STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
Petitioner,
Case No. 15-4631
V.
A SAFE HAVEN ASSISTED LIVING, LLC,
AHCA Nos. 2015002966
2015004836
RENDITION NO.: AHCA-(5 -01t.jO -S-OLC
Respondent.
I
FINAL ORDER
Having reviewed the Administrative Complaint, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows:
The Agency issued the attached Administrative Complaint and Election of Rights form to the Respondent. (Ex. 1) The parties have since entered into the attached Settlement Agreement, which is adopted and incorporated by reference into this Final Order. (Ex. 2)
The officer of the Respondent, Maritza Perez, is prohibited from Agency licensure as set forth in the Settlement Agreement.
The Respondent shall pay the Agency $4,000.00. If full payment has been made, the cancelled check acts as receipt of payment and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. A check made payable to the "Agency for Health Care Administration" and containing the AHCA ten-digit case number should be sent to:
Central Intake Unit
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 61
Tallahassee, Florida 32308
ORDERED at Tallahassee, Florida, on this day of /Vb ,2015.
e Secretary
ea h Care Administration
1
Filed December 7, 2015 4:12 PM Division of Administrative Hearings
NOTICE OF RIGHT TO JUDICIAL REVIEW
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.
CERTIFICATE OF SERVICE
/f8/
I CERTIFY that a true and correc of this Final Order was sei:ved yn the below-named persons by the method designated on this ..zL_ .a-..4/ , 2015.
Richard J. Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308
Telephone: (850) 412-3630
Facilities Intake Unit Agency for Health Care Administration (Electronic Mail) | Central Intake Unit Agency for Health Care Administration (Electronic Mail) |
David Selby, Assistant General Counsel Office of the General Counsel Agency for Health Care Administration (Electronic Mail) | Maritza Perez, Individually and as Officer A Safe Haven Assisted Living, LLC 9000 86th Ave. N. Seminole, FL 33777 (U.S. Mail) |
J. Bruce Culpepper Administrative Law Judge Division of Administrative Hearings (Electronic Mail) | Joelle Smouse, Administrator A Safe Haven Assisted Living, LLC 9000 86th Ave. N. Seminole, FL 33777 (U.S. Mail) |
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
Petitioner,
V. CASE NOS. 2015002966
2015004836
A SAFE HAVEN ASSISTED LIVING, LLC,
Respondent.
I
ADMINISTRATIVE COMPLAINT
COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration
(Agency), by and through its undersigned counsel, and files this Amended Administrative Complaint against the Respondent, A Safe Haven Assisted Living, LLC (Respondent), pursuant to Sections 120.569 and 120.57, Fla. Stat. (2014), and alleges:
NATURE OF THE ACTION
This is an action against an assisted living facility (' ALF') to impose three $500 fines (Counts I, II & V), two $1,000 fines (Counts III & IV), to assess a $500 survey fee (Count VI), said fines and fee totaling $4,000, and to revoke its license (Count VII).
JURISDICTION AND VENUE
The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Fla. Stat. (2014).
Venue lies pursuant to Florida Administrative Code ("F.A.C.") Rule 28-106.207.
PARTIES
The Agency is the regulatory authority responsible for licensure of ALFs and enforcement of all applicable state statutes and rules governing ALFs pursuant to the Chapters 408, Part II, and 429, Part I, Fla. Stat, and Chapter 58A-5, F.A.C., respectively.
Respondent operates a 20 bed ALF at 9000 86th Ave N, Seminole, FL 33777, license #12103.
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 statutes and rules.
COUNT I - $500 UNCLASSIFIED FINE
(Case No. 2015002966: Tag AZ809 - Proof of Financial Ability to Operate)
The Agency re-alleges and incorporates paragraphs 1 - 5 and Count Vas if fully set forth herein.
The Agency conducted a complaint investigation (CCR #2015000998) on 3 February, 2015.
Based on observation and interviews the facility failed to provide proof that it had the financial viability to operate. The facility failed to provide Agency surveyors with access to books, records, and any other financial documents necessary to determine its financial stability.
The Agency received complaints alleging that the facility was not paying utility bills, liability insurance, or Workman's Compensation. Despite efforts by the Agency's surveyors to review facility records it failed to provide them as required.
Surveyors observed a scarcity of food and that the facility failed to maintain the required emergency food supply (See Count V). Also observed was a woman parked in front who delivered milk and food on 2 occasions during the day of the visit, and staff carrying in groceries. Staff later
identified the facility owner as the person who dropped off the food but she did not enter, identify herself, or make contact with the 2 surveyors onsite then.
A surveyor telephoned the owner on 2/4/15 at 11:30 am but there was no response.
When the Administrator was called at 11:35am she said she does not have any facility financial information, but can contact the owner. The surveyor provided the Administrator a list of items needed from the owner: proof of payment of liability insurance, Workman's Comp, gas bill, electric bill, and emergency management plan approval page. The Administrator stated she "will get with the owner and have them emailed asap." The surveyor told her that the proof of payments needed to be emailed or faxed that day. When requested, the Administrator read the list of requested items to ensure accuracy and to confirm the surveyor's email address. As of2/14/15 the owner did not respond.
The surveyor telephoned the owner on 2/5 at 2:50 pm but there was no answer and no response. The surveyor then telephoned the facility at 2:55pm and the phone message stated "Call not going through. Please try again later. "
Per resident and staff interviews conducted at the facility on 2/3 it appeared that it did not have adequate resources to meet resident needs. Residents stated it did not have enough money to provide the supplied needed for activities and did not provide enough staff to meet residents' needs. Staff stated there are not enough staff to care for the residents and indicated that paychecks have not been available three times on Friday paydays (every 2 weeks) but were delayed until the following Monday afternoons.
Florida laws about proof of financial ability to operate and records maintenance state:
408.803 Definitions.-
As used in this part, the term:
"Controlling interest" means:
The applicant or licensee;
A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or
A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider.
The term does not include a voluntary board member.
408.810 Minimum licensure requirements.-In addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license.
Upon application for initial licensure or change of ownership licensure, the applicant shall furnish satisfactory proof of the applicant's financial ability to operate in accordance with the requirements of this part, authorizing statutes, and applicable rules. The agency shall establish standards for this purpose, including information concerning the applicant's controlling interests. The agency shall also establish documentation requirements, to be completed by each applicant, that show anticipated provider revenues and expenditures, the basis for financing the anticipated cash-flow requirements of the provider, and an applicant's access to contingency financing. A current certificate of authority, pursuant to chapter 651, may be provided as proof of financial ability to operate. The agency may require a licensee to provide proof of financial ability to operate at any time if there is evidence of financial instability, including, but not limited to, unpaid expenses necessary for the basic operations of the provider.
A controlling interest may not withhold from the agency any evidence of
financial instability, including, but not limited to, checks returned due to insufficient funds, delinquent accounts, nonpayment of withholding taxes, unpaid utility expenses, nonpayment for essential services, or adverse court action concerning the financial viability of the provider or any other provider licensed under this part that is under the control of the controlling interest. A controlling interest shall notify the agency within 10 days after a court action to initiate bankruptcy, foreclosure, or eviction proceedings concerning the provider in which the controlling interest is a petitioner or defendant. Any person who violates this subsection commits a misdemeanor of the second degree, punishable as provided ins. 775.082 ors. 775.083. Each day of continuing violation is a separate offense.
Section 408.803, Fla. Stat. (2014)
59A-35.062 Proof of Financial Ability to Operate.
(3) Definitions. The following definitions apply to this section for proof of financial ability to operate.
(e) "Financial instability" means the provider cannot meet its financial obligations. Evidence such as the issuance of bad checks, an accumulation of delinquent bills, or inability to meet current payroll needs shall constitute prima facie evidence that the ownership of the provider lacks the financial ability to operate. Evidence shall also include the Medicare or Medicaid program's indications or determination of financial instability or fraudulent handling of government funds by the provider.
Rule 59A-35.062, F.A.C.
SSA-5.024 Records.
The facility must maintain required records in a manner that makes such records readily available at the licensee's physical address for review by a legally authorized entity. If records are maintained in an electronic format, facility staff must be readily available to access the data and produce the requested information. For purposes of this section, "readily available" means the ability to immediately produce documents, records, or other such data, either in electronic or paper format, upon request.
Rule 58A-5.024, F.A.C.
In sum, Respondent failed to provide the required evidence of financial stability, as described above.
Respondent was cited for an unclassified deficiency, defined in subsection (3) as:
408.813 Administrative fines; violations.-As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine.
Unless the amount or aggregate limitation of the fine is prescribed by authorizing statutes or applicable rules, 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 ins. 55.03 for each day beyond the date set by the agency for payment of the fine.
Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients. The scope of a violation may be cite 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:
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.
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. If a class III violation is corrected within the time specified, a fine may not be imposed.
The agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include:
Violating any term or condition of a license.
Violating any provision of this part, authorizing statutes, or applicable rules.
Exceeding licensed capacity.
Providing services beyond the scope of the license.
Violating a moratorium imposed pursuant to s. 408.814.
Section 408.813, Fla. Stat. (2014)
The fine for an unclassified deficiency is determined as set forth in subsection (3) in ,r 10.
WHEREFORE, Petitioner seeks to impose a $500 fine.
COUNT II - $500 UNCLASSIFIED FINE
(Case No. 2015004836: Tag AZ809 - Proof of Financial Ability to Operate)
The Agency re-alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.
A follow up to the 3 February, 2015, complaint investigation was conducted on 24 April, 2015.
a. Based on observation and interviews, the facility again failed to provide proof of its financial stability. The facility failed to provide surveyors with access to books, records, and any other financial documents maintained by the facility to the extent necessary to determine the facility's financial stability in order to correct the February deficiency.
b. During an interview with Staff 'A' on 4/24 at about 1:30 PM she said she does not have access to financial records or other documents needed to determine financial stability. She did state that she received a telephone call from the fire sprinkler company on 4/22 and 4/23 about a bill due from about a year ago. She left the information for the Administrator who had not been in to get it.
Florida laws about proof of financial ability to operate and records maintenance are set forth in 18.
In sum, Respondent again failed to provide the required evidence of financial stability, as described above.
Respondent was cited for an unclassified deficiency, defined in 110.
The fine for an unclassified deficiency is determined as set forth in 1 10.
WHEREFORE, Petitioner seeks to impose a $500 fine.
COUNT III - $1,000 UNCORRECTED CLASS III FINE
(Case No. 2015004836: Tag A0008 - Admissions - Health Assessment)
The Agency re-alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.
1st Survey - 2/3/15 (paragraphs 20 - 24)
On 3 February, 2015, the Agency began a complaint investigation (CCR #2015000998).
a. The Agency learned based on observation, record reviews and interviews that the facility failed to ensure that all residents had a face-to-face medical examination completed by a health care provider and recorded on AHCA Form 1823, Resident Health Assessment for Assisted Living Facilities, within 60 calendar days before the individual's admission or within 30 calendar days after admission.
b. The surveyors began their investigation at the facility on 2/3 starting at about 9:00 am. Per record review, 7 of 7 residents were admitted without having had a face-to-face medical examination completed by a health care provider within 60 calendar days before admission or within 30 calendar days afterwards, detailed as follows:
Resident #1 was admitted on 1/21/15; the last medical examination is dated 12/15/14 Resident #2 was admitted on 1/21/15; the last medical examination is dated 3/1/14 Resident #3 was admitted on 9/20/14; the last medical examination is dated 3/1/14
Resident #4 was admitted on 9/20/14; the last medical examination is unknown. The resident's AHCA Form 1823 is not dated.
Resident #5 was admitted on 1/21/15; the last medical examination is dated 4/16/14. Resident #6 was admitted on 1/21/15; the last medical examination is dated 6/24/14. Resident #7 was admitted on 1/21/15; the last medical examination is dated 6/24/14. Per observation on 2/3 all 7 residents are current residents.
c. Per interviews with staff, residents, and a family member, plus review of the admission/discharge log, all 7 residents were confirmed as current residents with the admission dates as cited above.
Florida laws regarding examinations and records maintenance state:
429.26 Appropriateness of placements; examinations of residents.-
Cl) The owner or administrator of a facility is responsible for determining the
appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. ...
If possible, each resident shall have been examined by a licensed physician, a licensed physician assistant, or a licensed nurse practitioner within 60 days before admission to the facility. The signed and completed medical examination report shall be submitted to the owner or administrator of the facility who shall use the information contained therein to assist in the determination of the appropriateness of the resident's admission and continued stay in the facility. The medical examination report shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection or upon request. An assessment that has been completed through the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program fulfills the requirements for a medical examination under this subsection ands. 429.07(3)(b)6.
