wie STATEOFFLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ‘ . : Case Nos. 2013005247 - vs. 0 . 2013005259 THE HARMONY HOUSE AT OCALA, LLC d/b/a THE HARMONY HOUSE AT OCALA, Respondent. ADMINISTRATIVE COMPLAINT The State of Florida Agency for Health Care Administration (hereinafter “Petitioner” or “Agency”), by and through undersigned counsel, files this Administrative Complaint against The Harmony House at Ocala, LLC d/b/a The Harmony House at - Ocala (hereinafter “Respondent”, pursuant to Section § 120.569 and Section § 120.57, Fla. Stat. (2012), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $9,000.00 based . upon FOUR State Class II deficiencies pursuant to Section § 429.19(2)(b), Florida Statutes (2012). JURISDICTION AND VENUE: 1. The Agency has jurisdiction pursuant to Section § 20.42, Section § 120.60 and Chapters 408; Part H, and 429, Part I, Fla. Stat. (2012). 2. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Patt II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. | 4, The Respondent operates a 54-bed assisted. living facility (“ALF” or “facility”) located at 5762 Southwest 6" Avenue, Ocala, FI: 34474, and is licensed as an ALF, license number 5828, 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. COUNT I- tag 0025 6. The Agency re-alleges and incorporates paragraphs (1) through (5) above as if fully set forth herein. 7: | Pursuant to Florida law:- Resident Care Standards. An assisted living facility shall provide care and fall appropriate to the needs of residents accepted for admission to the 1) SUPERVISION. Facilities shall offer personal supervision, a as appropriate for each resident, including the following: a) Monitor the quantity and quality of resident diéts in accordance with Rule 58A-5,020, F.A.C. b) _— Daily observation by designated staff of the activities of the ’ resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. C) General awareness of the resident’s whereabouts, The resident __-..__._.__._may. travel independently in the community. ect conninace em wnt d) —_ Contacting the resident's health care provider and other appropriate patty such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which _ resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. Fla, Admin. R. 58A-5.0182 EE Resident bill of rights. _ (1). No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: ~~ a) Live in a safe and decent living environment, free from abuse 4 and neglect. b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Section § 429.28, Fla. Stat. (2012) ! 8. On January 8, 2013, the Agency conducted complaint investigation CCR# 2013000159 and found the facility out of compliance with the Rule and Statute set forth above, Based on record review and interviews, the facility did not provide appropriate supervision to prevent falls, Findings included: . Resident #4 . During an interview with DCF on the date of the survey, the DCE _tepresentative said that Resident #4 had been pushed down by another resident in the facility on December 13, 2012. According to the medical _- -.- fxaminer, the resident expired as a result of injuries sustained from the fall. m, . She said that a staff member (“Employee B”) witnessed the incident but had ~~~ been terminated [ostensibly] because alcohol was smelled on her breath while ~ at work, ; : Resident #4’s, records included an observation log which documented the following: “On October 25, 2012, Resident #4 was sent to the hospital because she had received a bump on her head after being knocked down by . another resident in the facility.” A later entry.on December 13, 2012, documented: “Resident #4 got into an altercation with another resident and was pushed, She fell to the floor and hit her head against the wall. This _ incident was witnessed by resident care assistant B (“Employee B”).” Employee B's written statement indicated that she witnessed Resident #4 following Resident #7 down the 100 hall on December 13, 2012: She heard Resident #7 tell Resident #4 to “go away.” She then saw Resident #7 push Resident #4 which caused her to fall backwards, hit her head and drop to the floor. Resident #5 Resident #5’s health assessment indicated that he had physical limitations, including an unsteady gate and frequent falls. The health assessment also required special precautions for falls. On September 19, 2012, Resident #5 was placed on hospice due to falling, loss of weight and weakness. The residents’ observation log and resident incident log included documentation to show that Resident fell 13 times between September 19 and December 25, 2012 after being placed on hospice. Besides hospice, the only other precaution instigated to prevent falls was to move Resident #5 closer to the resident care station for closer observation. 9. The failure of the facility to appropriately intervene to prevent the multiple dangerous falls sustained by Residents ## 4 & 5 are unacceptable and a violation of law. 10. The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of facility residents, and directly . threatened the physical or emotional health, safety, or security of the facility residents. 