Mar 1? 2009 10:39 MAR-17-2889 18:52 AGENCY HEALTH CARE ADMIN 856 921 @158 P.@823 BTATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ve. Cage No, 2008013522 CLAY COUNTY MEDICAL INVESTORE, LLC d/b/a LIFE CARE CENTER OF ORANGE PARE Respondent. / ADMINISTRATIVE COMPLAINT Petitioner, the Florida Agency for Health Care Administration (“AHCA"), through undersigned counsel, files this Administrative Complaint against the above-named Respondent (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2007)*, and alleges: NATURE OF THE ACTION 1. This is an action to impose an adminiatrative fine in the amount of $6,643 (the “Fine Amount”) against Respondent, pursuant to Section 408.040, Florida Statutes, and Florida Administrative Code Rule 59C-1.021. tunless otherwise noted, all statutes and rules hereinafter cited are to the indicated year’s version of the statute or rule becayse this is the controlling year in question. Page 1 of 11 Mar 1? 2009 10:40 MAR-1?-2889 18:52 AGENCY HEALTH CARE ADMIN 856 921 4158 2. For the calendar year 2007 (the “Calendar Year"), Respondent failed to comply with the Medicaid condition upon its Certificate of Need (secon), a copy ef which is attached to this complaint as Exhibit A. JURISDICTION AND VENUE 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes, and also Sections 408.031-408.045, Florida's “Health Facility and Services Development Act.” 4, Venue is determined by Florida Administrative Code Rule 28-106.207. PARTIES 5, Pursuant to Chapter 408, Florida Statutes, and Chapter 59C-1, Florida Administrative Code, AHCA is the licensing and enforcing authority with regard to community nursing home laws and rules. é. Respondent ig a limited liability company authorized under the laws of Florida to do business, Respondent operates a community nursing home located at 2145 Kingsley Avenue, Orange Park, Florida 32703 and is the licensee on the CON igsued on September 19, 1995 for a minimum of 53.55% of the 180 bed facility's total annual patient days shall be provided to Medicaid patients. The CON number is 7737; a copy of the CON is attached to this complaint ag Exhibit A. Page 2 of 11 P9723 Mar 1? 2009 10:40 MAR-17?-2889 18:53 AGENCY HEALTH CARE ADMIN 856 921 4158 count I Respondent failed to meet ite Medicaid condition Section 409.040, Florida Statutes Florida Administrative Code Rule 59C-1.021 7. AHCA re-alleges paragraphs 1-6 above. 8. Respondent failed to comply with its Medicaid condition ag reported to the Agency in its Florida Nursing Home Utilization Report for the year 2007, a copy of which is attached to this complaint ag Exhibit B,. The facility responded to a request to provide a facility report, a copy of the report is attached to this complaint as Exhibit Cc. 9. Respondent failed to comply with the condition set forth in its CON, as required by Section 408.040, Florida Statutes, which provide, in part, as follows: 408.040 Conditiona and monitoring (1) (a) The agency may issue a certificate of need, or an exemption, predicated upon statements of intent expressed by an applicant in the application for a certificate of need. Any conditions imposed on a certificate of need or an exemption based on such statements of intent shall be stated on the face of the certificate of need or in the exemption approval. (b) The agency may consider, in addition to the other criteria specified in s. 408.035, a statement of intent by the applicant that a specified percentage of the annual patient days at the facility will be utilized by patients eligible for care under Title KIX of the Social Security Act, Any certificate of need issued to a nursing home in reliance upon an applicant's statements that a specified percentage of annual patient days will be utilized by residents eligible for care under Title XIX of the Social Security Act must include a statement that such certification is a condition of issuance of the certificate of need, The certificate-of-need program Page 3) of 11 ay P.1a/23 MAR-17-2889 above-mentioned fine amount pursuant to Florida Administrative Mar 1? 