Except as provided ins. 429.07, if a medical examination has not been completed within 60 days before the admission of the resident to the facility, a licensed physician, licensed physician assistant, or licensed nurse practitioner shall examine the resident and complete a medical examination form provided by the agency within 30 days following the admission to the facility to enable the facility owner or administrator to determine the appropriateness of the admission. The medical examination form shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection by the agency or upon request.
Any resident accepted in a facility and placed by the department or the Department of Children and Families shall have been examined by medical personnel within 30 days before placement in the facility. The examination shall include an assessment of the appropriateness of placement in a facility. The findings of this examination shall be recorded on the examination form provided by the agency. The completed form shall accompany the resident and shall be submitted to the facility owner or administrator. Additionally, in the case of a mental health resident, the Department of Children and Families must provide documentation that the individual has been assessed by a psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse, or an individual who is supervised by one of these professionals, and determined to be appropriate to reside in an assisted living facility. The documentation must be in the facility within 30 days after the mental health resident has been admitted to the facility.
An evaluation completed upon discharge from a state mental hospital meets the requirements of this subsection related to appropriateness for placement as a mental health resident providing it was completed within 90 days prior to admission to the facility. The applicable department shall provide to the facility administrator any information about the resident that would help the administrator meet his or her responsibilities under subsection (1). Further, department personnel shall explain to the facility operator any special needs of the resident and advise the operator whom to call should problems arise. The applicable department shall advise and assist the facility administrator where the special needs of residents who are recipients of optional state supplementation require such assistance.
Section 429.26, Fla. Stat. (2014)
SSA-5.0181 Admission Procedures, Appropriateness of Placement and Continued Residency Criteria.
HEALTH ASSESSMENT. As part of the admission criteria, an individual must undergo a face-to-face medical examination completed by a health care provider as specified in either paragraph (a) or (b) of this subsection.
A medical examination completed within 60 calendar days before to the individual's admission to a facility pursuant to Section 429.26(4), F.S. The examination must address the following:
The physical and mental status of the resident, including the identification of any health-related problems and functional limitations;
An evaluation of whether the individual will require supervision or assistance with the activities of daily living;
Any nursing or therapy services required by the individual;
Any special diet required by the individual;
A list of current medications prescribed, and whether the individual will require any assistance with the administration of medication;
Whether the individual has signs or symptoms of Tuberculosis, Methicillin Resistant Staphylococcus Aureus, Scabies or any other communicable disease, which are likely to be transmitted to other residents or staff;
A statement on the day of the examination that, in the opinion of the examining health care provider, the individual's needs can be met in an assisted living facility; and
The date of the examination, and the name, signature, address, telephone number, and license number of the examining health care provider. The medical examination may be conducted by a health care provider licensed under Chapters 458,459 or 464, F.S.
A medical examination completed after the resident's admission to the facility within 30 calendar days of the admission date. The examination must be recorded on AHCA Form 1823, Resident Health Assessment for Assisted Living Facilities, October 2010. The form is hereby incorporated by reference. AHCA Form 1823 may be obtained http://www.flrules.org/Gateway/reference.asp?No=Ref-04006.
Faxed or electronic copies of the completed form are acceptable. The form must be completed as instructed.
Items on the form that may have been omitted by the health care provider during the examination do not necessarily require an additional face-to-face examination for completion. The facility may obtain the omitted information either orally or in writing from the health care provider.
Omitted information must be documented in the resident's record. Information received orally must include the name of the health care provider, the name of the facility staff recording the information, and the date the information was provided.
Electronic documentation may be used in place of completing the section on AHCA Form 1823 referencing Services Offered or Arranged by the Facility for the Resident. The electronic documentation must include all of the elements described in this section of AHCA Form 1823.
Any information required by paragraph (a) that is not contained in the medical examination report conducted before the individual's admission to the facility must be obtained by the administrator using AHCA Form 1823 within 30 days after admission.
Medical examinations of residents placed by the department, by the Department of Children and Families, or by an agency under contract with either department must be conducted within 30 days before placement in the facility and recorded on AHCA Form 1823 described in paragraph (b).
An assessment that has been conducted through the Comprehensive, Assessment, Review and Evaluation for Long-Term Care Services (CARES) program may be substituted for the medical examination requirements of Section 429.26, F.S., and this rule.
Any orders for medications, nursing, therapeutic diets, or other services to be provided or supervised by the facility issued by the health care provider conducting the medical examination may be attached to the health assessment. A health care provider may attach a DH Form 1896, Florida Do Not Resuscitate Order Form, for residents who do not wish cardiopulmonary resuscitation to be administered in the case of cardiac or respiratory arrest.
A resident placed on a temporary emergency basis by the Department of Children and Families pursuant to Section 415.105 or 415.1051, F.S., is exempt from the examination requirements of this subsection for up to 30 days. However, a resident accepted for temporary emergency placement must be entered on the facility's admission and discharge log and counted in the facility census; a facility may not exceed its licensed capacity in order to accept such a resident. A medical examination must be conducted on any temporary emergency placement resident accepted for regular admission.
Rule 58A-5.0181, F.A.C.
Respondent was cited for a Class III violation, defined in subsection (2) c) in, 10.
The Agency notified Respondent by letter dated 19 February, 2015, that it had 30 days to correct all deficiencies, to wit, by on or about 19 March, 2015.
2nd survey - 4/24/15 (paragraphs 25 - 30)
On 24 April, 2015, the Agency conducted a follow up to the 3 February complaint investigation.
a. The Agency learned based on interviews, observations and record reviews, the facility failed to ensure that the health assessments for Residents #2, 4 & 9 were was required by law.
b. A review ofresident records showed that 6 of the 7 residents who were admitted to the facility from their Guided Management facility had been examined by a health care provider either on 2/9 or 4/15, and the AHCA Form 1823 health assessments were incomplete regarding these residents:
Resident #2. The Form dated 2/9/15 listed a diagnosis of Paranoid Schizophrenia with special needs listed as "medications and support". Section 2A on page 3 of contained a written statement under self care tasks of "medication administration". Section 2 B asks: Does the individual need help with taking his or her medications (meds)? Yes No If yes, please place a checkrnark in front of the appropriate box below: Needs Assistance with Self
Administration of Medications or Needs Medication Administration. Both sections were marked yes. Staff'A' when interviewed stated the facility does not administer medications and that she believes he gets a shot once a month for his psychiatric needs.
Resident #4. His Form dated 4/15/15 showed under Cognitive or Behavioral status Schizoaffective disorder and anxiety disorder. In Section lD the form asks: "In your professional opinion, can this individual's needs be met in an assisted living facility, which is not
a medical, nursing or psychiatric facility?" It was not marked either a yes or a no. When interviewed on 4/24 at about 11 AM he said he received Risperdal injections every 2 weeks from a visiting nurse and that he sees a psychiatrist 4 times a year. He also stated he was one of the residents who came from the other facility that was closed down.
Resident #9. The Form showed diagnoses of Depression, DMII (diabetes mellitus), HTN (hypertension) and Neuropathy with cognitive or behavioral status of depression and anxiety and special precautions of unsteady gait/fall precautions. Under Section ID the form asks: "In your professional opinion, can this individual's needs be met in an assisted living facility, which is not a medical, nursing or psychiatric facility?" This question was not marked with either a yes or a no.
Florida laws regarding examinations and records maintenance are forth in ,i 22.
In sum, Respondent again failed to ensure that all residents had completed AHCA Form 1823 health assessments done in a timely manner, as set forth above.
Respondent was cited again for this class III violation, defined in ,i 10.
The same constitutes an uncorrected class III violation with the fine determined as follows:
429.19 Violations; imposition of administrative fines; grounds.-
In addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility ...
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:
(c) Class "III" violations are defined ins. 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.
Section 429.19, Fla. Stat. (2014)
WHEREFORE, the Agency intends to impose a $500 fine.
COUNT IV - $1,000 UNCORRECTED CLASS III FINE
(Case No. 2015004836: Tag AL240 - LMH- Licensing)
The Agency re-alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.
1st Survey - 2/3/15 (paragraphs 32 - 38)
On 3 February, 2015, the Agency began a complaint investigation (CCR #2015000998).
a. The Agency learned based on observation, record reviews, and interviews, the facility failed to obtain a Limited Mental Health (LMH) specialty license before admitting one or more mental health residents.
Per record review and staff interviews on 1/21/15 mental health Resident #5 and others were admitted from Guided Management Inc., a related ALF in New Port Richey. Guided Management, a closed facility owned by the same owners as the current facility, had a LMH license whereas Respondent does not.
Per observation Resident #5 was currently residing at the facility.
Per 2/3 interview with staff on duty on 1/21 five persons were dropped off by the owner's son and a maintenance worker from Guided Management Inc. at about 6:30 pm. Only one staff person was working at the facility at that time and he thought the arrivals were from the Department of Corrections as he had not been informed that any new residents would be arriving.
Per review of the facility Admission/Discharge Log, mental health Resident# 5 and others were admitted to the facility on 1/21. As of2/3 the facility census of 19 in-house residents included at least one mental health resident although it was never issued a LMH
specialty license by the Agency.
Florida laws regarding the LMH specialty license state:
58A-5.029 Limited Mental Health.
LICENSE APPLICATION.
Any facility intending to admit three or more mental health residents must obtain a limited mental health license from the agency before accepting the third mental health resident.
Facilities applying for a limited mental health license that have uncorrected deficiencies or violations found during the facility's last survey, complaint investigation, or monitoring visit will be surveyed before the issuance of a limited mental health license to determine if such deficiencies or violations have been corrected.
429.26 Appropriateness of placements; examinations of residents.-
(1) The owner or administrator of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident's representative or designee or the resident's family, guardian, surrogate, or attorney in fact. ...
Section 429.26, Fla. Stat. (2014)
429.02 Definitions.-
When used in this part, the term:
(15) "Mental health resident" means an individual who receives social security disability income due to a mental disorder as determined by the Social Security Administration or receives supplemental security income due to a mental disorder as determined by the Social Security Administration and receives optional state supplementation.
Section 429.03, Fla. Stat. (2014)
58A-5.0131 Definitions.
In addition to the terms defined in Section 429.02, F.S., the following definitions are applicable in this rule chapter:
(20) "Mental Disorder" for the purposes of identifying a mental health resident, means schizophrenia and other psychotic disorders; affective disorders; anxiety related disorders; and personality and dissociative disorders. However, mental disorder does not include residents with a primary diagnosis of Alzheimer's disease, other dementias, or mental retardation.
Rule 58A-5.03 l, F.A.C.
429.075 Limited mental health license.-
An assisted living facility that serves three or more mental health residents must obtain a limited mental health license.
To obtain a limited mental health license, a facility must hold a standard license as an assisted living facility, must not have any current uncorrected deficiencies or violations, and must ensure that, within 6 months after receiving a limited mental health license, the facility administrator and the staff of the facility who are in direct contact with mental health residents must complete training of no less than 6 hours related to their duties. Such designation may be made at the time of initial licensure or relicensure or upon request in writing by a licensee under this part and part II of chapter 408. Notification of approval or denial of such request shall be made in accordance with this part, part II of chapter 408, and applicable rules. This training will be provided by or approved by the Department of Children and Families.
Facilities licensed to provide services to mental health residents shall provide appropriate supervision and staffing to provide for the health, safety, and welfare of such residents.
A facility that has a limited mental health license must:
Have a copy of each mental health resident's community living support plan and the cooperative agreement with the mental health care services provider. The support plan and the agreement may be combined.
Have documentation that is provided by the Department of Children and Families that each mental health resident has been assessed and determined to be able to live in the community in an assisted living facility with a limited mental health license.
Make the community living support plan available for inspection by the resident, the resident's legal guardian, the resident's health care surrogate, and other individuals who have a lawful basis for reviewing this document.
Assist the mental health resident in carrying out the activities identified in the individual's community living support plan.
A facility with a limited mental health license may enter into a cooperative agreement with a private mental health provider. For purposes of the limited mental health license, the private mental health provider may act as the case manager.
Section 429.075, Fla. Stat. (2014)
Florida law regarding unlicensed activity states:
408.812 Unlicensed activity.-
A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not
advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license.
The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency.
It is unlawful for any person or entity to own, operate, or maintain an
unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense.
Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance.
When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s. 408.814 and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation.
