STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case No. 2005004708 HILLANDALE, 0. s« BR 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 administrative fines in the amount of $2,000.00 based upon Respondent being cited for two State Class I] deficiencies pursuant to §400.419(2)(b) 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 III, 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 I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, a facility must monitor the continued appropriateness of placement of a resident in the facility. Fla. Admin. Code R. 58A-5.0181(4)(d), Section 400.426(1) Fla. Stat., (2004). 8. That a resident of an assisted living facility must not be a danger to self or others as determined by a physician, or mental health provider. Fla. Admin. Code R. 58A-5.0181(1 )(g). 9. That on May 16, 2005, the Agency conducted a revisit to the appraisal survey of the Respondent facility. 10. That based upon observation, interviews with staff, and review of resident records, it was determined that the facility Administrator failed to monitor residents for continued appropriate placement for ten of ten sampled residents due to multiple aggressive behaviors that cannot be managed in an assisted living facility setting. it. That the residents who have been identified by the Agency as inappropriate for continued placement in an assisted living facility require intensive behavioral residential habilitation. The eligibility for such services is contingent upon the resident engaging in the following behavior within the past six months: behavior that caused injury, creates a life threatening situation, set a fire, attempted suicide, caused damage to property over a thousand dollars, that was unable to be controlled via less restrictive means and necessitated the use of restraints, resulted in arrest and confinement and requires visual supervision during all waking hours. 12. That resident number two’s health assessment dated November 17, 2004, listed diagnoses including, but not limited to, Schizophrenia, Autism, with severe vision impairment, and SIB (Self-Injurious Behaviors). The assessment also noted the presence of "impulsive aggressive behaviors". 13. That Petitioner’s representative’s observed on May 16, 2005 at approximately 7:00 a.m. that the door to the facility’s men's bathroom had two pushed-in broken areas on the door panels. 14, That Petitioner’s representative interviewed the Respondent’s staff member who indicated that resident number two had "punched out the door about a week ago”. 15. That resident number two, an aggressive male resident who was observed as almost 6 feet in height and weighed almost 200 pounds, placed other residents at risk. 16. That the Respondent’s records contain no indicia that the resident’s aggressive behavior was evaluated or assessed to determine whether the resident continued to meet residency criteria for an assisted living facility, i.e. whether the resident was a risk to self or others. 17. That Petitioner’s representative reviewed the Respondent’s records regarding resident number three. Said record reflected as follows: a. That resident number three’s facility behavior monitoring form (undated) reflected three behaviors from 8:00 - 8:20 p.m.; b. That the resident was described as "very agitated today. He/she hit several clients and staff (named) on the back with a fist!"; c. That in response to the resident's behaviors, Respondent’s staff placed the resident on a floor mat and two staff utilized the BARR (Brief Assisted Required Relaxation) procedure, i.e. a 4-point restraint by staff. 18. That the Respondent’s records contain no indicia that the resident’s aggressive behavior was evaluated or assessed to determine whether the resident continued to mect residency criteria for an assisted living facility, ie. whether the resident was a risk to self or others. 19. That the Petitioner’s representatives reviewed the Resident’s records regarding resident number five, which reflected as follows: a. That the resident had diagnoses of Schizophrenia and Mental Retardation; b. That the facility behavior monitoring form, on April 1, 2005, noted the resident was "screaming/crying; eating out of garbage", and on April 14, 2005, had hit and bitten a staff member who required Emergency Room transport as the bite "drew blood"; c. That the "Resident Observation Log", in entries dated May 2, 3, and S, 2005, noted the resident was hallucinating, and had increased physical aggression to others, some days twice a day. 20, That the Respondent’s records contain no indicia that the resident’s aggressive behavior was evaluated or assessed to determine whether the resident continued to meet residency criteria for an assisted living facility, i.e. whether the resident was a risk to self or others. 21. That the petitioner’s representatives observed resident number five during the survey from 6:30 a.m. until the residents left the facility for their treatment program at approximately 9:00 a.m. 22. That resident number five was observed to intrude into the personal space of others, at times was not easily redirected, getting into verbal altercations, and shoving another resident. 23. That the Respondent’s records contain no indicia that the resident’s aggressive behavior was evaluated or assessed to determine whether the resident continued to meet residency criteria for an assisted living facility, i.e. whether the resident was a risk to self or others. 