Ok- p [oer pops Peg STATE OF FLORIDA 98 fp, o™ ED AGENCY FOR HEALTH CARE ADMINISTRATION “#~ 4 fi * 2: STATE OF FLORIDA, AGENCY FOR Abgyt!Slon oe 47 HEALTH CARE ADMINISTRATION, WARE AT Ve “ARTY Petitioner, vs. Case No. 2008000872 ARC BAHIA OAKS, INC., d/b/a BAHIA OAKS LODGE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“Agency”), by and through the undersigned counsel, and files this Administrative Complaint against ARC BAHIA OAKS, INC., d/b/a BAHIA OAKS LODGE (“Respondent” or “Respondent Facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the sum of one thousand dollars ($1,000.00) based upon two cited uncorrected State Class III deficiencies pursuant to Section 429.19(2) (c), Florida Statutes (2007). . JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and 429.07, and Chapter 408, Part II, Florida Statutes (2007). 2. Venue lies pursuant to Florida Administrative 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 state statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes, and Chapter 58A-5 Florida Administrative Code. 4. Respondent operates a 100-bed assisted living facility located at 2186 Bahia Vista Street, Sarasota, Florida 34239, and is licensed as an assisted living facility, license number 7099. 5. Respondent was at all times material to the allegations of this complaint 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 one (1) through five (5), as if fully set forth in this count. 7. Pursuant to Florida law, Section 429.28(1), Florida Statutes (2007), guarantees each resident of an assisted living facility: § 429.28. Resident bill of rights (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. 8. Rule 58A-5.0185, Florida Administrative Code, sets forth a minimum for the “established and recognized standards within the community” and requires: (5) MEDICATION RECORDS. (a) For residents who use a pill organizer managed under subsection (2), the facility shall keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider's name, the resident's name, the date dispensed, the name and strength of the drug, and the directions for use. (b) The ‘facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident's health care provider, the health care provider's telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. (6) MEDICATION STORAGE AND DISPOSAL. (a) In order to accommodate the needs and preferences of residents and to encourage residents to remain as independent as possible, residents may keep their medications, both prescription and. over-the-counter, in their possession both on or off the facility premises; or in their rooms or apartments, which must be kept locked when residents are absent, unless the medication is in a secure place within the rooms or apartments or in some other secure place which is out of sight of other residents. However, both prescription and over-the-counter medications for residents shall be centrally stored if: 1. The facility administers the medication; 2. The resident requests central storage. The facility shall maintain a list of all medications being stored pursuant to such a request; 3. The medication is determined and documented by the health care provider to be hazardous if kept in the personal possession of the person for whom it is prescribed; 4. The resident fails to maintain the medication ina safe manner as described in this paragraph; 5. The facility determines that because of physical arrangements and the conditions or habits of residents, the personal possession of medication by a resident poses a safety hazard to other residents; or 6. The facility's rules and regulations require central storage of medication and that policy has been provided to the resident prior to admission as required under Rule 58A-5.0181, F.A.C. (b) Centrally stored medications must be: 1. Kept in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times; 2. Located in an area free of dampness and abnormal temperature, except that a medication requiring refrigeration shall be refrigerated. Refrigerated medications shall be secured by being kept in a locked container within the refrigerator, by keeping the refrigerator locked, or by keeping the area in which refrigerator is located locked; 3. Accessible to staff responsible for filling pill- organizers, assisting with self-administration, or _ administering medication. Such staff must have ready access to keys to the medication storage areas at all times; and 4. Kept separately from the medications of other residents and properly closed or sealed. (c) Medication which has been discontinued but which has not expired shall be returned to the resident or the resident's representative, as appropriate, or may be centrally stored by the facility for future resident use by the resident at the resident's request. If centrally stored by the facility, it shall be stored separately from medication in current use, and the area in which it is stored shall be marked "discontinued medication." Such medication may be . reused if re-prescribed by the resident's health care provider. (d) When a resident's stay in the facility has ended, the administrator shall