STATE OF FLORIDA OF py a AGENCY FOR HEALTH CARE ADMINISTRATION JUL 79 Pit 1 iF 22 STATE OF FLORIDA re : AGENCY FOR HEALTH CARE heey ADMINISTRATION, shied Petitioner, CASE NO: 2004002375 vs. CLEARVIEW MANOR, INC. i ~ YO d/b/a CLEARVIEW MANOR Uo 2 ¥R Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersignec counsel, and files this Administrative Complaint against CLEARVIEW MANOR, INC., d/b/a CLEARVIEW MANOR (hereinafter “Respondent”) and alleges the following: NATURE OF THE ACTION 1. This is an action to impose administrative fines on Respondent pursuant to Section 400.419(1) (c), Florida Statutes (2003). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 3. AHCA, Agency for Health Care Administration, has jurisdiction over Respondent pursuant to Chapter 4¢0 Part IIT, Florida Statutes. 4. Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Coce. 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 and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 1080 S. Clearview Avenue, Tampa, FL 33629. 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, having been issued license number 9643. COUNT I RESPONDENT FAILED TO ENSURE THAT THE RESIDENT’S RECORD INCLUDED A COPY OF THE RESIDENT’S CONTRACT WITH THE FACILITY, EXECUTED AT OR PRIOR TO ADMISSION, INCLUDING ANY ADDENDUMS TO THE CONTRACT. Fla. Admin. Code R.58A-5.024(3) (i)and 58A-5.025(1) (2003) Section 400.424(1)and(5), F.S. (2003) REPEAT CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about May 14, 2002, an appraisal survey was conducted at Respondent’s facility. 9. Based on a review of two resident files, neither file contained a copy of the resident’s contract with the facility, executed at or prior to admission. The file of one resident, date of admission 4/12/02, contained a contract between the resident and his former facility; the file of one cther resident, date of admission 2/24/02, was not signed by the resident. 10. Respondent was provided a mandated correction date of May 14, 2002. 11. On or about July 29, 2003, a follow-up survey was conducted at Respondent’s facility. At this time, the above- listed deficiency had been corrected. 12. On or about February 26, 2004, a complaint survey was conducted at Respondent’s facility. 13. Based on resident record review, it was determined that the facility did not have resident contracts for 4 of 16 residents reviewed or reported as residing in the facility (#11, #14, #15, #19). The findings include: 1. Review of resident #11's resident record revealed a blank contract, the contract did not list the name of the facility, the name of the resident or the payment amount and was not signed by a representative of the facility. 2. Interview with the Administrator, at 11:00 a.m. on 2/26/04, revealed that resident #14 and resident #15 had residcd in the facility for 4 days. Interview confirmed that there were no records for these two residents and no contract with the facility. 3. Interview with the Administrator, at 11:00 a.m. on 2/26/04, revealed that resident #19 had been admitted to the facility on 2/25/04. She stated there had been no contract executed between the resident and the facility. 14. Respondent was provided a mandated correction date of March 26, 2004. 15. The above actions or inactions are a violation of Rules 58A-5.024(3) (i) and 58A-5.025(1), Florida Administrative Code (2002), and Sections 400.424(1) and 400.424(5), Florida Statutes, which require the facility to ensure that the resident’s record include a copy of the resident’s contract with the facility, executed at or prior to admission, including any addendums to the contract. 16. Said violation constitutes the grounds fcr the imposed repeat Class III deficiency in that it indirectly cr potentially threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (c), Florida Statutes (2003), the Agency is authorized to impose a fine in the amount of five hundred dollars ($500). COUNT ITI RESPONDENT FAILED TO ENSURE THAT STAFF WHO PROVIDE DIRECT CARE TO RESIDENTS OBTAIN A MINIMUM OF 1 HOUR IN-SERVICE TRAINING IN INFECTION CONTROL. IN VIOLATION OF Fla. Admin. Code R.58A-5.0191(2) (a) (2003) Fla. Admin. Code R.58A-5.0191(10) (e) (2003) REPEAT CLASS III DEFICIENCY 17. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 18. On or about May 12, 2002, an appraisal survey was conducted at Respondent’s facility. 19. Based on a review of two employee files and on interview with the Owner of the facility, the file of one employee, date of application 02/02, did not contain documentation of her receipt of one hour in-service training in infection control. In interview with the Owner on 05/14/02 at 9:45 a.m., it was established that this employee has been working in the facility for over 30 days. 20. Respondent was provided a mandated correction date of May 24, 2002. 