2009 10:40 18:53 AGENCY HEALTH CARE ADMIN 856 921 @158 shall notify the Medicaid program office and the Department of Elderly Affairs when it imposes conditions as authorized in this paragraph in an area in which a community diversion pilot project is implemented. (c) A certificate holder or an exemption holder may apply to the agency for a modification of conditions imposed under paragraph (a) or paragraph (b). If the holder of a certificate of need or an exemption demonstrates good cause why the certificate or exemption should be modified, the agency shall reissue the certificate of need or exemption with such modifications as may be appropriate. The agency shall by rule define the factors constituting good cause for modification. (d) If the holder of a certificate of need or an exemption fails to comply with a condition upon which the issuance of the certificate or exemption was predicated, the agency may assess an administrative fine against the certificate holder in an amount not to exceed $1,000 per failure per day. Failure to annually report compliance with any condition upon which the issuance of the certificate or exemption wag predicated constitutes noncompliance. In assessing the penalty, the agency shall take into account ag mitigation the degree of noncompliance. Proceeds of such penalties shall be deposited in the Public Medicaid Assistance Trust Fund. kok O* 10. The foregoing violation warrants imposition of the Code Rule $9C-1.021, which provides, in part: 59c+1,021 Penalties. (1) General Provisions. The agency shall initiate administrative proceedings for revocation of a certificate of need for violation of paragraphs 408.040(2) (a) and ({(b), F.S., or the assessment of administrative fines for failure to comply with conditions placed ona certificate of need as specified under Rule 59C-1.013, F.A.c ‘ * ek (3) Penalties for Failure to Comply with Certificate of Need Conditions. The agency shall review the annual compliance report. submitted by the health care providers Page 4 of 11 P.iiv23 MAR- 17-2889 Mar 1? 2009 10:41 14:53 AGENCY HEALTH CARE ADMIN 856 921 4158 who are licensed and operate the facilities or services and other pertinent data to assess compliance with certificate of need conditions. Providers who are not in compliance with certificate of need conditions shall be fined. For community nursing homes or hospital-based skilled nursing units certified as such by Medicare, the first compliance report on the status of conditions must be submitted 30 calendar days following the eighteenth month of operation or the first month where an 85 percent occupancy is achieved, whichever comes first. The schedule of finea is as follows: (a) Facilities failing to comply with any conditions set forth on the Certificate of Need will be assessed a fine, mot to exceed $1,000 per failure per day. In assessing the penalty the agency shall take into account the degree of noncompliance. (b) The assessed fine shall be paid to the agency within 45 calendar days after written notification of assessment by certified mail or within 30 calendar days after final agency action if an administrative hearing has been requested. If a health care provider desires it May vemit payment according to a payment schedule accepted by the agency. The health care provider must aubmit the schedule of payments to the ageney within 30 Calendar days after the date of receipt of the notification of assessment or 21 calendar days after final agency action, The final balance will be due no later than 6 months after the health care provider has been notified in writing by the agency of the amount of the assessed fine or 6 months after final agency action. 11. AHCA, in determining the penalty imposed, considered the degree of noncompliance. WHEREFORE, AHCA demands the following relief: (1) enter factual and legal findings as set forth in thia Count; (2) impose the above-mentioned fine amount for the viclation; and (3) impose such other relief as this tribunal may find appropriate. Page 5 of 11 P.1a/23 Mar 1? 2009 10:41 MAR-1?-2889 18:54 AGENCY HEALTH CARE ADMIN 856 921 4158 P1323 NOTICE RESPONDENT is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Hldg. 3, MS #3, Tallahassee, Florida, 32308; Attention: Agency Clerk. RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING Is NOT RECEIVED BY ‘THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Submitted ag of the date indicated on the below Certificate of Service. anne . mes H, Harris sistant General Counsel Fla. Bar No, 817775 Agency for Health Care Administration 525 Mirror Lake Drive, North Suite 330H St, Petersburg, Florida 33701 Phone: 727-552-1435 Fax: 727-552-1440 Page 6 of 11 Mar 1? 2009 10:41 MAR-1?