Certified Mail Receipt (7001 0360 0003 3804 6142) : STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 7 4 S U. 27 Petitioner, C 2) > ( AHCA NO.: 2004007572 “vs: ' . KIVA OF PALATKA, LLC. d/b/a KIVA OF PALATKA, - Respondent. oy ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION e undersigned counsel, and files this Administrative ~ (“AHCA”), by and through th Complaint against KIVA OF PALATKA, L.L.C. d/b/a KIVA OF PALATKA, (“Kiva of Palatka, LLC. ”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2004), alleges: NATURE OF THE ACTION n administrative fine against Kiva of Palatka, 1. This is an action to impose a pursuant to Sections 400.419(2)(b), 400.4174(2), and Chapter 435, Fla. Stat. (2004), and Sections 58A-5- 0190); and 58A-5.023(1)(a), Fla. Admin. Code. (2004). [JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 400, Part Ill and Section Sections 120.569 and 120.57, Fla. Stat. (2004). 3. Venue lies in Putnam County, Palatka, Florida, pursuant to Se Fla. Stat. (2004); Rule 58A5, Florida Administrative Code (2003), t 28.106.207, Fla. Stat. (2004). PARTIES 4., AHCA, is the regulatory authority responsible for “and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part IIL, Fla. Stat. and Rules 584°5, Florida Administrative Code (2004). 5. Kiva of Palatka is a for-profit. corporation, whose 30-bed astistad. living facility is located at 201 Zeagler Drive, Palatka, FL. Kiva of Palatka is licensed. as an assisted living facility license # AL827; certificate number #13224, effective February 24, 2003 through August 21, 2004. Kiva of Palatka was at all times material hereto, licensed facijity under the licensing authority of AHCA, and required to comply with all applicable rules, 1 and: statutes . COUNT I KIVA OF PALATKA FAILED TO ACQUIRE A LEVEL I BACKGROUND SCREENING CLEARANCE ON ONE OUT OF ELEVEN EMPLOYEES CURRENTLY EMPLOYED AT THE FACILITY. FAILURE TO ACQUIRE LEVEL I OYEES WHO ARE HIRED BACKGROUND SCREENING CLEARANCE ON EMPL‘ BY THE COMPANY HAS THE POTENTIAL TO PUT RESIDENTS AT RISK FOR ABUSE, NEGLECT, OR OTHER HARM. STATE TAG A511-STAFFING STANDARDS Section 400.419(2)(b), Fla. Stat. (2004) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS a Section 58A-5.019(3), Fla. Stat. (2004) RESIDENTS CARE STANDARDS CHAPTER 435, Fla. Stat. (2004) 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. : personal services to resident ad screenin operati ' @ e . , i , 7. On or about July 14, 2004, AHCA conducted an unannounced biennial licensure survey at the Respondent's facility. AHCA ‘cited the Respondent based ‘on the . findings below, to wit: a.) On or about July 14, 2004, Kiva of Palatka failed to acquire a level 1 background screening clearance on one out of eleven employees currently employed at the facilicy. Failure. to acquire Level I background screening clearance on employees who are t ‘hired by the company has the potential to put residents at risk fot abuse, neglect, or other harm. " of Section 58A-5.019(3), Fla. Admin. 8. The above constitutes a violation Code (2004), which require that all staff, hired on or ‘after October 1, 1998, to provide t fl . 400.4174, F.S., s must be screened in accordance with Section and meet the screening standards of Section 435, 03,'F.S. A packet containing background 8 forms and instructions may be obtained from the AHCA Background Screening Unit, 2727 Mahan Drive, Tallahassee, FL 32308; telephone (850) 410-3400. 9. The above constitutes a violation of Section 400.419(2)(b), Fla. Stat. (2004), which requires that a Class II violations ate those conditions or occurrences related to the on and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class | violations. The agency shall impose an administrative. fine for a cited class Il violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. Ww 10. The above constitutes a violation of Section 400.4174(2), Flas State ator of an assisted living facili dyhich requires that the owner or administr | 1 level 1 background screening, as set forth ih chapter 435, on all em after October 1, 1998, who perform personal services as Agency may exempt an individual from employment disqualification as set fo 435. ° lation alleged herein constitutes a class Il deficiency, and'warrants a 11. The vio fine of $1,000. 