In addition to granting injunctive relief pursuant to subsection (2), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules.
Any person aware of the operation of an unlicensed provider must report that provider to the agency.
§408.812, Fla. Stat. (2014)
In sum, Respondent failed to obtain a LMH specialty license yet admitted Resident #5 and possibly others who were 'mental health residents', as defined above.
Respondent was cited for a Class III violation, defined in1 10.
The Agency notified Respondent by letter dated 19 February, 2015, that it had 30 days to correct all deficiencies, to wit, by on or about 19 March, 2015.
2nd survey-4/24/15 (paragraphs 39 - 44)
On 24 April, 2015, the Agency conducted a follow up to the 3 February complaint investigation.
a. The Agency learned based on observation, record reviews, and interviews that the facility continued to fail to obtain a LMH specialty license before admitting and/or allowing continued residency by one or more mental health residents.
Former Resident #5 (redesignated as #4 for this survey) remained in the facility yet it had not applied for a LMH specialty license.
A review of this resident's record, who was previously identified as a mental health resident, revealed schizoaffective disorder, and case management from Baycare Behavioral Health
Staff A was asked to provide the income source for the 6 new residents identified and she was unable to do so. The Administrator's 4/28 email indicated that she believed the facility only had 2 limited mental health residents. She was asked to supply information related to their source of income and whether or not they receive Optional State Supplementation (OSS) funds. She did not respond to the surveyors' request. Resident #4, who previously resided there, met the definition of a mental health resident and still resided there, therefore, once again the facility was required to have a LMH specialty license but did not.
Staff A stated during an interview on 4/24 at about 10 AM that there is "a psych
person who comes to see those residents that came from Guided Management". She named the 6 residents. She also stated that she worked at Guided Management and understood that they had a Limited Mental Health license there for those 6 residents.
Florida laws regarding the appropriateness of placements are forth in, 34.
In sum, Respondent again failed to ensure that it either did not admit any resident it was not allowed to have and/or that it obtained the required LMH specialty license prior to admitting or allowing to continue residency one or more mental health residents, as set forth above.
Respondent was cited again for this class III violation, defined in 1 10.
The same constitutes an uncorrected class III violation with the fine determined as set forth in 130.
WHEREFORE, the Agency intends to impose a $500 fine.
COUNT V - $500 UNCLASSIFIED FINE
(Case No. 2015004836: Tag A0093 - Food Service - Dietary Standards)
The Agency re-alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.
A follow up to the 3 February, 2015, complaint investigation was conducted on 24 April, 2015.
a. Based on observation, interview and record review, the facility failed to 1) post a weekly menu, 2) provide therapeutic meals for a resident as ordered by the health care provider, and 3) maintain a required meal substitution log.
At about 9:30 am the surveyor observed that no weekly menus were posted. The undated 4 week menu cycle was posted in the kitchen and in a glass enclosed showcase to the hallway adjacent to the administrator's office. At about 4 pm Staff 'A' and 'B' were observed holding a dry erase board outside of the kitchen area leading to the dining room. 'A' was hammering nails in to the wall and stated that they were going to use the board to inform the residents of the daily menu.
The lunch meal was observed at about 12 pm. While in the kitchen with Staff 'A' who prepared the meal she was asked if anyone was on a therapeutic diet. She stated that Resident #1 was on a low potassium diet. She retrieved a chart that was pinned to a board and
stated that she gave the resident white bread today (instead of whole wheat) and a smaller portion of mashed potatoes.
Resident #1 was interviewed at about 3:50 pm. She receives dialysis treatment. She stated that she was served mashed potatoes and soup with beans today which is contrary to her renal diet. She stated that the staff serves her mashed potatoes and tomatoes all the time but she doesn't eat them because she knows they are excluded from her diet.
Resident #1's AHCA Form 1823 health assessment dated 1/20/15 indicated a renal diet as ordered by the health care provider. The facility 's registered dietician approved menu dated 1/22/15 does not include a renal diet as part of its therapeutic menu.
At approximately 12:30 pm Staff 'A' stated that she was unaware of a meal substitution log. She stated that she substituted soups today to avoid waste. The day's menu also called for succotash but she stated that she did not know what that was and none was prepared. When interviewed at about 1 pm 'B' stated that she was unaware of a meal substitution log. There was no meal substitution log produced for the surveyors as of the time they exited the facility.
Florida law about food service dietary standards states:
SSA-5.020 Food Service Standards.
GENERAL RESPONSIBILITIES. When food service is provided by the facility, the administrator, or an individual designated in writing by the administrator, must be responsible for total food services and the day-to-day supervision of food services staff....
DIETARY STANDARDS.
The meals provided by the assisted living facility must be planned based on the current USDA Dietary Guidelines for Americans, 2010, which are incorporated by reference and available for review at: http://W\\rw.flrules.org/Gateway/reference.asp?No=Ref-04003, and the current summary of Dietary Reference Intakes established by the Food and Nutrition Board of the Institute of Medicine of the National Academies, 2010, which are
incorporated by reference and available for review at: http://iom.edu/Activities/Nutrition/SummaryDRis/~/media/Files/Activity%20Files
/Nutrition/DRis/New%20Material/5DRI%20Values%20S ummaryTables%2014.pd
f. Therapeutic diets must meet these nutritional standards to the extent possible.
The residents' nutritional needs must be met by offering a variety of meals adapted to the food habits, preferences, and physical abilities of the residents, and must be prepared through the use of standardized recipes. For facilities with a licensed capacity of 16 or fewer residents, standardized recipes are not required. Unless a resident chooses to eat less, the facility must serve the standard minimum portions of food according to the Dietary Reference Intakes.
All regular and therapeutic menus to be used by the facility must be reviewed annually by a licensed or registered dietitian, a licensed nutritionist, or a registered dietetic technician supervised by a licensed or registered dietitian, or a licensed nutritionist to ensure the meals meet the nutritional standards established in this rule. The annual review must be documented in the facility files and include the original signature of the reviewer, registration or license number, and date reviewed. Portion sizes must be indicated on the menus or on a separate sheet.
Daily food servings may be divided among three or more meals per day, including snacks, as necessary to accommodate resident needs and preferences.
Menu items may be substituted with items of comparable nutritional value based on the seasonal availability of fresh produce or the preferences of the residents.
Menus must be dated and planned at least 1 week in advance for both regular and therapeutic diets. Residents must be encouraged to participate in menu planning. Planned menus must be conspicuously posted or easily available to residents. Regular and therapeutic menus as served, with substitutions noted before or when the meal is served, must be kept on file in the facility for 6 months.
Therapeutic diets must be prepared and served as ordered by the health care provider.
Facilities that offer residents a variety of food choices through a select menu, buffet style dining, or family style dining are not required to document what is eaten unless a health care provider's order indicates that such monitoring is necessary. However, the food items that enable residents to comply with the therapeutic diet must be identified on the menus developed for use in the facility.
The facility must document a resident's refusal to comply with a therapeutic diet and provide notification to the resident's health care provider of such refusal.
For facilities serving three or more meals a day, no more than 14 hours must elapse between the end of an evening meal containing a protein food and the beginning of a morning meal. Intervals between meals must be evenly distributed throughout the day with not less than 2 hours nor more than 6 hours between the end of one meal and the beginning of the next. For residents without access to kitchen facilities, snacks must be offered at least once per day. Snacks are not considered to be meals for the purposes of calculating the time between meals.
Food must be served attractively at safe and palatable temperatures. All residents must be encouraged to eat at tables in the dining areas. A supply of eating ware sufficient for all residents, including adaptive equipment if needed by any resident, must be on hand.
A 3-day supply of nonperishable food, based on the number of weekly meals the facility has contracted with residents to serve, must be on hand at all times. The quantity must be based on the resident census and not on licensed capacity. The supply must consist of foods that can be stored safely without refrigeration. Water sufficient for drinking and food preparation must also be stored, or the facility must have a plan for obtaining water in an emergency, with the plan coordinated with and reviewed by the local disaster preparedness authority.
Rule 58A-5.020, F.A.C.
In sum, Respondent failed to 1) post a weekly menu, 2) provide therapeutic meals for Resident #1 as ordered by the health care provider, and 3) maintain a required meal substitution log, as described above.
Respondent was cited for an unclassified deficiency, defined in 110.
The fine for an unclassified deficiency is determined as set forth in 10.
WHEREFORE, Petitioner seeks to impose a $500 fine.
COUNT VI - $500 SURVEY FEE
The Agency re-alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.
Pursuant to Section 429.19 (7), Fla. Stat., 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), Fla. Stat., to verify the correction of the violations.
The complaint investigation resulted in the finding of a violation that was the subject of the complaint.
Respondent is therefore subject to a $500.00 survey fee.
WHEREFORE, the Agency intends to assess a $500 survey fee.
COUNT VII- REVOCATION
The Agency re-alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.
Pursuant to the attached Final Order (Ex. 1), Guided Management, Inc. recently had its application for a change of ownership denied, a basis for revocation.
As reflected in composite Ex. 2, the applications for the Petitioner and Guided Management, they share a common controlling interest as defined below. As to the Petitioner, Maritza Perez is the 100% owner (see page 4 of 3/27/14 application, Ex. 2); as to former licensee Guided Management, Inc., she is a 75% owner (see page 4 of the 10/15/13 application, Ex. 2).
Florida laws define a 'controlling interest' and address license revocation where, as in this instance, a licensed ALF also operated or operates another ALF whose application was denied:
408.803 Definitions.-As used in this part, the term:
"Controlling interest" means:
The applicant or licensee;
A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or
A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider.
Section 408.803, Fla. Stat. (2013)
408.806 License application process.-
(}) An application for licensure must be made to the agency on forms furnished by the agency, submitted under oath, and accompanied by the appropriate fee in order to be accepted and considered timely. The application must contain information required by authorizing statutes and applicable rules and must include:
4. Each controlling interest if the applicant or controlling interest is an individual.
Section 408.806, Fla. Stat. (2014)
429.14 Administrative penalties.-
In addition to the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or for the actions of any facility employee:
An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility.
The determination by the agency that the owner lacks the financial ability to provide continuing adequate care to residents.
Misappropriation or conversion of the property of a resident of the facility.
Failure to follow the criteria and procedures provided under part I of chapter 394 relating to the transportation, voluntary admission, and involuntary examination of a facility resident.
(i) Knowingly operating any unlicensed facility or providing without a license any service that must be licensed under this chapter or chapter 400.
(k) Any act constituting a ground upon which application for a license may be denied.
The agency may deny a license to any applicant or controlling interest as defined in part II of chapter 408 which has or had a 25-percent or greater financial or ownership interest in any other facility licensed under this part, or in any entity licensed by this state or another state to provide health or residential care, which facility or entity during the 5 years prior to the application for a license closed due to financial inability to operate; had a receiver appointed or a license denied, suspended, or revoked; was subject to a moratorium; or had an injunctive proceeding initiated against it.
In addition to the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or for the actions of any facility employee:
An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility.
(i) Knowingly operating any unlicensed facility or providing without a license any service that must be licensed under this chapter or chapter 400.
Section 429.14, Fla. Stat. (2014)
Florida laws also state the following, in addition to the applicable provisions in Section
429.14 in ,i 57, additional bases for license revocation to include unlicensed activity and other grounds:
408.810 Minimum Iicensure requirements.-
In addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license.
(9) A controlling interest may not withhold from the agency any evidence of financial instability, including, but not limited to, checks returned due to insufficient funds, delinquent accounts, nonpayment of withholding taxes, unpaid utility expenses, nonpayment for essential services, or adverse court action concerning the financial viability of the provider or any other provider licensed under this part that is under the control of the controlling interest. A controlling interest shall notify the agency within IO days after a court action to initiate bankruptcy, foreclosure, or eviction proceedings concerning the provider in which the controlling interest is a petitioner or defendant. Any person who violates this subsection commits a misdemeanor of the second degree, punishable as provided ins. 775.082 ors. 775.083. Each day of continuing violation is a separate offense.
Section 408.810, Fla. Stat. (2014)
408.812 Unlicensed activity.-
(!) A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license.
The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an ac_tion for @ injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency.
It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person
or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense.
Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance.
When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s. 408.814 and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation.
In addition to granting injunctive relief pursuant to subsection (2), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules.
Any person aware of the operation of an unlicensed provider must report that provider to the agency.
Section 408.812, Fla. Stat. (2014)
408.815 License or application denial; revocation.-
(}) 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:
An intentional or negligent act materially affecting the health or safety of a client of the provider.
