ceteleiatetmtend ate de sntedactan obit omer - STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2013007722 License No. 9803 ADVANCED REJUVENATION, LLC, d/b/a ; File No. 10350 ADVANCED WELLNESS CENTER, Provider Type: Health ‘Care Clinic Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Admninistration: (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Advanced Rejuvenation, LLC, d/b/a Advanced Wellness Center (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate a health care clinic and to impose an administrative fine of $25,500.00. . PARTIES 1. The Agency is the regulatory authority responsible for the licensure of health care clinics and the enforcement of all applicable statutes and rules governing health care clinics in Florida. Chs. 408, Part IL, and 400, Part X, Florida Statutes; Ch. 59A-33, Fla. Admin. Code. 2. ° The Respondent was issued a license to operate a health care clinic located at 2033 Wood Street, Suite 210, Sarasota, Florida 34237, and was at all times material required to - comply with the applicable statutes and rules governing such licensure. 3. On July 3-9, 2013, the Agency conducted a survey of the Respondent’s Facility. , COUNT I Failure to Display License Certificate 4, Under Florida law, it is unlawful to provide services that require licensure, of operate or maintain a provider that offers or provides services that require licensure, weithout first obtaining from the Agency.a license. authorizing the provision of such services or thes operation or maintenance of such provider. § 408.804(1), Fla, Stat, (2013). A license must be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued. § 408,804(2), Fla. Stat. (2013). . 5. ; Based upon observation and staff interview, the Respondent failed to display its license certificate as required by law. 6. During an observation at 9:45 am. on July 3, 2013, it was revealed that the Respondent’s license certificate was not displayed in the front waiting room where all patients enter the facility or any other conspicuous location within the facility, . 7, A full tour of the Respondent’s facility was conducted at 10:00 a.m. 8. The license certificate was not observed to be posted or displayed throughout the tour of the Respondent’s facility. 9. An interview was conducted with the Respondent’s chiropractor at 11:30am. 10. The chiropractor stated he does not know where the license certificate is located. - 11. . He asked the receptionist, located in the front waiting room area, if she knew where the license certificate was located. She stated she was not able to find it. 12. -Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license,.and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. , 2 L pee | Evecare i ore eee WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administrations _ seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT II Failure to Amend License Application 13, Under Florida law, unless otherwise specified in Chapter 408, Part Il, authorizing statutes, or applicable rules, any information required to be reported to the Agency must.be submitted within 21 calendar days after the report period ot effective date of the information, whichever is eatlier, including, but not limited to, any change of: (a) Information contained in the most recent application for licensure, (b) Required insurance or bonds. § 408.8 10(3), Ha. Stat. (2013), 14, Based upon a review of the Respondent’s license application, staff interview and a teview of Patient # 1’s bill, the Respondent failed to. put on its application or amend its application to reveal the performance of Adipose Stem Cell procedures, ) 15. A review of the Respondent’s application shows it provides services related to cardiology, chiropractic, naturopathy, ultrasound, family medicine and massage therapy. 16. Areview of the bill for Patient #1 dated 7/2/13 showed "Fat Graft for Prp". Fat is medically termed adipose tissue. Fat graft refers to "mini-liposuction." PRP is an. acronym for platelet-rich plasma. 17. The Respondent provided the research protocol for the procedure on the bill. 18. The research trial protocol (ADI-PD-US-001, December 19, 2012) for adipose- derived stem cell for treatment of patients with chronic obstructive pulmonary disease (COPD) was reviewed. Section 3.1 describes extracting adipose tissue, “rinsing, draining, enzymatic digesting and isolating endothelial cells from adipose tissue... The endothelial/stem cells will be _ subsequently...delivered to the patients." This is done by injection. Although not included in the protocol, PRP is used for growth factor to complement the stem cells. 19. An interview-was conducted with the Respondent’s chiropractor on 7/3/13 at 3 terete abe Fev ePar bs BS Pen FO OO OOS . 11:00 am. 20. The chiropractor stated the Facility also provides a procedure called Adipose . t Stem Cell (ASC). The chiropractor stated this procedure is experimental at this time. 21. “He further stated an application was completed and sent to Ageless Regenerative Institute on May 6, 2013 to be part of this study. This information, however, was not sent to the ~ Agency. 22. . In résponse to Agency inquiry, the chiropractor stated that he was not aware of whether the Facility ‘had submitted an addendum to the initial application and serat it to the Agency, . 