STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case No. 2012002559 TRINITY ASSISTED LIVING FACILITY, CORP., d/b/a TRINITY ASSISTED LIVING FACILITY, Respondent. / ADMINISTRATIVE COMPLAINT , COMES NOW the Agency for Health Care Administration (the * wagency”) and files this administrative complaint against Trinity Assisted Living Facility, Corp., d/b/a Trinity Assisted Living Facility (the “Respondent” or “Respondent Facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION Pursuant to Chapters 408 and 429, Florida Statutes, this is an action to impose an administrative fine in the amount of one \ thousand dollars ($1,000.00), based upon two (2) State class IIT deficiencies, JURISDICTION AND VENUE i. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429.07, Florida Statutes. : 2. Venue lies pursuant to Florida Administrative Code R. Page 1 of 12 Filed September 6, 2012 12:24 PM Division of Administrative Hearings 28-106.207. PARTIES 3. The Agency licenses assisted living facilities in Florida and enforces all applicable state statutes and rules governing assisted living facilities, pursuant to Chapters 408, Part If, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4, Respondent operates an eight (8) bed assisted living | facility located at 6015 N Himes Avenue, Tampa, Florida 33614, License number 10742. 5. At all times material to the allegations of this administrative complaint, the Respondent was required to comply with all applicable rules and statutes. COUNT I A008i 6. The Agency re-alleges and incorporates above paragraphs one (1) through five (5), as if fully set forth in this count. 7. Rule 58A-5,0191(2), Florida Administrative Code, requires: (2) STAFF IN-SERVICE TRAINING. Facility administrators or managers shall provide or arrange for the following in- service training to facility staff: (b) Staff who provide direct care to residents must receive \ a minimum of 1 hour in-service training within 30 days of i employment that covers the following subjects: Pe 1. Reporting major incidents. 2. Reporting adverse incidents. Page 2 of 12 3. Facility emergency procedures including chain-of~command and staff roles relating to emergency evacuation. (c) Staff who provide direct care to residents, who have not taken the core training program, shall receive a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1. Resident rights in an assisted living facility. 2..Recognizing and reporting resident abuse, neglect, and exploitation. (d) Staff who provide direct care to residents, other than nurses, CNAs, or home health aides trained in accordance with Rule 59A-8.0095, F.A.C., must receive 3 hours of in~ service training within 30 days of employment that covers the following subjects: : 1. Resident behavior and needs. 2. Providing assistance with the activities of daily living. (f) All facility staff shall receive in-service training regarding the facility’s resident elopement response policies and procedures within thirty (30) days of employment. 1. All facility staff shall be provided with a copy of the facility’s resident elopement response policies and procedures. 2. All facility staff shall demonstrate an understanding “and competency in the implementation of the elopement response policies and procedures. 8. Rule 58A-5.024, Florida Administrative Code, requires: (2) STAFF. RECORDS. (a) Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition, records shall contain the following, as applicable: 1. Documentation of compliance with all staff training required by Rule 58A-5.0191, F.A.C.; (4) RECORD INSPECTION. (a) All records required by this rule chapter shall be available for inspection at all times by staff of ‘the agency, the department, the district long-term care ombudsman council, and the advocacy center for persons with disabilities. Page 3 of 12 we 9. The Agency conducted a biennial relicensing survey of Respondent on September 7, 2011. 10. Based on the Agency’s surveyor’s review of Respondent’s records and interviews, the Agency determined that one (1) of three (3). of Respondent’s direct care staff, who had — been employed at least 30 days, had not received all required training. 11. The Agency’s surveyor’s review of Respondent's personnel files during the September 7, 2011, Agency survey found that Staff #4, who was hired in July of 2009, did not have any documentation verifying that she had received any formal | training in the following areas: 10 a. resident elopement prevention and response; 10 b. emergency procedures, evacuation protocol and major and adverse incident reporting; 10 c. resident rights; and 10 d. recognizing and reporting resident abuse, neglect and exploitation. 