STATE OF FLORIDA % AGENCY FOR HEALTH CARE ADMINISTRATION ~2 Ay rf; : é STATE OF FLORIDA, LY ( [ aS | AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No.: 2008008918 vs. SIERRA LIFECARE, INC., 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, SIERRA LIFECARE, INC., (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION This is an action to impose a fine in the amount of two hundred and forty thousand dollars ($240,000.00) pursuant to Sections 400.484(2), and 400.474 Florida Statutes (2008), and Rule 59A-8.0086 Florida Administrative Code for nine Class I deficiencies. JURISDICTION AND VENUE 1., The Agency has jurisdiction over the Respondent pursuant to Chapters 400, Part III, and 408, Part II, Florida Statutes, (2008). 2. Venue lies in Broward County pursuant to 120.57 Florida Statutes (2008), and Chapter 28, Florida Administrative Code (2008). | PARTIES 3. The Agency is the licensing and enforcing authority with regard to Home Health Agencies pursuant to Chapters 400, Part III, and 408, Part II, Florida Statutes (2008) and Chapter 59A-8, Florida Administrative Code. 4. Respondent is a Home Health Agency located at 4300 N. University Drive, Suite E-103, Lauderhill, Florida, 33351, having been issued license number 21863096. COMMON FACTUAL ALLEGATIONS 5. That on or about July 14-18, 2008, the Agency conducted a Re-Licensure Survey at Respondent’s facility. 6. That Petitioner’s representative reviewed Respondent’s clinical record for patient number eleven (11) during the survey and noted as follows: a. b. The patient was admitted to the Respondent’s care on September 10, 2007; Diagnoses included nerve and muscular symptoms/NEC (not elsewhere classified), chronic respiratory failure, seizures, and tracheostomy complications; An order, upon hospital discharge dated April 13, 2008, directed to resume home health nursing and mechanical ventilation from 8 P.M. to 8 A.M; A modification order, dated April 25, 2008, documents to "keep the oxygen saturations over 92 percent, and if the patient does not maintain oxygen saturations the ventilator with oxygen is to be placed back on the patient.” The physician signed plan of care (hereinafter ‘POC”) for May 7 through July 5, 2008 documents physician's orders for mechanical ventilation via the LTV 950, a model of ventilator equipment, with the following settings: Oxygen at | liter per minute with humidification, SIMV-PC/PS (Synchronized Intermittent Mechanical Ventilation with Pressure Control/Pressure Support), IMV (Intermittent Mechanical Ventilation) of 25, PEEP (Positive End Expiratory Pressure) of +7, Pressure Support of 19, IT (Inspiratory Time) 0.6 milliliters, and P/K (Peek) Pressure of 19; The POC does not document any evidence the patient is to be off the ventilator during the day, and skilled nursing hours are ordered for twenty (20) hours per day through July 5, 2008 with the provision that hours may be adjusted secondary to caregiver work schedule, and hours may be decreased due to the nursing shortages; . Sixty (60) Day Summary documents reflect that the patient was hospitalized in April, 2008 due to respiratory distress requiring a change in ventilator settings; . The notes of the Respondent’s registered nurse on duty May 24, 2008 from 11:00 P.M. to 7:00 A.M. record oxygen saturations between 98-100% (well oxygenated) via the ventilator with the final note of 7:00 A.M. containing evidence of documentation that the patient was in no distress, and report was given to the oncoming nurse; | Respondent’s oncoming licensed practical nurse documented on the Shift Note Record for May 25, 2008 at 07:00 A.M. that report was received and noted the patient was "in crib awake, with vital signs: 97.2 temperature, heart rate 110, respirations 30, oxygen saturations 97% at room air, tracheostomy intact." The documentation contained no evidence that the patient is mechanically ventilated and is no evidence of documentation of ventilator settings; . At7:10 A.M., documentation notes the "off-going" registered nurse started the respiratory treatment then left; At 7:20 A.M., shift note records document that the family caregiver came in the room and turned off the ventilator but left tubing in place; . Further documentation reflected that about five (5) minutes later the caregiver came back, assessed the patient, said they would be back, and then left; n. At 7:35 A.M., the Respondent’s licensed practical nurse documents was "looking through the clinical record to review the medications and the pulse oximetry beeped...saw a reading of a heart rate of 60 and got up to check the probe and see if there was a kink." 0. The entry continued to document that “[Family member] came in and greet me then made some comment about the beep (alarm). I told her [relative caregiver] turned off the ventilator and I am checking to see what the beep is. [Family member] went over to the head of the [patient’s bed] to greet [patient] because [patient] appears to be sleeping. I was gently tapping [patient’s] legs to arouse [patient]. At the same time {family member] realized [patient] was not responding to either of us. {Family member] reached for Ambu bag while I took off the vent tubing from the trach. I took the bag from [family member] and began give air to [patient]. p. The licensed practical nurse further documents the family member handed the Ambu (Brand-Manual Ventilation) bag to the nurse, who documents that the nurse began giving air and called 911 (Paramedics); q. The patient was transported to the hospital and expired on May 28, 2008. 7. That Petitioner’s representative interviewed the registered nurse, employee number six (6), on July 16, 2008 and noted as follows: a. That employee number six (6) was the registered nurse who provided care to patient number eleven (11) from 11 P.M. on May 24 through 7 A.M on May 25, 2008; b. That the nurse knew that the patient’s trained family caregiver would be leaving the home; That the nurse knew that the oncoming licensed practical nurse, employee number one (1), was not proficient with the ventilator usage; That the nurse had begun the patient’s respiratory treatment via the ventilator prior to the nurse’s departure at the end of the shift and the treatment was still ongoing upon the nurse’s departure; That the trained in home caregiver had directed the nurse to leave, indicating that the trained care giver would remove the patient from the ventilator after the respiratory treatment was completed; That the nurse left the home, returned to check on the patient, and the care giver again indicated that it was okay and that the care giver would remove the ventilator before the care