11. The fine for the violation has been increased beyond the minimum due to the gravity of the violation, including the probability that death or serious physical or emotional harm to the resident could have or did occur, that the potential ham was significant, and/or that __u..the facility knew or should have known for an unreasonable amount of time that the resident should be discharged to a higher level of care. wee ed 12. The Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2012). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,000.00, against Respondent, an ALF in the State of Florida, pursuant to Section § 429.19(2)(b), Florida Statutes (2012). . COUNT I - tag A0077 13, The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 14. Pursuant to Florida law: Assisted Living Facilities - Staffing Standards: (1) ADMINISTRATORS. Every facility shall be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required by Part I of Chapter 429, F, S., and this rule chapter. (a). The administrators shall: 1. Be at least 21 years of age; 2. If employed on or after August 15, 1990, have a high school _ diploma or general equivalency diploma (G.E.D.), or have been an operator or administrator of a licensed assisted living facility in the State of Florida for at least one of the past 3 years in which the facility has met minimum standards. Administrators employed on or after October 30, 1995, must have a high school diploma or G.E.D.; 3. Be in compliance with Level 2 background screening standards pursuant to Section 429.174, F.S.; and 4, Complete the core training Tequirement pursuant to Rule Leen oo OOAS.0191, RAC, eee anes soa me tee Date cmt eee vee (b) Administrators may supervise a maximum of either three assisted living facilities or a combination of housing and health care facilities or 15. 2013000159 and found the facility out of compliance with the Rule set forth above. Based on interviews and record review, the facility did not have a CORE trained administrator. agencies on a single campus, However, administrators who supervise more than one facility shall appoint in writing a separate “manager” ‘for each facility who must: 1. Be at least 21 years old; and ° 2, Complete the core training requirement pursuant to Rule 58A-5.0191, F.A. C, (c) Pursuant to Section 429.176, F.S., facility owners shall notify both the Agency Field Office and Agency Central Office within ten (10) days of a change in a facility administrator on the Notification of Change of Administrator, AHCA Form 3180-1006, January 2006, which is incorporated by reference and may be obtained from the . Agency Central Office. The Agency Central Office shall conduct a background screening on the new administrator in accordance with ’ Section 429,174, F.S., and Rule 58A-5,014, F.A.C. Fla, Admin. Code Rule 58A-5.019 On January 8, 2013, the Agency conducted complaint investigation CCR # Findings included: 16. During an interview with “Administrator H,” she said she became the administrator of the facility around October 16, 2012. She was not CORE trained at that time and, had 90 days to complete the training. She took the CORE class but had not taken the CORE test so she was not certified. She was scheduled to take the CORE test on January 24, 2013, more than two weeks.after the survey began. The facility’s failure to assure that its administrator was appropriate trained and certified is unacceptable and a violation of law. 17, The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of facility residents, and directly threatened the physical or emotional health, safety, or security of the facility residents. 18. The fine for the violation has been increased beyond the minimum due to the gravity of the violation, including the probability that death or serious physical or emotional harm to the residents could have or did occur and that the potential harm was significant, “19. The Agency cited the Respondent for a Class II violation in accordance with ‘Section 429,19(2)(b), Florida Statutes (2012). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00, against Respondent, an ALF in the State of Florida, pursuant | “to Section § 429.19(2)(b), Florida Statutes (2012). | COUNT II - tag A0010 20. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 21. Pursuant to Florida law: Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. : (1) ADMISSION CRITERIA. An individual must meet the following’ minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license: (a) Be at least 18 years of age. (b) Be free from signs and symptoms of any communicable disease which is likely to be transmitted to other residents or staff; however, a person who has human immunodeficiency virus (HIV) infection may be admitted to a facility, provided that he would otherwise be eligible for admission according to this rule, (c) Be able to perform the activities of daily living, with supervision or- ee cannes seein ene assistance if necessary. . (d) Be able to transfer, with assistance if necessary. The assistance of more than one person is permitted. (e) Be capable of taking his/her own medication with assistance from - staff if necessary. 