STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION a STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2005004710 HILLANDALE, 0 J -aXK¥K2 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against HILLANDALE (hereinafter Respondent), pursuant to Section 120.569 and 120.57 Fla. Stat., (2004), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of one thousand dollars ($1,000.00) based upon two cited uncorrected State Class III deficiencies pursuant to §400.419(2)(c) Fla. Stat. (2004). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part IIT, Florida Statutes, and; Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 24-bed assisted living facility located at 6333 Langston Avenue, New Port Richey, Florida 34652, and is licensed as an assisted living facility, license number 10549. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT 1 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, the facility must contact the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. Fla. Admin. Code R. 58A-5.0182 (1)(d). 8. That the Agency conducted an appraisal survey of the Respondent facility on March 22, 2005. 9. That based upon the review of records and interview, it was determined that the facility did not notify the attending physician of a significant change in a resident's condition in one of five residents in the survey sample, in that the resident had been involuntarily hospitalized without the facility notifying the health care provider. 10. That the Petitioner's representative reviewed the Respondent’s records regarding resident number five. 11. That the resident’s medical records reflect that on March 17, 2005, at approximately 10:30 P.M., the resident became physically aggressive to staff and residents. 12. That Respondent’s staff summoned law enforcement to the facility, who involuntarily hospitalized the resident for mental health evaluation due to the resident’s behavior. 13. That the resident's record indicated that the resident had an attending physician. 14. That the Respondent’s record contained no indication that the resident’s physician was notified of the resident’s significant change requiring involuntary hospitalization, said failure being in violation of law. 15. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 16. That the Agency provided Respondent with a mandatory correction date of April 22, 2005. 17. That on May 16, 2005 the Agency conducted a revisit to the appraisal survey at the Respondent facility. 18. That based on interview and the review of records, the facility failed to notify the residents’ case managers of significant changes in resident behavior in a timely manner. 19. That the Petitioner’s representative reviewed the Respondents records. 20. That the Respondent’s April and May 2005 "reactive strategy recording form” reflected the following: a. A prone restraint (BARR, or Brief Assisted Required Relaxation) was utilized on resident number one on May 14, 2005 as a result of "hitting, throwing objects." b. A prone restraint was utilized on resident number four on April 14, 2005 as a result of aggression to staff, on April 19, 2005 as a result of aggression to others and staff, and on April 23, 2005 as a result of “acting up after being accused of stealing, attacked (another resident)." c. A prone restraint was utilized on resident number eight on April 12, 2005 for being aggressive. d. A prone restraint was utilized on resident number ten on April 11, 2005 as a result of aggression to property and staff, on April 19, 2005 as a result of aggression to staff, and on Apri! 21, 2005 as a result of self injurious behavior and aggression to staff. e. A prone restraint was utilized on resident number twelve on April 11, 2005 as a result of aggression to property and on April 30, 2005 as a result of aggression to staff. f. A prone restraint was utilized on resident number thirteen on April 12, 2005 as a result of aggression and again on April 19, 2005 as a result of aggression to staff and property destruction. g. A prone restraint was utilized on resident number fourteen on April 16, 2005 as a result of aggression to staff and on April 22, 2005 on four separate occasions as a result of property destruction, aggression to property, a second instance of aggression, and a second instance of property destruction. h. A prone restraint was utilized on resident number six on April 3, 2005 as a result of elopement and again on April 15, 2005 as a result of aggression to staff. 21. That the above recited reflect instances of resident’s changes in mood or behavior, as evidenced by the use of physical restraint due to extremely violent behavior: 22. — That there is no indicium in the resident records to indicate, upon the significant change and deterioration of these residents behaviors, that the resident’s case managers were notified. 23. That on May 16, 2005, the Petitioner’s representatives interviewed a representative of the agency which is responsible for the case management of the above-mentioned residents. 24. That the representative indicated that no timely report of these incidents was made to their agency. 25. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for an uncorrected State Class II] deficiency. 26. That the Agency provided Respondent with a mandatory correction date of June 16, 2005. 27. That the same constitutes an uncorrected State Class III deficiency under the provisions of law, Section 400.419(2)(c) Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2004). COUNT I 28. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. That pursuant to Florida law, an up-to-date record of adverse incidents must be maintained by the facility. Section 400.423(2), Fla. Stat. (2004). 30, That Florida law requires an adverse incident report be filed with the Agency for Health Care Administration within twenty-four hours of the incident and a second report within fifteen days of the incident. Section 400.423 (3)(4) Fla. Stat. (2004), R. S8A-5.0241 Fla. Admin. Code. 31. That the Agency conducted an appraisal survey of the Respondent facility on March 22, 2005. 32. That based upon the review of records and interview, it was determined that the facility did not have a record of adverse incidents and did not report said incidents as required by law for two of five residents in the survey sample. 33. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number one, which reflect the following: a. That the resident had a diagnosis of Schizoaffective Disorder and Hypertension as annotated on the resident’s health assessment dated November 17, 2004; b. That in January 2005, with no specific date documented, the resident eloped down the street, picked up a piece of glass, and threatened to cut his/her wrist; c. That law enforcement and paramedics were summoned and the resident was involuntarily hospitalized under the Baker Act. 34. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number five which reflect that resident, on March 17, 2005, at approximately 10:30 P.M., became physically aggressive to staff and other residents resulting in the resident’s involuntary hospitalization for mental health under the authority of law enforcement who had been summoned to the facility. 