return all medications to the resident, the resident's family, or the resident's guardian unless otherwise prohibited by law. If, after notification and waiting at least 15 days, the resident's medications are still at the facility, the medications shall be considered abandoned and may disposed of in accordance with paragraph (e). (e) Medications which have been abandoned or which have expired must be disposed of within 30 days of being determined abandoned or expired and disposition shall be documented in the resident's record. The medication may be taken to a pharmacist for disposal or may be destroyed by the administrator or designee with one witness. (£) Facilities that hold a Special-ALF permit issued by the Board of Pharmacy may return dispensed medicinal drugs to the dispensing pharmacy pursuant to Rule 64B16-28.870, F.A.C. (7) MEDICATION LABELING AND ORDERS. (a) No prescription drug shall be kept or administered 4 by the facility, including assistance with self- administration of medication, unless it is properly labeled and dispensed in accordance with Chapters 465 and 499, F.S., and Rule 64B16-28.108, F.A.C. If a customized patient medication package is prepared for a resident, and separated into individual medicinal drug containers, then the following information must be recorded on each individual container: 1. The resident's name; and 2. Identification of each medicinal drug product in the container. (b) Except with respect to the use of pill organizers as described in subsection (2), no person other than a pharmacist may transfer medications from one storage container to another. (c) If the directions for use are "as needed" or "as directed," the health care provider shall be contacted. and requested to provide revised instructions. For an "as needed" prescription, the circumstances under which it would be appropriate for the resident to request the medication and any limitations shall be specified; for example, “as needed for pain, not to exceed 4 tablets per day." The revised instructions, including the date they were obtained from the health care provider and the signature of the staff who obtained them, shall be noted in the medication record, or a revised label shall be obtained from the pharmacist. (d) Any change in directions for use of a medication for which the facility is providing assistance with self-administration or administering medication must be accompanied by a written medication order issued and signed by the resident's health care provider, or a faxed copy of such order. The new directions shall promptly be recorded in the resident's medication observation record. The facility may then place an "alert" label on the medication container which directs staff to examine the revised directions for use in the MOR, or obtain a revised label from the pharmacist. (e) A nurse may take a medication order by telephone. Such order must be promptly documented in the resident's medication observation record. The facility must obtain a written medication order from the health care provider within 10 working days. A faxed copy of a signed order is acceptable. (f) The facility shall make every reasonable effort to ensure that prescriptions for residents who receive assistance with self-administration of medication or medication administration are filled or refilled ina timely manner. (8) OVER THE COUNTER (OTC) MEDICATIONS. (a) A stock supply of OTC medications for multiple resident use is not permitted in any facility. (ob) Non-prescription over-the-counter drugs, when centrally stored, shall be labeled with the resident's name, and the manufacturer's label with directions for use shall be kept with the medication. (c) When an over-the-counter medication is prescribed by a health care provider, the medication becomes a prescription medication and shall be managed in accordance with prescription medication under this rule. 9. Additionally, Respondent Facility has as “established and recognized standards within the community”: 9.1. Respondent Facility's policy, Medication Storage and Labeling, dated 3/01/00, which states in the Medication Labeling section, "No prescription drug shall be kept on the premises unless it has been legally dispensed and labeled for the resident for whom it is prescribed according to state law. Non-prescription ordered medications must be labeled with the resident's full name, apartment number and with directions unobscured. The contents of any medication container having no label or with an illegible label may not be accepted by the community or taken by the resident." 9.2. Respondent Facility's Controlled Drug Record policy, dated 3/1/00, which states "Schedule II controlled drugs used by Residents receiving medication supervision assistance will be recorded. ... Before assisting the Resident with Medications, be sure the amount recorded is the same as the actual amount in the medication container. If it does not match notify the Residence Manager or Wellness Coordinator to facilitate problem solving and complete an incident report." 10. On March 7-8, 2006, the Agency conducted a Biennial Survey of the Respondent facility. 