STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, IE O02/ vs. : Case No. 2010011630 Petitioner, RENITA E. IVEY, 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 Renita EB. Ivey (hereinafter Respondent), pursuant to Section 120.569 and 120.57, Florida Statutes (2010), and alleges: | NATURE OF THE ACTION . This is an action to revoke the Respondent's license to operate an adult family care home (hereinafter also referred to as “AFCH”) pursuant to § 408.815, Florida Statutes (2010) and to impose an administrative fine in the sum of five hundred dollars ($500.00) pursuant to §429.71(1), Florida Statutes (2010). JURISDICTION AND VENUE “1. - The Agency has jurisdiction pursuant to §§.20.42, 120.60, Florida Statutes (2010) and Chapters 408, Part IT, and 429, Part I, Florida Statutes (2010). 2. Venue lies pursuant to Fla, Admin, Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of adult family care homes and enforcement of all applicable state statutes and rules governing adult family care homes pursuant to the Chapters. 408, Part II, 429, Part II, Florida Statutes (2010), and Chapter 58A-14 Florida Administrative Code. . 4. Respondent operates a five (5) bed adult family care home located at 526 A Avenue, Live Oak, Florida 32064, and is licensed as an adult family care home, license number 6905408. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. ’ COUNTI . 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That under Florida law, an adult family-care home provider is responsible for: 1. The operation and maintenance of the AFCH in accordance with Part VII of Chapter 400, F.S. (now Chapter 429, Part I), and this rule chapter. Rule 58A-14.008(2)(b)1, Florida Administrative Code. 8. That from October-1, 2010 through October 12, 2010, the Agency conducted a complaint investigation (CCR# 2010010243) of the Respondent's facility. _ 9, That based on record review and interview, the facility failed to operate the Adult Family Care Home (AFCH) in accordance to the rules and regulations by falsifying the facility’ 's records and intentionally conducting the negligent act of misleading a Skilled Nursing Facility (SNF) ' into believing that a discharged resident (Resident #2) would be living in her AFCH. This negligent act resulted in the resident being left unsupervised which also resulted in the resident's death. 10. That an interview was conducted on 09/30/10 at 10:48 AM with an Investigator from the Attorney General's Office. According to the investigator, he had visited Renita Ivey's Adult Family Care Home (AFCH) and. found her to have seven residents residing in-the AFCH. Further interview with the Investigator revealed that all seven residents are assisted with their 2 medications. 11, That during the interview with the Provider on 10/1/10 at 9:10 AM, she stated that Resident #2 knew that he/she was not going to live in the licensed home before he/she was discharged from the nursing home. Continued interview revealed that the resident was a family member and she had not received any money for rent from the resident. 12. That a review of the social services records at the SNF revealed that the Social Services (SS) Director documented information regarding the planning of Resident #2's discharge. Entries in the notes reveal that the SS Director spoke directly with Mrs. Ivey on two occasions, Review of the SNF's "Release of Responsibility For Leave of Absence", form revealed that on 09/13/10 the Provider signed it indicating that Resident #2 was going to "Ivey AFCH (Renita)". 13.° That an interview on 10/6/10 at 3:00 PM with the Social Services Assistant revealed that’ he also spoke to Mrs. Ivey regarding the resident's discharge. The Social Service Assistant stated that he was under the impression, left by Mrs. Ivey, that the resident would be staying in the licensed home. The Social Service Assistant also revealed that he was unaware of other homes that may have housed tesidents. 14. That an interview, conducted with the Provider on 10/11/10 at 3:37 PM revealed Resident #2 had all of his/her records from the SNF with him/her and they were not in the facility. The Provider further admitted that she did contact the SNF to make arrangements to take Resident #2 out of the SNE, but the resident knew he/she would not be living at the AFCH. 15, That an interview conducted with the Provider on 10/12/10 at 11:37 AM revealed that on the day Resident #2 was discharged from the SNF, her husband picked the resident up from the facility. Further interview revealed that later on that evening, she received a cali from the SNF informing her that no one had signed the "Release of Responsibility For Leave of Absence," form. According to the Provider, on that day, at around 8:30 PM, she personally went to the facility and signed the document. According to the provider, she looked for Resident #2's 3° missing record, but she could not find it amongst the resident's belongings. 16. That an interview with the Director of Social Services on 10/12/10 at 12:55 PM confirmed that one of the signatures on the release form belonged to the Provider and the other to the facility staff. 17. That a review of the ABC 27 news website revealed that Resident #2 was struck by a train on 9/25/10 at 1:41 AM. 18. Class I violations are those conditions or practices related to the operation and maintenance of an adult family-care home or to the care of residents which the agency determines present an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional hari would result therefrom. The © condition or practice that constitutes a class I violation must be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required -for correction, A class I . deficiency is subject to an administrative fine in an amount not less than $500 and not exceeding $1,000 for each violation, A fine may be levied notwithstanding the correction of the deficiency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an adult family-care home in the State of Florida, pursuant to § 429,71(1)(a), Florida Statutes (2010). COUNT II 19. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 20. The Agency re-alleges and incorporates Count I of this administrative complaint as if fully set forth herein. That under Florida law, the Agency may deny or revoke the license of an AFCH operator based upon the facility’s (a) intentional or negligent act materially affecting the health or safety of a resident of the facility or (b) a violation of the facility’s authorizing statutes 4 or applicable rules, in this particular instance, Chapter 429, Part II, Florida Statutes (2010), and Chapter 58A-14, Florida Administrative Code, respectively, or (c) a. violation of ‘this part, authorizing statutes, or applicable rules. § 408.815 Florida Statutes (2010). 21. That under Florida law, when a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s, 408.814 and a fine of $1,000 per day, uniess otherwise specified by authorizing statutes, against each licensec until such time as the appropriate license is obtained for the unlicensed operation. §408.812(5), Florida Statutes (2010). 22. That on October 1, 2010, the Agency conducted a complaint investigation (CCR# . 2010010244) of the Respondent's facility. 23. That based on interview and record review, the provider was operating an unlicensed Assisted Living Facility by caring for two individuals at a home other than her licensed Adult Family Care Home (AFCH), 24, During the complaint survey an interview was conducted on 10/01/10 at 8:30 AM with the provider at the Adult Family Care Home. The Provider indicated that she was caring for a resident who did not live at the licensed location. 25. That an interview with owner Mrs. Renita Ivey and her husband, disclosed that the resident was being housed at the home located across the street from the licensed AFCH. 26, That a further interview revealed that another individual had been discharged from a licensed Skilled Nursing Facility (SNF), under the provider's licensed home, but this resident . also had been living across the street. 27, That Resident #1 and Resident #2 were reported to be living in the home occupied by the provider's husband at 504 A Avenue, ‘Live Oak, Florida. According to the Provider's husband, Resident #2 was a relative and resided with him across the street. 5 28. That a review of Resident #2's SNF record revealed that the resident requested to be discharged to this provider's AFCH. According to the resident's record, all of the paperwork had been faxed to the provider, 29. That a further review of the resident's record revealed that on 09/16/10, the provider contacted Social Services and requested additional paperwork, which the facility faxed to the AFCH. 30. That an interview with the SNF's Social Worker on 10/5/10 at 3:30 PM revealed he thought the resident was going to the Provider's licensed home, as hé was unaware of any other. address for the provider. 31. _ That Respondent has violated the minimum requirements of law of Chapters 408, Part II, 429, Part Il, and Chapter 58A-14, Florida. Administrative Code as described with particularity within this complaint. 32, That Respondent has a duty.to maintain. its operations in accord with the minimum requirements of law and to provide cate and services al mandated minimum standards. — 33, That Respondent has violated the provision of Chapter 429, Part II, Florida Statutes (2010), and Chapter 58A-14, Florida Administrative Code, 34. That the above reflect grounds for which the Agency may revoke Respondent’s licensure to operate an adult family-care home in the State of Florida. 35. That based thereon, individually and collectively, the Agency seeks the revocation of the Respondent’s licensure. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an adult family-care home in the State of Florida, pursuant to §§ 408.815, Florida Statutes (2010). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I and IT; (B) Recommend an administrative fine against Respondent in the total amount of $500; (C) Revoke Respondent’s license # 6905 408 to operate an adult family care home; (D) Assess attorney’s fees and costs; and . | ) (E) Grant all other general and equitable relief allowed by law. Respondent is 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive; MS #3, Tallahassee, Florida 32308, (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. Respectfully submitted this day of December, 2010. Carlton Enfinger Fla. Bar.0793450 Agency for Health Caté Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.412.3630 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7001 0360 0003 3808 3505 to. Facility Administrator and Owner Renita E. Ivey, 526 A Avenue, Live Oak, Florida 32064 on December A, 2010: Copy furnished to: Kris Mennella, FOM Scivi CE D MAIL RECEIPT -Momestic fai! Only; No. insura NeO..Cove Retum Reco) Restricted Delivery (Endorsement Rocurea) Total Postape & Fees etree m SENDER: COMPLETE Tis SECTION PCTION ON DEL @ Complete items 4, 2, and 3, Also complete item 4 if Restricted Delivery Is desired. © Agent ™ Print your name and address on the reverse Ad, Z evict Addressee _|' 80 that we can return the card to you. ted Date of Delivery ® Attach this card to the back of the mailplace, ~ or on the front If space permits, 1. Articla Addressed to: - D. Is delivery address different from tem 1? LJ Yea if YES, enter delivery address below: C1] No Rewhe TE . Ve. S2q A Aceug’ 8. Sepite Type aX: 20 Uf Certined Mall a Express Malt f . Q 6K ©) Registered . 1 Foturn Receipt for Merchandiee f ee \ FSA f Ol insured Mall =O G.0.0. 4. Restricted Delivery? (Extra Fea) 0 Yes 7003 0360 0003 3808 3505 PS Form 3811, February 2004 Domestic Return Recelpt a . 00°00C' OLS HBAQ: z Bsuvrioa \ ooroos $ oF oz sequieced gquds ON PUL SIBHOG PeUPUNE OAL “ C91 100102 # ASYO.. 3O HICNO wNOLLWELSININGVss BHL auvo Hal HO5 AONIOV WOOT JO SLV1S = _OL AV ‘ ee DWEQOIHOHINOS aN HOSY waLuwae

Docket for Case No: 11-000021