4 WHEREFORE, AHCA demands the following relief: 1. Enter factual and_ findings as set forth in the allegations of this . administrative complaint. i 2, Impose a fine in the amount of $1,000. . COUNTIH.. ) KIVA OF PALATKA FAILE ENVIRONMENT FOR THE RING KNIFE TO BE KEPT RESIDENTS IN THE FACILITY BY A RESIDENT IN THEIR ROOM, NOT SECURED OR OUT OF SIGHT. FAILURE TO PROVIDE A SAFE ENVIR ALL RESIDENTS AT RISK FOR INJURY ST. p TO PROVIDE A SAFE TE TAG A100 1-PHYSICAL PLANT STANDARDS ; Section 400.419(2)(b), Fla. Stat. (2003) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS ; Section 58A-5.023(1)(a), Fla. Admin. Code (2003) PHYSICAL PLANT STANDARDS 12. | AHCA realleges and incorporates paragraphs (1) through G) as if fully set forth herein. 13. On or about July 14, 2004, AHCA conducted an unannounced biennial licensure survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: \ @ , @ . ' a) On or about July 14, 2004, Kiva of Palatka failed to provide a safe «the resident’s in their facility by allowing a paring knife to be kept bya , ‘or environment fo resident in their room, not secured or out of sight. Failure to provide a safe environment for all residents places all residents at risk for injury and possible decline in health. 14. _The above constitutes a violation of Section 58A-5.023(1)(a), Fla. Admin. Code (2004), which requires that the ALF shall be located, designed, equipped, and maintained to promote a residential, non-medical environment, , and provide for the safe care and supervision of all residents. 15. The above constitutes a violation of Section 400.419(2)(b), Fla. Stat. (2004), which requires that a Class II violations are those conditions or occurrences related to the 1 care of residents. which’ the. : operation and maintenance of a facility or to the persona 7 agency determines directly threaten the physical or émotional health, safery, or security of the facility residents, other than class I violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the ‘violation. , 16. The violation alleged herein constitutes a class II deficiency, and warrants a fine of $1,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000. SURVEY FEES TOTALLING $500 PURSUANT TO “ Section 400.419(10), Fla. Stat. (2003), RIGHT OF ENTRY. ' \ : 17. AHCA realleges and incorporates paragraphs (1) through (5). t forth herein. 18. The above constitutes a violation of Section 400.419(10), Fla: $ : ' \ requires that in addition to any administrative fines imposed, the agency survey fee, equal to the lesser of one half of the facility's ‘biennial license ani $500, to cover the cost of conducting initial, complaint investigations chat resalt in the finding of a violation that was the subject of the complaint or monitoring vi i under s. 400.428(3)(c) to verify the correction of the violations. 4 : Respondent is notified that it has a right to request an administrative hearing pursuant to ' Section ‘120.569, Florida Statutes (2004). Specific options for administrative action are set. ‘out in the attached Election of Rights (one page) and explained in. the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, arid delivered to the Agency for Health Care ; Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO. REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. f . + . . «Respectfully Submitted this BS an of A 4 “sf 2004, Leon County, Tallahassee, Michael O. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 | 2727 Mahan Drive Tallahassee; Florida 32308 ' (850) 922-5873 (office) . (850) 921-0158 (fax) Kris Mennella & " Agency Clerk: "Agency for Health Care , : Administration — ' CERTIFICATE OF SERVICE ] HEREBY cen that a true and correct copy of the foregoing has been served 4 ig ts FS , 2004 to Julie Young, Administrator, Kiva of Palatka, 201 Zeagler | Drive, Palatka, Palatka, Florida 32177. "Michael O. Mathis, Esq.

Docket for Case No: 04-003372