A violation of this part, authorizing statutes, or applicable rules.
Section 408.815, Fla. Stat. (2014)
WHEREFORE, Petitioner seeks to revoke Respondent's license based on all
applicable grounds set forth i,n
57 and if 58.
Exhibits 1 & 2 - as stated.
f-/
Submitted this_£ day of July, 2015.
Edwin D. Selby a
Fla. Bar. No. 262587 .
Assistant General Counsk HCA 525 Mirror Lake Dr N, 330H
St. Petersburg, FL 33701
Ph (727) 552-1942; fax 552-1440
NOTICE OF RIGHTS
Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873.
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.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoin as been served by USPS certified mail, Return Receipt No.7013 2250 0001 4950 3219 on;../-;:;. July, 2015, to Administrator Joelle Smouse, A Safe Haven Assisted Living, LLC, 9000 86th Ave N, Seminole, FL 33777, and by regular USPS mail to Registered Agent Donald Hahn, 9000 86th Ave N,
Seminole, FL 33777. LI( ) //"
U
.
1
Edwin D. Selby, Esq. cc: Patricia Caufman, AHCA Area 5 Field Office Manager
/ / ,,
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
RE. A SAFE HAVEN ASSISTED LIVING, LLC, CASE NOS. 2015002966 2015004836
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 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) 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:
Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any;
The file number of the proposed action;
A statement of when you received notice of the Agency's proposed action; and
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) _
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.
Signed: -----"DC..Ca=t.c...e:'-- _
Print Name: Title:
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
FILED
/.I.HCA
AGENCY CLERK
GUIDED MANAGEMENT, INC.,
2015 APR 20 A fO: 05
vs.
Petitioner,
DOAHNO. 14-5518
AHCA No. 2014010078
License No. 5630
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
File No. 11953249
Provider Type: Assisted Living Facility
Respondent.
-----------------'/
FINAL ORDER
This cause was referred to the Division of Administrative Hearings (DOAH) where the assigned Administrative Law Judge ("ALJ"), Elizabeth W. McArthur, conducted a formal administrative hearing. At issue was whether the Agency for Health Care Administration ("the Agency") properly denied the Petitioner's change of ownership application for an assisted living facility. The Recommended Order of Dismissal dated January 30, 2015, is attached to this Final Order and incorporated by reference. The ALJ subsequently entered an Order Closing File.
FINDINGS OF FACT
The Agency adopts the findings of fact set forth in the Recommended Order of
Dismissal.
CONCLUSIONS OF LAW
The Agency adopts the conclusions of law set forth in the Recommended Order of Dismissal.
ORDER
Based upon the foregoing, the Agency's October 9, 2014, Notice of Intent to Deny for Change of Ownership is upheld and the Petitioner's request for administrative hearing
is dismissed with prejudice. The parties shall govern themselves accordingly.
In accordance with Florida law, the existing license shall not expire for 30 days.
At the conclusion of 30 days or upon the discontinuance of operations, whichever is first in time, the Petitioner shall immediately return the license certificate for the license which is the subject of this action to the appropriate licensure unit in Tallahassee, Florida.
In accordance with Florida law, the Petitioner is responsible for retaining and appropriately distributing all client records within the timeframes prescribed in the authorizing statutes and applicable administrative code provisions. The Petitioner is advised of Section 408.810, Florida Statutes.
In accordance with Florida law, the Petitioner is responsible for any refunds that may have to be made to the clients.
The Petitioner is given notice of Florida law regarding unlicensed activity. The Petitioner is advised of Section 408.804 and Section 408.812, Florida Statutes. The Petitioner should also consult the applicable authorizing statutes and administrative code provisions. The Petitioner is notified that the cancellation of an Agency license may have ramifications potentially affecting accrediting, third party billing including but not limited to the Florida
Medicaid program, and private contracts.
ORDERED on this I,c-d.ay of
C-=l0--1-d ' 2015 in Tallahassee, Florida.
NOTICE OF RIGHT TO JUDICIAL REVIEW
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.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the below-named person(s) by U.S. Mail or the method designated on this .2()of
lpn'/ ,201s.
·
Richard J. Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3
Tallahassee, Florida 32308-5403
(850) 412-3630
Facilities Intake Unit Agency for Health Care Administration (Electronic Mail) | Catherine Anne Avery, Unit Manager Assisted Living Unit Agency for Health Care Administration (Electronic Mail) |
Katrina Derico-Harris Medicaid Accounts Receivable Agency for Health Care Administration (Electronic Mail) | Patricia Caufman, Field Office Manager Local Field Office Agency for Health Care Administration (Electronic Mail) |
Shawn McCauley Medicaid Contract Management Agency for Health Care Administration (Electronic Mail) | Teresita A. Vivo, Assistant General Counsel Office of the General Counsel Agency for Health Care Administration (Electronic Mail) |
Honorable Elizabeth W. McArthur Administrative Law Judge Division of Administrative Hearings (Electronic Filing) | Maritza Perez Guided Management, Inc. 5434 Adams Morgan Way New Port Richey, Florida 34653 (U.S. Mail) |
3
NOTICE OF FLORIDA LAW
408.804 License required; display.--
It is unlawful to provide services that require licensure, or operate or maintain a provider that offers or provides services that require licensure, without first obtaining from the agency a license authorizing the provision of such services or the operation or maintenance of such provider.
A license must be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued.
408.812 Unlicensed activity. --
A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license.
The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency.
It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense.
Any person or entity that fails to cease operation after agency notification may be fined
$1,000 for each day of noncompliance.
When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s. 408.814 and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation.
In addition to granting injunctive relief pursuant to subsection (2), if the agency detennines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of
the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules.
Any person aware of the operation of an unlicensed provider must report that provider to the agency.
STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
GUIDED MANAGEMENT, INC.,
Petitioner,
vs. Case No. 14-5518
AGENCY FOR HEALTH CARE ADMINISTRATION,
Respondent.
I
RECOMMENDED ORDER OF DISMISSAL
Pursuant to notice, the final hearing in this cause was convened on January 22, 2015, at 9:30 a.m. in Tallahassee, Florida, before Elizabeth W. McArthur, Administrative Law Judge, Division of Administrative Hearings (DOAH).
APPEARANCES
For Petitioner: No appearance
For Respondent: Teresita A. Vivo, Esquire
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 STATEMENT OF THE ISSUE
Whether the request for an administrative hearing filed on Petitioner's behalf on November 4, 2014, to contest Respondent's proposed denial of an application to change ownership of a licensed assisted living facility should be dismissed with prejudice because of Petitioner's abandonment of its challenge.
PRELIMINARY STATEMENT
On October 9, 2014, the Agency for Health Care Administration (Respondent) issued a notice to Guided Management, Inc. (Petitioner), advising of the intent to deny Petitioner's application to change ownership of a licensed assisted living facility. Petitioner was informed of its right to contest the denial, and a timely request for a disputed-fact administrative hearing before a DOAH Administrative Law Judge was filed by Maritza Perez on Petitioner's behalf. Respondent forwarded the matter to DOAH, and the case was assigned to the undersigned.
By Initial Order issued on November 21, 2014, the parties were directed to consult and submit information to facilitate scheduling, including dates available for hearing and preferred location. Petitioner did not comply with the Initial Order.
Respondent filed a unilateral response in which it provided its available dates and preferred location, and represented that several attempts were made to contact Petitioner, to no avail. The hearing was set for January 22, 2015, in Tallahassee, Florida, based on the information provided by Respondent and the absence of any contrary information from Petitioner.
A Notice of Hearing and Order of Pre-Hearing Instructions were issued on December 10, 2014. Also issued that day was a separate Order directed to Petitioner, as a corporation, to explain that the corporation was required to designate an
individual to represent the corporation, and provide documentation that the person purporting to represent the corporation was properly authorized by the corporation. In addition, if the representative was not an attorney licensed in Florida, the representative would need to demonstrate qualifications to represent the corporation in the administrative hearing. A deadline of January 8, 2015, was set for the required documentation to be filed. Petitioner was informed that failure to comply with the Order could result in Petitioner not being allowed to participate in the final hearing due to lack of an authorized or qualified representative. Petitioner filed nothing in response to this Order, either by the deadline of January 8, 2015, or thereafter.
Shortly before the hearing, Respondent served a notice that it would take Petitioner's deposition on January 15, 2015, through a corporate representative with knowledge of specific matters listed in the notice. Respondent filed a Motion to Dismiss Petition for Administrative Hearing (Motion) late in the day on January 15, 2015, in which Respondent represented that Petitioner failed to appear at its noticed deposition.
The Motion asserted that, in light of Petitioner's failure to comply with the orders described above, and Petitioner's failure to appear at its noticed deposition, it was apparent that Petitioner had abandoned its request for an evidentiary hearing.
Along with the Motion, Respondent also filed a Motion to Expedite Time for Filing a Response, since the deadline for Petitioner to file a response otherwise would be the day of the final hearing, January 22, 2015. No order was entered expediting the time in which Petitioner could respond to the Motion; instead, ruling on the Motion was reserved.
Petitioner did not file or exchange a witness list, exhibit list, or proposed exhibits, pursuant to the Order of Pre-Hearing Instructions. Respondent timely filed and served its witness list, exhibit list, and proposed exhibits.
The final hearing was convened as noticed. No one appeared at the final hearing on behalf of Petitioner. No one filed anything with DOAH or telephoned DOAH to indicate whether Petitioner did or did not intend to appear at the hearing that it requested. Counsel for Respondent appeared, along with Respondent's representative and witnesses. A court reporter was in attendance, having been retained by Respondent pursuant to its obligation (as stated in the Notice of Hearing) to record the proceedings.
Counsel for Respondent represented on the record that she
received an email communication from Maritza Perez stating that Petitioner would not be appearing at the hearing, and that Petitioner intended to relinquish the license for the assisted living facility.
Respondent renewed the pending Motion, asking the undersigned to dismiss the request for hearing with prejudice. In addition, Respondent made an ore tenus motion on the record for sanctions against Petitioner, and requested the undersigned
to reserve jurisdiction for the purpose of allowing Respondent to reduce its motion to writing and document its costs and attorney's fees incurred.
As summarized below, rather than grant Respondent's Motion to Dismiss, the undersigned is entering this Recommended Order of Dismissal, based on the findings of fact and conclusions of law below. In addition, jurisdiction is reserved to consider Respondent's motion for an award of reasonable attorney's fees and costs as a sanction against Petitioner.
FINDINGS OF FACT
Petitioner is the applicant for a change of ownership of a licensed assisted living facility.
By Notice of Intent to Deny, Respondent gave Petitioner notice that its application would be denied, subject to Petitioner's right to contest the denial in an administrative hearing.
A timely request for an administrative hearing involving disputed issues of material fact was filed on behalf of Petitioner.
However, after filing the hearing request, Petitioner took no further action to avail itself of the hearing it requested. Petitioner failed to comply with requirements specified in the Initial Order, the Order regarding designation of a representative for the corporation, or the Order of Pre Hearing Instructions. Petitioner failed to appear at a duly noticed deposition. Petitioner failed to respond in opposition to a Motion to Dismiss that took the position that Petitioner had abandoned its hearing request. And finally, Petitioner failed to appear at the final hearing that Petitioner had requested.
Based on Petitioner's failure to appear and offer evidence, there is no evidentiary basis on which findings can be made regarding whether Petitioner's application for change of ownership is entitled to approval.
Petitioner did, in fact, abandon its hearing request, but did not do so responsibly, with sufficient notice so that costs would not be incurred convening a hearing when Petitioner apparently did not intend to appear.
Throughout the pendency of this proceeding, Petitioner has been allowed to operate the assisted living facility for which it applied to change ownership. As of the hearing date, Petitioner still had not relinquished the facility's operating license. Despite the fact that Petitioner expressed to Respondent that Petitioner did not intend to appear at the
hearing it requested, Petitioner only communicated a vague intent to relinquish the license to Respondent at some unspecified point in the future.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this proceeding.
§§ 120.569 and 120.57(1), Fla. Stat. (2014).
As the applicant challenging the denial of its change of ownership application, Petitioner has the burden of proving that its application should be approved. Fla. Dep 1 t of Transp. v.
J.W.C. Co., 396 So. 2d 778, 788 (Fla. 1st DCA 1981).
Petitioner failed to meet its burden of proof.
Accordingly, Respondent should take final agency action denying Petitioner's change of ownership application, with such provisions as are necessary or appropriate to close down the assisted living facility that Petitioner has been operating while its hearing request remained pending.