11. Based on observation, record review and staff interview the Respondent Facility failed to comply with the resident Bill of Rights regarding access to adequate and appropriate health care consistent with established and recognized standards within the community for 3 --Residents #2, #6 and #7 -- of 8 sampled residents. 12. Specifically, the Respondent Facility failed to provide residents with access to adequate and appropriate health care consistent with established and recognized standards within the community as evidenced by: (1) prescribed medications not available for Residents #2 and #7; (2) physician's order not followed for calcium supplement for Resident #7; (3) controlled drugs or narcotics not accurately monitored or reconciled and not consistently and accurately documented on controlled drug records per facility policy for Residents #2, #6 and #7. 13. Review of Resident #7's Medication Verification form, signed by the physician on 10/7/04, revealed an order for Milk of Magnesia suspension, to be taken 60 cc at bedtime as needed for constipation. 13.1. Further review of the Resident #7's record revealed a Physician Communication was faxed to the physician on 1/18/06 which indicated the resident was complaining of stomach pain and loose stool. The physician returned the form on 1/19/06 with an order for Imodium A-D, 1 caplet three times a day as needed for loose stool. 13.2. Review of Resident #7's March 2006 Medication Administration Record (MOR) revealed the medications Milk of Magnesia and Imodium A-D were listed as prescribed to be given PRN (as needed). 13.3. Observation of Resident #7's medication storage cabinet with the Wellness Coordinator on 3/7/06 at 3:15 p.m., revealed there was no Imodium A-D or Milk of Magnesia (MOM) available to provide to the resident on an as needed basis per physician's orders. 13.4. Interview with the Wellness Coordinator on 3/7/06 at 4:30 p.m., confirmed the Imodium A-D has been prescribed in 1/06 but had not been sent from the pharmacy. She stated it was not available for the resident if the resident needed it, and she would order it “today.” The Wellness Coordinator further confirmed she had found a bottle of Milk of Magnesia in the unlocked side of the cabinet that was purchased from a local drugstore. The Wellness Coordinator stated the resident's spouse must have purchased it. She confirmed that it was not labeled for Resident #7 and had not been obtained from the pharmacy and that the Wellness Coordinator had moved the Milk of Magnesia into the resident's locked medication storage compartment. The Wellness Director further stated she did not know where the resident's Milk of Magnesia or Imodium A-D were, and she did not know why they were not in the cabinet with the other medications. 13.5. Observation of the bottle of Milk of Magnesia with the Wellness Coordinator on 3/7/06 at 4:30 p.m., revealed it contained a price sticker from a local drugstore and it was not labeled with a pharmacy label or the resident's name. The Wellness Coordinator confirmed she had moved the bottle from the unlocked side of the cabinet where the resident's spouse stored the medications 10 and put it in with the resident's prescribed medications. The Wellness Coordinator was not aware that this was not an acceptable medication practice. 13.6. Further review of Resident #7's record revealed an order from the physician dated 11/10/05 for "Caltrate 1000 mg qd (every day)." A hand-written note on the order indicated the order was faxed to the pharmacy on 11/11/05. 13.7. Review of Resident #7's March 2006 Medication Observation Record revealed the 11/10/05 physician’s order was transcribed to read, “Antacid 500 mg Chew Tab, Tums Tablet Chewable, Chew Tablet Three Times Daily." The times listed on the Medication Observation Record were 9:00 a.m., 1:00 p.m., and 5:00 p.m. The Respondent Facility’s staff members were signing off on Resident #7’s Medication Observation Record that they were providing the medication to Resident #7 three times a day. 13.8. Interview with the Wellness Coordinator on 3/8/06 at 2:45 p.m., confirmed the Medication Observation Record did not agree with the physician's order. She stated she had spoken to the pharmacist who stated he had made the determination to transcribe the order to the Medication Observation Record in the manner set forth in paragraph 13.7 because the calcium needed to be given three 11 times a day due to "bioavailability" of the calcium. The Wellness Coordinator confirmed the pharmacy did not obtain a clarification order from the physician for the change in the calcium dosage to 1500 ng. The Wellness Coordinator further confirmed there was no other order in the resident's record which indicated the facility clarified the order or that the physician had approved the change in the medication dosage and time of administration. 13.9. Further review of Resident #7's Medication Verification form, signed by the physician on 10/7/04, revealed an order for Temazepam, generic for Restoril, an insomnia medication, 15 mg at bedtime daily. 