STATE OF FLORIDA Ay AGENCY FOR. HEALTH CARE Dusit, bag STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. HCB-H-01-0015 Ten Broeck, Jacksonville, L.L.C, d/b/a Ten Broeck Hospital Respondent. / i ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this COMPLAINT, the AGENCY FOR HEALTH CARE ADMINISTRATION ("Agency") intends to impose an administrative fine for each day of non-compliance upon Ten Broeck, Jacksonville, L.L.C., (H 10-4016) ("Respondent") for violations involving Prior Year Reports. As grounds for the imposition of this administrative fine, the Agency will show: 1. Respondent is @ hospital as defined by § 395 .002(12), Florida Statutes and is located at 6300 Beach Boulevard, Jacksonville, FL 32216. 2. Pursuant to Section 408,061(4)(a), Florida Statutes, and Rule 59E-5.201, Florida Administrative Code, Respondent is required to file with the Agency within 120 days subsequent to the end of its fiscal year, its Prior Year Report which consists of an original and one copy of its actual report prepared and submitted in compliance with the Florida Hospital Uniform Reporting System Manual on forms adopted by the Agency, two copies of its audited financial statements, and one copy of its Medicare cost repart. EXHIBIT "A" 3. Respondent failed to submit a complete and accurate Prior Year Report for its 2001 fiscal year by 04/30/2002. Pursuant to Rule 59E-2.024(5), Florida Administrative Code, the Agency sent a deemed not filed notice to Respondent on 05/07/2002, which specified the corrections needed to bring its report into compliance with statutory and rule requirements, allowed ten (10) working days to provide the agency with the requested information, and gave notice that Respondent would be subject to imposition of an administrative fine if the requested information was not timely filed. A copy of the deemed not filed notice is attached hereto as Exhibit “A” and incorporated herein by reference. Respondent received the deemed not filed notice on 05/13/2002. , 4, The Agency sent a second notice of delinquent filing to the hospital on 06/06/2002. Respondent received the deemed not filed notice on 06/10/2002. A copy of this notice is attached hereto as Exhibit “B”. 5. Respondent failed to submit the Prior Year Report, Audited Financial Statements, and Medicare Cost Report to the Agency within ten (10) working days ftom the date of its receipt of the notice of violation as required therein, and, as of the date of this administrative complaint, has still not complied with the requirements of law and rules as set forth herein and in the notice of violation. 6. Based on the foregoing, Respondent has violated: §408.061(4)(a), Florida Statutes and Rule 59E-5.201, Florida Administrative Code, and Respondent is thereby subject to the penalties set forth in Section 408.08, Florida Statutes, which provides that any hospital which refuses to file a report, fails to timely file a report, files a false réport, or files an incomplete report shall be punished by a fine not to exceed $1,000 per day for each day in violation, to be fixed, imposed, and collected by the Agency, Each day in violation shall be considered a separate offense. 7. Respondent's violations constitute a: second accurrence for tie purpose of calculating fines pursuant to Rule 59E-2,025, Florida Administrative Code. 8. Pursuant to Rule 59E-2.024(5), Florida Administrative Code, the imposition of an administrative fine will be calculated from Apri} 30", 2002, the original due date of the report. Respondent's failure to file its 2001 Prior Year Report in a timely manner is subject to a fine of 340,00 per day pursuant to Rule 59E-2.025 (1)(a), Florida Administrative Codé. In addition to the foregoing, if a complete report is not filed prior to the entry of the Order sought