DOAH has jurisdiction to resolve Respondent's ore tenus
motion for sanctions made on the record at the final hearing by separate final order. See, e.g., Procacci Commercial Realty,
Inc. v. Dep't of Health & Rehab. Servs., 690 So. 2d 603, 606 (Fla. 1st DCA 1997). Therefore, while issuance of this Recommended Order of Dismissal serves to relinquish DOAH's jurisdiction over the merits of Petitioner's change of ownership
application, jurisdiction is reserved to consider Respondent's request for sanctions through a separate final order.
Since Petitioner was not present when Respondent made its request for sanctions on the record at the final hearing, Respondent shall set forth its motion for sanctions in writing, which shall be served on Petitioner and filed at DOAH by no later than February 23, 2015. Failure to file and serve a motion for sanctions by the deadline shall be considered a withdrawal of Respondent's ore tenus request for sanctions, and an order will be entered closing DOAH's file.
If Respondent timely files and serves a written motion for sanctions, Petitioner shall file at DOAH any written response to·Respondent's motion that Petitioner wants the undersigned to consider by no later than March 9, 2015. If Petitioner files a written response, Petitioner shall serve a copy of the response on counsel for Respondent at the same time the response is filed at DOAH and certify in its written response that a copy of the response was provide to counsel for Respondent.
RECOMMENDATION
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent, Agency for Health Care Administration, issue a final order: (a) dismissing with prejudice Petitioner's request for an administrative hearing;
denying Petitioner's change of ownership application; and
imposing such requirements for the orderly transfer of any residents and relinquishment of the assisted living facility license as is necessary or appropriate.
Jurisdiction is reserved for consideration of Respondent's motion for sanctions against Petitioner, which will be resolved by separate final order.
DONE AND ENTERED this 30th day of January, 2015, in Tallahassee, Leon County, Florida.
ELIZABETH W. MCARTHUR
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 30th day of January, 2015.
COPIES FURNISHED:
Teresita A. Vivo, Esquire
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 (eServed)
Maritza Perez
Guided Management, Inc. 5434 Adams Morgan Way
New Port Richey, Florida 34653
Elizabeth Dudek, Secretary
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 1
Tallahassee, Florida 32308 (eServed)
Stuart Williams, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 (eServed)
Richard J. Shoop, Agency Clerk
Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308 (eServed)
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions within
15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.
AHCA USE ONLY:
Application#: "5'.'""a /4>
Check#: A S!:2
Cheek Amt:1'7(" 0!:: p...
Batch#:
Ale#: ll 4-5 S-i?Z<!9
Health Care Licensing Application
ASSISTED LIVING FACILITIES
Under the authority of Chaplenl 408 Pait II and 429 Florida Statutas (F.S.). and Chapters 59A-3S and 58A-5, Florida Admlniltratiw Code (F.A.C.), an appllcatiOn II heNby made to operate an anlat8d living facility a indicated below:
Provider / Licensee lnfonnation
A. :-::t.:" .; -= ;. .· ;•:,,.._,.,.,.. J{ ' "'!"'•Jocaf#on. | |||||
ucenae I cror aachange or ownership applcatlone) 5630 | Natlonal Provider Identifier (NPI) (If applicable) | Medlc:are # (CMS CCN) | Medicaid# | ||
Name of As91•tad Living Faclllty (If opetWd under a fictitious name, 11st that here) GUIDED MANAGEMENT, INC. | |||||
Str9etAddresa 5341 PALMETIO ROAD | |||||
City NEW PORT RICHEY | County PASCO | State FL | Zip 34652 | ||
Telephone Number (727) 848-5692 | Fax Number (727) 846-8112 | E-mall Addreu | Provider Website | ||
Malling Address or Same• above (All mall wtn be sent to this addNIIU) | |||||
I | |||||
MARITZA PEREZ | (727) 645-3125 | ||||
Contact e-mail addrese or U Do not have e-n,atl | NOTI:: Bypn:,wtdlngyourNldadcllNayou..-to·--,te-mall coriwpondenoatroih... .. . . . . . | ||||
a . -·:- •·lnfO. imlation-,.... . . . . . • | thef'c>l».W#ni tor the entJt¥SNlt/rlil.-• ,,. ,,,,,,.,, . .. . .·. . . . . ·. . | ||
Licerwee Name (the,. of the corpomlon, LLC, lndlvldual, etc.) GUIDED MANAGEMENT, INC. | Federal Employer Identification Number (EIN) 20-8624285 | ||
Malling Address or Same as above | I I | ||
Telephone Number | Fax.Number | E-mallAddren | |
Deecrlptkm of Ucen888 (check one): For Profit 181 Corporation 0 Umltad Liability Company D Partnership □OlndMdual Other | ft2tfgtProftl e RECEIVED 0 Corporation □0 Rellgloua Affiliation 0 City/County MAR 2 7 2014 Other 0 Hospital Dlatrict Central System& Managomant Unit | ||
AHCA Fonn 3110-1008, Revised May 2013
Page 1 of8
Sedlon 59A-35.060(1 ), Florida Adminiatrative Code
Form available at: h«Q://ahca.myflorida.com/MCHQ/COREBILUINDEX.SHTML
AGENCY EXHIBIT
Application Type, Number of Beds and Fees
Indicate the type of application with an •x.· Applications wlU not be proceeeed If Ill applicable fees are notIncluded. AH fen are nonrefundable. Renewal and Change of Ownership appticatlons must be received 60 days prior to the expiration of1he Rc:ense or the proposed effective date of the change to avoida late fine. If the renewal application ia received by the Agency less than 60 days prior to the expiration date, ItIs subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application pmcess or by separate notice.
TYPE QF APPLICATION
0 Initial Ucensure
Wu this entity previously licensed 88 an Assisted Living FaclHty In Florida? YES O NO 0
I I
ff yes, please provide the name of the agency (If different), 1he EIN # and the year 1he prior license expired or dosed:
j NAME: EIN # Year Expired/Closed:
0 Renewal Lioensure
tBl Change of Ownership
D Change during licensure period
0 Add Specialty License
D lncreaseJDecraase in number of licensed beds {see Section 2E)
D FaciNty Nane Change to:
D Other: (please specify) -
0 Change to lnlstrator (no fee requil9d)
TYPE OF LI<;ENSE
Proposed Effective Date: Proposed Effective Date: 5/28/14
Effective Date of Change:
181 Standard D Limited Nursing Services (LNS) MAR 2'1 2014
181 Limited Mental Health (LMH) 0 Extended Congregate Care {ECC) Cenlnll ·
If applying for an LNS or ECC license, has the facility maintained a standard license for the past two calendar..,..._
licensed if licensed less than two years? 0 YES O NO {STOP - You 8f8 not eligible; please skip to Section C).
If applying for an LNS or ECC license, has the facility been sanctioned during the past two calendar years? D YES O NO If applying for an ECC license, list the total number of ECC beds n,quested:
Identify the building, wing, floor, and rooms designated for ECC services:
□
If applying for a LMH license, does the fadflly currently hold a Standard license and have no uncorrected deficiencies?
YES ONO
RECEIVEE
NUMBER OF BEDS
Pleaae enter the Number of Beds (cummtly lic9ns8d or proposed for initial applicants):
MAR 2 7 20t
Central Syate
Managomant U
If this is a renewal application, did you admit a private pay resident into a designated OSS Bed? D YES
If yes, please remit the fee for the OSS beds used for private pay realdents ($64.00 x # of beds converted=$ l
181 NO
IcIo0u1nEt : ro,.,..an itr,,,.tW.
IIIWDlb. edlplew aee s.cfion·2E. Do not Include the m,aIHllf.JbfH'ofbeds In this
OSS Beds; 6 + Private Pay Beds; 10 = Total Beds (OSS and Prlvale Pay Beds): 16
Number of LNS Beds (if applieableJ:
,Number of ECC Beds {ff appHcableJ: _
UCENSURE FEES - If this application igs to request an inaease or decrease in the number of licensed beds (not for an initial,
renewal or change of ownership} please skip to section 20.
Action | Fee | TOTAL Fl!E8 |
LICENSE FEE Standard A.Lr (Initial, Renewal and Change ofOwnetahip): 0 Uc::ense Fee Exemption (County or Municipal Government pu,-iant to 429.07(5\ F.S.)• $ 0.00 | $64.96 per private pay bed x 10 number of beds+ $387.73 (nottoexceed$14,253.tu) | $ 1037.33 |
Specialty License - Extended Congregate Care (ECC) | $546.07 1- $10.15 per bed x #of beds | $ |
Specialty License - Limited Nursing ServiOe (LNS) | $322.TT+$10.15perbed X # ofbeds | $ |
Specialty License - limited Mental Health (LMH) | NO EXTRA FEE | $-0- |
Biennial Assessment Fee - Not to exceed $300 | $2.00 per bed X 16 # Of beds | $ 32.00 |
Late Fee - If the renewal application Is mailed less than 60 days prior to license expiration date of the license. | $50 per day late fee charge not to exceed one- half of the current license fee or $500. Enter whichever isless. | $ |
Change During Ucensure Period/Replacement license | $ 25.00 | $ 25.00 |
TOTAL FEES INCLUDED WITH APPLICATION: | $ 1094.33 | |
,,,_,,,_ cfteclr ormoneyordflrpayableto IINtAgencytorHedll.c..,.Admlnllttatlon (AHCA} NOTE: Slanerehedcs and lel1')0IIIIY cl1'ICk81118 nottJIOC6Pltd. | ||
INCREAS§lDECREASE IN BED CAPACITY - If requesting an increase or decrease inthe cunent number of ricensed beds (not for an initial, renewal or change of ownership) please complete this section.
Total number of currently licensed beds:
Total number of beds to be O Increased or O Decreased:
Typeof .... | TOTAL FEES | |
Private Pay Beds $64.96 per private pay bed x _ number of new beds | $ $ 0.00 $ $ | |
OSSBeds | No fee f9C1Uired for increase of beds. $25.00 fee to change license $10.15 per bed X _# of beds | |
LNSBeds | ||
TOTAL for SECTION D Pleil# make check ormoney order,,.,.,,,_lo the A,encyftN,-,,,,·Cate Admlnlsndon (AHCA) | ||
NOTE: SMwdHlcband ,,_,c:IMClal.,.nofacceptld. | ||
,..
ADD A SPECIALTY BETWEEN LICENSERENEWAL PERIOD - If 1he facility cummtly holds a Standard license, and this
application is to add an LNS or ECC specialty lia,nse between biennial license renewal periods:
Action | lOTAL FEES | |
Specialty Ucense • Extended Congregate Care (ECC} | $546.07+$10.15perbed X _#ofbeds {fee is proraf9d at $22.75 per month X the I of months until tht license exniru 1- $10.15 tJIJl' bedt | $ |
Specialty Lioense - Limited Nursing Service (LNS) | $322.TT+$10.15perbed x _# ofbeds (fee IS pmrated at 13.44 per month X the #of months untH tht Hctlnse exninls + $10.15_,.hM1I | $ |
c:hange r10e11se | $0.00 | |
TOTAL for SECTION E ,,, make checlcor moneyOldlr,,_,_.II>.._ A//f,nCYfor Hetlfh C.. Admln/attatlon (MICA} | $ | |
. | NOTE: St1111rcllec:b·tnd- no1..,.,,· | |
.Specialty License - Limited Menial Health (LMH) I No fee required for increase of beds. $25.00 tee to
Controlling Interests of Licensee
AUTHORITY:
Pursuant to tectlon 408.806{1}(a) and (b), Florida S1atutes, an application for licenaure muet include: the name, add,...and Social Security number of the applicant and each controlling lntereet, if the applicant or controlllng lntel"Nt is an Individual; and the name, addteM, and federal employer Identification number (EIN) of the applicant and each c:ontroHlng lntenlst. If the applicant or controlling lnlltnlet la not an Individual. Dlecto.ura of Social Security number(e) la mandatory. The Agency for Health Care Adminlatratlon •hall UH tueh lnfonnatlon for purpoM8 of ucurlng the proper Identificationof persons Haled on this application for Dce11111.n. However, In an effort to pn,lact all personal lnfonnatlon, do not Include Soc:lal Security
numbers on this fonn. All Social Security numbera must be en18ntd on the Health ea,.Ucenslng Application Addendum,
AHCA Form 3110-1024.
