STATE OF FLORIDA tN AGENCY FOR HEALTH CARE ADMINISTRATION | #y AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2005004352 LIFE CARE CENTERS OF AMERICA — . afbia LIFE CARE CENTER OF CITRUS O S- HG [> Respondent. / ADMINISTRATIVE COMPLAINT Petitioner, the Florida Agency for Health Care Administration (“AHCA”), through i undersigned counsel, files this Administrative Complaint against the above-named Respondent (‘Respondent’) pursuant to Sections 120.569 and 120.57, Florida Statutes (2003)', and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $27, 192 (the “fine amount”) against Respondent, pursuant to Section 408.040, Florida Statutes, and Florida Administrative Code Rules 59C-1.013 and 59C-1.021. 2. For the calendar year 2003 (the “calendar year”), Respondent failed to comply with the Medicaid condition upon its Certificate of Need (“CON”), a copy of which is attached to this complaint at Exhibit A. ‘Unless otherwise noted, all statutes and rules hereinafter cited are to the indicated year’s version of the statute or rule because this is the controlling year in question. Pagel of 8 JURISDICTION AND VENUE 3. This tribunal has jurisdiction over Respondent pursuant to Sections 120.569 and 120.57, Florida Statutes, and Sections 408.031 - 408.045, Florida’s “Health Facility and Services Development Act.” 4, Venue is determined by Florida Administrative Code Rule 28-106.207. PARTIES 5. Pursuant to Chapter 408, Florida Statutes, and Chapter 59C-1, Florida Administrative Code, AHCA is the licensing and enforcing authority with regard to community nursing home laws and rules. 6. Respondent is a corporation authorized under the laws of Florida to do business. Respondent operates a community nursing home located at 3325 Jerwayne Lane, Lecanto, Florida, 34461 and is the licensee on the CON issued on March 29, 1996 for the construction of 9 beds in addition to the existing 111 bed community nursing home, with the condition that a minimum of 55% of its 120 bed facility’s total annual patient days shall be provided to Medicaid. The CON number is 8090; a copy of the CON is attached to this complaint as Exhibit A. COUNT I (Respondent failed to meet its Medicaid condition) Section 408.040, Florida Statutes Florida Administrative Code Rule 59C-1.013 Florida Administrative Code Rule 59C-1.021 7. AHCA re-alleges paragraphs 1-6 above. 8. Respondent failed to comply with its Medicaid condition as reported to the Agency in its Florida Nursing Home Utilization Report for the year 2003, a copy of Page2 of 8 which is attached to this complaint as Exhibit B, and its facility report, a-copy of which is attached to this complaint as Exhibit C. Respondent failed to comply with the condition set forth in its CON, as required by Section 408.040, Florida Statutes, and Rule 59C-1.013, Florida Administrative Code, which provide, in part, as follows: 408.040 Conditions and monitoring (1)(a) The agency may issue a certificate of need predicated upon statements of intent expressed by an applicant in the application for a certificate of need. Any conditions imposed on a certificate of need based on such statements of intent shall be stated on the face of the certificate of need. (b) The agency may consider, in addition to the other criteria specified in s. 408.035, a statement of intent by the applicant that a specified percentage of the annual patient days at the facility will be utilized by patients eligible for care under Title XIX of the Social Security Act. Any certificate of need issued to a nursing home in reliance upon an applicant's statements that a specified percentage of annual patient days will be utilized by residents eligible for care under Title XIX of the Social Security Act must include a statement that such certification is a condition of issuance of the certificate of need. The certificate-of-need program shall notify the Medicaid program office and the Department of Elderly Affairs when it imposes conditions as authorized in this paragraph in an area in which a community diversion pilot project is implemented. (c) A certificate holder may apply to the agency for a modification of conditions imposed under paragraph (a) or paragraph (b), If the holder of a certificate of need demonstrates good cause why the certificate should be modified, the agency shall reissue the certificate of need with such modifications as may be appropriate. The agency shall by rule define the factors constituting good cause for modification. (d) If the holder of a certificate of need fails to comply with a condition upon which the issuance of the certificate was predicated, the agency may assess an administrative fine against the certificate holder in an amount not to exceed $1,000 per failure per day. In assessing the penalty, the agency shal] take into account as mitigation the relative lack of severity of a particular failure. Proceeds of such penalties shall be deposited in the Public Medicaid Assistance Trust Fund, : OK 59C-1.013 Monitoring Procedures (4) Reporting Requirements Subsequent to Licensure or Commencement of Services. All holders of a certificate of need that was issued predicated upon conditions expressed on the face of the certificate of need shall provide annual compliance reports to the agency. The reporting period shall be January | through December 31 of each year. The holder of a certificate of need who began operation after January 1 will report from the date operation began through December 31. The compliance report shall be submitted no later than April 1 of the subsequent year. (a) The compliance report will contain information necessary for an assessment of compliance with conditions on the certificate of need, utilizing measures, such as a percentage of