STATE OF FLORIDA 0% 2 AGENCY FOR HEALTH CARE ADMINISTRATION SEp 23 p MG: } . AGENCY FOR HEALTH CARE AnH) VIS iOn « 2) ADMINISTRATION, He MIST A va CAP Noe Petitioner, AHCA No.: 2004004334 Return Receipt Requested: 7002 2410 0001 4237 5954 7002 2410 0001 4237 7484 ve. T.L.C. HOME, INC. d/b/a TLC III, Respondent. y- OY - AY (cH ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against T.L.C. Home, Inc. d/b/a TLC III (hereinafter “TLC III”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $6,307.00 [$6,000.00 + $307.00] pursuant to Sections 400.414 and 400.419, Florida Statutes 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, Chapter 28-106, Florida Administrative Code. 3. Venue lies in Dade County pursuant to Section 120.57 Florida Statutes, 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 (2003) and Chapter 58A-5 Florida Administrative Code. 5. TLC III operates a 6-bed assisted living facility located at 8395 S. W. 112 Street, Miami, Florida 33156. TLC III is licensed as an assisted living facility under license number 9762. TLC III 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 TLC III FAILED TO MAINTAIN RECORDS ON SITE. RULE 58A-5.024(4) (a), FLORIDA ADMINISTRATIVE CODE (FACILITY RECORDS STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. TLC III was cited with twelve (12) Class III deficiencies due to licensure surveys conducted on January 8, 2004 and March 10, 2004. 8. Based on a biennial licensure survey conducted on January 8, 2004 and based on observation, interview and record review, it was revealed that the facility did not have personnel files available for surveyor inspection. The findings are as follows. 9. A facility tour conducted on January 8, 2004, at 10:00 AM revealed that the facility did not have personnel files on site available for surveyor inspection. Staff interview with the caregivers confirmed that there were no personnel files available for inspection. 10. Record review revealed that there were no records available for review at the facility. Records had to be obtained from another facility in order to be reviewed. 11. The mandated correction date was designated as February 8, 2004. 12. Based on a survey conducted on March 10, 2004 and based on observation, interview, and record review, it was revealed that the facility still failed to maintain personnel records on site. 13. Based on the foregoing, TLC III violated Rule 58A- 5.024(4) (a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT II TLC III FAILED TO ENSURE THAT DURING TEMPORARY ABSENCE OF THE ADMINISTRATOR, A STAFF MEMBER WAS DESIGNATED IN WRITING AS BEING IN CHARGE. RULE 58A-5.019(4) (a)5, FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. Based on a biennial licensure survey conducted on January 8, 2004 and based on personnel and record review and staff interview, it was revealed that the administrator did not ensure that the facility had an employee trained and able to take charge in case of the absence of the administrator or manager. 16. The mandated correction date was designated as February 8, 2004. 17. Based on a follow-up survey conducted on March 10, 2004 and based on personnel and record review, it was revealed 4 that the facility still did not ensure that during temporary absence of the administrator, a staff member was designated in writing as being in charge. This is an uncorrected deficiency from the survey of January 8, 2004. 18. Based on the foregoing, TLC III violated Rule 58A- 5.019(4) (a)5, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT III TLC III FAILED TO ENSURE THAT THE FACILITY HAS CURRENT CLEARANCE FROM METRO FIRE DEPARTMENT. SECTION 400.441(1) (a)1l.m, FLORIDA STATUTES RULE 58A-5.015(1) (a)3, FLORIDA ADMINISTRATIVE CODE (FACILITY RECORDS STANDARDS) CLASS III VIOLATION 19. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 20. Based on a_ biennial licensure survey conducted on January 8, 2004 and based on record review and interview, it was revealed that the administrator failed to ensure that the facility had a current clearance from the Metro Fire Department for the year of 2003. 21. The mandated correction date was designated as March 10, 2004. 22. Based on a follow-up survey conducted on March 10, 2004 and based on interview and record review, it was revealed that the facility still did not have a current clearance from the Metro Dade Fire Department. Documentation revealed that the facility failed fire inspections on March 12, 2004 and March 15, 2004. This is an uncorrected deficiency from the survey of January 8, 2004. 