DEFINITIONS:
Controlling mle'91111, aa defined In eublectlon 408.803(7). Florida Statutes, are the applicant or llc:enaee; a peraon or entity that serves as an officer of, rs on the board of dlrvctora of, or ha• a 5.perc:ent or greaar ownerahlp lnterwt in the applicant or flcenaee; or a person or entity that serves as an officer of, la on the board of dlrector9 of, or has a &-percent or gntaar ownenthip Interest In the
management company or other entity, relabtd or unrelated, with which the applicant or licensee contracts to manage the
provider. The tenn does not Include a volun1ary board member.
Voluntary Board Member, as defined In subNction 408.803(13), Florida Statutae, means a board member orofficer of a not. for.profit corporation or organization who aervee solely In a voluntary capacity, don not recetve any remuneration for hie or her Hrvlces on the board of directors, and has no tfnanclal Interest in the cOll)On.tlon or organization.
In Sections A and B below, provide the infonnation for each indlvidual or entity (corporation, partnership, aeaoclatlon) with
5% orgreater ownership interest In the licensee. Attach additional sheet& If necessary.
FULL NAME.of lNDMIJUAL or INfflV• | PER80NAL IIUSINE8S ADDREl9 | TELEPHONE NUIIIIER | (NolSNa). | % |
·CJINNIRIHIP | ||||
IN'fMES\" | ||||
MARITZA PEREZ | 5434 ADAMS MORGAN WAY NEWPORT RICHEY, FL 34653 | (727) 645-3125 | RECEIVE' | 100% ) |
I | ||||
1¥1/"\I\ I L.U | T | |||
Central Syster -- ,. ..... .,,, | !18.. ,.,. |
.- ,. - - 1111 AA
Individual and/or Entity Ownership of Licensee -
Board Members and Officers of Licensee
···-
fflLE | FULLNAIIE | . PERSONAL OR IUSINE88.ADDRl88 | TELPHONI NUIIIER | .OME"ft811P |
ICIERl!iST | ||||
Director/CEO | ||||
PrNident | ||||
Vice Prnident |
Voluntary Board Members and Officers of Ucensee
If the lieenSee Is a not.for-profit corporation/orgnization,provide the requested information for each indfvldual that serves as a voluntary board member. Attach additional sheets if necessary.
RILLNAIii!. | TaEPHONE._.... | |
Administration
·• nn.E.. | . NAME | E....._ | |
Administrator/Managing EmDlovee | DONALD KAHN | 813-4-82--874-5 | ddk11hnt1rn1 1 com |
Chief Financial Officer/ Person responsible for financial operations | MARITZA PEREZ | 727-6453125 | m rez93 vahoo.com |
Management Company Controlling Interests
Does a company other than the licensee manage the llcenaad provider?
If IZI NO, skip to section 5 - Required Disclosure.
If D YES, provide the following infonnation:
RECEIVII
MAR 2 7 2014
Name of Management Company | j | EIN (No SSNs) | Telephone Number/ FalJl9(1lfal '6yattt MlnagemAnt , | ||||
Street Address | I | j E-mail Address | I | ||||
Malling Address or USame as above | |||||||
City | State | j Zip | |||||
Contact Person | Contact E-mail | Contact Telephone Number | |||||
11:8
nit
In Sections A and B below, provide the infonnatlon for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest In the management oompany. Attach additional sheets if necessary.
Individual and/or Entity Owne,ship of Management Company
Board Members and Officers of Management Company
nn.e | FULLNAIIE | PERSONAL OR IUSINE8IADOREi8:. . | NIJIIIER· | % ·ltnEREIT |
Director/CEO | ||||
President | ||||
Vice President | ||||
Secretary | ||||
Treasurer | ||||
Other: |
'TEU;PtlO.tle
Voluntary Board Members and Officers of Management Company
If the management company is a not-for-profit corporation/organization,provide the requested infonnation for each individual that
Hrvel as a voluntary board member. Attach additional sheets if necessary.
FULL NAME· | PERSONAL OR BUSINEIS ADDRE88 | 1ELEPHONI NUIIIER | |
Central Systems
Management Unit
Required Disclosure
The following diacloaurea are required:
Pursuant to subsection 408.809(1}(d), F.S., the applicant shall submit to the agency a description and explanation of any
convictions of offenses prohibited by sectiOns 435.04 and 408.809(5), F.S., for each conbolllng interest.
Has the applicant or any Individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to subsection 408.809{1)(d), Florida Statutes? (These offenses are listed on the Affidavit of Compliance with Backgroynd Screening Reqyirements. AHCA Form #3100-0008.) YES O NO 181
If yes, enclose the foUowing infonnation:
D The full legal name of the ind'ividual and the position held
DA description/explanation of the conviction(s)-lfthe individual has received an exemption from disqualification for the
offense, include a copy
Pursuant to section 408.810(2), F.S., the applicant must provide a description and explanation of any exclusions, suspensions, or
terminations from the Medicare, Medicaid, or federal Clinical Laboratory Improvement Amendment (CUA} programs.
.Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily withdrawn from participation in Medicare or Medicaid in any state? YES O NO
If yes, enclose the following infonnation:
0 The full legal name of the individual and the position held
0 A description/explanation of the exdusion, suspension, termination or Involuntary withdrawal.
Pursuant to section 408.815(4), F.S., does the applicant or any controlling interest in an applicant have any of the following:
YES O | NO181 | Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, within the previous 15 years prior to the date of this application; |
YES O | NO 181 | Terminated for cause from the Florida Medicaid program pumiant to s. 409.Q1 . and not been in good standing with the Florida Medicaid program for the most recent 5 years; |
YES D | NO181 | Terminated for cause, pursuant to the appeals procedures established by the state or federal government, from the federal Medicare program or from any other state Medicaid program, have not been in good standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and the termination was less than 20 years prior to the date of this application. |
Provider fines and Financial Information
Pursuant to subsection 408.831(1)(a), Florida Statutes, the Agency may take action against the applicant, lic:ensee, or a licensee which shares a common control&ng interest with the applicant If they have failed to pay all outtlanding 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? YES 0
If yes, please complete the following for each Incidence (attach additional sheets if necessary):
Amount: $
assessed by: 0 Agency for Health Care AdministrationCase#
0 CMS
Date of related inspection, application or overpayment period if applicable: Due date of payment: _
Is there an appeal pending from a Final Order? YES O NO D
Please attach a copy of Iha approved repayment plan If applicable.
Other Program Specific Information
RECEIVED
MAR 2 7 2014
Central System,
Managoment Unit
Please provide the following information for the requested positions:
A. Does the owner, administrator, or any facilty representative se,ve as "representative payee· or as power of attorney for any ALF residents? 0 YES 1'81 NO
,_. .. ,_,....,_• .,.indMdull or \\torl!QIMI on behalf of a (Le;IOCialNGUllty
securlyo, - }.·AIWldentniuitglveei:lnientfoi'anowner,admhdll(illOroff'aC!IIIIY......,.tolCt11thielr···
·payeeorpower.dallomay. .
If yes, section 429.27(2), F.S., states that you must obtain a surety bond or continuum bond from a licensed surety company. Has
a surety or continuum bond been obtained? 0 YES 181 NO Please attach acopy.
Is the ALF a part of acontinuing care retirement community (CCRC) pursuant to Chapter 651, F.S.? 0 YES 181 NO
If yes, attach acopy of your Certificate of Authority With the initial or change of ownership appl tion.
C. Does the ALF participate in a Medicaid Waiver program? lkrYES O NO If yes, please provide your Medicaid number: i#9',;/ JOO
tic
8. Affidavit
I, U;,{J rLY swear or affinn, under penally of perjury, that the•-Isin this
app i n are true and . As adminiStrator or authorized representative of the above named provider/facility, I
hereby attest that all employees required by law to undergo Level 2 background screening have met the minimum standards of sections 435.04, and 408.809(5), Florida Statutes (F.S.) or are awaiting screening results.
In addition, I attest that all employees subject to Level 2 screening standards have attested to meeting the requirements for qualifying for emplo ·-aiii:I agree to inform me immediately if convicted of any of the disqualifying offenses while
employed here Q,-;,i,eicified in subsection 435. , S.
1
Title
Notice: If you are a Medicaid provider, you may have a separate obligation to notify the Medicaid program of a name/address change, change of ownership or otherchange of information. Please refer to your Medicaid handbooks for additional information about Medicaid program policy regarding changes to provider enrollment Information.
RETURN THIS COMPLETED FORM WITH FEES AND ALL REQUIRED DOCUMENTS TO:
AGENCY FOR HEALTH CARE ADMINISTRATION ASSISTED LIVING UNIT
2727 MAHAN DR., MS 30
TALLAHASSEE FL 32308-5407
Queations?
Review the infonnation available at hgp://ahca.myfforida.com/
or contact the Agency at (850) -412-4304
RECEIVED
MAR 2 7 2014
Central Syutema
Management Unit
AHCA F0f111 3110-1008, Revised May 2013 Section 59A-35.060(1), Florida Administrative Code
Health Care Licensing Application ASSISTED LIVING FACILITIES
Under UM, authority of Chapters 408 Part II and 429 Florida Statutes (F.S.), and Chapters 59A-35 and 58A-5, Florida Administrative Code (F.A.C.), an application is hereby made to operate an assisted living facility as indicated below:
Provider / Licensee Information
A. Provider Information - please complete the following for the assisted living facility name and location. Provider name, address and laleahone number will be lls1ed on ldJn:l/www-. -ndtw.aov/ | ||||
License # (for renewal & change of ownership applications) 12103 | National Provider Identifier (NPI) (if applicable) 1003175936 | Medicare # (CMS CCN) | Medicaid# | |
Name of Assisted Living Facility (If operated under a fictitious name, list that here) A SAFE HAVEN ASSISTED LIVING, LLC | , | |||
Street Address 9000 86TH AVENUE, NORTH | ||||
SEMINOLE | PINELLAS | FL | 33777 | |
Telephone Number (727) 623-9073 | Fax Number (727) 623-9093 | E-mail Address | Provider Website | |
Mailing Address or181 Same as above (All mall will be sent to this address) I | I | |||
I | ||||
Maritza Perez | (727) 645-3125 | |||
Contact e-mail address or D Do not have e-mail | NOTE: By provtding your Hnail address you agrve to accept e-mail correspondence from1he Agency | |||
8. Ucensee Information - please complete the following for the entity seeking to operate the assisted living facilltv. | |||
Licensee Name (the name of the corporation, LLC, individual, etc.) A SAFE HAVEN ASSISTED LIVING, LLC | Federal Employer Identification Number (EIN) 27-4130957 | ||
Mailing Address or IZI Same as above | I | I | |
Telephone Number | Fax Number | E-mail Address | |
Description of Licensee (check one): For Profit D Corporation 181 Limited Liability Company 0 Partnership □D Individual Other | Not for Pmfit 0 Corporation □D Religious Affiliation Other | □Public State 0 City/County 0 Hospital District | RECEIVED OCT 15 2013 Central Systems Management Unit |
AHCA Form 3110-1008, Revised May 2013
Page 1 of8
Sedion 59A-35.060(1), Florida Administrative Code Form available at: http://ahca.mytlorida.com/MCHO/COREBILL/INDEX.SHTML
AHCA USE ONLY:
File#: I/{}tz ft I 5 9
Application #: 5 lc/ 7 2..
- /5a
Check#: IS-Oft,
Batch#: IO 3606 7.. 5 z-
Check Amt: 5"S z, uo - $®, cflJ
Application Type, Number of Beds and Fees
Indicate the type of application with an "X•. Applications will not be processed if all applicable fees are not included. All fees are
nonrefundable. Renewal and Change of Ownership applications must be received 60 days prior to the expiration of the license or the proposed effective date of the change to avoid a late fine. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice.