herein, Respondent shall be subject to a fine of $25,000 for failure to file a report as provided in Rule 59E-2.025(c), Florida Administrative Code. 9. YOU ARE FURTHER NOTIFIED that you haye a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel or other qualified representative (at your own expense), to take testimony, to call or.crogs- examine witnesses, to have subpoena and/or subpoena duces tecurn issued, and to present written evidence or argument if you request a hearing, Chapter 59-1, Part II, Florida Administrative Code, constitutes the Agency's procedural rule for administrative proceedings resulting from this complaint. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, your request for an administrative hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, and must set forth with specificity disputed issues of material fact, Failure to set forth such disputed issues of material fact may be treated by the Agency as an election by you of an informal proceeding under §120.57(2), Florida Statutes. All requests for a hearing shall be made to: Agency for Health Care Administration, MS #3, Bldg, #3, 2727 Mahan Drive, Tallahassee, Florida 32308, Attention: Office of the General Counsel, Agency Clerk, copies to Christopher J. Augsburger, Regulatory Analyst Supervisor, Bureau, Health Facility Regulation. 10. All payments of administrative fines shall be by check or money order payable to. the Agency for Health Care Administration. Reference shall be made to Respondent's name, facility number, and the case number on this Complaint, and shall be sent to the Agency for Heaith Care Administration, Bureau Health Facility Regulation, Fort Knox Office Plaza, Building #1, MS #28, 2727 Mahan Drive, Tallahassee, Florida 32308, Attention: Christopher J. Augsburger, Regulatory Analyst Supervisor, Bureau, Health Facility Regulation... 11. YOU ARE FURTHER NOTIFIED that failure to request a heating within twenty- one (21) days of service 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, 1HEREBY CERTIFY that a true copy hereof was sent by U. S. Certified Mail, Return Receipt Requested to Wesley Robbins, Chief Executive Officer, Ten Broeck Hospital, 6300 Beach Boulevard, Jacksonville, FL 32216 this 9" day of August 2002, Regulatory Andlyst Supervisor Bureau Health Facility Regulation Agency for Health Care Administration af STATE OF FLORIDA JEB BUSH, GOVERNOR [o May 7, 2002 Wesley Robbins | ; L ; } Chief Executive Officer ; Ec y hee f- Ten Broeck Hospital ; 6300 Beach Blvd. Jacksonville, FL 32216 RE: 2001 Prior Year Repart Hospital Number 10-4016 FYE: 12 Deemed-not-Filed Notice of Violation Dear Mr. Robbins: Pursuant to rule 598-2.024, 598-5.103, 59E-5.204 and 59B-5,206 F.A:C,, the above referenced report has been found incomplete and deemed not filed for the following reason(a): oY Prior Year Actual Report Pursuant to rule 59E-5,201 and 59ER-5.206 F. AC, your hospital is required to submit to the Agency its actual report in electronic format. Please submit (1) 3.5 inch diskette pursuant to the formatting requirements provided in Rule 59E-5.206, i Audited financial statements Pursuant to mule 59E-5.201 F.A.C., your hospital is required to submit the hospital’s audited financial statements. Please submit (1) copy of the audited financial statemenits, Draft copies are not accepted. a Medicare Cost Report . Pursuant to mile 59E-5,.201 F.AC., your hospital is required to submit (1) copy of the Medicare Cost Report. Please submit (1) copy of the Medicare Cost Report. 