giver left. 8. That Petitioner’s representative reviewed Respondent’s personnel record for employee number six (6), the registered nurse who provided services to patient number eleven (11) from 11 P.M. on May 24 through 7 A.M. on May 25, 2008, and noted as follows: a. b. The nurse was hired on December 2, 1996 as a licensed practical nurse; The nurse obtained licensure as a registered nurse on March 7, 2008; An undated self-assessed skill check list document for respiratory assessment, listing airway and Ambu was left blank; An annual evaluation dated March 2, 2007, while the employee was still a licensed practical nurse, notes the employee is dependable and on time; An annual evaluation dated March 7, 2008 notes that the employee is polite and available for interpreting when needed; Documents reflected the employee completed a three 930 hour in-service on laptop/ventilators on November 11, 2006; g. Documents reflected that the employee attended an in-service on the LPV 1150, a ventilator, on May 2, 2008. 9. That Petitioner’s representative interviewed Respondent’s director of nursing on July 15, 2008 who indicated as follows: a. That Respondent does not offer ventilator training; b. That when a nurse is hired, the nurses already have ventilator training; c. Respondent does provide updates. 10. That Petitioner’s representative requested that any ventilator updates or in-services sign- in sheets be produced; however Respondent did not produce the same. 11. That Petitioner’s representative interviewed Respondent’s registered nurse supervisor on July 15, 2008 who indicated that : a. There are no ventilator policy and procedures located in the homes of ventilator patients; b. There is the DME (Durable Medical Equipment) information in a binder and a "cheat sheet" attached to the ventilator. 12. That Petitioner’s representative reviewed Respondent’s personnel record regarding employee number one (1), the licensed practical nurse referenced in paragraph six (6) above, and noted as follows: a. The licensed practical nurse had cared for patient number eleven (11) on May 25, - 2008; b. The nurse had been hired on January 17, 2007; c. The nurse’s license was effective as of November 27, 2007; d. An undated self-assessed skill check-list document identified the nurse as a licensed practical nurse and the employee self assessed a three (3), identified on the form as “limited experience and requires some assistance,” in the area of establishing an airway, chest percussion, nasal canula, face mask, endotracheal intubation/extubation, and metered dose inhaler treatments (MDI); e. The nurse self-assessed a two (2), identified on the form as "performing infrequently with 6-12 months experience and assistance is required” in the area of Ventilators, Use and Complications of PEEP, CPAP (Continuos Positive Airway Pressure) and IMV; f. Absent from the Respondent’s personnel records was any evidence or documentation reflecting that this nurse had been observed for competency by the Respondent in the areas; g. A performance evaluation of the nurse signed by Respondent’s Director of Nursing and dated April 12, 2008, notes that the nurse is "oriented to vents (Ventilators) but doesn't feel comfortable.” 13. That the Petitioner’s representative reviewed Respondent’s “Active Caregivers by Skill” list provided by Respondent on July 15, 2008 and noted as follows: a. The list is utilized by Respondent’s Staffing Coordinators for assigning skilled nursing staff; b. The entry regarding employee number one (1), the licensed practical nurse above discussed, documents that the nurse has pediatric experience; c. There is no entry describing the nurse’s experience or competency with ventilators; d. There is no entry which would reflect the lack of competence of nurse employee number one (1) as identified in Respondent’s records and self-assessments in providing care for mechanically ventilated patients. 14. That Petitioner’s representative, with Respondent’s Director of Nursing, attended a home visit for patient number four (4) on July 15, 2008 commencing at approximately 2:45 P.M. and through observation and interview noted the following: a. Respondent’s registered nurse, employee number seven (7), was on duty for the patient’s care; b. The registered nurse was asked basic questions regarding "troubleshooting" or problem solving in response to ventilator alarms; c. When asked how to respond to a high-pressure alarm, the nurse indicated that the nurse would suction the patient and try to reconnect; d. Ifthe ventilator was still alarming, the nurse would call 911(Emergency Medical Rescue); e. Upon question, the nurse was unable to verbalize the basic protection and maintenance of a tracheostomy tubed airway; f. The nurse did not include in the explanation of such care the use of an Ambu bag; g. During the twenty-five (25) minutes of observation and interview, the Respondent’s registered nurse attempted to read or review the ventilator’s manual twice; h. Directly after the conclusion of the home visit for patient number four (4), Respondent’s Director of Nursing indicated that the impression of the observation was "Speechless". 15. That Petitioner’s representative reviewed Respondent’s records regarding patient number four (4) during the survey and noted as follows: a. The patient was admitted to the Respondent’s care on July 11, 2006; b. The patient had diagnoses of Klinefelter's syndrome, Acute Respiratory Failure, Convulsions, and Laryngotracheal Anomaly; c. The Physician Ordered Plan of Care (POC) for the certification period June 30, 2008 through August 28, 2008 documented the patient required eighteen (18) hours of skilled nursing a day through August 28, 2008; d. The orders are for continuous use of an LTV 900 ventilator (Laptop Ventilator) with the following settings: SIMV (Spontaneous Intermittent Mandatory Ventilation) rate 23, Total volume 160 cubic centimeters, pressure support 17, PEEP +5, and IT (Inspiratory Time) of 0.8 seconds. 16. That Petitioner’s representative reviewed Respondent’s personnel records of the registered nurse referenced immediately above, employee number seven (7), and noted as follows: a. The nurse was hired on November 2, 2007; b. The nurse’s licensure was effective September 11, 2007; c. A self-assessed skill check list document identified that the registered nurse self assessed a three (3), identified on the form as “limited experience and requires some assistance,” in the area of establishing an airway, ambuing technique, use and complications of ventilators utilizing PEEP, CPAP, and IMV. d. That the Petitioner’s representative reviewed Respondent’s “Active Caregivers by Skill” list provided by Respondent on July 15, 2008 and noted that annotated next to the entry identifying employee number seven (7) was “rusty on laptops” meaning laptop ventilators. 