21. On or about July 29, 2003, a follow-up survey was corducted at the facility. 22. Based on personnel record review and staff interview, it was determined that the facility failed to ensure that direct care staff had received a minimum of 1 hour in-service training in infection control before providing care for residents for 3 of 3 personnel records reviewed. The findings include: Review of 3 personnel records, for two direct care staff and the Administrator, who also provides direct care, revealed that the 3 staff had not received the | hour minimum in-service training in infection control. The Administrator and 1 direct care person were hired in August 2002 and the other direct care person was hired in September 2002. Interview with the Administrator and the owner, on 07/29/03 at 12:00 p.m., revealed that this training had not been provided. 23. Respondent was provided a mandated correction date of August 29, 2003. 24. On or about October 20, 2003, a second follow-up suxvey was conducted at Respondent’s facility. At this time, the above-listed deficiency had been corrected. 25. On or about February 26, 2004, a complaint survey was conducted at Respondent’s facility. 26. Based on review of personnel record, it was determined that the facility did not have documentation that two of two employees had a minimum of 1 hour in-service training in infection control prior to providing personal care to residents. The findings include: 1. Interview with the Administrator, at 11:00 a.m. on 2/26/04, revealed that she had been employed by the facility since 1/2/04. Review of the Administrator's personnel record revealed no documentation that she had received an in-service on infection control. 2. Interview with the other caregiver, at 11:00 a.m. on 2/26/04, revealed that she had been employed by the facility for 8 days. Review of her personnel record revealed no documentation that she had received an in-service on infection control. 27. Respondent was provided a mandated correction date of March 26, 2004. 28. The above actions or inactions are a violation of Rule 58A-5.0191(2) (a), Florida Administrative Code, whica requires that staff who provide direct care to residents, other than nurses, certified nursing assistants, or home health aides trained in accordance with Rule 59A-8.0095, F.A.C., must receive a minimum of 1 hour in-service training in infection control, including universal precautions, and facility sanitation procedures before providing personal care to residerts. Documentation of compliance with the staff training requirements of 29 CFR 1910.1030, relating to blood borne pathogens, may be used to meet this requirement. 29. Additionally, Rule 58A-5.0191(10) (e), Florida Administrative Code, requires that any required training shall be cocumented in the facility’s personnel files. This 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. 30. Said violation constitutes the grounds for the imposed repeat Class III deficiency in that it indirectly cr potentially threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (c), Florida Statutes, the Agency is authorized to impose a fine in the amount of five hundred dollars ($500). 31. Pursuant to Section 400.419(9), Florida Statutes, 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 400.428(3) (c) to verify the correction of the violations. In this case, AHCA is authorized to assess a survey fee in the amount of one hundred fifty-four dollars ($154.00). 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, Count II and Count III; 2. Impose a fine and survey fee in the amount of one thousand one hundred fifty-four dollars ($1,154.00) for the violations cited in Count I, Count II and Count III against the Respondent, pursuant to Sections 400.419(1) (b), 400.419(c) and 400.419(9), Florida Statutes; 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, ~~. Jf). coy Katrina D. Lacy, EsquYre AHCA - Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive N., #330G St. Petersburg, Florida 33701 (727) 552-1525 office (727) 552-1440 fax 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. 7003 1010 0002 4667 0326 to Kevin Kladakis, Owner, 4008 Sevilla Street, Tampa, FL 33629 and Receipt No. 7003 1010 0002 4667 0340, to Deetra Taylor, Administrator, Clearview Manor, 1080 S. Clearview Ave., Tampa, FL 33629 on the jdt aay of May, 2004. squire atrina D. Lacy, Copies furnished to: Kevin S. Kladakis, Owner Clearview Manor, Inc. 4008 Sevilla Street Tampa, FL 33629 (Certified U.S. Mail) Deetra Taylor, Administrator Clearview Manor Inc. 1080 South Clearview Avenue Tampa, FL 33629 (Certified U.S. Mail) Katrina D. Lacy, Esq. PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. __inthe amount of $ , which represents payment of the Administrative Fine imposed by AHCA. Facility Name AHCA No.

Docket for Case No: 05-002488