23. Based on the foregoing, TLC III violated Section 400.441 (1) (a)l.m, Florida Statutes and Rule 58A-5.015(1) (a) 3, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT IV TLC III FAILED TO ENSURE THAT AN ADMINISTRATOR, WHO SUPERVISED MORE THAN ONE FACILITY, APPOINTED IN WRITING A SEPARATE MANAGER FOR EACH FACILITY. RULE 58A-5.019(1) (b), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS ) CLASS III VIOLATION 24. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. Based on a _ biennial licensure survey conducted on January 8, 2004 and based on file and record review and staff interview, it was revealed that the administrator did not appoint an employee at the facility as the manager. 26. The administrator did not ensure that the facility had a manager appointed as required by law when the administrator supervises 2 other facilities in the area. 27. The mandated correction date was designated an February 8, 2004. 28. Based on a follow-up survey conducted on March 10, 2004 and based on file and record review and staff interview, it was revealed that during the follow-up survey, the facility still failed to ensure that the administrator, (who supervised more than one facility) appointed in writing a separate manager for each facility. This is an uncorrected deficiency from the survey of January 8, 2004. 29. Based on the foregoing, TLC III violated Rule 58A- 5.019(1) (b), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT V TLC III FAILED TO ENSURE THAT DIRECT CARE STAFF RECEIVED INFECTION CONTROL TRAINING. RULE 58A-5.0191(2) (a), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0191(10) (e), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS III VIOLATION 30. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7 31. Based on a biennial licensure survey conducted on January 8, 2004 and based on record review and staff interview, the administrator did not ensure that all members of the staff were current with the required Infection Control training. Three out of three employees were not current with their infection control training. 32 The mandated correction date was designated as February 8, 2004. 33. Based on a follow-up survey conducted on March 10, 2004 and based on observation, interview and record review, it was revealed that the facility still failed to ensure that direct care staff received infection control training. This is an uncorrected deficiency from the survey of January 8, 2004. 34. Based on the foregoing, TLC III violated Rule 58A- 5.0191 (2) (a), Florida Administrative Code and Rule 58A- 5,0191(10) (e), Florida Administrative Code herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT VI TLC III FAILED TO ENSURE THAT THE EMERGENCY MANAGEMENT PLAN WAS SUBMITTED TO THE OFFICE OF EMERGENCY MANAGEMENT. SECTION 400.441(1) (b), FLORIDA STATUTES RULE 58A-5.026(2) (a), FLORIDA ADMINISTRATIVE CODE (EMERGENCY MANAGEMENT STANDARDS) CLASS III VIOLATION 35. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. Based on a biennial licensure survey conducted on January 8, 2004 and based on interview and record review, it was revealed that the facility did not have a current emergency management plan (within the last 365 days) approved by the Emergency Management Division available for surveyor to review. 37. Staff interview with the administrator confirmed that there was no approved plan available for inspection. 38. The mandated correction date was designated as February 8, 2004. 39. Based on a follow-up survey conducted on March 10, 2004 and based on interview and record review, it was revealed that the facility still failed to ensure that the emergency management plan was submitted to the Office of Emergency Management. This is an uncorrected deficiency from the survey of January 8, 2004. 40. Based on the foregoing, TLC III violated Section 400.441(1) (b), Florida Statutes and Rule 58A-5.0126(2), Florida Administrative Code and herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT VII TLC III FAILED TO ENSURE THAT ALL EMPLOYEE RECORDS CONTAINED VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE. SECTION 400.4275(4), FLORIDA STATUTES RULE 58A-5.024(2) (a), FLORIDA ADMINISTRATIVE CODE (STAFF RECORD STANDARDS) CLASS III VIOLATION 41. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 42. Based on a licensure survey conducted on January 8, 2004 and based on record review and interview, it was revealed that the administrator did not ensure the facility maintained current personnel records containing verification of freedom from communicable disease including tuberculosis in the personnel files at the facility. The facts include the following. 43. Record review and staff interview revealed that none of the members of the staff were cleared from a doctor to work at the facility. 44. The mandated correction date was designated as February 8, 2004. 