24. ‘That the Petitioner’s representatives reviewed the Respondent’s records regarding resident number eight, which reflected the following: 25. a. That the resident, according to the "Residential Habilitation Goals" form dated April 12, 2005, was "very combative” and "hit 2 peers" and “hit walls”; b. That the residential Habilitation Goals memorialized similar behaviors on April 20, 2005, which included aggression to staff and peers; c. That the facility behavior monitoring form noted that the resident had a negative behavioral occurrence on May 1, 2005 from 4:00-8:00 (no notation of a.m. or p.m.) and indicated that the "person was restrained or PCM (Professional Crisis Management) used” due to "aggression to person, property, self (self-injurious behavior)"; d. That notes on the reverse of the form read, "Acted out all day!!! Pushing, shoving and hitting clients and staff. 1 arm wrap (a type of restraint by staff) was used, and that the restraint was not effective until four hours later, after more than 10+ incidents.” That the Respondent’s records contain no indicia that the resident’s aggressive behavior was evaluated or assessed to determine whether the resident continued to meet residency criteria for an assisted living facility, i.e. whether the resident was a risk to self or others. 26. That the Petitioner’s representatives reviewed the Respondent’s records regarding resident number four, which reflected the following: a. That the Behavior Intervention Plan dated February 21, 2005 noted that the resident’s “aggressive behaviors put her and others at risk of serious harm;" b. That this plan indicated the resident's problem behaviors include: "Aggression to others... Property Destruction... Self-Injurious Behavior... Elopement;” c. That the Reactive Strategy Recording forms for April of 2005 annotate that the resident required prone restraint (BARR) on three occasions as a result of violent behaviors, on April 14, 2005 for "aggression to staff,” on April 19, 2005 for aggression to others and aggression to staff, and on April 23, 2005 for "acting up after being accused of stealing. Attacked (another resident);” d. That the Behavioral Intervention Plan dated February 21, 2005 provided that should the resident’s "behavior become severely disruptive.” staff are to implement procedures including "prone restraint for the most severe cases." 27. That the Respondent’s records contain no indicia that the resident’s aggressive behavior was evaluated or assessed to determine whether the resident continued to meet residency criteria for an assisted living facility, ie. whether the resident was a risk to self or others. In fact, the resident’s Behavioral Intervention Plan appears to identify such behavior, yet the Respondent took no action to relocate the resident to an acceptable placement. 28. Florida law prohibits the use of restraints in assisted living facilities. Fla. Admin. Code R. 58A-5.0182(6)(h). 29, That residents whose behaviors require the utilization of restraints fall outside the scope of residents appropriate for placement in an assisted living facility and place other resident’s at risk of harm. 30. That the Petitioner’s representative reviewed the Respondent’s reactive strategy recording form for April and May 2005 revealed the following residents as requiring restraints: 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 April 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. 31. That all of these residents exhibited violent behavior, which put their own safety and the safety of other residents at risk. 32. That residence in an assisted living facility is inappropriate for persons who are a danger to themselves or others. 33. That no records reflect that the respondent facility reviewed the above referenced residents for continued appropriate placement in an assisted living facility despite repeated acts of violence involving self-abuse, aggression to other residents, and aggression toward staff. 34. That the facility's use of restraints, which falls outside the scope of assisted living facility licensure, indicates that these residents’ safety and the safety of others cannot be assured in an assisted living facility. 35. That the Agency determined that this deficient practice was related to the operation and maintenance of the Respondent facility or to the personal care of the Respondent’s residents and directly threatened the physical or emotional health, safety, or security of the Respondent's residents. 36. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 37. The Agency provided Respondent with a mandatory correction date of May 30, 2005. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT I 38. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 39. That pursuant to Florida law, the use of physical restraints shall be limited to half-bed rails, and only upon the consent of the resident or the resident’s representative, and by written order of the resident’s physician, who shall review the order biannually. Fla. Admin. Code R. 58A-5.0182(6)(h). 40. That on May 16, 2005, the Agency conducted a re-visit to the appraisal survey of the Respondent facility. 4l. That based upon review of records, observation, and interview, it was determined that the facility had the capacity to use physical restraints on residents in the utilization of a seclusion or time out room and utilized prone restraint on residents. 