Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: ARC BAHIS OAKS, INC., D/B/A BAHIA OAKS LODGE
Judges: T. KENT WETHERELL, II
Agency: Agency for Health Care Administration
Locations: Sarasota, Florida
Filed: Apr. 07, 2008
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Tuesday, May 27, 2008.
Latest Update: Mar. 15, 2025
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STATE OF FLORIDA 98 fp, o™ ED
AGENCY FOR HEALTH CARE ADMINISTRATION “#~ 4
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STATE OF FLORIDA, AGENCY FOR Abgyt!Slon oe 47
HEALTH CARE ADMINISTRATION, WARE AT Ve
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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
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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
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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
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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:
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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
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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
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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
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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.
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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,
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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
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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
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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
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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.
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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
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Docket for Case No: 08-001702
Issue Date |
Proceedings |
May 27, 2008 |
Order Closing File. CASE CLOSED.
|
May 22, 2008 |
Joint Motion to Relinquish Jurisdiction filed.
|
Apr. 16, 2008 |
Order of Pre-hearing Instructions.
|
Apr. 16, 2008 |
Notice of Hearing (hearing set for September 2 and 3, 2008; 9:00 a.m.; Sarasota, FL).
|
Apr. 15, 2008 |
Joint Response to Initial Order filed.
|
Apr. 14, 2008 |
Agency`s First Request for Production of Documents filed.
|
Apr. 14, 2008 |
First Request for Admissions filed.
|
Apr. 14, 2008 |
Notice of Service Petitioner`s First Set of Interrogatories, Request for Admissions and Request for Production of Documents to Respondent filed.
|
Apr. 08, 2008 |
Initial Order.
|
Apr. 07, 2008 |
Administrative Complaint filed.
|
Apr. 07, 2008 |
Election of Rights filed.
|
Apr. 07, 2008 |
Petition for Formal Administrative Proceedings filed.
|
Apr. 07, 2008 |
Notice (of Agency referral) filed.
|