17. That Petitioner’s representative jointly interviewed Respondent’s staffing coordinators and Director of Nursing on July 16, 2008 and noted the following: a. That employee number four (4) is the lead staffing coordinator; b. That employee number four (4) is an emergency medical technician (hereinafter “EMT”); c. The staffing coordinators are all non-professionals and hold no licensure; d. The staffing coordinators are responsible for assigning the care of all patients; e. After hour calls go to a answering service who then “beep” Respondent’s staffing coordinators; f. The “on-call” staffing coordinator takes the call, though the answering service contacts all three (3) coordinators; g. Ifaskilled nurse calls and is not able to attend or complete and assignment, the staffing coordinators determine and assign a replacement skilled nurse; h. The lead staffing coordinator indicated that a skilled nurse’s competency to accept a ventilator assignment is determined by a call to the nurse and asking if the nurse is comfortable with the assignment and has cared for mechanically ventilated patients. 18. That Petitioner’s representative reviewed Respondent’s policy and procedure entitled “Referral and Acceptance of Clients” and noted at section 3.3 a provision mandating that a registered nurse or coordinator working under the supervision of a registered nurse will assign staff members to clients according to clinical needs and the qualifications and availability of staff. 19. That Respondent presented no information which would reflect that a registered nurse assigned skilled staff for patient care or that staffing coordinators were supervised by a registered nurse in making skilled staff assignment decisions. 20. That Petitioner’s representative interviewed Respondent’s Director of Nursing regarding staffing policies and noted as follows: a. That the director indicated that discussions had occurred on May 26, 2008 regarding the change of policy following the outcome of patient number eleven da); b. That the director could produce no notes of or other documentation regarding these discussions; c. The director memorialized the alleged discussions of May 26, 2008 on July 15, 2008 and provided a copy of this newly prepared document to Petitioner’s representative, the same reflecting: i. That each case will be staffed using the highest trained employee; ii. That if special skills are needed for a patient, such as a ventilator nurse, no other nurse is to be staffed; iii. That the director of nursing is to be notified of any staffing concerns related to employee abilities versus patient medical requirements; iv. That tracheostomy patients will not be staffed with nursing personnel who have not changed a tracheostomy and demonstrated proficiency via a checklist. 21. That there is no indication that a registered nurse was to conduct skilled staff assignments or that a registered nurse would supervise coordinators in the assignment of skilled staff to patient care. 22. That there is no indication that the policy changes memorialized by the director of nursing during the survey and purportedly discussed in May 2008 had been instituted since the alleged discussion on May 26, 2008. COUNT I 23. | The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 24. That pursuant to Florida law, the home health agency shall have written policies and procedures governing 24 hour availability to licensed professional nursing staff by active patients of the home health agency receiving skilled care. These procedures shall describe an on-call system whereby designated nursing staff will be available to directly communicate with the patient. For agencies which provide only home health aide and homemaker, companion and sitter services and who provide no skilled care, written policies and procedures shall address the availability of a supervisor during hours of patient service. Fla. Admin. Code R. 59A- 8.0003(10)(d). 25. That based upon observation, interview, and the review of records, Respondent failed to ensure that professional nursing staff are available for the assignment of skilled nursing care at all times including after hours on call as non-professional staff fielded calls and made skilled staff assignments without supervision of a registered nurse. 26. That Respondent’s failure to ensure that licensed professional nursing staff are available as required is illustrated by Respondent’s failure to follow its policy and procedure regarding “Referral and Acceptance of Clients” in its lack of: a. A registered nurse to assign skilled staff to patient care; b. A registered nurse supervising non-professional non-licensed coordinators responsible for the assignment of skilled care to patients; c. Systems to ensure that the assignment of skilled care to patients weighs staff competencies against the patient’s clinical needs; d. Systems which identify known deficits in skilled staff competencies for utilization by staff responsible for the assignment of skilled care to patients; e. The implementation of corrective action where Respondent self-identified deficiencies in its skilled care assignment scheme and subsequently proposed corrective measures. 27. That this deficient practice resulted in a systematic failure of Respondent to ensure that assigned skilled care staff possessed competencies to meet patient needs, including, but not limited to, Respondent’s assignment of a licensed practical nurse with known lack of competencies in ventilator care to a medically-fragile, neuro-muscularly impaired patient requiring intermittent mechanical ventilation, patient number eleven (11), without benefit of oversight by a registered nurse; and during the assigned licensed practical nurse’s shift, the mechanical ventilator connected to the patient was shut-off without disconnecting the tubing to the patient resulting in a lack of adequate oxygen or air to the patient for an undetermined amount of time culminating in the patient's death. In addition, a registered nurse with known and demonstrated lack of competencies in ventilator and related care was assigned to a mechanical ventilator dependent patient, patient number four (4). 28. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 29. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 30. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. § 400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT II 31. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 32. That pursuant to Florida law, “Director of Nursing” means a registered nurse who is a direct employee, as defined in subsection (9), of the agency and who is a graduate of an approved school of nursing and is licensed in this state; who has at least 1 year of supervisory experience as a registered nurse; and who is responsible for overseeing the professional nursing and home health aid delivery of services of the agency. §400.462(10), Florida Statutes (2008). 33. That pursuant to Florida law, "Direct employee" means an employee for whom one of the following entities pays withholding taxes: a home health agency; a management company that has a contract to manage the home health agency on a day-to-day basis; or an employee leasing company that has a contract with the home health agency to handle the payroll and payroll taxes for the home health agency. §400.462(9), Florida Statutes (2008). 34. That pursuant to Florida law, the director of nursing of the agency shall meet the criteria as defined in Section 400.462(10), F.S. Fla. Admin. Code R. 59A-8.0095(2)(a)(1). 35. That based upon observation, interview, and record review the Home Health Agency (HHA) failed to ensure that skilled nursing services were furnished under the supervision and direction of the Director of Nursing. 36. That the Petitioner’s representative reviewed Respondent’s records regarding fifteen (15) patients and located no annotations which would reflect that the Respondent’s director of nursing or other individual assured that personnel assigned to perform skilled care for the patient possessed competencies in the skills required by the patient. 37. That the above reflects that Respondent failed to ensure that is Director of Nursing fulfilled regulatory responsibilities related to overseeing the professional nursing services in that the Director of Nursing permitted the following: a. Allowed non-professional staff to assign licensed staff to meet patient needs; b. Allowed the assignment of an unqualified licensed practical nurse to care for a medically-fragile, neuro-muscularly impaired patient requiring intermittent mechanical ventilation without the benefit of oversight by a registered nurse; c. Failed to ensure the competencies of skilled nursing staff met the needs of patients; d. Failed to assure that a registered nurse assigned to a second patient requiring ventilator care possessed minimum competencies to meet potential emergent needs of the patient; e. Failed to ensure that skilled personnel providing ventilator care had training in ventilator care; f. Failed to conduct competency evaluations of skilled staff; g. Failed to review patient care records to assess whether skilled care being provided met the clinical needs of patients; h. Failed to implement corrective action where deficient practice relating to the assignment of skilled care to patients was identified and corrective action recommended. 38. That these failures placed patients at immediate risk and inter alia, contributed, in part, to a patient experiencing the lack of oxygen for an indeterminate time, the patient later expiring In addition, patients were subjected to the immediate and ongoing risks related to this ongoing and systematic lack of supervision related to the assessment of competencies, the assignment and supervision of skilled staff, the evaluation of patient needs, and the implementation of provider policy and procedure. 39. The cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration 40. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 41. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. § 400.484(2)(a), Florida Statutes (2007). WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2007). COUNT III 42. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 43. That pursuant to Florida law, the director of nursing of the agency shall: (2) Supervise or manage, directly or through qualified subordinates, all personnel who provide direct patient care; (3) Ensure that the professional standards of community nursing practice are maintained by all nurses providing care; (4) Maintain and adhere to agency procedure and patient care policy manuals. Fla. Admin. Code R. 59A-8.0095(2)(a)(2-4). 44. That pursuant to Florida law, if the administrator is not a physician or registered nurse, the director of nursing shall: (1) Establish service policies and procedures in compliance with Chapter 64E-16, F.A.C., and state health statutes and administrative rules pursuant to Section 381.0011(4), F.S., which generally conform to recommended Centers for Disease Control (CDC) and Occupational Safety and Health Agency (OSHA) guidelines for safety, universal precautions and infection control procedures; (2) Employ and evaluate nursing personnel; (3) Coordinate patient care services; and (4) Set or adopt policies for, and keep records of criteria for admission to service, case assignments and case management. Fla. Admin. Code R. 59A-8.0095(2)(b)(1-4). 45. That Petitioner’s representative reviewed Respondent’s Quality Improvement Program (QIP) during the survey and noted that section 7.1 ensures performance-based credentialing for each nurse through the effective use of skills checklist, on-site performance evaluations and other tools and identifying marginal or substandard performers for enhanced training or termination as appropriate. 46. That Respondent’s personnel records for skilled staff nurses numbered one (1), six (6), and seven (7) did not reflect an ongoing skilled staff evaluation system in practice lacking, inter alia, evidence of on-site performance evaluations, other evaluative tools, or the provision for remedies, including but not limited to enhanced training, to address lacks in professional competencies. 47. That the above reflects that Respondent, by and through its agents director of nursing and administrator failed to fulfill its regulatory responsibilities as illustrated by the following: a. The failure to supervise and manage all personnel who provide direct patient care including, but not limited to, the failure to supervise skilled staff who self-identify the need for supervision with certain competencies, the failure to supervise the assignment of skilled staff; the failure ensure known skill deficiencies in skilled personnel are addressed or that such staff are insulated from duties including such personnel’s assignments; The failure to evaluate skilled nursing personnel and their competencies in providing skilled care; The failure to take action to ensure that known deficiencies in skilled staff performance are addressed in accord with written policy and procedure; The failure to ensure that care services are coordinated to ensure that competent staff are assigned to patients with particular and identified needs; The failure to ensure that policies and procedures are adopted and implemented to ensure that patient admission, case assignment, and case management meet the needs of patients with competent personnel. 