STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA Nos: 2001024631, Petitioner, 2001012041, 2002013971, 2002029561 Vv. Return Receipt Requested: 7000 1670 0011 4845 7649 DAWSON ADULT CARE, INC., d/b/a 7000 1672 0011 4845 7632 DAWSON ADULT CARE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through undersigned counsel, and files this Administrative d/b/a Dawson Complaint against Dawson Adult Care, Inc., Adult Care (hereinafter “Dawson Adult Care” or “Dawson”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine totaling $28,000.00, pursuant to Sections 400.414, 400.419, Florida Statutes (2000), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and Chapter 28-166, Florida Administrative Code. 3. Venue lies in Palm Beach County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2001), and Chapter 58A-5, Florida Administrative Code. 5. Dawson Adult Care operates a 3l-bed assisted living facility located at 669 West 6° Street, Riviera Beach, Florida 33404. Dawson Adult Care is licensed as an assisted living facility; license number AL5821, with an expiration date of June 9, 2004. Dawson Adult Care was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I DAWSON FAILED TO MAINTAIN THE FACILITY TO PROMOTE A RESIDENTIAL, NON-MEDICAL ENVIRONMENT, AND PROVIDE FOR THE SAFE CARE OF ALL RESIDENTS. (PURSUANT TO A SURVEY CONDUCTED ON 3/1/01) 58A-5.023(1) (a), F.A.C. (PHYSICAL PLANT STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Based on observation at the time of the survey conducted on 03/01/01, the Agency’s surveyor determined that Dawson failed to maintain the facility to promote a residential, non-medical environment, and provide for the safe care of all residents. Findings include the following: a) The surveyor observed that the door track of the patio doors leading to the patio were warped, rusted, broken, bent and twisted. The footing was very uneven. The surveyor herself had actually tripped on the warped, rusted, broken, bent and twisted door tracks. The surveyor believed that the warped, rusted, broken, bent and twisted door tracks presented an imminent danger to residents and/or guests. The surveyor warned the facility that the warped, rusted, broken, bent and twisted door tracks were a hazard and presented an imminent danger to residents and/or guests. The surveyor warned the facility that the doorway was unsafe and needed to be attended to immediately. The surveyor believed that other residents or guests had tripped on the door tracks. Shortly thereafter, on the day of the survey, Resident #4 tripped on the warped, rusted, broken, bent and twisted tracks, fell out the door onto the concrete patio, and sustained head injuries to the back and left sides of his/her head. The resident appeared dazed from the fall and had slurred speech. The resident was taken to the hospital and admitted on 3/01/01. b) The surveyor also found that the facility had several sharp and rusted gardening tools on the patio. There were rakes, shovels, hoes and blades. This situation also presented a hazard to residents, and presented an imminent danger to the residents. 8. Based on the foregoing, Dawson Adult Care violated Rule 58A-5.023(1) (a), Florida Administrative Code, a Class I violation, pursuant to Section 400.419(1) (a), Fla. Stat., which carries, in this case, an assessed fine of $10,000.00. COUNT II DAWSON FAILED TO MAINTAIN THE FACILITY TO PROMOTE A RESIDENTIAL, NON-MEDICAL ENVIRONMENT, AND PROVIDE FOR THE SAFE CARE OF ALL RESIDENTS. 58A-5.023(1) (a), F.A.C. (PHYSICAL PLANT STANDARDS) UNCORRECTED CLASS II VIOLATION 9. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 10. Based on observation at the time of a survey conducted on 01/16/01, the Agency’s surveyor determined that Dawson failed to maintain the facility to promote a residential, non-medical environment, and provide for the safe care of all residents. Findings include the following: (a) The surveyor found unattended gallons of bleach, insecticide, and caustic cleaning supplies throughout the facility on tables, chairs and on the floors in the hallways. The cleaning supplies and insecticide were not in use, as there were no staff members on duty or volunteers observed to be cleaning. During interview with the surveyor, a resident stated that is where the insecticide is usually kept (outside of Room 2). (b) The surveyor observed broken, discarded furniture throughout the facility, both inside and outside. wu Some of the furniture had rusted metal and splintered wood, with many dangerous, jagged edges. There were broken chairs, with missing legs, arms and some were unsteady, without cushions. They presented a danger to any resident that would attempt to use them and were a tripping hazard, as they littered the walkways and could prevent exit in case of emergency. Two of the rooms had broken dressers, with handles missing from drawers that would not close. (c) The surveyor found that the floors of two bathrooms were wet and soaked with a liquid that had a strong urine odor. This presented a slipping hazard as well as an unsanitary, non-residential condition. There were no towels or toilet paper observed in any of the bathrooms for resident/staff use. Mandated correction date: 01/18/01. 