45. Based on a follow-up survey conducted on March 10, 2004 and based on observation, interview and record review, it was revealed that the facility still failed to ensure that all employee records contained verification of freedom from 10 communicable disease. This is an uncorrected deficiency from the survey of January 8, 2004. 46. Based on the foregoing, TLC III violated Section 400.4275(4), Florida Statutes and Rule 58A-5.024(2) (a), Florida Administrative Code herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT VIII TLC III FAILED TO ENSURE THAT ALL EMPLOYEE RECORDS CONTAINED VERIFICATION OF FREEDOM FROM TUBERCULOSIS. RULE 58A-5.019(2), FLORIDA ADMINISTRATIVE CODE (STAFF RECORD STANDARDS) CLASS III VIOLATION 47. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. Based on a biennial licensure survey conducted on January 8, 2004 and based on record review and interview, it was revealed that the administrator did not ensure that the facility maintain current personnel records containing verification of freedom from communicable disease including tuberculosis in the personnel files at the facility. The facts include the following. 49. Facility tour conducted on January 8, 2004 at 10:00 a.m. revealed that no staff members were current with tuberculosis (TB) screening to work at the facility. 11 50. Record review and staff interview revealed that the administrator and employees were not cleared with a current TB screening from a doctor to work at the facility. The mandated correction date was designated as February 8, 2004. 51. Based on a follow-up survey conducted on March 10, 2004 and based on interview and record review, it was revealed that the facility still failed to ensure that all employee records contained verification of freedom from tuberculosis. 52. Based on the foregoing, TLC III violated Rule 58A- 5.019(2) (a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT IX TLC III FAILED TO ENSURE THAT ALL EMPLOYEES COMPLETED CONTINUING EDUCATION COURSE ON HIV/AIDS BIENNIALLY. SECTION 400.4275(2), FLORIDA STATUTES RULE 58A-5.0191(3), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a)1, FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0191(10), FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 53. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 54, Based on a_ biennial licensure survey conducted on January 8, 2004 and based on record review and staff interview, 12 it was revealed that the administrator did not ensure that all members of the staff were current with their HIV training. Three out of three employees were not current with their required HIV training. The mandated correction date was designated as February 8, 2004. 55. Based on a follow-up survey conducted on March 10, 2004 and based on record review and interview, it was revealed that the facility still failed to ensure that all employees completed continuing education course on HIV/AIDS biennially. This is an uncorrected deficiency from the survey of January 8, 2004. 56. Based on the foregoing, TLC III violated Section 400.4275(2), Florida Statutes, Rule 58A-5.0191(3), Florida Administrative Code, Rule 58A-5.024 (2) (a)1, Florida Administrative Code, and Rule 58A-5.0191(10), Florida Administrative Code , herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT X TLC III FAILED TO ENSURE THAT STAFF THAT PREPARE OR SERVE FOOD RECEIVED A MINIMUM OF ONE HOUR TRAINING IN SAFE FOOD HANDLING PRACTICES. RULE 58A-5.0191(2) (e), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.020(1) (d), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a)1, FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) 13 CLASS III VIOLATION 57. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 58. Based on a biennial licensure survey conducted on January 8, 2004 and based on record review and staff interview, it was revealed that the administrator did not ensure that all members of the staff, who prepare or serve food, were current with the food services handling training. Three out of three employees were not current with required food services handling training. 59. The mandated corrected date was designated as February 8, 2004. 60. Based on a follow-up survey conducted on March 10, 2004 and based on observation, interview, and record review, it was revealed that the facility still failed to ensure that staff, who prepare or serve food, received a minimum of 1 hour training in safe food handling practices. This is an uncorrected deficiency from the survey of January 8, 2004. 