sox snRNA ES TAN a4 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, CASE NO: 2003004556 vs. 1307 EAST BAKER STREET TRUST, d/b/a AUTUMN EAST I, 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 1307 EAST BAKER STREET TRUST, d/b/a AUTUMN EAST I (hereinafter “Respondent”) and alleges the following: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent pursuant to Sections 400.419(1) (b) and 400.419(9), Florida Statutes (2002). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes (2002) and Chapter 28-106 Florida Administrative Code (2002). 3. AHCA, Agency for Health Care Administration, has jurisdiction over Respondent pursuant to Chapter 400, Part III, Florida Statutes (2002). 4. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes (2002), and Chapter 28 Florida Administrative Code (2002). PARTIES 5. 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 (2002) and Rules 58A-5, Florida Administrative Code (2002). 6. Respondent is an assisted living facility located at 1307 East Baker Street, Plant City, Fl 33566. Respondent, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code (2002), having been issued license number 5108. COUNT I RESPONDENT FAILED TO ENSURE THAT, WHEN PROVIDING ASSISTANCE WITH SELF-ADMINISTRATION OF MEDICATION, STAFF OBSERVE THE RESIDENT TAKE THE MEDICATION. R.58A-5.0185(3) (c), Fla. Admin. Code (2002) Section 400.4256(3) (f), F.S. (2002) UNCORRECTED CLASS III 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about March 25, 2003, a complaint survey was conducted at Respondent’s facility. 9. Based on a review of the March 2003 Medication Observation Record (MOR) of resident #1, and an interview at approximately 10:00 a.m. on March 25, 2003 with a staff member responsible for assisting the resident with medications, it was noted that the MOR for March 24, 2003 was not initialed by the person assisting the resident with medications. Findings: The March 2003 MOR for Resident #1 lists the medication, Mirapex 25mg, to be given to Resident #1 daily at 1:00 a.m., 5:00 a.m., 9:00 a.m., 12:00 p.m. and 9:00 p.m. The MOR wag not initialed for this medication for the 1:00 a.m., $:00 a.m., 5:00 p.m. and 9:00 p.m. doses. The staff member responsible for assisting the resident with these medications stated that he/she did give the medications as required, but forgot to initial the record four (4) times. Resident #1 stated that he/she did receive the medications. 10. Respondent was provided a mandated correction date of April 25, 2003. 11. On or about May 27, 2003, a follow-up survey was conducted at Respondent’s facility. 12. Based on a review of the April and May 2003 Medication Observation Record (MOR) of Resident #1 and an interview at approximately 12:00 p.m. on May 27, 2003 with the administrator, it was noted that the MOR form was not initialed by the person assisting the resident with medications. During the administrator’s interview, it was learned that the facility had hired a supervisor to monitor the passing of all medications to the residents at the appropriate times. Findings: The April 2003 MOR for Resident #1 lists the medication, Mirapex 25mg, to be given to Resident #1 daily at 9:00AM, 12:00PM, 9:00AM, 5:00PM, 9:00PM and 1:00AM. The MOR was initialed for this medication each time it was given with no problems. The administrator indicated each staff member giving the medication was to fax a paper to her at the end of every shift to verify if the medication was or was not given. The May 2003 MOR for Resident #1 documents that the Mirapex 25 mg was to be given in the same manner as the April medication. The MOR was not initialed, as given on May12, 2003 at 9:00PM, 1:00 AM or 5:00AM. Additionally, the following list of prescribed medications were not listed as given to Resident #1 during May, 2003. Sinemet 25/100 9:00AM 5-16-03 Sinemet 25/100 9:00PM 5-12-03 Sinemet 25/100 1:00AM 5-24, 5-25, or 5-26 Seroquel 25 mg 9:00PM 5-12-03 Artane 5mg 1 tab 5:00PM 5-08-02, 5-19, £-20, 5-21, 5-22 or 5-23 Artane 5mg 1/2 tab 9:00PM 5-12 and 5-26 13. The above actions or inactions are a violation of Rule 58A-5.0185(3) (c), Florida Administrative Code (2092), which requires that if a facility is providing assistance with self- administration of medication, the staff must observe the resident take the medication. 14. The above actions or inactions are also a violation of Section 400.4256 (3) (f), Florida Statutes (2002), which provides, in part, assistance with self-administration of medication includes keeping a record of when a resident receives assistance with self-administration under this section. 15. Said violation constitutes the grounds for the imposed uncorrected Class III deficiency in that it does not threaten the health, safety or security of the facility’s residents. Pursuant to Section 400.419(1) (d), Florida Statutes (2002), the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 16. Pursuant to Section 400.419(9), Florida Statutes (2002), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under Section 400.428(3) (c), Florida Statutes (2002), to verify the correction of the violations. In this case, AHCA is authorized to assess a survey fee in the amount of five hundred dollars ($500). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following: 1. Make factual and legal findings in favor of the Agency on Count I; 2. Impose a fine and survey fee in the amount of one thousand five hundred dollars ($1,500) against the Respondent, pursuant to Sections 400.419(1) (b) and 400.419(9), Florida Statutes (2002), respectively; and 3. Any other general and equitable relief as deemed appropriate. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. 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: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Katrina D. Lacy, Esquire AHCA - Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7002 2030 0007 8499 6300, to William A. Brown, Registered Agent for Autumn East I, 106 W. Stanley Street, Tampa, FL 33674, on August [4h , 2003. abdiey | atrina D. Lacy, Copies furnished to: William A. Brown Registered Agent for Autumn East I 106 W. Stanley Street Tampa, FL 33674 (Certified U.S. Mail) Waverleen Farina Administrator Autumn East I 1307 E. Baker Street Plant City, FL 33566 (U.S. Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330G St. Petersburg, Fl 33701

Docket for Case No: 03-003322