1. If the individual needs assistance with self-administration the facility must inform the resident of the professional qualifications of facility staff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain the resident's or the resident's surrogate, guardian, or attorney-in-fact's written informed consent to provide such assistance as required under Section 429.256, F.S. 2. The facility may accept a resident who requires the administration of medication, if the facility has a nurse to provide this service, or the resident or the resident's legal representative, designee, surrogate, guardian, or attorney-in-fact contracts with a licensed third party to provide this 8 service to the resident, (f Any special dietary needs can be met by the facility, -(g) Not be a danger to self or others as determined by a physician, or mental health practitioner licensed under Chapters 490 or 491, F.S. (h) Not require licensed professional mental health treatment on a 24- hour a day basis. (i) Not be bedridden. (j) Not have any stage 3 or 4 pressure sores. Aresident requiring care . Of a stage 2 pressure sore may be admitted provided that: 1. The facility has a LNS license and services are provided pursuant to a plan of care issued by a physician, or the resident contracts directly with a licensed home health agency or a nurse to provide care; - 2, The condition is documented in the resident's record; and 3. If the resident's condition fails to improve within 30 days, as documented by a licensed nurse or physician, the resident shall be discharged from the facility. ar?) Not require any of the following nursing services: 1, Oral, nasopharyngeal, or tracheotomy suctioning; 2. Assistance with tube feeding; 3. Monitoring of blood gases; 4, Intermittent positive pressure breathing therapy; or 5. Treatment of surgical incisions or wounds, unless the surgical incision or wound and the condition which caused it have been stabilized and a plan of care developed. (1) Not require 24-hour nursing supervision. _ (m) Not require skilled rehabilitative services as described in Rule 59G-4,290, F.A.C, (n) Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator shall base the decision on: 1, An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429,26, F.S., and subsection (2) of this rule; 2. The facility's admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and. 3. The ability of the facility to meet the uniform fire safety standards for assisted living facilities established under Section 429.41, F.S., and Rule Chapter 69A-40, F.A.C. (0) Resident admission criteria for facilities holding an extended "congregate care license are described in Rule 58A-5.030, F.A.C.... (4) CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility shall be the same as the criteria for admission, As part of the continued residency criteria, a resident must have a face-to-face medical examination by a licensed health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant changé is defined in Rule 58A-5,0131, F.A.C. The results of the examination must be recorded on AHCA Form 1823, which is incorporated by reference in paragraph (2)(b) of this rule. The form must be completed in _..agcordance with that paragraph. After the effective date of this rule, providers shall have up to 12 months to comply with this requirement. (a) The resident may be bedridden for up to 7 consecutive days. (b) A resident requiring care of a Stage IE pressure sore may be retained. provided that: 1, The facility has a LNS license and services are provided . pursuant.to a plan of care issued by a licensed health care provider, or the resident contracts directly with a licensed home health agency or a nurse to provide care; . ; 2. The condition is documented in the resident's record; and 3, If the resident's condition fails to improve within 30 days, as documented by a licensed health care provider, the resident shall be discharged from the facility. . (o) A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: 1. The resident qualifies for, is admitted to, and consents to the services of a licensed hospice which coordinates and ensures the provision of any additional care and services that may be needed; 2. Continued residency is agreeable to the resident and facility;, 3. An interdisciplinary care plan is developed and implemented by a licensed hospice in consultation with the facility. Facility - staff may provide any nursing service permitted under the facility's license and total help with the activities of daily living; and 4, Documentation of the requirements of this Paragraph 4 is maintained in the resident's file. (d) The administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. (e) Continued residency criteria for facilities holding an extended congregate care license are described in Rule 58A-5.030, F.A.C. (6) DISCHARGE. If the resident no longer meets the criteria for continued. residency, or the facility is unable to meet the resident's needs, as determined _.. .by.the facility, administrator or licensed health care provider, the resident shall be discharged in accordance with Section 429.28(1), F.S. Fla. Admin. R. 58A-5.0181 22, On J anuary 17, 2013, the Agency conducted an unannounced Change of Ownership and Extended Congregate Care survey and found the facility out of compliance with the Rule set forth above. Based on record review and interviews, the facility failed to ensure that all residents met the continued residency criteria. Findings included: Resident #7’s clinical record indicated