48. That as a result of these deficient practices, patients of Respondent are at immediate risk, such risks illustrated by and including, but not limited to: a. The assignment of skilled nurses who had not demonstrated competency in nursing care and services related to the use of ventilators are assigned to at least two (2) patients receiving such care, one of which suffered oxygen deprivation and ultimately death; b. The assignment of skilled care by non-skilled non-licensed individuals without the benefit of oversight and control by licensed personnel; c. The failure to implement policies and procedures to ensure the assignment of staff with demonstrated competencies in specialized care to patients requiring specialized care; d. The failure to evaluate skilled care staff competencies despite known and staff self-identified deficiencies in identified care services; e. The failure to address known deficiencies in skilled staff skill levels in accord with policy and procedure. 49. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 50. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 51. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. § 400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT IV 52. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 53. That pursuant to Florida law, the director of nursing shall establish and conduct an ongoing quality assurance program which assures: (1) Case assignment and management is appropriate, adequate, and consistent with the plan of care, medical regimen and patient needs; (2) Nursing and other services provided to the patient are coordinated, appropriate, adequate, and consistent with plans of care; (3) All services and outcomes are completely and legibly documented, dated and signed in the clinical service record; (4) Confidentiality of patient data is maintained; and (5) Findings of the quality assurance program are used to improve services. Fla. Admin. Code R. 59A-8.0095(2)(c). 54. That based upon observation, interview, and the review of records, Respondent failed to ensure that skilled nursing services were furnished under the supervision and direction of the Director of Nursing to ensure case management is appropriate adequate and consistent with the plans of care. 55. That the Petitioner’s representative reviewed Respondent’s records regarding fifteen (15) patients and located no annotations which would reflect that the Respondent’s director of nursing or other individual assured that personnel assigned to perform skilled care for the patient possessed competencies in the skills required by the patient. 56. That Petitioner’s representative interviewed Respondent’s director of nursing on July 15, 2008 who indicated as follows: a. That Respondent does not offer ventilator training; b. That when a nurse is hired, the nurses already have ventilator training; 20 c. Respondent does provide updates. 57. That Petitioner’s representative requested that any ventilator updates or in-services sign- in sheets be produced; however Respondent did not produce the same. 58. That Petitioner’s representative reviewed Respondent’s Quality Improvement Program (QIP) during the survey and noted as follows: a. That section 7.1 ensures performance-based credentialing for each nurse through the effective use of skills checklist, on-site performance evaluations and other tools and identifying marginal or substandard performers for enhanced training or termination as appropriate; b. That section 7.2 Quality Improvement Monitoring and Responsibility documents responsibility for the QI program rests with the Board of Directors. Administrative responsibility for the QI program is delegated to the Administrator, supervising nurse or quality assessment coordinator who may delegate certain activities. The policy defines that the Administrator oversees the quality improvement process, and confers on a regular basis with the quality assessment coordinator and others to review trends and assess problems. The policy directs the Administrator to report to the President immediately on significant problems, including corrective action taken, required follow-up and monitoring measures. This was requested but not provided by the end of the survey. 59. That Petitioner’s representative requested a copy of the information reflecting the required reporting of significant problems, corrective action, follow-up, and monitoring as required by Respondent’s quality improvement policy, however the same was not provided to Petitioner by the conclusion of the survey. 21 60. That Respondent’s director of nursing failed to establish and conduct an ongoing quality assurance program as illustrated by the following: a. The failure to ensure that case assignment is appropriate, adequate, and consistent with patient needs including, but not limited to, the assignment of skilled nursing personnel to patients with identified needs, i.e. ventilator care, who have known a identified deficiencies in their competencies to provide such care, and the failure to ensure skilled staff are assigned to responsibilities consistent with demonstrated competencies in the care services required by the patient; b. The failure to ensure that nursing services are coordinated, appropriate, adequate, and consistent with plans of care including, but not limited to, the failure to implement a skilled staff assignment scheme by which skilled staff who are assigned possess competencies in accord with patient needs, the failure to review patient care to ensure that skilled staff who are assigned possess competencies in accord with patient needs, the failure to ensure that staff responsible for the assignment of skilled staff possess professional competencies to assure the aforementioned, the failure to adequately identify and evaluate skilled staff competencies, the failure to assign skilled staff in accord with Respondent’s policy and procedure, and the failure to ensure that a registered nurse participates in the assignment of skilled staff; c. The failure to ensure that deficiencies identified by the Respondent and corrective action planned is documented and implemented in a timely manner to protect patient well-being including the failure to amend its policy and procedure, and the implementation thereof, to reflect the assignment of skilled personnel in accord with patient needs; 22 d. The failure to ensure training of personnel where deficiencies in skill levels have been identified or to insulate staff possessing such deficiencies from providing care in the identified area of deficient competence; e. The failure to follow its policy and procedure related to the assessment and evaluation of skilled staff competencies; f. The failure to follow its policy and procedure regarding reporting of significant problems, corrective action, follow-up, and monitoring as required by Respondent’s quality improvement policy. 