2727 Mahan Drive « Mail Stop #28 Visit AHCA Online at Tallahassee, FL 32308 www.fdhe state fies Pursuant, to rule 59H-2.024(5), please submit the required information within 10 working days from the date you receive this letter, Any subsequent administrative fines will be imposed from the due date of the report. Section 408.08 of the Florida Statutes provides that any hospital which refuses to file one timely basis reports or other information required to bé filed with the Agency, shall be punished by a fine not to exceed $1,000 per day for each day in violation. Failure to provide these corrections will result in the matter being forwarded to our legal counsel for appropriate action. please contact me at. ‘Thank you very much for your cooperation, If you have any questions, 850/922-7434. - ; Te | Paul wit Joo : Regulatory Analyst S -gstiuday NHNLaH dO LHL THs OF “ Bo HAOtAND dO'd0) LV vans HOW Td | ih \ oa Comptete items 1, 2, and 3, Alao complete tem 4 Hf Restricted Delivery Is desired. | ( it Print your name and address on the reverse so that we can return the card to you. . ® Attach this card to the back of the maliplece, or on the front f space permits. /2) - O49 — ~ D. bs dativery i YES, enter dalvery addrass below: 4. Afticle Addressed to: ) “(con Breck Hoop tl) 4%, Service Typs . ve fetertiied Ma Cl Expresa Mel TO Registered “Cl Retum Revelpt insured Matt 1 6.0.0. Son Fy) belo oo} b 4, Restricted Delivery’? (Exire Fee) t i iglechumber (Copy from Service late) - . bate a AF | PS Form SB11, July 1988 Domestlo Retum Receipt : a a 4JEB BUSH, GOVERNOR June 6, 2002 ‘Wesley Robbins an Chief Executive Officer . Ten Broeck Hospital . | 6 6300 Beach Blvd, : E. ra L ‘ l, ‘ Jacksonville, FL. 32216 RE: 2001 Prior Year Report, FYE: 12/31/01 Hospital Number - 10-4016 © Deemed-not-Filed Notice of Violation Dear Mr. Robbins: Pursuant to rule 59B-2.024, 59E-5.103, 59B-5.204 and 59E-5,206 F.AC., the above referenced report has been found incomplete and deemed not filed for the following reason(s): Prior Year Actual Report Pursuant to rule 59E-5.201 and 59E-5,206 F.A.C., your hospital is required to submit to the Agency its actual report in electronic format, Please submit ) 3.5 inch diskette pursuant to the formatting requirements provided in Rule 59B-5,206, EY” Audited financial statements Pursuant to mile 59E~-5.201 F.AC,, your hospital is required to submit the hospital’s audited financial statements. Please submit (1) copy of the audited financial statements. Draft copies are not accepted, oO Medicare Cost Report Pursuant to rule 59H-5.201 F. AC, your hospital is required to submit (1) copy of the Medicare Cost Report. Please submit (1) copy of the Medicare Cost Report, ne A . 2727 Mahan Drive » Mail Stop #1 Visit AHCA online at Tallahassee, FL 32308 www, fdhe.state,fl.us oO i) & a Pursuant to mule 598-2, 02405), please submit the required information withiri 10 working days from. the date you receive this letter. Any subsequent administrative fines will be imposed from ‘the due date of the report. Section 408.08 of the Florida Statutes provides that any hospital which refuses to file on a timely basis reports or other information required to bs filed with the Agency, shall be punished by a fine not to exceed $1,000 per day for each day in violation. Failure to provide these corrections will result in the matter being forwarded to our legal counsel for appropriate action. Thank you very much for your cooperation, If you have any questions, please contact me at © 850-922-7434, Sincerely, Paul Kenne Regulatory Analyst don the reverse side? SENDER: G Complete Heme 7 andor 2 tor additonal weniona. Complete lems 3, an, and ab, iw] Print your amy and addraan of the reverse of thin form po that wa can ratum this Valse wish to receive the follow- ing services (for an extra tes): ‘1. Tl Addrasage's Address o Ata it form to the from of the maiiplece, of on the back if space does not 2, CO Restricted Delivery par a Wyte "Ratum Recalpt Requaated’ on the malipiace below the artista number, The | 6 Retum Recaipt will anow to