23. Inresponse to Agency request, the chiroptactor was unable to find any addendum to the most recent application submitted to the Agency. 24. Pursuant to Section 408.813, Florida Statutes (2013), the Agency may impose'an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: (a) Violating any term or condition of a license. ) Violating any provision of this part, authorizing statutes, or applicable rules. ,.. (d) Providing services beyond the scope of the license. § 408.813(3), Fla. Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $500.00 against the Respondent. COUNT Mi N otice of Insurance Fraud Display 25. Section 400.9935(9) Florida Statutes, states in pertinent part: 400.9935 Clinic responsibilities.— ee (9) In addition to the requirements of part II of chapter 408, the clinic shall display a sign-in a conspicuous location within the clinic readily visible to all patients indicating that, pursuant to s. 626.9892, the Department of Financial Services may pay rewards of up to $25,000 to persons providing information leading to the artest and conviction of persons committing crimes investigated by 4 esse sich ae | FOvraranan Fl ROPER FY EOS the Division of Insurance Fraud arising from. violations of s. 440.105, s. 624.15, s, 626.9541, s. 626,989, or s. 817.234. An authorized employee of the Divisiora of Insurance Fraud may make unannounced inspections of a clinic licensed unader this part as necessary to determine whether the clinic is in compliance with ~this subsection. A licensed clinic shall allow full and complete access to the premises to such authorized employee of the division who makes an inspection. to. determine compliance with this subsection. , 26. Based upon observation and staff interview, the Respondent did not post the Division of Insurance Fraud information in a conspicuous place. | . 27. During an observation at 9:45 a.m., on July 3, 2013, it was revealed the sign for the Division of Insurance Fraud was posted in the front massage therapy room. . 28, Aninterview was conducted with the Respondent's chiropractor at 9:50 a.m. 29. The chiropractor stated that most, but not all, of the patients came in the massage _ therapy room. 30. The chiropractor was informed that all of the patients should have access to this | information prior to going into any examination room. 31, The chiropractor stated this posting will be moved to the front waiting room. 32. “The Respondent failed to display the notice of insurance fraud notice in a conspicuous location within the clinic readily visible to all patients. -33, Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT IV Patient’s Right to Report Complaints and Abuse 34. Section 408.810(5)(a)(b), Florida Statutes, states in pertinent part: 408.810 Minimum licensure requirements. — In addition to the, licensure 5 oi aes Sd ee ne requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in omder to obtain and maintain a license. . * oe (5\(a) On ot before the first day services are provided to a client, a licensee nuust _ jnform the client and his or her immediate family or representative, if appropriate, of the right to report: . 1. Complaints. The statewide toll-free telephone number for reporting complaint to the agency must be provided to clients in a manner that is clearly legible and must include the words: “To report a complaint regarding the services -you receive, please call toll-free (phone number).” 2. Abusive, neglectful, or exploitative practices, The statewide toll-free telephone number for the central abuse hotline must be provided to clients in a manner ‘that is clearly legible and must include the words: “To report abuse, neglect, or exploitation, please call toll-free (phone number).” 3. Medicaid fraud, An agency-written description of Medicaid fraud and the statewide toll-free telephone number for the central Medicaid fraud hotline naust be provided to clients in a manner that is clearly legible and must include the words: “To report suspected Medicaid fraud, please call toll-free @hone number).” . The agency shall publish a minimum of a 90-day advance notice of a change in the toll-free telephone numbers. . (b) Each licensee shall establish appropriate policies and procedures for " providing such notice to clients. 35. Based upon observation, patient record review, and staff interview, the facility ' failed to provide 3 of 3 patients with the statewide toll-free telephone number to report complaints concerning their services and the abuse, neglect, exploitation (ANE) toll-free number. ; 36. facility. 37. At 9:45 am, on 7/3/13, observation was conducted jn the waiting room of the There was no information for patients concerning the toll-free numbers of the complaint department of the Agency for Health Care Administration (AHCA) or-for the toll-free number for ANE reporting. 38.: 39, 40. 41. A full tour of the facility was conducted at 10:00 a.m. “ Observation showed this information was not posted throughout the facility, Three patient records were reviewed. There was no documentation in the patient files showing they are given written 6 information concerning the toll-free numbers of these 2 agencies. 42. Aninterview was conducted with the chiropractor on 1 13 at 9:50 am, 43. He confirmed this information is not posted in the facility. . 44, He stated he was not aware of this requirement. 