual that ~wokantary board member, Attach additional sheets if fecessary. ms “Menameyaame FELEHPGH USER 727-823-1625 a: Don Vachon 727-823-1628 4.__ Management Company Controlling interests Doss # company other than the licenses manage the licensed provider? If BQNO, skip to section 6 - Required Disclosure. If (1 YES, provide the following information: ara in Sections A and B below, provide the Information for each individual or entity (corporation, partnership, association) with 8% or greater ownership Interest in the management Company. Altach additional sheets if necessary. A. Individual andor Entity Ownership of Management Company AHCA Fon 3170-1008 Racard De gatas rr terre amenneatsivinnernmertinerenert ey gg we AHCA Form 3110-1008, Revised Auguat 2011 Section 50A-35.060(1), Florida Administrative Code Page 6 of B Form avallabie at: tiladahca myilomia cow Purdicata: EGE! s) YO C. Voluntary Board Members and Officers of Management Company ye management company is not for-profit corparationvorganization, prove the requested information for each Individual that Servet #6 ® voluntary board member. Altech additional sheets & necessary. ; : 5 Required Basia ———————————____ The following disclosures are required: A. Pursuant to subsection 408,808(1)(d), F.S., the applicant ahell submit to the agency a description and explanation of any Convictions of offenses prohibited by sections 435.04 and 408.809(6), F.S., for each Controting interest. Nas the OF any incividuial Keted In sections 3 and 4 of thie been convicted of fevel 2 offense pursuant to suteacon Ame, Pca Sete? Gc cs seein bee zo staan ih Back Mt Screening Beauirementa, AHGA Form #3100.0008,) ves (] NO ifyes, enclose the folowing Information: 1] The fut aga! name of the Individual and the position held descriptions LIA do acony 7 ne Comicton() the inddual hes receved an exemption fam disqualification forthe offense, inchude a copy 8. Rumuart to section 408,610(2), F.8., the applicant must provide a description and lanation of any exclusions, suspensions, 0° terminations trom the Medicare, Nedioats Cl improvement. ti , OF federal inical Laboratory (CLIA) programs. vince fom pcan he et 4 ops eon exuded, sponded tiated or mort \ithdrawm from participation in Medicare or Mediceld in any state? Yes [] NO fd if yes, enciose the following information: O The full legal name of the individual ane] the position held C0 A descriptior/expianation of the exclusion, suspension, termination or Involuntary withdrawal, AHCA Form 3110-1000, Revised Auguet 9000 enact ores os AHCA Form 3110-1008, Revised August 2014 Seotion 59A-96.060(1), Florida Administrative Code Page 6 of 8 Form avallable at: itty. fake giviloneta, cOnuPcinatiecrtt! iepane fe c) ) RECEIVED APR 06 2012 ne seninitee neon i ne “Central Systems tt © _Pureuant to section 408.816(4),F.S., dows the epplicent or any controling interest in an applicant have ary of the roffanagement U YESC] NOBY Convicted of or entered g plea of guilty of nolo contendere tn, regardless of adjudication, a TO ; felony under chapter 409, chapter 817, chapter 693, 21 U.5.C. ss. 801-970, or 42 U.S.C. 88, 1395-1396, within the Previous 16 years prior to the date of this application: : YES(] NOD Terminated for cause from the Florida Medicaid Program pursuant tas. 409 91%, and hot been in good standing : with the Florida Medicald program for the most recent 5 years, : : were ‘YES [7 NOBQ Terminated for cause, pursuant to the appeals procedures estahlishad by the state or federat goverment, from the octal ante Program of fom eny other state Medicaid progam, have not been in good evancingy eae oy 20 year Bi an oF the federal Medicare program forthe moal recent § years and the tennination seas nesses” 20 years prior to the date of this , 6. _Provider Fines and Financial Information z= ) Pureuant to subsection 499,831(1)(a), Fiorida Statutes, the Agency may teke action st the applloant, licanaee, oF a licensee which interest with the all nets shares a oderion controfing epplicant f they