61. That the above deficient practice reflects systematic failure which placed patient health, safety, and well-being in immediate risk and resulted in a pattern where skilled staff ere assigned without regard to the level of the staff members competencies in relation to the patient’s needs, including the assignment of staff without competencies in ventilator care to patients numbered four (4) and eleven (11), skilled personnel are assigned by non-licensed non-professionals without a registered nurse’s oversight, corrective action as a result of negative outcomes is not implemented, and known deficiencies in skilled staff skills are allowed to remain deficient without a concomitant limitation of care responsibilities. 62. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 63. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 23 64. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. § 400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT V 65. | The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 66. That pursuant to Florida law, a registered nurse shall be currently licensed in the state, pursuant to Chapter 464, F.S., and: (1) Be the case manager in all cases involving nursing or both nursing and therapy care; (2) Be responsible for the clinical record for each patient receiving nursing care; and (3) Assure that progress reports are made to the physician for patients receiving nursing services when the patient’s condition changes or there are deviations from the plan of care. Fla. Admin. Code R. 59A-8.0095(3)(a). 67. That based upon observation, interview, and the review of records, Respondent failed to ensure that a registered nurse managed patient care as required by law. 68. That Respondent failed to ensure that a registered nurse managed patient care in Respondent’s failure to: a. Ensure that skilled staff assignments were made by or under the direction of a registered nurse where non-licensed non-professionals were solely responsible for determining the assignment of skilled nurses to patient care; 24 b. Ensure that patient care provided by skilled staff was performed by staff who possess competencies required by the needs of the patient; c. Ensure that clinical records reflect that skilled staff competencies met patient needs. 69. That this deficient practice resulted in systematic failures that resulted in the assignment of skilled staff who did not possess competencies in ventilator care to two (2) patients, one of whom suffered a negative impact as a result of oxygen deprivation, despite Respondent’s knowledge that the staff members did not possess competencies in ventilator care, despite the knowledge of other skilled staff that skilled staff did not possess competencies in ventilator care, and further resulted in the lack of case review to determine whether care and service provided by skilled staff met the needs of the patient census. 70. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 71. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 72. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. §400.484(2)(a), Florida Statutes (2008). 25 WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT VI 73. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 74. That pursuant to Florida law, a registered nurse may assign selected portions of patient care to licensed practical nurses and home health aides but always retains the full responsibility for the care given and for making supervisory visits to the patient’s home. Fla. Admin. Code R. 59A-8.0095(3)(b). 75. That based upon observation, interview, and the review of records, Respondent failed to ensure that the Registered Nurse retained full responsibility for the care provided by the Licensed Practical Nurse (LPN) and was competent to assist with a mechanically ventilated patient. 76. That the Petitioner’s representative reviewed Respondent’s records regarding fifteen (15) patients and located no annotations which would reflect that the Respondent’s director of nursing or other individual assured that personnel assigned to perform skilled care for the patient possessed competencies in the skills required by the patient. 77. That the failure to ensure that a registered nurse retained full responsibility for care given to patients as assigned to a licensed practical nurse is illustrated by: a. Respondent’s registered nurse, employee number six (6), leaving the care and treatment of patient number eleven (11) to a licensed practical nurse, employee number one (1), despite the knowledge of nurse employee number six (6) that nurse number one (1) lacked competence in addressing ventilator use by patients, though the patient was currently receiving respiratory therapy through a 26 ventilator; b. Respondent’s failure to utilize a registered nurse in determining the assignment of licensed practical nurses for patient care, said decisions delegated to non- professional non-licensed staff. 78. That as a result of this deficient practice, a licensed practical nurse who lacked competencies related to care related to ventilator use was assigned and permitted to attend to a medically-fragile, neuro-muscularly impaired patient requiring intermittent mechanical ventilation, patient number eleven (11), without benefit of oversight by a registered nurse and during said assignment, the mechanical ventilator connected to the patient was shut-off without disconnecting the tubing to the patient, resulted in a lack of adequate oxygen to the patient for an undetermined amount of time and culminating in the patient's death. In addition, licensed practical nurses were assigned 0 care for patients without the advise, consent, and delegation of duties by a registered nurse, but rather by non-licensed non-professional staff. 79. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 80. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 81. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. 27 §400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT VII 82. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 83. That pursuant to Florida law, a licensed practical nurse shall be currently licensed in the state, pursuant to Chapter 464, F.S., and provide nursing care assigned by and under the direction of a registered nurse who provides on-site supervision as needed, based upon the severity of patients medical condition and the nurse’s training and experience. Supervisory visits will be documented in patient files. Provision shall be made in agency policies and procedures for annual evaluation of the LPN’s performance of duties by the registered nurse. Fla. Admin. Code R. 59A-8.0095(4)(a). 84. That based upon observation, interview and the review of records, Respondent failed to ensure that the licensed practical nurse was under the direction of a registered nurse and was competent to assist with mechanically ventilated patient. 85. That this deficient practice is illustrated by Respondent’s assignment of a licensed practical nurse, nurse employee number one (1) to care for a patient receiving ventilator care where: a. Respondent’s registered nurse number six (6) who cared for patient eleven (11) on the shift prior, knew that nurse number one (1) did not possess competencies in ventilator care; 28 b. Respondent’s registered nurse number six (6) who cared for patient eleven (11) on the shift prior, knew that patient number eleven (11) was receiving therapy via ventilator care when the nurse left the patient’s home; c. Respondent failed to provide on site supervision by a registered nurse in light of the severity of the patient’s condition and the training and experience of nurse number.one (1). 86. That as a result of this deficient practice, nurse number one (1) who lacked competencies in ventilator care was left, without registered nurse supervision, to care for a medically-fragile, neuro-muscularly impaired patient requiring intermittent mechanical ventilation, patient number eleven (11), and during the shift of nurse number one (1), the mechanical ventilator connected to the patient was shut-off without disconnecting the tubing to the patient resulting in a lack of adequate oxygen to the patient for an undetermined amount of time culminating in the patient's death. 87. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 88. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 89. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. 29 §400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT VII 90. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 91. That pursuant to Florida law, the skilled care services provided by a home health agency, directly or under contract, must be supervised and coordinated in accordance with the plan of care. §400.487(6), Florida Statutes (2008). 92. That based upon observation, interview and the review of records, Respondent failed to ensure that skilled care services were supervised and coordinated in accord with patient plans of care. 93. That Respondent’s failures to maintain liaison to ensure their efforts are coordinated effectively and to support the objectives in the Plan of Care are illustrated by: a. The failure of Respondent to formulate and implement a plan for the assignment of skilled care whereby skilled care providers possess competencies to meet the clinical needs of patients as illustrated in plans of care including, but not limited to, the failure or inability of staffing coordinators to assign skilled care providers in such a manner that the skilled care providers assigned possessed competencies in service and care areas which were necessary for the patients plan of care resulting in the assignment of skilled care personnel who did not possess competencies in ventilator care to two (2) patients receiving ventilator services; 30 b. The failure of Respondent to mange patient care in such a manner that the competencies of skilled care were evaluated and supervised, including but not limited to the failure to provide supervision of licensed practical nurse by registered nurses and the failure to review patient care to weigh patient care needs against assigned staff competencies. c. The failure to ensure that ventilator training and competency was achieved by skilled care personnel prior to the assignment of skilled care personnel to patients requiring ventilator care. 94. That as a result of this deficient practice, patients of respondent were assigned skilled care givers without any assessment or review of the competency of assigned staff to perform the care the patient required in a plan of care. Non-professional non-licensed staff assigned skill care staff absent the oversight of a registered nurse and without sufficient knowledge of skilled care staff competencies and patient care needs. Among noted facts, this resulted in the assignment of a licensed practical nurse with known lack of competencies in ventilator care to a medically-fragile, neuro-muscularly impaired patient requiring intermittent mechanical ventilation, patient number eleven (11), without benefit of oversight by a registered nurse; and during the assigned licensed practical nurse’s shift, the mechanical ventilator connected to the patient was shut-off without disconnecting the tubing to the patient resulting in a lack of adequate oxygen or air to the patient for an undetermined amount of time culminating in the patient's death. In addition, a registered nurse with known and demonstrated lack of competencies in ventilator and related care was assigned to a mechanical ventilator dependent patient, patient number four (4). 95. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate 31 Moratorium on Admissions by the Agency for Health Care Administration. 96. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 97. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. §400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). COUNT JX 98. The Agency re-alleges and incorporates paragraphs one (1) through twenty-two (22) as if fully set forth herein. 99. That pursuant to Florida law, when a home health agency accepts a patient or client for service, there shall be a reasonable expectation that the services can be provided safely to the patient or client in his place of residence. This includes being able to communicate with the patient, or with another person designated by the patient, either through a staff person or interpreter that speaks the same language, or through technology that translates so that the services can be provided. The responsibility of the agency is also to assure that the patient or client receives services as defined in a specific plan of care, for those patients receiving care under a physician, physician assistant, or advanced registered nurse practitioner’s treatment 32 orders, or in a written agreement, as described in subsection (3) below, for clients receiving care without a physician, physician assistant, or advanced registered nurse practitioner’s orders. This responsibility includes assuring the patient receives all assigned visits. Fla. Admin. Code R. 59A-8.020(1). 