patient days, that are consistent with the stated condition. The following information shall be provided in the holder’s annual compliance report: 1. The time period covered by the measures; 2. The measure for assessing compliance with each of the conditions identified and described on the face of the certificate of need; 3. The way in which the conditions were evaluated by applying the measures; 4. The data sources used to generate information about the conditions that were measured; 5. The person and position responsible for supplying the compliance report; 6. Any other information necessary for the agency to determine compliance with conditions; and 7. If applicable, the reason or reasons, with supporting data, why the certificate of need holder was unable to meet the conditions set forth on the face of the certificate of need. Page3 of 8 (b) A change in the licensee for a facility or service does not affect the obligation for that facility or service to continue to meet conditions imposed on a certificate of need and to provide annual condition compliance reports. (c) Conditions imposed on a certificate of need may be modified consistent with Rule 59C- 1.019, F.A.C, (5) Violation of Certificate of Need Conditions. Health care providers found by the agency to be in noncompliance with conditions set forth in their certificate of need shall be fined as defined in Rule 59C-1.021, F.A.C. 10. The foregoing violation warrants imposition of the above-mentioned fine amount pursuant to Florida Administrative Code Rule 59C-1.021, which provides, in part: 59C-1.021 Penalties. (1) General Provisions. The agency shall initiate administrative proceedings for revocation of a certificate of need for violation of paragraphs 408.040(2)(a) and (b), F.S., or the assessment of administrative fines for failure to comply with conditions placed on a certificate of need as specified under Rule 59C-1.013, F.A.C ok (3) Penalties for Failure to Comply with Certificate of Need Conditions. The agency shall review the annual compliance report submitted by the health care providers who are licensed and operate the facilities or services and other pertinent data to assess compliance with certificate of need conditions. Providers who are not in compliance with certificate of need conditions shall be fined. For community nursing homes or hospital-based skilled nursing units certified as such by Medicare, the first compliance report on the status of conditions must be submitted 30 calendar days following the eighteenth month of operation or the first month where an 85 percent occupancy is achieved, whichever comes first. The schedule of fines is as follows: (a) Facilities failing to comply with any conditions set forth on the Certificate of Need will be assessed a fine, not to exceed $1,000 per failure per day. In assessing the penalty the agency shall take into account the relative lack of severity of a particular failure. (b) The assessed fine shall be paid to the agency within 45 calendar days after written notification of assessment by certified mail or within 30 calendar days after final agency action if an administrative hearing has been requested. If a health care provider desires it may remit. payment according to a payment schedule accepted by the agency. The health care provider must submit the schedule of payments to the agency within 30 calendar days after the date of receipt of the notification of assessment or 21 calendar days after final agency action. The final balance will be due no later than 6 months after the health care provider has been notified in writing by the agency of the amount of the assessed fine or 6 months after final agency action. 11. AHCA, in determining the penalty imposed, considered the relative lack of severity of a particular failure. WHEREFORE, AHCA demands the following relief: (1) enter factual and legal findings as set forth in this Count; (2) impose the above-mentioned fine amount for the violation; and (3) impose such other relief as this tribunal may find appropriate. NOTICE RESPONDENT is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative Page4 of 8 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, MS #3, Tallahassee, Florida, 32308; Attention: Agency Clerk. RESPONDENT IS FURTHER NOTIFIED THAT 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 as of the date indicated on the below Certificate of Service. ROK Donna La Plante, Senior Attorney Fla. Bar No. 0966193 Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3, MS #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-9313 CERTIFICATE OF SERVICE J HEREBY CERTIFY that a copy of 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 0600 0024 9206 3788) to Respondent, Attention: Administrator, at 3325 Jerwayne Lane, Lecanto, Florida, 34461 on this 22 ry of August 2005. Donna La Plante, Senior Attorney Page5 of 8 RO we TP osy eed Garaplata.ltems.1, 2, and 3, Also complete iterfic IFRestricted Delivery is desired. w Print your name and address on the reverse so that we can return the card to you. m Attach this card to the back of the mailpiece, or on the front if space permits. A. Signature Lb. st Agent x VA. fe Cl Addresses B. Recelved by (Printed “Fee var Lack A birtlasley ee to D. Is delivery address different from item 1? L1Yes 1. Article Addressed to: If YES, enter delivery address below: No Lif Care Cones of Arena BE .O Heth St, nw Cle veto nd, TN) Bb 7320 3. ax Type Certified Mall [4 Express Mail D0 Registered 2 Retum Aeceipt for Merchandise Oi Insured Mail 1 G.0.D. 4, Restricted Delivery? (Extra Fea) DO Yes 2, Article Numb it ee GO OLOO COA4I20 0 27H 45 PS Form 3811, August 200% Damestic Return peep : BOF 0043 9% 102595-02-M-1540

Docket for Case No: 05-003913