have falled to outstanding fines, Hens, or overpayments assessed by inal order of eee reorder of hs Center Waar an aed Seren Path we es ek te ee ° Unless a repayment §s approved by the agency. Are there any incidences of outstanding fines, lens or overpayments as described above? yes (] NO & IF yas, please complete the following for each incidence (attach additional sheets Hnecessary): Amount: $____ assessedby: — [(] Agency for Health Care Administration Case # 1 cms Date of related inspection, application or overpayment petiod if applicable: — Due date of payment; {8 there an appeal pending from a Final Order? yes J NO oO Please attach » copy of the syproved repayment plan H applicable, 7. Other Program Specific Information ‘Please provide the following Information for the requested positions: A. Does the owner, administrator, or facity representative serve ax "representative payee" oF as power of attomey for any ALF residents? —] YES [[} NO “vy Representative Payee is on individu entity who receives payments on beheif of a resident (1 . Bock] SecuNity benefits, supplemental social sécurty oF optional state supplomentstion). Aeldet mt ha conort for en ome, hice ofaolyonteamretve hae " representative payee or power of atiomey. If yes, aaction 429.27(2), F.S,, states that you mea obtain & surety bond or continutim bond from @ Ncensed suraty company. Has @ surely or continuum bond been abtainad? YES [} NO Please attacha copy. B. le the ALF’ a part of a continuing care retirement community (CCRC) pureuant to Chapter 681, FS? () YES RB No ites, atlach a copy of your Certificate of Authorty with the intial or change of ownership application. C. Doss the ALF participate in a Madicald Walver program? [] YES [NO tyes, please provide your Medicaid number: AHA Form 3110-1008, Revised Augual 2011 59A-38,080(1), Page 7 of 8 i Section , Florida Administrative Code Form avaliable at: itty ation amelqiga ‘at Henge . heebonge ou | O me RECEIVED APR 06 2n12 Contrat § 19 anagamant tr 8. Affidavit t, ob hereby swear or affirm, under penalty of perjury, that the statements in this In addition, | attest thet all employees subject to Level 2 screening standards have attested to meeting the requirements ; for qualifying for emplayment and agree to inform me immediately if convicted Of any of the disquatifying offenses while 4 Lroabl € Vaal , n Smiay jSTrq ter Zt f By) oe AGENCY FOR HEALTH CARE ADMINISTRATION ASSISTED LIVING UNIT FORM WITH FEES AND ALL REQUIRED Questions? Review the information avaliable at: itou/ahea myflorte.cony “ff oF contact the Assisted Living Unit at (880) 412-4304 — tenner tlintnreene YR tHE nt Ait aN enwerwntnt nica ndetninsrseny ue vse « AHGA Form 3110-1008, Revised August 2011 : Section 89A-35.080(1), Florida Administrative Code Page 8 of 8 Form avallable at: hititatioe mvdiritis sonst ititientisie Geena US. Postal Service . = a CERTIFIED MATL RECEIPT (Domestic ‘Mail. ‘Only; No Insurance Coverage Provided) ‘ )Fon delivery information: visit our website at wwviusps.comy ony OFFICIAL USE Postage 2OD4IDI Certified Fae Postmark Here shh Return Reclapt Fea (Endorsement Required) Restricted Delivery Fea (Endorsement Required) 7004 11460 8003 3739 $527 COMPLETE THIS SECTION ON DELIVERY ‘SENDER: COMPLETE THIS SECTION A. Signature x Ya DDALMLA B. Repelved oa Printed Name) H. | ™ Complete items 1, 2, and 3, Also complete item 4 If Restricted Delivery is desired. { ® Print your name and address on the reverse {so that we can return the card to you. i | @ Attach this card to the back of the mallpiece, : or on the front if space permits. "4, Article Addressed to: | int t coer tRetasbu ne oor % th Shree} Norby Sh Potasburg, FU3310) 3, Service Type ertified Matt [2] Express Mall LD Registered C1 Return Receipt for Merchandise - O Insured Mall [1 6.0.D. 4. Restricted Delivery? (Extra.Fee) oO Yes trantertom serico bey” [OM \\loQ OD0'S 3139 (Sa PS Form 3811, February 2004 Domestic Return Recelpt 102595-02-M-1840

Docket for Case No: 12-002256

Orders for Case No: 12-002256