11. As a result of a follow-up survey conducted on 01/24/01, and based on observation, the Agency’s surveyor again found that Dawson failed to maintain the facility to promote a residential, non-medical environment, and provide for the safe care of all residents. Findings include the following: (a) Bottles of caustic cleaning supplies were observed on a cart/table on the open patio area between the two buildings of the facility. There were several bottles of bleach, six quart bottles of ammonia, approximately eighteen large bottles of a bright yellow cleaning solution and approximately 25 small 2802 bottles of this cleaning solution stored on the cart/table. (b) Two space heaters were observed; one was sitting on a chair in the entry room and the other space heater was observed in a public bathroom. (c) The surveyors found that the above-cited conditions or occurrences in paragraphs 10 and 11 directly threatened the physical or emotional health, safety, or security of the residents. 12. Based on the foregoing, Dawson Adult Care violated Rule 58A-5.023(1) (a), Florida Administrative Code, an uncorrected Class II violation, pursuant to Section 400.419(1) (b), Fla. Stat. (2000), which carries, in this case, an assessed fine of $5,000.00. COUNT IIT DAWSON ADULT CARE FAILED TO OBTAIN WRITTEN CONSENT AGREEMENTS FROM RESIDENTS BEFORE CHARGING THEM FOR SEPARATE SERVICES (SERVICES NOT PROVIDED AS PART OF THE STANDARD MONTHLY RATE). 400.427(5), Fla. Stat. (FISCAL STANDARDS) UNCORRECTED CLASS III VIOLATION 13. BHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 14. During an appraisal visit conducted on 01/16/01, and based upon review of the available record for the month of December (year not specified) and interview with the owner at the time of the survey on 01/16/0lthe Agency's surveyor found that Dawson failed to obtain written consent agreements from residents before charging them for separate services (services not provided as part of the standard monthly rate). The surveyor found that residents were charged various fees for personal loans, hair repair, cable TV, and podiatry services without any specific written consent agreement from the residents. B Findings include the following: (a) One resident was charged $10.00 for hair repair on 11/29. He appeared to be due $33.00 for the month of December. (ob) One resident was charged for December: cable-$11.00, Podiatry- $15.00 (6/16/00) and personal loan- $5.00, for a total of $31.00. He appeared to be due $12.00 for the month of December. (c) One resident was charged: 11/22-$35.00- (1/2)=$18.00 for hair repair, 12/9- Podiatry $30.00-1/2 = $15.00, and 12/14- personal loan $5.00, for a total of $38.00. He appeared to be due $5.00 for December. (d) One resident had a $15.00 Podiatry balance from 6/16 and a 1/2 Podiatry balance from 12/9, for a total due of $30.00. He appeared to be due $13.00 for December. (e) One resident had a charge of $30.00 for Podiatry on 12/-9 and appeared to be due $217.00 for the month of December and previous months. 15. There were no written consents given by these residents for these specific charges and the owner was unable to show evidence that the funds due were provided to the residents. The personal funds due the residents for the month of January were not as of the date of the survey (01/16/01) provided to the residents. The owner stated that she had not had time to get to the bank. Correction Date Given: 2/14/01 16. When a follow-up visit was conducted on 3/01/01, the surveyor determined that this deficiency/violation remained out of compliance since the survey of 1/16/01, even though the facility was supposed to have corrected the deficiency/violation by 2/14/01. Findings include: (a) Based on a review of 3 resident records, the surveyor determined that the facility did not have written consent to manage the residents’ funds. (b) There was no written consent in any of the residents’ files giving the facility the right to manage residents’ funds. (c) There was no statement of the costs of services or supplies to a resident while at the facility. 