100. That pursuant to Florida law, "Admission" means a decision by the home health agency, during or after an evaluation visit to the patient's home, that there is reasonable expectation that the patient's medical, nursing, and social needs for skilled care can be adequately met by the agency in the patient's place of residence. Admission includes completion of an agreement with the patient or the patient's legal representative to provide home health services as required in s. 400.487(1). §400.462(2), Florida Statutes (2008). 101. That based upon observation, interview, and the review of records, Respondent failed to ensure that the patients’ medical and nursing needs could be adequately met by Respondent in admitting the patients. 102. The failure of Respondent to ensure that patient needs can be met by Respondent prior to admission of patients, and the failure to assure such needs are met, include: a. That failure of Respondent to timely assess the competencies of skilled care staff; b. The failure of Respondent to assure that known deficits in competencies of skilled care staff are either remedied or that skilled care possessing such deficits are insulated from assignments requiring such competencies; c. The failure to utilize skilled care registered nurse staff to evaluate patient needs prior to assignment of skilled care staff: d. The failure to utilize skilled care registered nurse staff to weigh competencies of skilled care providers prior to assigning the skilled care providers to complete direct patient care; 33 e. The failure to ensure that licensed practical nurses are supervised by a registered nurse where the complexity of care required and the competencies of the licensed practical nurse require supervision; f. The failure to evaluate patient care on an ongoing basis to determine that skilled care provided is adequate in quality and competence to meet the needs of the patient and the patient plan of care. . 103. That as a result of this deficient practice, Respondent accepted patients and assigned skilled care nurse without taking steps, such as staff training, staff competency evaluation, and staff supervision, by which Respondent could have a reasonable expectation that assigned skilled nursing possessed the competencies necessary to meet patient needs and the services required within the patients plan of care. Such deficient practice resulted in, inter alia, the assignment of a licensed practical nurse with known lack of competencies in ventilator care to a medically- fragile, neuro-muscularly impaired patient requiring intermittent mechanical ventilation, patient number eleven (11), without benefit of oversight by a registered nurse; and during the assigned licensed practical nurse’s shift, the mechanical ventilator connected to the patient was shut-off without disconnecting the tubing to the patient resulting in a lack of adequate oxygen or air to the patient for an undetermined amount of time culminating in the patient's death. In addition, a registered nurse with known and demonstrated lack of competencies in ventilator and related care was assigned to a mechanical ventilator dependent patient, patient number four (4). 104. That the cumulative effect of these failures resulted in a crisis situation in which the health and safety of patients are at risk and the issuance of an Emergency Order of Immediate Moratorium on Admissions by the Agency for Health Care Administration. 105. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or 34 was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with a State Class I deficiency. 106. That a Class I deficiency is any act, omission, or practice that results in a patient’s death, disablement, or permanent injury, or places a patient at imminent risk of death, disablement, or permanent injury. Upon finding a Class I deficiency, the Agency shall impose an administrative fine in the amount of $15,000 for each occurrence and each day that the deficiency exists. §400.484(2)(a), Florida Statutes (2008). WHEREFORE, Agency intends to impose an administrative fine in the amount of $30,000.00 against Respondent, a home health agency in the State of Florida, pursuant to Sections 400.484(2)(a) and 400.474, Florida Statutes (2008). Respectfully submitted this 5 day of August, 2008. 4 Themasd. Walsh, II, Esq. #14 Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 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. 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 35 ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7007 1490 0001 6908 7469 on August .5_, 2008 to Haya Rabone, Administrator, Sierra Lifecare, Inc., 4300 N. University Drive, Suite E-103, Lauderhill, Florida, 33351 and by U.S. Mail to Donna Szczebak O’Neil, Esq., Registered Agent, 301 E. Commercial Blvd., Ft. Lauderdale, Florida 33334. ; Of Thomas J. Walsh IL, Esquire ¥ Copies furnished to: Haya Rabone, Administrator Donna Szezebak O’Neil, Esq. Sierra Lifecare, Inc. Registered Agent 4300 N. University Dr., Suite E-103 301 E. Commercial Blvd. Lauderhill, Florida, 33351 Ft. Lauderdale, Florida 33334 (U.S. Certified Mail) (U.S. Mail) Arlene Mayo-Davis Thomas J. Walsh, II, Esquire Agency for Health Care Admin. Agency for Health Care Administration 5150 Linton Blvd, Suite 500 525 Mirror Lake Drive, #330G Delray Beach, FL 33484 St. Petersburg, FL 33701 (U.S. Mail) (Interoffice Mail) 36 COMPLETE THIS SECTIO! DELIVERY SENDER: COMPLETE = Complete items 1, 2, a... v. Also complete item 4 if Restricted Delivery is desired. ® Print your name and address on the reverse so that we can return the card to you. ’ m Attach this card to the back of the mailpiece, or on the front if space permits. : 1. Article Addressed to: Py B. Received by ( Printed Name) Vitel D. Is delivery address different from item 12 [1 Yes {f YES, enter delivery address below: C1 No Haya Rabone, Administrator Sierra Lifecare, Inc. 4300 N. University Dr., Suite E-103 Lauderhill, Florida, 33351 -o-e- + fant . Service Type © Certified Mall 1 Express Mall ORegistered (iAeturn Recelpt for Merchandise C1 insured Mail 0 C.0.D. . Restricted Delivery? (Extra Fee) Clyes 2, Article N : - avon 7007 L480 OOOL BA0B ?4b4 ; PS Form 3811, February 2004 Domestic Return Receipt 402595-02-M-1540

Docket for Case No: 08-004351