45. He does: not know if this information is. given to each patient as a- reading material. 46. The facility is required to provide this information to all patients. 47. Pursuant to Section 400.995(1), Florida Statates, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, | . seeks to impose an administrative fine of $5,000.00 against the Respondent. 4 COUNTY | , Clinic Responsibilities — Office Surgery 48. Section 400.9935(1)(); Florida Statutes, states in pertinent part: 400.9935 Clinic responsibilities. — ; (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to ‘accept legal, responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: 4 (f) Ensure compliance with the recordkeeping, office surgery, and adverse : incident reporting requirements of chapter 456, the respective practice acts, and 4 rules adopted under this part and past II of chapter 408. . 49, Florida Administrative Code Rule §9A-33.012(5)(m) states in pertinent part: (5) To facilitate a licensure survey, the health care clinic shall have the following ; . 59A-33.012 Survey Requirements and Process. a materials readily available for review at the time of the survey: i (ec) Any policies, procedures, guidelines, checklists that demonstrate corapliance a with the medical records retention, disposition, reproduction, and disclosure requirements of the medical or clinic director’s practice act. 7 aL etttaladint ptt des bon sel 50. Based upon interviews with family and staff, review of patierat ‘records, emergency medical service (EMS) report, and clinic policies, the Respondent’s facility failed to follow its policies for 1 of 3 patients sampled (Patient #1) who died during a proceedure at the health care clinic. 51. The facility's medical director failed to report-the adverse incident as required by “facility policy and Section 459,026, Florida Statutes. 52. The facility's medical director failed to maintain treatment records as required by Section 459.015, Florida Statutes. 53. The facility’s medical director failed to follow the clinic policy for maintaining an emergency “crash kit.” 54. The facility’s medical director failed to ensure compliance with incident reporting, recordkeeping, and office safety policies and requirements. 55. A review of the Sarasota County Fire Depariment report dated 6AT/3 showed that it was called to the Respondent's facility that day. . 56. The reason for the call was because a patient had a seizure. 57, ‘When EMS arrived at the Respondent’s facility, the office staff told them that EMS was canceled and not needed. . 58: . The EMS team continued with its call to make patient contact. 59. Once the team was able to make patient contact, it received information from the physician about the procedure performed on Patient #1. .60. | The EMS team asked Patient #1 if she wanted to be transported to the hospital. 61. She declined, but wanted to use the bathroom. 62. She was helped to the bathroom by one of the EMS team and an office staff, 63. Once Patient #1 finished using the bathroom the patient lost consciousness, 64, Patient #1 had agonal respirations (abnormal breathing by gasping and labored : 8 [Pores A ett tla aldara ee aden Hee oa, breaths). 65. The EMS team had a difficult time assessing her carotid pulse (located in her neck), 66. Patient #1 was placed on a stretcher and additional EMS staff was callecd. 67. Patient #1 did not have a pulse and CPR (cardio-pulmonary resuscitation) was initiated. 68, Patient #1 was placed on the paddles revealing PEA (pulseless electrical activity). . 69. This information showed that the Patient had no pulse, 70. The Patient had a difficult intravenous (IV) access so an intraosseons (10) infusion was established. 71. . This is the process of injecting directly into the marrow of a bone to provide a non-collapsible entry point into the systemic venous system. 72. 10 technique is used in emergency situations to provide fluids and medication when IV access is not available or not feasible. . . 73. Patient #1 was then intubated (putting a breathing tube down the patient's throat). 74. CPR was continued and the Patient remained PEA (pulseless electrical activity) throughout the entire episode. 75. The EMS team asked the Patient’s husband if he wanted it to continue CPR. 76. The husband requested the EMS team to stop resuscitation efforts. 77. The EMS team stopped CPR. ‘ 78. Patient #1 was removed from the stretcher to a bed in a front room and covered. 79. The EMS tea left the facility when police arrived. 80. A telephone interview was conducted with Patient #1's husband on 7/2/13 at 4:30 p.m. . 81, He stated on 6/17/13 the medical director and chiropractor were performing a 9 86. 87, “88, 89, 90, 91. 92. 93. 94, 65 96. 97. 98. not. 100, 101. 102. wth Wit te eth Ldn ee met tlonil a. 82, 83. 84. 