17. Based on the foregoing, Dawson Adult Care violated Section 400.427(5), Fla. Stat., an uncorrected Class III violation, which carries, in this case an assessed fine of $1,000.00. COUNT IV DAWSON ADULT CARE FAILED TO MAINTAIN LIABILITY INSURANCE COVERAGE AT ALL TIMES 400.4275(3), Fla. Stat., and/or Rules 58A-5.021(8), and/or 58A-5.024(1) (g), F.A.C. (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19, At the time of survey on 01/16/01, the Agency’s surveyor found that the facility was not able to provide evidence of current liability coverage and/or failed to maintain liability insurance coverage at all times. The surveyor called the facility on 01/18/01 and spoke with the Administrator, who stated that he would fax a copy of their proof of insurance. The surveyor made a follow-up call to the Administrator later that day, when only an insurance 10 bill was provided, and the surveyor found that the facility’s insurance policy was never renewed by the facility and had in fact expired on 11/25/00. Correction Date: 02/14/01. 20. On the follow-up survey conducted on 3/1/01, the surveyor found that the deficiency/violation remained out of compliance, even though the facility was supposed to have corrected the deficiency/violation by 2/14/01. 21. Based on an interview with the owner, the surveyor found that the facility had been unable to obtain insurance coverage. The facility's insurance coverage had expired on 11/25/00. 22. Based on the foregoing, Dawson Adult Care violated Section 400.4275(3), Fla. Stat., and/or Rules 58A- 5.021(8), and/or 58A-5.024(1) (g), F.A.C., an uncorrected Class III violation, which carries, in this case an assessed fine of $1,000.00. COUNT V DAWSON ADULT CARE FAILED TO HAVE A STAFF MEMBER AWAKE AT ALL HOURS OF THE DAY AND NIGHT Rule 58A-5.0191(4) (a) (3), F.A.C. (STAFFING STANDARDS) UNCORRECTED CLASS II VIOLATION 11 23. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 24. Based upon interview with the owner at the time of the survey conducted on 01/16/01, the Agency’s surveyor found that the facility failed to have a staff member awake at all hours of the day and night. The surveyor found that no staff members were scheduled to be on duty and awake from 11:00 pm to 6:00 am for five nights (Monday to Friday). The surveyor found that on Saturday, no staff members are scheduled to be on duty and awake from 10:00 pm to Sunday morning. The schedule provided only one employee working on Sundays from 11:00 am to 4:00 pm. The surveyor called the facility’s owner for clarification and to inquire about who was scheduled to be on duty and awake each night, and the owner told the surveyor that she is on duty each night and lives upstairs. The owner, who stated that that she is on duty each night, also stated that she slept during the night, while she is on duty. Correction date assigned: 01/18/01. 25. Based upon interview with the owner at the time of the follow-up survey conducted on 01/24/01, the Agency’s surveyor again found that the facility failed to have a staff member awake at all hours of the day and night. The owner of the facility again stated that she lives on the 12 premises and does not require much sleep. She stated that she is awake most of the night and can be on duty both day and night. This is an uncorrected violation from the 1/16/01 survey. 26. Based on the foregoing Dawson Adult Care violated Rule 58A~-5.0191(4) (a) (3), F.A.C., n uncorrected Class II violation pursuant to Section 400.419(1) (ob), Fla. Stat. (2000), which carries in this case an assessed fine of $5,000.00. COUNT VI DAWSON ADULT CARE FAILED TO ENSURE THAT EACH RESIDENT HAS A SIGNED CONTRACT, EXECUTED PRIOR TO OR AT ADMISSION. 400.424(1) (5), Fla. Stat., and/or 58A-5.024(3) (1), and/or 58A-5.025(1), F.A.C. (RESIDENT RECORDS STANDARDS) REPEATED CLASS III VIOLATION 27. AHCA re~alleges and incorporates paragraphs (1 through (5) as if fully set forth herein. 28. During the survey conducted on 02/18/02 and based on record review, the Agency’s surveyor determined that one of the three records reviewed did not have a contract present. Resident #3, who was admitted on 12/02/01, did not have a contract. When requested to by the surveyor, the administrator was unable to produce this required contract and confirmed that it was not present. 13 29. Based on the foregoing Dawson Adult Care violated Section 400.424(1) (5), Fla. Stat., and/or Rules 58A- 5.024(3) (i), and/or 58A-5.025(1), F.A.C., a repeated Class III violation from the surveys of 1/16/01 and 3/16/00, which carries in this case an assessed fine of $1,000.00. COUNT VII DAWSON ADULT CARE FAILED TO ENSURE THAT RESIDENTS’ MEDICAL EXAMINATION REPORTS, OR HEALTH ASSESSMENTS, WERE COMPLETE AND CONTAINED ALL REQUIRED INFORMATION. 58A-5.0181(2) (a), F.A.C. (ADMISSION CRITERIA STANDARDS) REPEATED CLASS III VIOLATION 30. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31. During the survey conducted on 2/18/02 and based upon review and interview, the Agency’s surveyor found that Dawson failed to ensure that residents’ health assessments, or medical examination reports, were complete and contained all required information. 32. The surveyor found that two of three resident records reviewed contained incomplete medical examination reports, or health assessments. These reports/assessments were not dated, and did not have the name, address, and phone number of the examining physician or ARNP. The administrator confirmed that these records were not complete. 