that he was admitted to the facility on August 19, 2012. His September 9, 2012, AHCA Health Assessment Form indicated no pressure ulcers upon admission, In October, 2012, the resident was sent to the hospital for dehydration, transferred to a nursing home then readmitted to the ALF, Documentation by a home health care agency revealed that the resident was being treated for a Stage II pressure sore on the left heel. During an interview, the home health nurse said she classified the wound as a Stage II originally but, after speaking with her supervisor, re-classified the ulcer as a Stage III. The resident’s October 12, 2012, re-admission AHCA Form 1823 required 24- hour nursing care for the resident, On November 7, 2012, the resident’s physician's documented a Stage II pressure ulcer at the left heel. On December 5, 2012, documentation indicated that the resident had a Stage IV pressure ulcer at the left heel. . The resident's heel was observed along with the administrator and home health nurse and it was still a stage III pressure sore. . 23. The facility’s failure to monitor the continued appropriateness for placement of a resident with a serious and worsening pressure sore and to timely discharge the resident when he no longer met the criteria for continued residency placed the resident at high risk and is a violation of Fla. Admin. R. 58A-5.0181. 24. The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of facility residents, and directly threatened the physical or emotional health, safety, or security of the facility residents. 25....... The fine for the violation has been increased beyond the minimum due to the gravity — of the violation, including the probability that death or serious physical or emotional harm to the resident could have or did occur, that the potential harm was significant, and/ or that ‘the facility knew or should have known for an unreasonable amount of time that the resident should be discharged to a higher level of care. 26. The Agency cited the Respondent for a Class II violation in accordance with Section 429,19(2)(b), Florida Statutes (20 12). y WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00, against Respondent, an ALF in the State of Florida, pursuant to Section § 429.19(2)(b), Florida Statutes (2012). COUNT IV - tag A0052 27. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if” fully set forth herein, 28. Pursuant to Florida law: on eae Assisted Living Facilities - Medication Practices Pursuant to Sections 429,255 and 429.256, F'.S., and this rule, licensed. facilities may assist with the self-administration or administration of medications to residents in 4 facility. A resident may not be compelled to take medications but may be counseled in accordance with this rule. (1) SELF ADMINISTERED MEDICATIONS. (a) Residents who are capable of self-administering their medications without assistance shall be encouraged and allowed to do so. (b) If facility staff note deviations which could reasonably be atiributed to the improper self-administration of medication, staff shall consult with the resident concerning any problems the resident may be experiencing with the medications; the need to permit the facility to aid the resident through the use of a pill organizer, provide assistance with self-administration of medications, or administer medications if ve ce sw nen uve Stich services are offered by the facility. The facility shall contactthe =, resident's health care provider when observable health care changes occur that may be attributed to the resident's medications. The facility _ shall document such contacts in the resident's records, 12 (3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) For facilities which provide assistance with self-administered. medication, either: a nurse; or ari unlicensed staff member, who is at "least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5.0191, F.A.C., and able to demonstrate to the administrator the ability to accurately read and interpret a | prescription label, must be available to assist residents with self- | , administered medications in accordance with procedures described in Section 429,256, F.S. (b) Assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed, retrieving and opening a properly labeled medication container, and providing assistance as specified in Section 429.256(3), F.S, In order to facilitate assistance with self-administration, staff may prepare and make available such items as water, juice, cups, and spoons. Staff may also return unused doses to the medication container, Medication, which appears to have been contaminated, shall not be returned to the container. (c) Staff shall observe the resident take the medication. Any concerns | about the resident's reaction to the medication shall be reported to the resident's health care provider and documented in the resident's record. (d) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to enable the resident to take medication as prescribed: 1. The health care provider may prescribe a medication schedule which coincides with the resident's presence in the facility; 2, The medication container may be given to the resident or a friend or farnily member upon leaving the facility, with this fact noted in the resident's medication