STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Case No. 2004007586 MAGNOLIA LTC INC., —_ nite MAGNOLIA MANOR, e Uf ° f U f 4 Respondent. ee ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against MAGNOLIA LTC INC., d/b/a MAGNOLIA MANOR (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $1,000 against Respondent, pursuant to Section 400.419(1)(c), Florida Statutes (2004); and Rules 58A-5.0191(2)(a) and (d), and S8A-5.0191(10)(e), Florida Administrative Code (2004). as cited for two Class III violations during a Complaint 3, 2004, AHCA 2. Respondent w Investigation AHCA conducted on or about June 21, 2004. On July 2 conducted a follow-up to the Complaint Investigation and found that the two Class III violations remained uncorrected. Page 1 of 10 @ @ JURISDICTION AND VENUE 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). 4. Venue shall be determined, pursuant to Chapter 28-106.207, Florida Administrative Code (2004). PARTIES 5. Pursuant to Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules. 6. Respondent is an assisted living facility located at 3339 Highway 17, Green Cove Springs, Florida 32043. Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), having been issued license number 10379. COUNT I de a minimum of one hour of in-service training to The Respondent failed to provi residents prior to the staff providing personal care staff who provide direct care to to residents. § 400.419(1)(c), Fla. Stat. (2004) Fla. Admin. Code R. 58A-5.0191(2)(a) (2004) Fla. Admin. Code R. 58A-5.0191(1 0)(e) (2004) 7. AHCA re-alleges paragraphs 1-6 above. 8. On or about June 21, 2004, AHCA conducted a Complaint Investigation at Respondent’s facility. AHCA cited Respondent for a violation, based on the findings below, to wit: two sampled personnel records on 6-21-04 at approximately 9:15 AM a) Review of tation regarding infection control training. revealed they did not contain documen Page 2 of 10 in-service training in infectio residents, as requ 9. Respondent failed to provide documentation of a minimum of one hour of n control for staff before providing personal care to ired by Fla. Admin. Code R. 58A-5.0191(2)(a) (2004) and Fla. Admin. Code R. 58A-5.0191(10)(e) (2004). 10. follows: “§8A-5.0191 Staff Training Requirements SERVICE TRAINING. Each facility must provi to facility staff. (a) Staff who provide certified nursing assistants, or home he: 59A-8.0095, F.A.C., must receive a minimum infection control, including universal precautions, before providing personal care to residents. Assisted living facility staff training is required, in pertinent part, as and Training Fees...(2) STAFF IN- ide the following in-service training direct care to residents, other than nurses, alth aides trained in accordance with Rule of 1 hour in-service training in and facility sanitation procedures Documentation of compliance with the 0.1030, relating to blood bome pathogens, staff training requirements of 29 CFR 191 may be used to meet this requirement.” (Fla. Admin. Code R. 58A-5.0191(2)(a) (2004)) -5.0191 Staff Training Requirements and Training Fees.. PROVIDER AND CURRICULUM APPROVAL; DOCUMENTATION...(e) Except a: rule shall be documented in the facility’s personnel fi include the title of the training program, course con! training provider’s name and the training provi of training. A certificate issued by the dep documentation of training provided by department staff. “658A .(10) TRAINING TRAINING s otherwise noted any training required by this les which documentation shall tent, date of attendance, the ‘der’s credentials, and number of hours artment shall provide sufficient ” (Fla. Admin. Code R. 58A- 5.0191(10)(e) (2004)) 11. For this violation, AHCA provided Respondent a mandated correction date of July 21, 2004. of the violation and the gravity of its prob wit: 12. “(c) Clas: and maintenance of a facility or to the p determines indirectly or potentially threaten or security of facility residents, other than c The foregoing violation constitutes a Class III violation due to the nature able effect on the residents of the facility, to s III violations are those conditions or occurrences related to the operation ersonal care of residents which the agency the physical or emotional heaith, safety, lass I or class II violations. A class I f not less than $500 and not exceeding violation is subject to an administrative fine o $1,000 for each violation...” (§ 400.419(1}(c), Fla. Stat. (2004)) Page 3 of 10 13. On July 23, 2004, AHCA conducted a follow-up to the Complaint Investigation at Respondent’s facility. AHCA cited Respondent for an uncorrected violation, based on the findings below, to wit: a) Review of three sampled personnel records of staff who perform personal care to residents on 7/23/04 at approximately 9:30 AM revealed that three of three records (#2, #3, and #5) did not contain documentation regarding infection p on 7-23-04 the training had not been control training. At time of the follow-uj completed as confirmed in an interview with the administrator at 10:15 AM. 14. The foregoing violation constitutes an uncorrected Class III violation due the residents of the facility, to the nature of the violation and the gravity of its effect on and warrants a fine of $500, to wit: “(c) Class II violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class I violations. A class II violation is subject to an administrative fine of not less than $500 and not exceeding Fla. Stat. (2004)) $1,000 for each violation...” (§ 400.419(1}(¢), 15. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of the administrator, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $500 for the referenced violation; and 3. Impose such other appropriate relief as this tribunal may find and deem appropriate. Page 4 of 10 COUNT II ide 3 hours of in-service training within 30 days of The Respondent failed to prov! de direct care to residents in resident behavior and employment to staff who provi needs, and providing assistance with activities of daily living. § 400.419(1)(c), Fla. Stat. (2004) Fla. Admin. Code R. 58A-5.0191(2)(d) (2004) Fla. Admin. Code R. 584-5.0191(10)(e) (2004) 16. | AHCA re-alleges paragraphs 1-6 above. 17. On or about June 21, 2004, AHCA conducted a Complaint Investigation at Respondent’s facility. AHCA cited Respondent for a violation, based on the findings below, to wit: a) Review of two sampled personnel records on 6/21/04 at approximately 9:15 AM revealed they did not contain documentation related to resident behavior and needs, and ADL training within 30 days of employment. 18. Respondent failed to provide documentation of 3 hours in-service training within 30 days of employment for staff who provide direct care to residents and assistance with activities of daily living (“ADL”), as required by Fla. Admin. Code R. §8A-5.0191(2)(d) (2004) and Fla. Admin. Code R. 58A-5.0191(10)(e) (2004). 19. Assisted living facility staff training is required, in pertinent part, as follows: d Training Fees...(2) STAFF IN- de the following in-service training are to residents, other than nurses, with Rule 59A-8.0095, F.A.C., “58A-5.0191 Staff Training Requirements an SERVICE TRAINING. Each facility must provi to facility staff...(d) Staff who provide direct c: CNAs, or home health aides trained in accordanc must receive 3 hours of in-service training within 30 days of employment...” (Fla. Admin. Code R. 58A-5.0191(2)(d) (2004)) “§8A-5.0191 Staff Training Requirements and Training Fees...(10) TRAINING TRAINING PROVIDER AND CURRICULUM APPROVAL; DOCUMENTATION...(e) Except as otherwise noted any training required by this rule shall be documented in the facility’s personnel files which documentation shall include the title of the training program, course content, date of attendance, the training provider’s name and the training provider’s credentials, and number of hours of training. A certificate issued by the department shall provide sufficient documentation of training provided by department staff.” (Fla. Admin. Code R. 58A- 5.0191(10)(e) (2004)) Page 5 of 10 20. For this violation, AHCA provided Respondent a mandated correction date of July 21, 2004. 21. The foregoing violation constitutes a Class Il violation due to the nature of the violation and the gravity of its probable effect on the residents of the facility, to wit: re those conditions or occurrences related to the operation lity or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class Il violations. A class Io violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation...” (§ 400.419(1)(c), Fla. Stat. (2004)) “(c) Class III violations a and maintenance of a faci 22. On July 23, 2004, AHCA conducted a follow-up to the Complaint Investigation at Respondent’s facility. AHCA cited Respondent for an uncorrected violation, based on the findings below, to wit: rsonnel records of staff who provide direct care to residents on AM revealed that two of three records (#2 and #5) ated to resident behavior and needs, and ADL At the time of the follow-up on 7-23-04 as confirmed in an interview with the a) Review of three pe 7/23/04 at approximately 9:30 did not contain documentation rel; training within 30 days of employment. the training had not been completed administrator at 10:15 AM. 23. The foregoing violation constitutes an uncorrected Class III violation due to the nature of the violation and the gravity of its effect on the residents of the facility, and warrants a fine of $500, to wit: violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class I violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation...” (§ 400.419(1}(c), Fla. Stat. (2004)) “(c) Class III 24. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Page 6 of 10 the administrator, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $500 for the referenced violation; and Impose such other appropriate relief as this tribunal may find and deem appropriate. NOTICE Respondent, MAGNOLIA LTC INC., d/b/a MAGNOLIA MANOR, 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 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, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. RESPONDENT IS FURTHER NOTIFIED, IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Submitted on this _| ST day of Octuteyr 2004, Timothy B. Elliott, Senior Attomes g Fla. Bar No. 210536 Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MSC #3 Tallahassee, FL 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-93 13 Page 7 of 10 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Return Receipt Requested (receipt# 7000 1530 0000 5684 9051) to Magnolia Manor, Attention: Administrator, 3339 Highway 17, Green Cove Springs, Florida 32043. Submitted on this | et day of ( de +o eh) 2004. for Timothy B. Elliott, Senior Atiomey 6 ¢) Page 8 of 10 Page 1 of 1 USPS - Track & Confirm Track & Confirm Track & Confirm Current Status Enter label number: You entered 7000 1530 0000 5684 9051 Your item was delivered at 2:22 pm on October 04, 2004 in GREEN COVE SPRINGS, FL 32043. 4 Track & Confirm FAQs C on On No a U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mait Only; No Insurance Coverage Provided) contact us government services }2 USPS. All Rights Reserved. Terms of Use Privacy Policy Postage il Certified Fee OMPLAINT Postmark Here Return Receipt Fee (Endorsement Required) Restricted Delivery Fee {Endorsement Required) Total Postage & Fees | $ ‘Apt. Y or POE P HIGH WHE LT evn emen nm City, State, ZIP+ 4 LE Wy, > : See Reverse for Instructions “S00 2530 DDOO 5684 9052 EAL LYE PS Form 3800, May 2000 10/07/2004

Docket for Case No: 04-004049