61. Based on the foregoing, TLC fil violated Rule 58A- 5.0191(2) (e), Florida Administrative Code, Rule S5B8A-5.020(1) (d), Florida Administrative Code, and Rule 58A-5.024(2) (a)l, Florida Administrative Code, herein classified as an uncorrected Class TII violation, which warrants an assessed fine of $500.00. 14 COUNT XI TLC III FAILED TO ENSURE THAT THE PERSON DESIGNATED AS SUPERVISING FOOD SERVICE OBTAINS ANNUALLY CONTINUING EDUCATION IN NUTRITION AND FOOD SERVICES IN AN ALF. SECTION 400.452(6), FLORIDA STATUTES RULE 58A-5.0191(6), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.020(1) (d), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a)1, FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 62. AHCA’ re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 63. Based on a_ biennial licensure survey conducted on January 8, 2004 and based on observation, interview, and record review, it was revealed that the administrator did not have any members of the staff currently trained in Nutritional In Service available for surveyor inspection. The facts include the following. 64. Staff interview with the administrator confirmed that none of the employees had Nutritional In Service training certificates available for inspection. 65. Record review revealed that the administrator was currently trained at the facility. 66. The mandated correction date was designated as February 8, 2004. 15 67. Based on a follow-up survey conducted on March 10, 2004 and based on observation, interview, and record review, it was revealed that the facility still failed to ensure that the person designated as supervising food service obtains annually continuing education in nutrition and food service in an ALF. This is an uncorrected deficiency from the survey of January 8, 2004. 68. Based on the foregoing, TLC II! violated Section 400.452(6), Florida Statutes, Rule 58A-5.0191(6), Florida Administrative Code, Rule 58A-5.020(1) (da), Florida Administrative Code, Rule 58A-5.024(2) (a)1, Florida Administrative Code, herein classified as an uncorrected Class ITI violation, which warrants an assessed fine of $500.00. COUNT XII TLC III FAILED TO ENSURE THAT ALL PERSONNEL RECORDS CONTAINED DOCUMENTATION OF COMPLIANCE WITH LEVEL I BACKGROUND SCREENING. SECTION 400.4275(2), FLORIDA STATUTES RULE 58A-5.019(3), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a)3, FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 69. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16 70. Based on a_ biennial licensure survey conducted on January 8, 2004 and based on interview and record review, the administrator did not have, nor did the administrator ensure that the facility had maintained the required background screening clearance for any employees working at the facility. The facts include the following. 71. Staff interview with the administrator confirmed that three employees sampled did not have a level 1 background screening records at the facility available for inspection during the time of the survey. 72. Record review revealed that there was no level 1 background screening records available for review at the facility. The mandated correction date is designated as February 8, 2004. 73. Based on a follow-up survey conducted on March 10, 2004 and based on observation, interview and record review, it was revealed that there were still no background screening records available for review at the facility. This is an uncorrected deficiency from the survey of January 8, 2004. 74. Based on the foregoing, TLC III violated Section 400.4275(2), Florida Statutes, Rule 58A-5.019(3), Florida Administrative Code, and Rule 58A-5.024(2) (a)3, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. 17 SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $307.00 has been assessed in this case. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against TLC III on Counts I through XII. 2. Assess an administrative fine of $6,000.00 against TLC III on Counts I through XII for the violations cited above. 3. Assess a survey fee of $307.00 against TLC III pursuant to Section 400.419(10), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. 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 (2003). Specific options for administrative action are set out in the attached Election of Rights and 18 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 Clerk, Agency for Health Care Administration, 2727 # £=Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. Zs sq. al Counsel h Care Agéncy for Administratik 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 19 Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Barbara Clifford, Administrator, TLC III, 8395 S. W. 112 Street, Miami, Florida 33156; Barbara Clifford, 12990 Névada Street, Miami, Florida 33156 on this Osthaay of , 2004. 20

Docket for Case No: 04-003464