12. In an interview with Respondent’s administrator at 12:10 p.m. on September 7, 2011, the administrator verified that ‘the above information was missing from the personnel record of Staff #4 who is a direct care member of Respondent's staff and who had not taken the core training program. Page 4 of 12 en eee ad 13. The Agency determined that the Respondent engaged in the deficient practice of failing to have documentation of completion of required training for. each member of Respondent’s staff who provided direct care to residents. The Agency determined that this deficient practice was related to the personal care of Respondent’s residents and indirectly or potentially threatened the health, safety, or security of the residents. 14. The Agency cited Respondent for a State class III deficiency. 15. ‘The Agency provided Respondent with a mandatory correction date of October 10, 2011. 16. On October 13, 2011, the Agency conducted a revisit survey at the Respondent's facility. 17. Based on the Agency’s surveyor’s review of Respondent’s records and interviews, the Agency determined that the Respondent still failed to have documentation that each member of Respondent’s staff providing direct care to residents had completed all required training. Specifically, Respondent lacked documentation of required training for one (1), Staff #6, of six (6) employees whose records were reviewed by the Agency's surveyor. 18. The Agency’s surveyor observed Staff #6 working in the facility assisting with resident care. Page 5 of 12 19, On 10/13/2011 at 10:00 a.m., the Agency surveyor conducted an interview with Respondent’s administrator. 20. During the interview with Respondent’s administrator, the Agency’s surveyor requested to review Respondent’s record of Staff #6’s in-service trainings, as is required for staff who _ provide direct care to residents. 21. Respondent’s administrator told the Agency’s surveyor that Staff #6 is a relative and works part time at the two facilities owned by the company. Respondent’s administrator was unable to provide any documentation that Staff #6 had received -any of the required trainings for direct care staff. 22. The Agency determined that the Respondent has once more engaged in the deficient practice of failing to have documentation of completion of required training for each member of Respondent's staff who provided direct care to residents. The Agency determined that this deficient practice was related to the personal care of Respondent’s residents and indirectly or potentially threatened the health, safety, or security of the residents. 23. The violation cited by the Agency’s surveyor on September 7, 2011, being again cited by the Agency’s surveyor on October 13, 2011, the Agency cited Respondent for an uncorrected State class III deficiency. WHEREFORE, the Agency intends to impose an administrative Page 6 of 12 fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Sections 408.813 and 429.19, Florida Statutes. COUNT II 0161 24. The Agency re-alleges and incorporates above paragraphs one (1) through five (5), as if fully set forth in this count. 25, Rule 58A-5.019, Florida Administrative Code, requires: (2) STAFF. (a) Newly hired staff shall have 30 days to submit a statement from a health care provider, based on an examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis, Freedom from tuberculosis must be documented on an annual basis. A person with a positive tuberculosis test must submit a health care provider’s statement that the person does not constitute a risk of communicating tuberculosis. Newly hired staff does not include an employee transferring from one facility to another that is under the same management or ownership, without a break in service. If any staff member is later found to have, or is suspected of having, a communicable disease, he/she shall be removed from duties until the administrator determines that. such condition no longer exists. (3) BACKGROUND SCREENING. (a) All staff, who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S., and meet the screening standards of Section 435.03, FS. 26. Rule 58A-5.024, Florida Administrative Code, requires: (2) STAFF RECORDS. (a) Personnel records for each staff member shall contain, at a minimum, a copy of the original Page 7 of 12 employment application with references furnished and verification of freedom from communicable disease including tuberculosis. ... (4) RECORD INSPECTION. ; (a) All records required by this rule chapter shall be available for inspection at all times by staff of the agency, the department, the district long-term care ombudsman council, and the advocacy center for persons with disabilities. 27. The Agency conducted a biennial relicensing survey of Respondent on September 7, 2011. 