-2889 18:54 AGENCY HEALTH CARE ADMIN 856 921 4158 P1423 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the original Administrative Complaint, Explanation of Rights form, and Election of Rights form have been sent: 1, by U.S. Certified Mail, Return Receipt Requested, Receipt # 7007 0220 0001 1589 3454 to Life Care Center of Orange Park, Attention: Administrator, at 2145 Kingsley Avenue, Orange Park, Florida 32703; 2, by U.S. Certified Mail, Return Receipt Requested, Receipt # 7007 0220 0001 1589 3461 to C.T. Corporation System, Registered Agent for Clay County Medical Investors, LLC, 1200 South Pine Island Road, Plantation, Florida 33324; and 3. by regular U.S. Mail to John F. Gilroy, ITI, P.A., 1435 East Piedmont Drive, Suite 215, Tallahassee, Florida 32308 on December { 2-, 2008, Yo mes H. Harris, Eaq. sistant General Counsel Page 7 of 11 Mar 1? 2009 10:41 MAR-17-2889 18:54 AGENCY HEALTH CARE ADMIN 856 921 @158 . EXHIBITS (AHCA v. Life Care Center of Orange Park, Case No.2008013522) EXHIBIT “A” - Respondent's CON # 7737, requiring a minimum of 53.55% of the 180 bed facility’s total annual patient days shall be provided to Medicaid patients. EXHIBIT “Be” - Florida Nursing Home Utilization Report for Year 2007, page 74, EXHIBIT “c” — Respondent's facility report for calendar year 2007, (All are copies) Page 11 of 11 P.1i5/23 Mar 1? 2009 10:42 MAR-1?-2889 18:54 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 1623 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ve. Case No. 2008013522 CLAY COUNTY MEDICAL INVESTORS, LLC d/b/a LIFE CARE CENTER OF ORANGE PARK Respondent . / ADMINISTRATIVE COMPLAINT Petitioner, the Florida Agency for Health Care Administration (“ANCA”), through undersigned counsel, files this Administrative Complaint against the above-named Respondent ("Respondent") pursuant to Sections 120.569 and 120.57, Florida Statutes (2007)*, and alleges: NATURE OF THE ACTION 1. This is am action to impose an administrative fine in the amount of $6,643 (the "Fine Amount”) against Respondent, pursuant to Section 408.040, Florida Statutes, and Florida Administrative Code Rule $9C-1.021, lunless otherwise noted, all statutes and rules hereinafter cited are to the indicated year’s version of the statute or. rule because this is the controlling year in question. Page 1 of 11 Mar 1? 2009 10:42 P.1?r/23 856 921 4158 AGENCY HEALTH CARE ADMIN MAR-17?-2889 18:55 E66L THLE 6621 WHOA . _ ‘ang Adezayy, Asoyertdsay aq g Ue apnPUr prom WSTya yun ares ayn>ecns paq oz e ysTqeyss Feys queoydde ayy (2) pue ‘uened prompayy 01 papraoid aq Preys Anpoey paq-Og] ap 10} sdup penuur [ej0y SY Jo %Cgres,, Jo UMUTUTUT ¥ (T) ‘SNOLLIGNOD "1809 UOHINTSUOD UT YOY’ TF Tg PUR WOHIMASUO? Mau Jo ISS 944/21 Sutayoaut (speq OT 207 paaordde) T0Od FoqUIMN pean Jo ayeoyHIaD OF uoTTPPe ouroy SursmMu peyrys paq-gg & PTIISUCD ‘NOLLATHDISAC IDalOwI % HORusiagns | > SIDRISIG ALVGNOILVNIAQAL GSSIASY ORFE-OZELE sessoUUay ‘puryaasD | 9661 SI Tequiadas — -ZEVO NOLLVNIARLL ‘SPE XOg “Od $661 “61 Jaquiaydag ‘LV SSSI "MUN 38995 INTE OZE¢ 782 FIG Sa. SESOD 1Loafoud ‘UY “EOPSUTY Jo s1ayUaD are} ayy] ELE THEGAINN c= ‘LNVOMad¥ (20/67 /8) PPBPOW uoRrpuoD;,. (88284 NOD) UnaAG JsD> ela papusury, ~polord sng 403 paou 1p saiyyiad UORe]STURUpY are> ippeezy Jo; Asuady an {apo sanensunopy eppoLy ‘T-Dsg erdeyD GIN “(z661 ddng) semqeyg eprops ‘ShO-LeU'g0F sucHDaS) ,AOy jueindo]sasq] saotatag pure AaqDeY wB[eay,, at Jo suorstaacd ary pyc, Ca4N AO ALVOILLYAD NOLLVYLSININGY 84YV> HLTVaH WOd ADNE: VaIuO1d 40 ALVIS Mar 1? 2009 10:42 P.18/23 856 921 4158 AGENCY HEALTH CARE ADMIN 1@:55 MAR- 17-2889 DISTRICT 4 NURSING HOME UTILIZATION (January 2007 - December 2007 Data) PATIENT DAYS TOTAL OCCUPANCY QUARTERLY TOTALS 0107-3207 QUARTERLY TOTALS O1AIT-12/07 Dayal Coonty 351 Cathedral Gerontology Center, Inc. 964 Edgewood Nursing Center 719 Harts Harbor Health Care Center 1037 = Jacksonville Nursing ad Rehabilitation Center 1222 Lakeside Nursing and Rebabititation Center 642 ° Lanier Manor 430° Summer Brook Health Care Center” Nassau County 1020 Life Care Center of Hilbard a72 Quality Health of Fernandina Beach 1029 Macclenny Mursing and Rehab Center 37000 W. Prank Wells Nursing Home Ciay Connty é- 1013 Consulate Health Care of Orange Park. 953 = Doctors Lake of Orange Park ™1 — Govertor’s Creek Health and Rehabilitation (O13 Heartland Health Care Center - Orange Park TH = Kingsley Place Care & Rehabilitation Center 1204 Life Care Center at Wells Crossing W180 Life Care Center of Orange Park 1085 Magnolia Manor (Inactive 9/8/99} 532 Pavilion For Health Care, The 1286 Terrace at Fleming Island, The Dovat Connty : 357 All Saints Catholic Nursing Home & Rehab Center, ins. 44 Cedar Hills Healthcare Center 442° Florida Christian Health Center (Closed 2/6/02) 1g12 Heartland Health Care Center - Jacksonville 499 Park Ridge Nursing Center 633 = Saint Catherine Laboure Manos, Inc. 1034 0 West Iucksonville Health and Rehabilitation Center EXHIBIT 74 AHCA o4fo4ng B Mar 1? 