Whom the article was delivered and the date rere 3, Arlicls Addressed to: : Tan Proce Hospi tal E \zicertiied : ’ {Express Mall __Tiinsured 1 Ratum Reosipt for Merchandise £] COD 7, Date of Delivery Nanton sie, cL 39 2Me Li le 5, Received By: (Print Nama) » a &. Addrasses's Address (Qnty if requested and At LK PMR fae is paicl) 8. Signature (Addraseae or Agent) ¥ _Js your Lil . : PS Form 3814, December 184 toases-s-p-0223 Damesiic Return Race » EXHIBIT "B" Re WORKSHEETA'«. ACU AL i f ' Eel ; Ty S py TRANSMITTAL AND CERTIFICATION fal l: OF PRIOR YEAR ACTUAL REPORT : OG = DECEIV AGENCY FOR HEALTH CARE ADMINI A iN fy - easy ao 2727 Mahan Driv ey & For Knox, Building 3 SEP 05 2002 f Tallahassee, Florida 32301 Con/Financia! Analysis Office Mail Stop 28 FROM son Bros Taciuc omits, (NAME OF HOSPITAL) (HRS LICENSE NO.) epoS Bed RNS 1 “HO \b (STREET ADDRESS) (AHCA NUMBER) Tadson we Frike SEES 3228 QOW MIN- VUSd (CITY AND ZIP CODE) (TELEPHONE) PERIOD FROM: aly 200% TO Nr 200\ I HEREBY CERTIFY THAT I HAVE EXAMINED THE ACCOMPANYING WORKSHEETS AS PART OF THE STATE OF FLORIDA UNIFORM REPORT AND SUCH OTHER WORKSHEETS AND FORMS INCLUDED FOR YOUR INFORMATION FOR THE ABOVE PERIOD, IN ACCORDANCE WITH AND SUBJECT TO THE PROVISIONS OF SECTION 407.51 (4), F.S. TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE INFORMATION CONTAINED IN THE REPORT SUBMITTED IS TRUE, ACCURATE. AND COMPLETE AND HAS BEEN PREPARED FROM THE HOSPITAL'S BOOKS AND RECORDS, EXCEPT AS NOTED. N ‘ ~ CHIEF EXECUTIVE OFFICER: ___s Baad Sndoauet (DATE) : Prrwt hk Reeve (TYPE OR PRINT) PS Raves (SIGNATURE) Vatow (DATE) CHIEF FINANCIAL OFFICER: TEN BROECK JACKSONVILLE, LLC Financial Statements for the Year Ended December 31, 2001 and Independent Auditors’ Report JE HIBIT "c" are 9 ar is Pig D Th: Bi Aap G He; A i A. nly Mee e ECEIVE sep 05 2002 Con/Financial Analysis Office Mail Stop 28 PROVIDER NO. 10-4016 TEN BROECK HOSPT.-JACKSONVILLE, PL. KPMG COMPU-MAX MICRO SYSTEM VERSION: 02.02 PERIOD FROM 01/01/2006 TO 12/31/2000 IN LIEU OF FORM CMS-2552-96 (12/98) 09/05/2002 13:55:17 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT WORKSHEET § CERTIFICATION AND SETTLEMENT SUMMARY PARTS I & II INTERMEDIARY C J) AUDITED DATE RECEIVED { 1 INITIAL t J RE-OPENING USE ONLY: { ] DESK REVIEWED INTERMEDIARY NO. if ) FINAL PART I - CERTIFICATION CHECK — ELECTRONICALLY FILED COST REPORT DATE: APPLICABLE BOX — MANUALLY SUBMITTED COST REPORT TIME: MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL, CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S) I HEREBY CERTIFY THAT I HAVE READ THE ABOVE STATEMENT AND THAT I HAVE EXAMINED THE ACCOMPANYING ELECTRONICALLY FILED OR MANUALLY SUBMITTED COST REPORT AND THE BALANCE SHEET AND STATEMENT OF REVENUE AND EXPENSES PREPARED BY TEN BROECK - JACKSONVILLE {10-4016) {PROVIDER NAME(S) AND NUMBER(S)) FOR THE cost REPORTING PERIOD BEGINNING 01/01/2000 AND ENDING 12/31/2000, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT AND COMPLETE STATEMENT PREPARED FROM THE BOOKS AND RECORDS OF THE PROVIDER IN ACCORDANCE WITH APPLICABLE INSTRUCTIONS, EXCEPT AS NOTED. I FURTHER CERTIFY THAT I AM FAMILIAR WITH THE LAWS AND REGULATIONS REGARDING THE PROVISION OF HEALTH CARE (SIGNED) OFFICER OR ADMINISTRATOR OF PROVIDER(S) TITLE DATE PART IJ - SETTLEMENT SUMMARY TITLE v TITLE XVIII TITLE XIX PART A PART B 1 2 3 4 1 HOSPITAL “24218 11002 2 SUBPROVIDER 1 3 SWING BED - SNF 4 SWING BED - NF 5 SKILLED NURSING FACILITY 6 NURSING FACILITY 7 HOME HEALTH AGENCY 8 OUTPATIENT REHABILITATION PROVIDER 9 HEALTH CLINIC 0 TOTAL -24218 11002 SweraHeune i= 10 THE ABOVE AMOUNTS REPRESENT ‘DUE TO’ OR 'DUE FROM! THE APPLICABLE PROGRAM FOR THE ELEMENT OF THE ABOVE COMPLEX INDICATED, - RECEIVE sep 06 2002 Con/Financiat Analysis Office Mail Stop 28 EXHIBIT "D"

Docket for Case No: 02-004039