A. TYPE OF APPLICATION
O Initial Licensure
Was this entity previously licensed as an Assisted Living Facility in Florida? YES O NO D
If yes, please provide the name of the agency (if different), the EIN # and the year the prior license expired or closed:
l NAME: I EIN # I Year Expired/Closed:
D Renewal Licensure
181 Change of Ownership Proposed Effective Date: 1143
D Change during licensure period
D Add Specialty License
0 Increase/Decrease in number of licensed beds (see Section 2E)
0 Facility Name Change to:
D Other: (please specify)
D Change to Administrator (no fee required)
Proposed Effective Date:
Effective Date of Change:
8. TYPE OF LICENSE
Standard
0 Limited Mental Health {LMH)
0 Limited Nursing Services (LNS)
D Extended Congregate Care (ECC)
If applying for an LNS or ECC license, has the facility maintained a standard license for the past two calendar years, or since initially licensed if licensed less than two years? 0 YES D NO (STOP - You are not eligible; please skip to Section C)
If applying for an LNS or ECC license, has the facility been sanctioned during the past two calendar years? D YES D NO If applying for an ECC license, list the total number of ECC beds requested:
Identify ttle building, wing, floor, and rooms designated for ECC services: -
If applying for a LMH license, does the facility currently o :sstan cense and have no uncorrected deficiencies? RECEIVED
NUMBER OF BEDS
OCT 15 2013
Central Systems
Please enter the Number of Beds (currently licensed or proposed for initial applicants): Management Unit
If this is a renewal application, did you admit a private pay resident into a designated OSS Bed? D YES NO
If yes, piease remit the fee for the OSS beds used for private pay residents ($64.00 x # of beds converted ;:$ J
NOTE: To request an increaseldecmase in the number of beds p/eBSB see Section 2E. Do not include the increase/dea'e8S8 numb8r of_ beds in this
count.
OSS Beds: _ + Private Pay Beds: _ = Total Beds (OSS and Private Pay Beds):
Num r of LNS Beds (if applicable): _
Number of ECC Beds (if applicable): _
UCENSURE FEES - If this application is Q!1ll to request an increase or deaease in the number of licensed beds (not for an initial, renewal or dlange of ownership) please skip to section 20.
Action | Fee | TOTAL FEES |
LICENSE FEE Standard ALF (Initial, Renewal and Change of C>Nnership): D License Fee Exemption (County or Municipal Government pursuant to 429.07(5), F.S.)== $ 0.00 | $64.96 per private pay bed x 2 number of beds+ $387.73 (not to exceed $14,253.64-) | $ 517.65 |
Specialty License - Extended Congregate Care (ECC) | $546.07 +$10.15 per bed X # of beds | $ |
Specialty License - Limited Nursing Service (LNS) | $322.77+$10.15perbed x # ofbeds | $ |
Specialty License - Limited Mental Health (LMH) | NO EXTRA FEE | $-0- |
Biennial Assessment Fee | $2.00 per bed x 20 # of beds | $ 40.00 |
Late Fee - If the renewal application is mailed less than 6·0 days prior to license expiration date of the license. | $50 per day late fee charge not to exceed one-- half of the current license fee or $500. Enter whichever is less. | $,SOO.()c) |
Change During Ucensure Period/Replacement License | $ 25.00 | $ 25.00 |
TOTAL FEES INCLUDED WITH APPLICATION: | $ 1082.65 | |
Please make check or money order payable u, the Agency for Health Cant Administration (AHCA) NOTE: Starter checks and temporary checl<s are not acoepted. | ||
INCREASE/DECREASE IN BED CAPACITY - If requesting an increase or decrease in the current number of licensed - IVED
for an initial, renewal or change of ownership) please complete this section. OCT 15 2013
Total number of currently licensed beds:
Total number of beds to be O Increased or O Decreased:
--c.e.ntral Systems
Type of Beds | #Increased | #Decreased | License Fee | ToTAL FEES |
Private Pay Beds | $64.96 per private pay bed X number of new beds | $ | ||
OSSBeds | No fee required for increase of beds. $25.00 fee to change license | $ 0.00 | ||
LNSBeds | $10.15perbed X _ #of beds | $ | ||
LMHBeds | No fee required for increase of beds. $25.00 fee to change license | $0.00 | ||
ECCBeds | $10.15perbed X -- #of beds | $ | ||
TOTAL for SECTION D | $ | |||
Please make check or money order payable u,the Agency for Health Care Administration (AHCAJ NOTE: Staner checlcs _,d tempo,Bry checlcs ant not acc:epfed. | ||||
- t Unit
ADD A SPECIALTY BETWEEN LICENSE RENEWAL PERIOD - If the facility currently holds a Standard Hcense, and this application is to add an LNS or ECC specialty license between biennial license renewal periods:
Action | Fee | TOTAL FEES |
Specialty License - Extended Congregate Care (ECC) | $546.07+$10.15perbed x #ofbeds (fee is prorated at $22.75 per month x the # of months until the license exDires +$10.15 oer bedJ | $ |
Specialty License - limited Nursing Seivice (LNS) | $322.n+$10.15perbed x # of beds (fee is prorated at 13.44 per month x the # of months until the ficense exoires + $10.15oerbedl | $ |
Specialty License - Limited Mental Health (LMH) | No fee required for increase of beds. $25.00 fee to change license | $0.00 |
TOTAL for SECTION E | $ | |
Please make check or money order payable to the Agency for Health Care Administntion (AHCA) NOTE: St.arler Chee/cs and temporary checlcs are not accepted. | ||
,
Controlling Interests of Licensee
AUTHORITY:
Pursuant to section 408.806(1)(a) and (b), Florida Statutes, an application for licensure must Include: the name, address and Social Security number of the applicant and each controlling interest, if the applicant or controlling intent&t is an Individual; and the name, address, and federal employer identification number (EIN) of the applicant and each controlling interest, if the applicant or controlling Interest is not an individual. Disclosure of Social Security number(s) Is mandatory. The Agency for
Health Care Administration shall use such infonnation for purposes of securing the proper identification of persons listed on this application for licensure. However, in an effort to protect all personal infonnation, do not Include Social Security numbers on this form. All Social Security numbers must be entered on the Health Care Licensing Application Addendum,
AHCA Fonn 3110-1024.
DEFINITIONS:
Controlling Interests, as defined in subsection 408.803(7), Florida S1atutes, are the applicant or licensee; a person or entity that serves as an officer of, is on the board of directors of, or has a 5-pereent or greater ownership interest in the applicant or licensee; or a person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the
management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The tenn does not include a votun1ary board member.
Voluntary Board Member, as defined in subsection 408.803(13), Florida Statutes, means a board member or officer of a not for-profit corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the board of directors, and has no financial interest in the corporation or organization.
In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership Interest in the licensee. Attach additional sheets if necessary.
Individual and/or Entity Ownership of Licensee
FULL NAME of INDMDUAL or ENTITY | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER | EIN (NoSSNs) | % OWNERSHIP INTti:REST |
JACQUELINE MIDDLETON | 18625 White Pine Circle Hudson, FL 34667 | (352) 942-3519 | 5% | |
SHEILA GARCIA | 2257 CIMARRON TERRACE PALM HARBOR, FL 34683 | (727) 510-7980 | -_-..-..-1:•v■1=n | 20% |
MARITZA PEREZ | . 5434 ADAMS MORGAN WAY NEW PORT RICHEY, FL 34653 | (727) 645-3125 | - nr r 1 1:;: 1n1'l | 75% |
....,_ - - -.- iv |
Board Members and Officers of Licensee
Central Systems
Management Unit
TITLE | FULL NAME | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER | % OWNERSHIP INTEREST |
DlrectorlCEO |
Presi nt | ||||
Vice President | ||||
Secretary | ||||
Treasurer | ||||
other: |
Voluntary Board Members and Officers of Licensee
If the licensee is a not-for-profit corporation/organization, provide the requested infonnation for each individual that serves as a voluntary board member. Attach additional sheets if necessary.
FULL NAME | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER · |
Administration
TITI.E | NAME | TELEHPONE NUMBER | E.filAIL |
Administrator/Managing Emolovee | JACQUELINE MIDDLETON | 352-942-3519 | jmiddleton1956(@,hotm.ail.eom |
Chief Financial Officer I Person responsible for financial ooerations | MARITZA PEREZ | 727-645-3125 |
Management Company Controlling Interests
Does a company other than the licensee manage the licensed provider?
If D NO, skip to section 5 - Required Disclosure.
If O YES, provide the following information:
Name of Management Company
EIN (No SSNs)
Telephone Number/ Fax
Street Address
E-mail Address
City County
Mailing Address or Same as above
City OCT
state Zip
State Zip
Contact Person Contact E-mail
Central Systems
Contact Telephone Number
In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary.
Individual and/or Entity Ownership of Management Company
FULL NAME of INDMDUAL or ENTllY | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER | EIN (NoSSNs) | %OWNERSHIP INTEREST |
Board Members and Officers of Management Company
TITLE | FUUNAME | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER | %OWNERSHIP INTEREST |
Director/CEO | ||||
President | ||||
Vice Pr9Sident | ||||
Secretary | ||||
Treasurer | ||||
Other: |
Voluntary Board Members and Officers of Management Company
If the management company is a not-for-profit corporation/organization, provide the requested information for each Individual that
serves as a voluntary board member. Attach additional sheets if necessary.
FULL NAME | PERSONAL OR BUSINESS ADDRESS | TELEPHONE NUMBER |
Required Disclosure
The following disclosures are required:
RECEIVED
OCT 15 2013
Central Systems Management Unit
Pursuant to subsection "408.809(1)(d), F.S., the applicant shall submit to the agency a desaiption and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809(5), F.S., for each controlling interest.
Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to subsection 408.809(1)(d}, Florida Statutes? (These offenses are listed on the Affidavit of Compliance with Background Screening Requirements, AHCA Form #3100-0008.) YES O NO 1ZJ
If yes, enclose the following information:
0 The full legal name of the individual and the position held
D A desaiptionfexplanation of the conviction(s) - If the individual has received an exemption from disqualificatiOn tor the
offense, include a copy
Pursuant to section 408.810(2}, F.S., the applicant must provide a description and explanation of any exclusions, suspensions, or ter'minations from the Medicare, Medicaid, or federal Clinical Laboratory Improvement Amendment (CUA} programs.
Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily withdrawn from participation in Medicare or Medicaid in any state? YES D NO 181
If yes, enclose the following information:
0 The full legal name of the individual and the position held
D A description/explanation of the exclusion, suspension, termination or involuntary withdrawal.
Pursuant to section 408.815(4), F.S., does the applicant or any controlling interest in an applicant have any of the following:
YES D | NO 1.81 | Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss. 801-970, or42 U.S.C. ss. 1395-1396, within the previous 15 years prior to the date of this application; |
YES D | NO 1.81 | Terminated for cause from the Florida Medicaid program pursuant to s. 409.913, and not been in good standing with the Florida Medicaid program for the most recent 5 years; |
YES D | NO 181 | Terminated for cause, pursuant to the appeals procedures established by the state or federal government, from the federal Medicare program or from any other state Medicaid program, have not been in good standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and the termination was less than 20 years prior to the date of this application. |
Provider Fines and Financial Information
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? YES D
If yes, please complete the following for each incidence (attach additional sheets if necessary):
Amount: $
assessed by: D Agency for Health Care Administration Case#
D CMS
Date of related inspection, application or overpayment period if applicable: Due date of payment:
Is there an appeal pending from a Final Order? YES 0 NO □
Please attach a copy of the approved repayment plan if applicable.
Other Program Specific Information
Please provide the following information for the requested positions:
RECEIVED
oct I 5 2013
Central Systems Management Unit
A. Does the owner, administrator, or any facility representative serve as "representative payee" or as power of attorney for any ALF residents? 0 YES 181 NO
Repruentatlve Payee is an individual or entity who receives payments on behalf of a resident (i.e. social security benefits, supplemental social security.C>r optional state supplementation). A resident must give consent for an owner, administrator or facility repiesentative to act as their rep.._.ntatNe payee or power of attorney.
If yes, section 429.27(2), F.S., states that you must obtain a surety bond or continuum bond from a licensed surety company. Has a surety or continuum bond been obtained? D YES D NO Please attach a copy. ·
B. Is the ALF a part of a continuing care retirement community (CCRC) pursuant to Chapter 651, F.S.? 0 YES 181 NO If yes, attach acopy of your Certificate of Authority with the initial or change of ownership application.
C. Does the ALF participate in aMedicaid Waiver program? 0 YES 181 NO If yes, please provide your Medicaid number:
Affidavit
I, ,f14r k [ /i,bq :hereby swear or affirm, under penalty of perjury, that the statements in this application are true and correct. As administrator or authorized representative of the above named provider/facility, I
hereby attest that all employees required by law to undergo Level 2 background screening have met the minimum standards of sections 435.04, and 408.809(5), Florida Statutes (F.S.} or are awaiting screening results.
In addition, I attest that all employees subject to Level 2 screening standards have attested to meeting the requirements for qualifying for employment and agree to inform me immediately if convicted of any of the disqualifying offenses while employed here as specified i subsection 435.04(5), F.S.