2009 MAR-17?-2889 18:56 AGENCY HEALTH CARE ADMIN 856 921 4158 P.19/23 ‘ie Law Offices of JOHN F. GILROY, HI, P.A. John F, Gilroy, HI 1695 METROPOLITAN CIRCLE, SUITE 2 John@izilroylay.com TALLAHASSEE, FL 32308 850, 385.1368; FAX: 850.422.0221 John E, Terrel «+ jterrel @ijeil “* Board Certified: State and Federal Government and Administrative Practice November 4, 2008 Ms. Cheslyn M. Green Health Services & Facilities Consultant Agency for Health Care Administration 2727 Mahan Drive, Building 1... , Re CEIVE Tallahassee, FL 32308 NOV 06 2008 Con/Financial Analysis Office Mail Stop 28 Re: CON Nos, 7737 Life Care Center of Orange Park CON Condition Compliance (2007) Dear Ms. Green: : Please accept this letter and attachment as the formal report by Life Care Center of Orange Park conceming its CON Condition Compliance for calendar year 2007. We have been authorized by the owner and licensee of the facility to act as its authorized representative for purposes of filing this report. Per Rule 59C-1,013(4)(a), Florida Administrative Code: « The time period covered by this report is January — December, 2007. « The measure for assessing compliance with the Medicaid condition is to determine. total patient days for the year and divide by the number of Medicaid patient days for the year. * The data used was the facility’s internal census tracking information generated on amonthly basis. (Attachment A). + The compliance report is being submitted by the undersigned under the authority of the facility administrator and licensee of the facility. Requirement for $3.55% Medicaid Patient Days The facility experienced a total of 62,138 total patient days in calendar year 2007. Of that number, there were 27,744 traditional Medicaid days and 3,105 hospice Medicaid days which equates to a total of 49.65% of all patient days. (Attachment A), Additionally, LCC Orange Park provided 5,330 days of care to residents who were Medicaid eligible but whose care was partially reimbursed under the Medicare program (“dual-eligible”). (Attachment B —- LCC Southeast Division Chart). Including those days of care provided to dual eligible residents results in a total of 36,179 days; which equates to a total of 58.22% of patient days exceeding the requirement, EXHIBIT C Mar 1? 2009 10:43 P,2a/23 856 921 4158 AGENCY HEALTH CARE ADMIN MAR-17?-2889 18:56 Yo grow rth Y Gaus CREP gee'¢ f tht ‘LZ ae, at ira tw thog ran dst gow pony Seq dA 9577 shay aosdsar LA sag anu preippesy € au gE £3 te Tet £6 if 6 3 bad rs] SE ozs clr aoe bet Et a Lid <7 dz 6 ot eg $2 6st S¥T SE. BRST cert TezT OELT iit GooT iil zee a ee or a +e mi Tet wi bhidy aH aang Aint SAMOMMEL OLLNTHd ASYSHLGS $79 garages SAVE Tt SAWO ZOVATYd 70H HOW OOT?TS 1H53 SAMO UEHLD RS GOLITS HD SAW dSOH AVA JS COTTE SA¥O OW Fovd.N FOLITS 4832 SAVO OIVS.M SHS f0fTTe L333 SAVO Ad JHS TOLTIO JTa0 SAYO CT¥3.M AWS 6OcTIa 0 OOH 4O0U GT¥3.0 SWS S0ZTTS (ALALWES SIO Tid JMS GOTT IG WOLLSTHNS30 2002 “TE Jaques ‘SAWO INSTI ALAN SAA a Aid JON Sid SOHHO —— MAR-17?-2889 18:56 Life Care Centers of America Southeast Division CON Medicaid Condition Compliance 2007 A+B Tretiiooal MCD Days pes HCD Hospice Days Mar 1? 2009 10:44 AGENCY HEALTH CARE ADMIN 856 921 4158 i A P.2i/23 [i thachmnt B Mar 1? 2009 10:44 P2e/23 856 921 4158 AGENCY HEALTH CARE ADMIN MAR-1?-2889 18:57 * } ro 3 d Boden HOLYHOGS05 HDISERINE DIO soynNoY uoijenseAg yied ehurlo “pices” jo 491UeD 0189 ON Mar 1? 2009 10:44 AGENCY HEALTH CARE ADMIN 856 921 @158 P.23/23 SCNDER: Conte PTF COMBE thf @ Complete tame 1, 2, in. 4, Also complete item 4 it Resticted Delivery Is desired. © Print your name and address on the reverse 60 that We can return the card ta you. @ Attach this card to the back of the mallplece, or on the front If apace permite. 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Docket for Case No: 09-001384