13.10. Review of Resident #7’s Medication Observation Record for 9/05 through 3/06 revealed that the Respondent Facility’s staff were signing that the resident was taking the medication nightly. 13.11. Observation of Resident #7's medication storage cabinet with the Wellness Coordinator on 3/7/06 at 3:15 p.m., and 4:55 p.m., revealed one bubble pack of Restoril with 2 pills in it dated 2/5/06 and one full bubble pack dated 3/7/06. 13.12. Review of the Resident #7’s Controlled Drug Record for Temazepam for 2/06 revealed the following was recorded: 12 30 pills no date either 2/5/06 or 2/6/06 29 pills 2/7/06 28 pills 2/8/06 27 pills 2/9/06 26 pills 2/10/06 24 pills 2/11/06 no documentation for 2/12/06 and 2/13/06 22 pills 2/14/06 21 pills 2/15/06 20 pills 2/16/06 19 pills 2/17/06 no documentation for 2/18/06 and 2/19/06 17 pills 2/20/06 no documentation for 2/21/06, 2/22/06, 2/23/06, 2/24/06 and 2/25/06 10 pills 2/26/06 no documentation for 2/27/06, 2/28/06, 3/1/06, 3/2/06, 3/3/06, 3/4/06 and 3/5/06 10 pills 3/6/06 13.13. Further review of the 11/05, 12/05 and 1/06 Controlled Drug Records revealed gaps in the recording of the amount of Temazepam given to Resident #7. There was no documentation of what was done with the remaining pills in the bubble pack at the end of each month. 13.14. Interview with the Wellness Coordinator on 3/7/06 at 4:55 p.m., revealed she was not aware the staff were not documenting the controlled drugs on a daily basis. She stated the facility policy was to reconcile the controlled drugs every shift and document on the Controlled Drug Record. She further stated she did not know why the drug record listed 10 pills remaining in the 2/06 bubble pack when there were only 2 pills left. She stated a new bubble pack and controlled drug sheet would be started on 13 3/7/06 and the pills from the previous pack would be returned to the pharmacy for reimbursement. 14. Review of Resident #2's Medication Observation Record revealed an order for Hydrocodone/APAP 5/500 tablet, “Take 1 tablet by mouth every 4 hours as needed prn [as needed] for pain.” Observation of the resident's medication cabinet on 3/07/06 revealed there were no Hydrocodone/APAP tablets in the cabinet. Review of the "Controlled Drug Record" for the Hydrocodone/APAP for this resident revealed a final entry on 7/30/05 that there were 6 tablets remaining. The undated next line revealed no Hydrocodone/APAP tablets were taken, and none remained. During an interview with the Wellness Director on 3/08/06, it was confirmed there was no record of what happened to the remaining 6 pills of Hydrocodone. A physician Communication dated 3/07/06 stated "Resident not using Lortabs [brand name for Hydrocodone]. Has not used in 3 months. Can we D/C please,” signed by the physician on 3/08/06. 15. During Medication Review on 3/7/06 at approximately 4:00 p.m., Resident #6's medication storage cupboard revealed an inaccurate narcotic count record compared to the actual number of controlled medication which remained in Resident #6’s bubble pack. 15.1. The medication, Hydrocodone/APAP 5/500 Tablets, (Vicodin 5/500) ordered "1 tablet by mouth every 14 4-6 hours as needed for pain" had 15 tablets enclosed in the bubble package. The narcotic controlled record recorded that 17 tablets were remaining. The Medication Observation Record memorialized the physician’s order but did not contain any notation indicating that any Hydrocodone had been administered to Resident #6. 15.2. Review of the facility's Controlled Drug Record policy, dated 3/1/00, revealed "Schedule II controlled drugs used by Residents receiving medication supervision assistance will be recorded. ... Before assisting the Resident with Medications, be sure the amount recorded is the same as the actual amount in the medication container. If it does not match notify the Residence Manager or Wellness Coordinator to facilitate problem solving and complete an incident report." 16. The Agency determined that the above deficient practice of failing to comply with the resident Bill of Rights regarding access to adequate and appropriate health care consistent with established and recognized standards within the community for three (3) of eight (8) sampled residents was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency. 16.1. The Agency provided Respondent with a 15 mandatory correction date of April 8, 2006. 16.2. During a re-visit survey conducted June 20, 2006 the Agency determined that the Respondent had corrected the deficiency. 17. On January 2-3, 2008, the Agency conducted a Biennial Survey of the Respondent. 18. Based on observation, record review, and staff interview, the facility failed to comply with the resident bill of rights regarding access to adequate and appropriate health care consistent with established and recognized standards within the community for 1, Resident #8, of 8 sampled residents. Specifically, Resident #8 did not receive medication as ordered by Resident #8’s primary care physician. 