/P-11.-IJ
Date
Notice: If you are a Medicaid provider, you may have a separate obligation to notify the Medicaid program of a name/address change, change of ownership or other change of information. Please refer to your Medicaid handbooks for additional infonnation about Medicaid program policy regarding changes to provider enrollment information.
RETURN THIS COMPLETED FORM WITH FEES AND ALL REQUIRED DOCUMENTS TO:
AGENCY FOR HEALTH CARE ADMINISTRATION ASSISTED LIVING UNIT
2727 MAHAN DR., MS 30
TALLAHASSEE FL 32308-5407
Questions?
Review the information available at http://ahca.myflorida.com/
or contact the Agency at (850) 412-4304
RECEIVED
OCT 15 2013
Central Systems Management Unit
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July 11, 2015 , 10:53 am
Delivered
SEMINOLE, FL 33777
Your item was delivered at 10:53 am on July 11. 2015 in SEMINOLE, FL 33777.
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. . Administrator, Joelle Smouse A Safe Haven Assisted livr , LLC
9000 86th Ave N. Seminole, .FL 33777
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07/29/2015 17:56 7278469109 JOHN ROSS PAGE 01/03
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
RE. A SAFE HAVEN ASSISTED LMNG, LLC, CASE NOS. 2015002966
2015004836
EL CTION OF RIGHTS
to
This Election of Rights form is attached to .a proposed action by the Agency for Health Cate Administration (A.HCA). The title may be·Notice of Jntent to Impose a Late Fee, Notice of Intent Impose ajLate Fine or Administrative Complaint.
Your Election of '.Rights must be returned by mail or by fax within 21 days of the day :voy receive fl\e attached Notice of Intent to Im_pose a Late Fee, Notice, of Intent to Imgose a Late Fine or Administrat\ive Complaint.
If yoQr 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 ARCA, you will have
.given up your right!to contest the Agency's proposed action and a final order will be issued.
-
(Please use this fo1T[1 unless you, your attorney or your representative preferto reply according to
Chapter 120, Florida Statutes and Rule 28, Florida Administrative Code.) PLEASE RETUR]'f YOQRE,LECTION OF RlGHTS TO THIS ADDRESS:
Agency for Health Care Administration·
· Attention: Agency Clerk
2727 Mahan Drive) Mail Stop #3
Tallahassee, Florid 32308
Phone: (850) 412- 630 Fax: (850) 921-0158
PLEASE SELECT ONLY l OF THESE 3 OPTIONS
c.r,
c::::t
OPTION ONE (l) Iadmit 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 Late Fee, the Notice of Iritent 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 vidence to the Agency to show that the proposed administrative action is too severe or that the fine should.be ,:educed.
OPTION TIIREE (3) .J{_ I dispute the allegations of fa.ct contained in the Notice of Intent to Impose i Late Fee, the Notice of Intent to Impose a Late :Fine, or Administrative Coin.plaint, and ;I requ.est a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before Administrative Law Judge appointed by the Division of Adminimative Hearings.
lfj
STATE OF FLORIDA
. AGENCY FOR HEALTH CARE ADMINISTRATION
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
Petitioner,
DOAH CASENO.15-4631
AHCA CASE NOS. 2015002966
. 2015004836
A SAFE HAVEN ASSISTED LIVING, LLC,
Respondent.
/
SETTLEMENT AGREEMENT
The State of Florida, Agency for Health Care Administration (hereinafter "the Agency"), and A Safe Haven Assisted Living,. LLC, and Maritza Perez, individually (hereinafter "the Licensee"), pursuant to Section 120.57(4), Florida Statutes, enter into this Settlement Agreement ("Agreement") and agree as foHows:
WHEREAS, the Licensee was at all times relevant an Assisted Living Facility ("ALF:')· licensed pursuant to Chapters 408, Part II and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code; and
WHEREAS, the Agency issued the Licensee an Administrative Complaint in this matter notifying it of the Agency's intent to impose $4,000 in fines and to revoke its license; and
WHEREAS, the Licensee requested a formal hearing; and
WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of1his proceeding; and .
NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound agree as follows:
All recitals herein are true and correct and are expressly incorporated herein.
The parties agree that the ''whereas" clauses incorporated herein are binding findings of the parties.
a. Upon full execution of this Agreement, the Licensee agrees to waive any and all appeals and proceedings to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), Florida Statutes, a formal proceeding under Subsection 120.57(1), Florida Statutes, appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or.quasi-court of competent jurisdiction; and agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it
. may be entitled., provided, however, that no agreement herein shall be deemed a waiver by either
party of its right to judicial enforcement of this Agreement.
b. DOAH case no. 15-4631. Specifically, immediately after the rendering of the Final Order Respondent shall enter into a joint motion with the.ARCA to move to relinquish jurisdiction of DOAH case·no. -15-4631· and cooperate fully until such jurisdiction is·m facr relinquished.
Upon full execution of this Agreement, the parties agree as follows:
Change of owner provisional licensure.
Upon the rendering of this Final Order the Agency shall grant the new owner/licensee, to wit, Seminole Senior Living, LLC, a six month provisional license in accordance with the terms set forth in the Agency's 12 October, 2015, letter attached as Ex. A. However, the fines identified below must be paid in full as a condition precedent to the issuance of the provisional license to the new licensee notwithstanding full compliance with all of the requirements set forth in the Agency's 10/12/15 change of ownership letter at Ex. A.
Fines.
Respondent shall· pay $4,000.00 by no later than within 30 days of the date this Final
l Order is rendered. As stated in subparagraph a. above, payment is full is a condition precedent to provisional Iicensure for Seminole Senior Living, LLC.
Prohibition Against Future Licensure. Respondent, and Maritza Perez, individually, ·agree that commencing on the date she signs this Agreement on behalf of both Respondent and herself, neither Respondent nor she shall thereafter:
apply for any type of license issued by the Agency; nor
hold or obtain any type of ownership interest, direct or indirect, or as an officer or board member, in any type of entity that holds or applies for a license issued by the Agency;
nor
hold or obtain any type of ownership interest, direct or indirect, in any
management company or other entity that operates·or manages a licensee issued by the Agency;
nor
-
Nothing in this Agreement limits the Agency's authority to deny new licensure based on
· any other eligibility criteria prescribe4 by law should either Respondent or she, notwithstanding the above prohibitions, apply in the future for any Agency license in any of the capacities set forth above.
Venue for any action brought to enforce the terms of this Agreement or the Final Order shall lie solely in Circuit Court in Leon County, Florida.
Notwithstanding the execution of this Agreement, the Licensee still denies the allegations set forth in the Administrative Complaint but recognizes that the Agency asserts the validity of the allegations raised therein. This Agreement shall not preclude the Agency from imposing a penalty against current Licensee for any deficiency/violation of statute or rule identified in a future survey of the Licensee, which constitutes an uncorrected deficiency from urveys identified in the Administrative Complaint.
This Agreement shall not preclude the Agency from using the deficiencies
identified in either or both actions in any decision regarding Iicensure of Licensee, including, but not limited to, licensure for limited mental health, limited nursing services, extended congregate care, or a demonstrated pattern of deficient performance. The Agency is not precluded from using the subject events for any purpose 'Within the jurisdiction of the Agency. Further, Licensee acknowledges and agrees that this Agreement shall not preclude or estop any other Federal, State, or local agency or office from pursuing any cause of action or taking any action, even if based on or arising from, in whole or in part, the facts raised in either or both actions. This Agreement does not prohibit the Agency from taking actic;m regarding the Licensee's ·Medicaid provider status, conditions, requirements or contract.
Upon full .execution of this Agreement the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and closing the above-styled case.
Each party shall bear its own costs and·legal fees.
This Agreement shall become effective on the date upon which it is fully executed
·· by all the partietf
The Licensee for itself and for all related or resulting organizations, successors or transferees, attorneys, heirs, and executors or administrators, discharges the State of Florida, Agency for 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 in any Federal or State court or administrative forum, including any claims arising out of this agreement, by or on behalf of Licensee or related facilities.
12,. This Agreement is binding upon all parties herein and those identified in the above paragraph of this Agreement.
In the event that the Licensee was a Medicaid provider at the subject time of the
occurrences alleged in the complaint herein, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 590-9.070, Florida Administrative Code.
The Licensee agrees that if any funds to be paid under this Agreement to the Agency are not paid as set forth above, this Final Order permits the Agency to deduct the amount assessed, or any portion thereof, from any present or future funds owed to the Licensee by the Agency, and that the Agency shall hold a lien against present and future funds owed to the Licensee for said amount until paid in full.
The undersigned have read and understand this Agreement and have the authority to bind their respective principals to it. Licensee's principal has the capacity to execute this Agreement. Licensee's principal understands that it has the right to consult with counsel and has knowingly and freely entered into this Agreement without exercising its right to consult with counsel. Licensee's principal affirms that she understands counsel for the Agency represents solely the Agency and Agency c6un.se1 has not provided legal advice to orinfluenced
Respondent in its decision to enter into this Agreement·.
This Agreement contains and incorporates the entire understandings and agreements of the parties. This Agreement supersedes any prior oral or written agreements between the parties. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void.
CONTINUED ON PAGE 6
All parties agree that facsimile and scanned signatures suffice for original signatures.
Enclosure - Ex. A (as stated)
1ste 1vmg,
The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement.
s y, Deputy Secretary Division o· th Quality Assurance Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, FL 32308
DATED: tt(Vs/,
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tuart F. Williams, General Counsel
Florida Bar No. 67031
Agency for Health Care Administration 2727 Mahan Dr, l\Jail Stop #3 .
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DATED:
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Edwin D. Selby, Assistant Gen Florida Bar No. 262587
Agency for Health Care Administration
525 Mirror Lake Dr., Suite 330 St. Petersburg, FL 33701
DATED: / .O I
900 veN.
r, i,!IPY(I#.;, Notary Public State of Flo
<; Mary A White
: j MyCommissionEE161P
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Seminole, FL 33777 DATED: /O-Zb--/[i
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October 12, 2015
Joelle Smouse, Administrator Seminole Senior Living LLC 5901 US Highway 19
New Port Richey, FL 34652
RICK SCOTT GOVERNOR
ELIZABETH DUDEK
SECRETARY
rossljdr@grnai].com; joelle14l@grnail.com
FileNumber: 11968159
License Number: 12103 Provider Type: A L F
RE: A Safe Haven AL, license number 12103, 9000 86 Avenue N, Seminole
Dear Ms. Smouse:
Your change of ownership (CHOW) application for a license has been accepted pending receipt of your proof of ownership (warranty deed/lease/operations transfer agreement) and liability insurance in the name of the applicant. These documents should be dated on or after November 14, 2015, which will be the end of the 60 day required application period. Once this infonnation is received a provisional license will be issued to Seminole Senior Living LLC.
A six month provisional license will be issued to the new licensee. During the six month provisional Iicensure period, the field offiqe will conduct a CHOW survey at the facility under the new ownership. If the field office finds no deficiencies, then a recommendation is given to the Tallahassee Central Office to issue a standard Iic.ense for a twoayearperiod less the time of the· provisional license.
If you need further assistance, please call me at (850) 412-4304. Sincerely,
;v
Patrice Spicer
Health Services and Facilities Consultant Assisted Living Unit
2727 Mahan Drive •MS#30 Tallahassee, FL 32308 AHCA.MyFlorida.com
Facebook.com/AHCAFlorida Youtu be.com/AHCAFlorida Twitter.com/AHCA FL SlldeSh are.net/AHCAFlor!da
| Issue Date | Proceedings |
|---|---|
| Dec. 07, 2015 | Agency Final Order filed. |
| Nov. 24, 2015 | Order Closing File and Relinquishing Jurisdiction. CASE CLOSED. |
| Nov. 20, 2015 | Joint Motion to Relinquish Jurisdiction filed. |
| Oct. 15, 2015 | Order Granting Continuance (parties to advise status by November 30, 2015). |
| Oct. 14, 2015 | Joint Motion to Continue Final Hearing filed. |
| Aug. 26, 2015 | Order of Pre-hearing Instructions. |
| Aug. 26, 2015 | Notice of Hearing (hearing set for October 22, 2015; 9:30 a.m.; St. Petersburg, FL). |
| Aug. 25, 2015 | Joint Response to Initial Order filed. |
| Aug. 18, 2015 | Initial Order. |
| Aug. 17, 2015 | Election of Rights filed. |
| Aug. 17, 2015 | Notice (of Agency referral) filed. |
| Aug. 17, 2015 | Administrative Complaint filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Nov. 25, 2015 | Agency Final Order |