record; 3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection (2), and given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident's medication record; or an easier to use form, such as unit dose packaging; 13 4, Medications may be separately presctibed anddispensedin 5 er (e) Pursuant to Section 429,256(4)(h), F.S., the term “competent resident” means that the resident is cognizant of when a medication is required and understands the purpose for taking the medication. (¢)) Pursuant to Section 429.256(4)(i), F.S., the terms “judgment” and “discretion” mean interpreting vital signs and evaluating or assessing a resident's condition. Fla. Admin. Code R. 58A-5.0185 HR Assistance with self-administration of medication (3) Assistance with self-administration of medication includes: (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. (b) In the presence of the resident, reading the label, opening the : container, removing a prescribed amount of medication from the Bo, container, and closing the container. (©) Placing an oral dosage in the resident's hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth, : (d) Applying topical medications. (e) Returning the medication container to proper storage. (f) Keeping a record of when a resident receives assistance with self- administration under this section. (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or calculating medication — doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed, (b) The preparation of syringes for injection or the administration of medications by any injectable route. (c) Administration of medications through intermittent positive - pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. (e) Administration of parenteral preparations. (f) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and at the request of a competent resident. (i) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unticensed petson, Section § 429.256, Fla. Stat. (2012) 29, On January 17, 2013, the Agency conducted an unannounced Change of Ownership and Extended Congregate Care survey and found the facility out of compliance with the Rule set forth above. Based on observations and interviews, the facility failed to assure the proper assistance. with self-medication and the administration of medication by licensed staff when so required, Findings included: The resident care aide (RCA) was observed crushing a Tylenol medication and mixing it with yellow pudding in a souffle cup then feeding the mixture to Resident #1 with a spoon. ° . During an interview, the RCA said the resident is unable to swallow the medication so mixing it with pudding was the only way the resident could take it. The resident had hospice care and the hospice nurses were aware of his swallowing problem. The RCA revealed that there were 4 hospice residents (including Residents ## 12, 15 & 16) that are spoon-fed their medication by the RCA during the medication pass. The above form of administering medications to the residents by the RCA was observed. with the corporate registered nurse. 15 30. ‘The facility’s failure to properly provide assistance with self-administration and to assure that only licensed staff adrhinistered medications to residents who needed such services is unacceptable and a violation of law. 31.’ The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of facility residents, and directly _ threatened the physical or emotional health, safety, or security of the facility residents. 32. The fine for the violation has been increased beyond the minimum due to the gravity _ of the violation, including the probability that death or serious physical or emotional harm to the resident could have or did occur, that the potential harm was significant. 26. The Agency cited the Respondent for a Class Ii violation in accordance with Section 429,19(2)(b), Florida Statutes (2012). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,000.00, against Respondent, an ALF in the State of Florida, pursuant to Section § 429.19(2)(b), Florida Statutes (2012). . NOTICE OF RIGHTS Respondent is notified that it has a right to request an administrative hearing pursuant to ‘Section § 120.569, Florida Statutes. Respondent also has the right to retain, and be _represented by an attortiey 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) 412-3671. Respondent is farther 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 e entry 0 of a final order by the Agency. CERTIFICATE OF SERVICE . I HEREBY CERTIFY that a true and correct copy of the foregoing Administrative 16 Complaint has been served by U.S. Certified Mail, Return Receipt No. 7011 0470 0000 7951 3395 to CT Corporation System, Registered Agent, 1200 South Pine Island Road, Plantation, FL 33324, and by U.S. Mail to Mary Alice Tillman, Administrator, The | Harmony House at Ocala, 5762 $,W. 60" Avenue, Ocala, FL 34474, this" M4, of July, 2013. STATE OF FLORIDA, AGENCY FOR HEALTHCARE ADMINISTRATION 525 Mirror Lake Dr. N., Suite 330H | ; " St. Petersburg, Florida 33701 ; ; (727) 552-1945; Fax: (727) 552-1440 . . , hurley @al florid { ’ Copy provided to: | Kris Menella, HFE Supervisor 17 CT Corporation Systems 1200 South Pine Island Road Plantation; FL 33324 70a oY70 DOOD 73S) T cee

Docket for Case No: 13-003331