42. That Petitioner’s representatives toured the Respondent facility on May 16, 2005. 43. Thata seclusion or time out room was observed and so identified by Respondent’s staff, including the maintenance of a “Time Out Log” annotating resident names, dates of use, and lengths of time a resident was secluded. Observation of the seclusion room reflected the following: a. That the room was wired to use an external magnetic lock of the type used in time out rooms and isolation rooms; b. That a button was wired into the wall to activate the locking mechanism; c. That the locking mechanism was in place in the door jamb, and only a small metal plate was required to bolt onto the door to make the system functional. 44. That the Petitioner’s representative interviewed the Respondent’s administrator immediately prior to exiting the facility who indicated the following regarding the seclusion room: a. That there was no longer electricity to the lock; b. That the administrator had done the work by disconnecting wires up in the ceiling, c. That as the administrator had disconnected the wires, there existed no documentation to verify or illustrate what precisely had been done. 45. That the Petitioner’s representative observed the magnetic lock, the wiring to the lock, and the "exit" (power) button remained in place at the time of their exit. 46. That the Petitioner’s representative reviewed the Respondents records. 47. 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 asa result of aggression to property and staff, on April 19, 2005 as a result of aggression to staff, and on April 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. 48. That the behavior monitoring form for resident number eight reflected the following: a. That the resident had a negative behavioral occurrence on May 1, 2005 from 4:00-8:00 (no notation of a.m. or p.m.); b. That a check placed on the form indicated that the "person was restrained or PCM (Professional Crisis Management) used “due to” aggression to person. property, self (self-injurious behavior)"; c. That the form noted on the back, "Acted out all day!!! Pushing, shoving and hitting clients and staff. 1 arm wrap was used, and that the wrap was not effective until four hours later”. 49. That restraints of this type are not appropriate for residents in an assisted living facility and are prohibited by applicable regulation. 50. That the Petitioner’s representative reviewed the Respondents Critical Incident Log dated May 14, 2005, which reflected the following: a. That there had been an altercation between resident number three and another resident; b. That at that time, staff applied the BARR procedure (Brief Assisted Required Relaxation) on resident number three for a period of five minutes. 51. That restraints of this type are not appropriate for residents in an assisted living facility and are prohibited by applicable regulation. 52. That the Agency determined that this deficient practice was related to the operation and maintenance of the Respondent facility or to the personal care of the Respondent’s residents and directly threatened the physical or emotional health, safety, or security of the Respondent's residents. 53. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 54. The Agency provided Respondent with a mandatory correction date of June 16, 2005. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). Respectfully submitted this a day of July 2005. Thomas J Walsh, II Fla. Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 727.552.1525 (office) 727.552.1440 (fax) 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 (onc page). All requests for hearing shall be made to the Agency for Health Care Administ ration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;T. elephone (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 OFA 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 1927 on July g _, 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. ox 1778, Safety Harbor, Florida 34695. mas J. Walsh, II Senior Attorney Copies furnished to: John Joseph Ross Gene Cowles Thomas J. Walsh, II 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 2005004708 Facility Name AHCA Case No. SENDER: COMPLETEHIS SECTION @ Complete items 1, 2, 1d 3. Also complete item 4 if Restricted Delivery is desirad.—_——_, @ 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 mailpiece, or on the front if space permits. 4. Restricted Delivery? (Extra Fee) D Yes 2, Article Number 7004 2510 0005 4o494 1840 _ _ecbooteg (Transfer from service raven 7 + PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 SENDER: COMPLETE Tyus SECTION ® Complete items 1, 2, at... 3. Also com) 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 mailpiece, or on the front if space permits. $s D. Is delivery address different from item 12 J Yes If YES, enter delivery address below: © No 1. Article Addressed to: John Joseph Ross Rel nce sector iNandate. (0333 Lownasston Avenue. NG a oo ry , CO Certified Mail, [3-exprece-Mai____. Bema Retum Receipt for Merchandise” Icon OC insured Mail (7 C.0.D. —_— New Pork Richey, Flt Rett Donan? is Fe) vag 2. Article Numb O02 peu, Aetele Number 2003 1010 ooge Seb? 1934 a 10050047910 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 05-002888