STATE OF FLORIDA Q2 AGENCY FOR HEALTH CARE ADMINISTRATION | ¢/;,,, STATE OF FLORIDA “ AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs AHCA NO: 06-01-0352-ALF MIGDALIA’S ACLF Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against MIGDALIA’S ACLF (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on MIGDALIA’S ACLF in the amount of FIVE HUNDRED dollars ($500) pursuant to Sections 400.414(1) (a) and 400.419(1) (a) Florida Statutes. Jurisdiction And Venue 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 3. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant Lo 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. Parties 4. AHCA, Agency for Health Care Administration, State of Florida, is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 5. Respondent, MIGDALIA’S ACLF, is an assisted living facility located at 2302 Lincoln Avenue, Tampa, Florida. MIGDALIA’S ACLF, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-S, Florida Administrative Code. COUNT I MIGDALIA’S ACLF FAILED TO ENSURE THAT HOSPICE RESIDENT’S RECORD CONTAINED AN INTERDISCIPLINARY CARE PLAN FOR ONE SAMPLED RESIDENT Fla. Admin. Code R. 58a-5.024(3) (n); Fla. Admin. Code R. S58A- 5.0181(4) (c)3; § 400.428(1) (J) Fla. Stat. (2001) CLASS III DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about 11/19/01 based on record review and interview, the facility did not ensure a Hospice Resident's record contained an interdisciplinary care plan for one sampled Hospice resident. 8. This same Class III deficiency regarding hospice resident's records remained uncorrected from an earlier visit on September 4, 2001, which had a mandated correction date of October 4, 2001. 9. The above referenced actions and or inactions, are violations of Fla. Admin. Code R. 58A.5-0181 and Fla. Admin. Code R. 58A-5.024(3)(n); requiring that an assisted living facility Hospice Resident's record will contain an interdisciplinary care plan, and Section 400.428 (1) (4) Florida Statutes; requiring that every resident of a facility have the right to access to adequate and appropriate health care consistent with established and recognized standards with in the community. 10. The above referenced violations constitute the grounds for the imposed uncorrected Class III deficiency and for which a fine of five hundred dollars ($500) is authorized under Section 400.419(1)(c) Florida Statutes. WHEREFORE, AHCA intends to impose a fine against the Respondent under Section 400.419(1) (c) Florida Statutes in the amount of five hundred dollars ($500). The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Regpectfully submitt Eileen O'Hara Garci Esquire AHCA ~- Senior Attoyney 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail Return Receipt No.Z 259 496 234, to Administrator Migdalia’s ACLF, 2302 Lincoln Avenue, Tampa Florida 33607, [Bay hot ° : ara /Garcia, Esquire Copies furnished to: Administrator Migdalia's ACLF 2302 Lincoln Avenue Tampa, Fl 33607 (U.S. Certified Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Eileen O'Hara Garcia, Esquire AHCA - Senior Attorney 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 PAYMENT FORM Agency for Health Care Administration Finance & Accounting Department P.O. Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find check No. in the amount of §$ , which represents payment of the administrative fine imposed by AHCA. Facility Name AHCA NO. Op fi STATE OF FLORIDA Uy og AGENCY FOR HEALTH CARE ADMINISTRATION <7, 9 4, ie, WY o EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDASTATUTES — 57 (To be used with Election of Rights for Administrative Complaint form - attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (‘AHCA” or “Agency”), you must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Complaint. You will be provided a copy of the final order, OPTION 2. If you do not dispute any material fact alleged in the Administrative Complaint (you admit each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 2 on the Election of Rights form. OPTION 3. if you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to a hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. STATE OF FLORIDA Q> AGENCY FOR HEALTH CARE ADMINISTRATION tip oe , Be #2) plo, “ ‘ of RE: MIGDALIA’S ACLF CASE NO. 06° 49952-AL ey, ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT”/:.. OS, PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) Q ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) Qf do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) Q / do dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If you choose OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. If you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. O Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT NOW -- REGARDOLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. {Please sign and fill in your current address.) Respondent (Licensee) Address: License. No. and facility type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Eileen O’Hara Garcia, Senior Attorney Agency for Health Care Administration §25 Mirror Lake Drive North, Room 310 St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Fax No. (727) 552-1440 TDD 1-800-955-8771

Docket for Case No: 02-003126