85. liposuction procedure on his wife (Patient #1), She had stage-4 emphysema and COPD (chronic obstructive pulmonary disease). ’ This procedure was supposed to prolong her life and was a last effort to save her. He knew this was an experimental procedure, He was told by one of the doctors there is a trial of 100 people a and hiss wife was the second patient to go through this procedure. ’ The husband was in the room watching during both steps of the procedure, His wife was awake throughout the procedure, The medical director took fat and blood’ out of his wife's abdomen, He and his wife then went to lunch. About an hour and a half later they carne back to the clinic. Both doctors were performing the next step of the procedure. They put the stem cells (from the abdomen) back in her ankle, During this stop his wife started to pass out. He requested. the doctors to call 911, and they both declined. They told him this was normal for her to pass out. The husband called 911 anyway. When EMS attived, the chiropractor pulled the line out of the ankle and took the stem ncells into another room, The husband said both of the doctors told the EMS staff to leave, but they would His wife did decline going to the hospital but wanted help to go to the bathroom. Once she went to the bathroom, she passed out and never revived. She died at the clinic. On 7/3/13, the 6/17/13 procedure records for Patient #1's procedure were 10 velba. vel Ae die elie a satees hee ed requested. 103. The record that was provided to the Agency indicated that the Patient 3eceived an injection to the left shoulder. . 104. The documentation also noted the Patient was released. 105. The note was signed by the medical director. ) 106. On 7/9/13, the facility provided a revised note with the shoulder injection section marked as error and initialed, 107. . The facility provided a typed recollection of the events of the day concerning (Patient #1) by the medical director but was unsigned. : 108. The facility's policy Section 1.2 Emergency Crash Kit was reviewed, 109. The policy indicates that it was the policy of the Respondent to have an emergency crash kit available at all times. The contents of the crash kit were listed, 110. During the tour of the facility on 7/3/13 no emergency crash kit was observed.. 111. An interview was conducted on 7/12/13 at 12:10 p.m. with the medical director. 112. He confirmed that there was no crash kit or emergency supplies at the clinic. 113. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Pait Il of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose an administrative fine of $5,000.00 against the Respondent, COUNT YI Clinic Responsibilities - Adverse Incidents 114. Section 400.9935(1)(f), Florida Statutes, states in pertinent part: 400.9935 Clinic responsibilities. — (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of 11 J sprucccastnantale the clinic. The medical director or the clinic director shall: (f) Ensure compliance with the recordkeeping, office surgery, and adverse incident reporting requirements of chapter 456, the respective practice acts, and rules adopted under this part and part II of chapter 408. - 115. Florida Administrative Code Rule 59A-33.012(5)(m) states in pertinemt part: 59A-33.012 Survey Requirements and Process. , (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: (g) Any policies, procedures, guidelines, checklists that demonstrate compliance _ With adverse incident reporting requirements and injury disclosure. 116. A review of the Respondent facility's policy for adverse incidents was conducted on 7/3/13. 117. The policy shows one of the reportable situations is death. 118. Death is automatically defined as an adverse incident that must be reported on the 1-Day Adverse Incident Report to the Agency within one business day of the occurrence of the incident, ) . ; 119. A blank Adverse Incident Report form (# DH-MQA 1030-12/06) was included with the facility's policy. 120. An interview was conducted with the chiropractor on 7/3/13 at 11:00 a.m. ; 121.. He stated an adverse incident report was not completed for anything since they were licensed by the Agency for Health Care Administration in May 2013. 122. A review of Patient #1's medical record showed she had a procedure performed on 6/17/13. 123. The bill showed it was a fat graft for Prp. 124. There was no documentation in the Patient's record she had died during this procedure. 125. An interview was conducted with the chiropractor on 7/3/13 at 1:15 p.m 12 alate amined edad wtedbywwee a 126. He stated the Patient did well with this procedure. 127. He was told a report to our Agency showed the Patient had in fact died. 128. He confirmed that he lied. 129. He was asked if an adverse incident report was completed on Patient #1, 130, He stated he did not do one and was unable to find any documentation of an adverse incident on Patient #1. 131. When the policy for adverse incidents was reviewed with the chiropractor he said an adverse incident should have been done because the Patient died. 132, On 7/9/13 at 2:30 p.m., the Agency conducted another visit to the Respondent's facility. 133. | The chiropractor was again asked if the facility had completed an adverse incident report. | . 134, He stated that it had been completed, 135. A review of the adverse incident report showed it was completed on an "Advanced Rejuvenation, LLC Incident Report" form. 136. ' Itis not the form to be used according to their policy and procedure. 137. | The chiropractor was asked if this report was sent to the Department of Health (DOR) and he stated it was not sent to the DOH. 138. An interview was conducted on 7/12/13 at 12:10 p.m. with the medical director, who was the other doctor performing this procedure for Patient #1. 139. He stated.an adverse incident report was not completed for this Patient for the incident on 6/17/13. - 140. He stated it was a tragic incident. 