14 33. Based on the foregoing, Dawson Adult Care violated Rule 58A-5.0181(2) (a), F.A.C., a repeated class III violation from the survey of 3/16/00, which carries in this case an assessed fine of $1,000.00. COUNT VIII DAWSON ADULT CARE FAILED TO ENSURE THAT STAFF PERSONNEL RECORDS CONTAINED DOCUMENTED THAT STAFF WERE FREE FROM COMMUNICABLE DISEASES ON AN ANNUAL BASIS 58A-5.019(2) (a), F.A.C. (STAFF RECORDS STANDARDS) REPEATED CLASS III VIOLATION 34. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 35. During the survey conducted on 2/18/02 and based upon record review, the Agency’s surveyor determined that two of four staff records did not contain any evidence that they had been tested during the past year and were free from tuberculosis/communicable diseases. These staffs had been hired in 9/01 and 2/01. 36. Based on the foregoing, Dawson Adult Care violated Rule 58A-5.019(2) (a), F.A.C., a repeated Class III from the survey of 3/06/00, which carries in this case an assessed fine of $1,000.00. COUNT IX DAWSON ADULT CARE FAILED TO ENSURE THAT EACH RESIDENT HAD A SIGNED CONTRACT, EXECUTED PRIOR TO OR AT ADMISSION. 400.424(1) (5), Fla. Stat., and/or 58A-5.024(3) (i), and/or 58A-5.025(1), F.A.C. (RESIDENT RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 37. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 38. During the survey, the Agency’s surveyor found that the facility failed to ensure that each resident had a signed contract present in the record, that had been completed at or prior to admission. Findings include the following: (a) One of three records reviewed did not have a contract present. Resident #3, who was admitted on 12/01/01, did not have a contract. When requested to by the surveyor, the administrator was unable to produce this required contract and confirmed that it was not present. This is a repeat violation from the surveys of 1/16/01 and 3/16/00. Correction date given: 3/20/02. 39. During the follow-up survey conducted on 4/09/02 and based upon review and interview, the surveyor found that the facility again did not ensure that each resident had a signed contract, executed at or prior to admission. Findings include the following: (a) A signed contract was not present in the record of resident #3. When requested to by the surveyor, 16 the administrator was unable to produce this required document and verified that it was not present. This resident is the same resident for whom a contract was not present during the Re-licensure survey of 2/18/02, and was supposed to be corrected by 3/20/02. This is an uncorrected violation from the survey of 2/18/02. 40. Based on the foregoing, Dawson Adult Care violated Section 400.424(1) (5), Fla. Stat., and/or Rules 58A-5.024(3) (i), and/or 58A-5.025(1), F.A.C., herein classified as an uncorrected Class III violation, which carries in this case an assessed fine of $1,000.00. COUNT X DAWSON ADULT CARE FAILED TO ENSURE THAT STAFF RECEIVED THE REQUIRED TRAINING IN: RESIDENT BEHAVIOR AND NEEDS, AND PROVIDING ASSISTANCE WITH ACTIVITIES OF DAILY LIVING 58A-5.0191(2) (d) and/or 58A-5.0191(10) (e), F.A.C. (STAFF TRAINING REQUIREMENTS) UNCORRECTED CLASS III VIOLATION 41. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 42. During the survey conducted on 2/18/02 and based upon record review and interview, the Agency’s surveyor found that that the facility failed to ensure that staff received the required training in: resident behavior and needs, and providing assistance with activities of daily living. Findings include the following: (a) Two of four staff records did not contain any evidence of this required training. These staff members had start dates in 9/01 and 2/01. During interview, the administrator confirmed that this training had not been provided to the respective staff members. Mandated Correction Date: 3/20/02 43. During the follow-up survey conducted on 4/09/02 and based upon record review and interview, the surveyor found that the facility again failed to ensure that staff received the required training in: resident behavior and needs, and providing assistance with activities of daily living. Findings include the following: (a) Two of two staff records did not contain any evidence of this required training. These staffs had start dates in 9/01 and 2/01. When requested to by the surveyor, the administrator was unable to produce any evidence of this required training having been accomplished. This is an uncorrected violation from the survey of 2/18/02. 44. Based on the foregoing, Dawson Adult Care violated Rules 58A~-5.0191(2) (ad), and/or 58A-5.0191(10) (e), 18 F.A.C., an uncorrected Class III violation that carries in this case an assessed fine of $1,000.00. COUNT XI DAWSON ADULT CARE FAILED TO ENSURE THAT THE ADMINISTRATOR RECEIVED THE REQUIRED ADDED CORE TRAINING 400.452(8), Fla. Stat. (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 45. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 46. During the survey of 2/18/02 and based upon record review and interview, the surveyor found that the facility did not ensure that there was significant compliance with assisted living regulations, and failed to ensure that the administrator received required added core training. Findings include the following: (a) Based upon the citations received as a result of this survey, the repeat citations involved, and the citations received during surveys conducted during this past year (on 1/15/02, 1/16/01 & 1/24/01) and the administrator’s evident lack of familiarity with the regulations, he/she was required to re-take in its entirety the core training for ALF operation. Mandated Correction Date: 3/20/02. 47. When a follow-up survey was conducted on 4/09/02 and based upon record review and interview, the surveyor found that the facility’s administrator did not receive the required added Core Training, even though he/she was required to correct or re-take the training by 3/20/02, (a) The administrator, as a result of the deficiencies received in the Re-licensure survey of 2/18/02 and other citations, had been required to repeat in its entirety the Core Training for ALF operation. The administrator was unable to produce any evidence that this training had been accomplished and confirmed that he/she had not attended this training. This is an uncorrected violation from the survey of 2/18/02. 48. Based on the foregoing, Dawson Adult Care violated Section 400.452, Fla. Stat., an uncorrected Class III violation, which carries in this case an assessed fine of $1,000.00. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 20 A. Make factual and legal findings in favor of the Agency on Counts I through XI. B. Assess administrative fines totaling $28,000.00 against Dawson Adult Care on Counts I through XI. Cc. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 N. W. 53rd Street, Miami, Florida, 33166; Attn: Kathryn F. Fenske. 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. 21 Copies furnis Diane Reiland hed to: Field Office Manager Agency for He Administratio 1710 East Tif West Palm Bea Gloria Collin Finance and A Agency for He Administratio 2727 Mahan Dr Tallahassee, alth Care n Kathryn F. Fenske Assistant General Counsel Agency for Health Care Administration Florida Bar # 0142832 8355 N. W. 53 Street Miami, Florida 33166 (305) 499-2165 fany Drive, Suite 100 ch, FL 33407 s ccounting alth Care n ive Florida 32308 Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Dr Tallahassee, ive Florida 32308 22 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Eric Dawson, Administrator, Dawson Adult Care, 669 W. 6° Street, Riviera Beach, Florida 33404, and to Doloris Dawson, 1220 w 3'4 Street, Riviera Beach, Florida 33404 on . / , 2002, KatHryn“F. Fenske 23 “a, i STATE OF FLORIDA fF fee AGENCY FOR HEALTH CARE ADMINISTRATION 02 Sep _ f om Kes, B) RE: CASE NAME: Dawson Adult Care CASE No. s0z0raeereeee a20at 3: 5/ 2002013971;'2402029561, IP ge lie ELECTION OF RIGHTS PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 0 ! 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) 0 ! 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) 8 1! 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. er to preserve your right to any hearing, your Election of Rights in this matter must be directed to by filing within twenty-one (21) days from the date you receive the Administrative 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. 6 Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT NOW .-. REGARDLESS 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: Agency for Health Care Administration, Kathryn F. Fenske, Assistant General Counsel, 8355 NW 537 Street, Miami Florida 33166 Telephone Number: (305) 499-2165 _; FAX (805) 499-2195 _; TDD 1-800-955-8771. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION the attached Election of Rights form and return it fully &xecuted to the address listed On the form, If you dispute the allegations in the Administrative Complaint and wai Your right to be heard, You should Select OPTION 7 ©n the election Of rights form. A final Order will be entered finding you Quilty of the Violations charged and imposing the Penalty Sought in the Complaint, You will be Provided a Copy of the fina} order, If you qi 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 (1999). 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(4), 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 Compiaint. If you do not respond at ail Within be issueg finding YOu guilty of the Violations Charged and imposing the penalty Sought in the Complaint.

Docket for Case No: 02-003772