35. That acts of elopement and events involving law enforcement are acts defined as adverse incidents, Section 400.423 (2)(c)(d) Fla. Stat. (2004). 36. That the Respondent had no record of these adverse incidents or the reporting of the same to the Agency for Health Care Administration. 37. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 38. That the Agency provided Respondent with a mandatory correction date of April 22, 2005. 39. That on May 16, 2005, the Agency conducted a revisit to the appraisal survey at the Respondent facility. 40. That based upon the review of records and interview, it was determined that the facility did not have a record of adverse incidents occurring within the past two years for two of eight residents in the survey sample. 41. That the Petitioner's representatives reviewed the Respondent’s records regarding resident number eight. 42. That the records of resident number eight reflect the following: a. That the resident had diagnoses including inter alia autism and mental retardation as reflected on health assessments dated September 29, 2004 and November 17, 2004; b. That the Residential Habilitation Goals documents of March and April 2005 memorialize that the resident was "very combative", "hit walls", and "hit 2 peers” on April 12, 2005; c. That an incident noted on the facility behavior monitoring form dated May 1, 2005, noted that the resident was "pushing, shoving and hitting clients and staff,” and that a "1 arm wrap (a physical takedown) was used,” that "it worked 4 hours later,” and noted the behaviors lasted from 4-8 (no documentation of a.m. or p.m.); 43. That there was no documentation that a one day or fifteen day report had been submitted for these events. 44. That the Administrator had no explanation during the exit interview at 1:45 p.m. on May 16, 2005. 45. That the Petitioner’s representatives reviewed the Respondent’s records regarding resident number three. 46. That the records of resident number three reflect the following: a. That the resident’s diagnoses include schizoaffective disorder, bipolar type according to the health assessment dated February 15, 2005; b. That the resident was admitted to the Behavioral Health Center on an involuntary hospitalization under the Florida Mental Health Act (a/k/a Baker Act) on February 8, 2005; c. That the involuntary hospitalization was initiated by the Pasco County Sheriff's Department due to aggressive and agitated behavior toward the staff and others at the local assisted living facility. 47. That these acts involving law enforcement and involuntary commitment are acts defined as adverse incidents. Section 400.423 (2) Fla. Stat. (2004). 48. That the Respondent had no record of these adverse incidents or the reporting of the same to the Agency for Health Care Administration. 49. That the petitioner’s representative interviewed the Respondent’s administrator on May 16, 2005 regarding the lack of adverse incident records and the administrator had no explanation for this record deficiency. 50. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for an uncorrected State Class III deficiency. 51. That the Agency provided Respondent with a mandatory correction date of June 16, 2005. 52. That the same constitutes an uncorrected State Class III deficiency under the provisions of law, Section 400.419(2)(c) Fla. Stat. (2004). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2004). submitted this 7 day of July 2005. J. Walsh, II Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 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 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7003 1010 0002 4667 1934 on July F, 2005 to: John Joseph Ross, Administrator, Hillandale, 6333 Langston Avenue, New Port Richey, Florida 34652, and by U.S. Mail to: Gene Cowles, Owner, Hillandale, P.O. Box 1778, Safety Harbor, Florida 34695. oynas J. Walsh, II Senior Attorney Copies furnished to: John Joseph Ross Gene Cowles Thomas J. Walsh, If Administrator Owner Agency for Health Care Admin. Hillandale Hillandale 525 Mirror Lake Drive, 330G 6333 Langston Avenue P.O. Box 1778 St. Petersburg, Florida 33701 New Port Richey, Florida 34652 | Safety Harbor, Florida 34695 | (Interoffice) (U.S. Certified Mail) (U.S. Mail) PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. _in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. Hillandale 2005004710 Facility Name AHCA Case No. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES (To be used with Election of Rights for Administrative Complaint form — attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (‘AHCA” or “Agency”), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date you receive the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A Final Order will be entered setting forth the allegations as being deemed admitted and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the Final Order. OPTION 2. If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Complaint.), Respondent may request an Informal Hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the Informal Hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an Informal Hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. _If the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a Formal Hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a Formal Hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent’s request for an Administrative Hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it. IF YOU SELECT OPTION 3, PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent’s original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the Election of Rights form with Respondent's selected option is not received by AHCA within twenty-one (21) days from the date of Respondent’s receipt of the Administrative Complaint, a Final Order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. SENDER: COMPLETETHIS SECTION COMPLETE THIS SECTIQN ON DELIVERY @ Complete items 1, z, _.1d 3. Also complete item 4 if Restricted Delivery is desire¢-————_—. @ Print your name and address on the raverse so that we can return the card to you. ™@ Attach this card to the back of the mailpiece, or on the front if space permits. Article Addressed to: Gene Cooles, ; ah m Oto % Saledy arbor Cori Bas 0.0), 2, Article Number 7004 2510 0005 4o49 1a40 _ROBOO TE —_ ens tn Sere TA) 20050 HTD + PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 SENDER: COMPLETE Ti ™ Complete items 1, 2, at... J. Also complete Item 4 if Restricted Delivery is desired. ™ Print your name and address on the reverse so that we can return the card to you. § Attach this card to the back of the mailplece, or on the front if space permits, D. Is delivery address different from item 1? C) Yes It YES, enter delivery address below: _[] No 1. Article Addressed to: John Joseph Ross Palin sector Wandate. (0333 lownasten Avenue ee —<$<——<——_$<$_<—_————— _ 3. C Certified Mai l legi C Retum Receipt for Merchandise insured Mal 06.00, -———~ Neew Yor c on a Fi. pS} 4. Restricted Delivery? (Extra Foe) O Yes 2. Article Number 7003 ] 7 “wD ie wa O10 0002 4eo7 19354 ~ 2005004710 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 05-002882