18.1. Administration of medication to Resident #8 was observed on 1/03/08 at 9:30 a.m., with the facility Care Associate (CA). The CA would enter her code into the medication dispenser, and a medication would be dispensed. The CA would then check the medication against the Medication Observation Record (MOR), sign for the medication dispensed and then would assist the resident with the medication. During this process Tylenol 325 mg was dispensed from the dispenser. The CA signed the Medication Observation Record in the “as needed" PRN section and then gave the medication to Resident #8. 16 18.2. Record review of the Medication Observation Record for Resident #8 after all the medication was given revealed the Tylenol 325 mg was written on the Medication Observation Record as Tylenol 325 mg tablet, “Take 1 tablet by mouth twice daily, take 1 tablet by mouth every 4 hours as needed for back pain.” This medication is listed in the "as needed" section of the Medication Observation Record. 18.3. Interview with the CA on 1/03/08 at 9:45 a.m., the CA was asked why she gave the Tylenol 325 mg to Resident #8 without asking Resident #8 if he had any back pain knowing that the order was written to be given as needed for back pain. The CA stated she thought it was a new order since the medication dispenser dispensed the Tylenol 325 mg so she just gave it to him. The CA was asked why she did not question the medication since there was no order to give the medication routinely, and it is noted as PRN. The CA stated she thought the person who received the new order might have just forgotten to write in on the Medication Observation Record so that is why she gave the medication without checking to see if the order had been changed. When asked what is the facility policy for documentation of an "as needed" medication, she stated she was taught in school to sign the back of the Medication Observation Record, stating when the medication was given, 17 how much of the medication was given and the effectiveness of the medication, so there would be a written record of the effectiveness of the medication. The CA stated that the Respondent Facility’s policy does not require staff members to document the results of an "as needed" medication. 18.4. Review of Resident #8’s records revealed on 10/11/07, there was a physician’s order for “Tylenol 325 mg 1 po BID 4 hrs as needed, DX back pain.” The fax date on the paper was 10/30/07. 18.5. There is also a copy of a physician script dated 11/08/07 for Tylenol 325 mg, “1 by mouth every 4 hours as needed,” with a fax date of 11/08/07. The Medication Observation Record for November 2007 revealed a change of order dated 10/30/07 for the order dated 10/11/07. The December 2007 Medication Observation Record shows the same order with one signature on the 12th. 19. Interview with the Wellness Director (WD) on 1/03/08 at 10:15 a.m., she stated when reviewing the Medication Observation Record dated January 2007 for Resident #8 the order reads that the medication should be given twice a day and as needed for back pain. The WD further reviewed Resident #8's chart and changed her mind stating she had read the Medication Observation Record incorrectly due to it was upside down and 18 that order meant to only give the Tylenol 325 mg as needed for back pain every 4 hours. The WD stated the CA should not have given a medication that was dispensed, and that was not listed as a medication that was due at that time. WD stated she does not know why the change of order read “10/30/07” when the order was written on 10/11/07. The WD also stated she was taught to write on the back of the Medication Observation Record the effectiveness of a medication but that the facility does not have a policy requiring the staff member to document the results or the time a PRN was given. The WD stated the facility CA would give a verbal report to each other what medications were given. The WD stated the facility policy is.to only chart by exception or change in resident condition. 20. There are two signatures for Tylenol 325 mg PRN on the 28th of December 2007 Medication Observation Record for Resident #8. When asked if the facility could show that the medication was given as per physician order the WD was unable to show documentation that the Tylenol 325 mg was given 4 hours apart as ordered by the physician. 21. Interview on 1/03/08 at around 1:00 p.m., the WD stated an incident report was written due to the fact that the pharmacy told her the medication dispenser was set to deliver Tylenol 325 mg twice a day and the pharmacy did not change the time of delivery of the Tylenol 325 mg from twice a day to PRN 19 as ordered back on 11/08/07, because of this the CA incorrectly gave Resident #8 Tylenol 325 mg that was not ordered for routine administration. 22. The Agency determined that this deficient practice of failure to administer Tylenol to Resident #8 as ordered by Resident #8’s physician was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class III deficiency. 23. The Agency provided Respondent with a mandatory correction date of February 3, 2008. 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 Section 429.19(2)(c), Florida Statutes (2007). COUNT II 24. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth in this count. 25. Pursuant to Florida law, the administrator or owner of a facility shall maintain personnel records for each staff member which contain, at a minimum, documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, anda copy of all licenses or certification held by each staff member 20 who performs services for which licensure or certification is required under this part or rule. Section 429.275(2), Florida Statutes (2007). 26. Pursuant to Florida law, staff personnel. records must be maintained by the Respondent Facility accessible to department and agency staff, and must contain, as applicable, inter alia, documentation of compliance with all staff training required by Rule 58A-5.0191, F.A.C. Florida Administrative Code R. 58A-5.024(2) (a) (1), Florida Administrative Code R. 58A- 5.0191(11). 27. Pursuant to Florida law, all facility employees must complete biennially, a continuing education course on HIV and AIDS. New facility staff must obtain an initial training on AIDS/HIV within thirty days of employment, unless the new staff person previously completed the initial training and has maintained the biennial continuing education training. Florida Administrative Code R. 58A-5.0191(3). 28. On March 7-8, 2006, the Agency conducted a Biennial Survey of the Respondent facility. 29. Based on record review, the facility failed to ensure 2, “Residents #3 and #7,” of 15 sampled employees, obtained an initial training on HIV/AIDS within 30 days of employment or completed biennially, a continuing education course on HIV and AIDS. 21 30. Employee #3 was hired on 11/17/05 and Employee #7 was hired on 12/15/05. Both Employee #3 and Employees #7 were hired as Food Servers. These hire dates occurred following the change in regulations requiring Assisted Living Facility (ALF) staff hired on or after 7/5/05 to complete initial training on HIV/AIDS within 30 days of employment. 31. Review of the personnel record records of Employees #3 and #7 revealed no documentation of initial training on HIV/AIDS by 1/4/06, the effective date of this change in Florida Statute and Florida Administrative Code. 32. The Agency determined that this deficient practice of failure to document employee’s completion of required training was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 32.1. ' The Agency provided Respondent with a mandatory correction date of April 8, 2006. 32.2. During a re-visit survey conducted June 20, 2006 the Agency determined that the Respondent had corrected the deficiency 33. On January 2-3, 2008, the Agency conducted a Biennial Survey of the Respondent. 34. Based on record review, the facility failed to ensure 1, “Employee #1,” of 5 employees completed continuing education 22 on HIV/AIDS biennially. 35. Employee #1 has been employed longer than 2 years. Review of personnel files of Employee #1 revealed no documentation of HIV/AIDS education after 6/15/05. 36. The Agency determined that this deficient practice of failing to document completion of required employee training was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a repeat State Class III deficiency. 37. The Agency provided Respondent with a mandatory correction date of February 3, 2008. 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 Section 429.19(2)(c), Florida Statutes (2007). aM Respectfully submitted this Qs day of February, 2008. mes H. Harris, Esq. a. Bar. No. 817775 Assistant General Counsel Agency for Health Care Administration 525 Mirror Lake Drive, 330H St. Petersburg, FL 33701 727-552-1435 Facsimile: 727-552-1440 Respondent is notified that it has a right to request an 23 administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. 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 Administrative Complaint and Election of Rights form has been served by U.S. Certified Mail, Return Receipt No. 7007 1490 0001 6907 5237 on February 25, 2008 to Mary Jo Harper, Administrator, Bahia Oaks Street, 2186 Bahia Vista Street, Sarasota, Florida 34239 and by U.S. Certified Mail, Return Receipt No. 70071490 0001 6907.5244 to CT Corporation -Syatem, ‘Registered Agent, Bahia Oake Lodge, 1200 8. Pine tTeland Rao; Plantation, FL 33324. mes H. Harris sistant General Counsel Copies furnished to: Mary Jo Harper, CT Corporation System Administrator Registered Agent Bahia Oaks Lodge Bahia Oaks Lodge 2186 Bahia Vista Street 1200 South Pine Island Rd. Sarasota, Florida 34239 Plantation, FL 33324 (U.S. Certified Mail) (U.S. Certified Mail) 24 David Day/Kriste Mennella Field Office Manager 2295 Victoria Ave., Room 340 Ft. Myers, Florida 33901- 3884 (U.S. Mail) James H. Harris, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330H St. Petersburg, Florida 33701 (Interoffice) 25 ’ USPS - Track & Confirm Page 1 of 1 BARES 200 900 0873 nn _—, Search Results Label/Receipt Number: 7007 1490 0001 6907 5244 Soe Status: Delivered Track & Confirm Enter Label/Receipt Number. Your item was delivered at 9:27 AM on February 27, 2008 in FORT LAUDERDALE, FL 33324. 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Docket for Case No: 08-001702