141. He was asked if the Patient had died of natural causes, 142. He stated the medical examiner would determine that, but that Patient #1 was so 13 pear wtb tibb ut cnbelbe oe tolnne compromised prior to this procedure by having COrD and stage 4 emphysema. 143, Since Patient #1 died during this ASC procedure and the physician had not conducted any type of investigation as to ‘why she died at that time, an adverse inciGent report was required and was not completed. 144, The medical director signed the death certificate. ‘145. The Sarasota Police Department made an incident report for the death. of Patient #1 on 6/17/13. 146. The Police Department's incident report concluded the Medical Examiner's Office would not respond and would accept the death certificate from the medical director. 147, The Respondent failed to demonstrate that it was in compliance with its policy for adverse incident recording. 148, Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewel, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner; State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT Vit License Revocation 149. The Agency te-alleges and incorporates by reference Counts I through VI as set forth above. 150. Pursuant to Section 408.815(1)(b)-(c), Florida Statutes, in addition to the ‘grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: ....(b) An intentional or negligent act materially affecting the health or safety of a client of the provider. (c) A violation of this part, authorizing statutes, or applicable , 14 151. Pursuant to Section 400.995(1), Florida Statutes, in addition to the te=quirements “of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation fox violations of the requirements of this part or rules of the Agency. ) . 152, The Respondent’s actions or inactions constituted a violation of Chapter 408, Part II, the authorizing statutes and the applicable rules. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to revoke the Respondent’s license to operate this facility. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration;. respectfully seeks a final order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. - Respectfully submitted on this BO'fey of July, 2013, : oN. al Andrea M. Lang, Senior Attorney Florida Bar No. 364568 Office of the General Counsel ; Agency for Health Care Administration . 2295 Victoria Avenue, Third Floor 4 , Ft. Myers, Florida 33901 4 ; : Telephone: (239) 335-1252 Facsimile: (239) 338-2699 tea date 1 0 bathe tac asdLane 4 menete lL ns 15 pian 0s Thai taalan tac sanolacdt TICE The Respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, and to be represented by its own counsel or qualified representative. Specific options for the administrative action are set -out in the attached Election of Rights form. : The Respondent i is further notified that if the Election of Rights form is not réceived by the Agency Clerk’ Office within twenty-one (21) days of the receipt of this Admanistrative Complaint, a Final Order will be entered. ; The Election of Rights form shall be delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308-5407; Telephone (850) 412-3630. _ CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served to the below named persons or entities on this the 20 aay of July, 2013. Choe ‘Andrea M. Lang, Senior Attorney Florida Bar No, 364568 Office of the General Counsel Agency for Health Care Administration 2295 Victoria Avenue, Third Floor Ft. Myers, Florida 33901 Telephone: (239) 335-1252 - ’ Facsimile: (239) 338-2699 Mark G. Kantzler, Medical Director Thomas Jones, Unit Manager Advanced Wellness Center Health Care Clinic Unit 2033 Wood Street, Suite 210 Agency for Health Care Administration Sarasota, Florida 34237 (Electronic Mail) (Certified Mail 7011 1570 0002 1695 8955) 16 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: . Advanced Rejuvenation, LLC AHCA No. 2013007722 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency- for Health - Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of - Intent to Impose a Late Fine or Administrative Complaint, Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AILCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 ~ Facsimile: 850-921-0158 PLEASE SE T ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing, I - understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. ‘! OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120,57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings, PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be , received by the Agency Clerk at the address above within 21 days of your receipt of this 17 lec onside ti wiod dain tabi, We proposed agency action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified reptesentative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4, A statement of when the respondent received notice-of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida ‘Statutes, may be available in this matter if the Agency agrees. Licensee Name: _ Contact Person: . : : Title: Address: : : _- Number and Street City Zip Code Telephone No. ; a Fax No. E-Mail (Optional) I hereby certify. that I ain duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. 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Docket for Case No: 13-003183