28. Based on the Agency’s surveyor’s review of Respondent’s records and interviews, two (2) of four (4) of Respondent's staff whose records were reviewed did not have verification they were free from communicable disease including tuberculosis (TB), while one (1) member of Respondent's staff did not have documentation of background screening. 29. The Agency's surveyor’s review of Respondent’ s employees’ personnel files during the September 7, 2011, Agency survey revealed that neither Staff #3, who was hired in duly of. 2011, nor Staff #4, who was hired in July of 2009, had a ‘statement from a health care provider attesting to their freedom from communicable disease including TB. In addition, no background screening report could be found for Staff #4, neither Level 1 nor Level 2 background screening. 30. In an interview with Respondent's administrator at 1:10 p.m. on September 7, 2011, the administrator verified to Page 8 of 12 the Agency’s surveyor that the above identified health assessments and background screening check were missing from the employees’ files. 31.’ The Agency determined that the Réspondent engaged in the deficient practice of failing to have documentation of each staff member’s meeting minimum health and background screening requirements for working in an assisted living facility. The Agency determined that this deficient practice was related to the personal care of Respondent’s residents and indirectly or potentially threatened the health, safety, or security of the residents. 32. The Agency cited Respondent for a State class IIT deficiency. ; 33. The Agency provided Respondent with a mandatory correction date of October 10, 2011. — 34. On October 13, 2011, the Agency conducted a revisit. survey at: the Respondent’s facility. 35. Based on the Agency’s surveyor’s observations and interviews, the Agency determined that the facility again failed to maintain personnel records documenting compliance with background screening and verification of freedom from communicable disease and tuberculosis for each employee. Page 9 of 12 we we 36. On October 13, 2011, the Agency’s surveyor had observed Staff #6 working in the facility assisting with resident care. 37, On 10/13/2011 at approximately 10:00 a.m., the Agency’s surveyor conducted an interview with Respondent’ s administrator and requested to review Staff #6’s personnel record. Respondent’s administrator told the Agency’s surveyor that Staff #6 is a relative and works part time at the two facilities owned by the company.” 38. Respondent’s administrator was unable to provide any personnel record for Staff #6, including documentation of an employment application, background screening, or verification from a health care’ provider that Staff #6 was free of communicable disease and tuberculosis. 39, The Agency determined that the Respondent had again been found to have engaged in the deficient practice of failing to have documentation of each staff member’s meeting minimum health and background screening requirements for working in an assisted living facility. . The Agency determined that this deficient practice was related to the personal care of Respondent’s residents and indirectly or potentially: threatened the health, safety, or security of the residents. 40. The deficiency identified during the Agency’s September 7, 2011, survey being again identified during the Page 10 of 12 Tampa, FL 33614, on May Agency's next survey of October 13, 2011, the Agency cited Respondent for an uncorrected State class III deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Sections 408.813 and 429.19, Florida Statutes. NOTICE OF RIGHTS 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, | JYallahassee, FL 32308, whose telephone number is 850-412-3630, RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS Of RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7003 1010 0001 3600 4156 to Diana M. Torres, Administrator/ Registered Agent, for Trinity Assisted Living Facility, Corp. d/b/a Trinity Assisted Living Facility, 6015 N. Himes Avenue, A&spistant General Counsel Fla. Bar. No. 817775 Page 11 of 12 H Agency for Health Care Administration 525 Mirror Lake Drive, 330D 4 St. Petersburg, Florida 33701 j : 727-552-1944 (office) | 727-552-1440 (facsimile) Copies furnished to: Patricia Caufman, Field Office Manager - Area 5 Page 12 of 12 USPS.com® - Track & Confirm Engtish Gustomer Service USPS Htobite #ZUSPS.COM Quick Taal Ship a Package Send Mail Track & Confirm CETEWAILUPDATES PRINT DETAILG YOUR LABEL NUMBER SRRVIOR STATUS OF YOUR ITEM 700310100001 36004156 Dellvered > Antival at Unit Processed through * UBPS Sort Factity : Check on Another item ; What's your label (or receipt) number? ‘ Find i LEGAL . ON USPS.COM Privacy Polley > Goverment Services » Toms of Use > Buy Stamps & Shop » FOIAy . 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Docket for Case No: 12-002911