STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, AHCA No. 2014000953 : License No. 1238096 HOLLYWOOD HILLS REHABILITATION File No. 100611 CENTER, LLC, Provider Type: Nursing Home Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Hollywood Hills Rehabilitation Center, LLC (hereinafter “the Respondent”), pursuant to sections 120.569 and 120.57, Florida Statutes (2013), and alleges as follows: NATURE OF THE ACTION This is an action to revoke the Respondent’s nursing home license. PARTIES 1, The Agency is the licensing and regulatory authority that oversees skilled nursing facilities (also called nursing homes) and enforces the state statutes and rules governing such facilities. Ch. 408, Part II, Ch. 400, Part II, Fla. Stat; Ch. 59A-4, Fla. Admin. Code. The "Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to sections 400.121, and 400.23, Florida Statutes, assign a conditional license pursuant to subsection 400.23(7), Florida Statutes, and assess costs related to the investigation and prosecution of this case pursuant to section 400.121, Florida Statutes. 2. The Respondent was issued a license by the Agency to operate a skilled nursing facility located at 1200 North 35" Avenue, Hollywood, Florida 33021, and was required to comply with the applicable state statutes and rules. FACTS COMMON TO ALL COUNTS 3. Under Florida law, “controlling interest” means: (a) The applicant or licensee; (b) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or (c) A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. § 408.803(7), Fla. Stat. (2013). 4, In addition to the Respondent, there exists Hollywood Pavilion, LLC (hereinafter “Hollywood Pavilion”), which was issued a license by the Agency to operate a hospital located at 1201 North 37 Avenue, Hollywood, Florida 33021, and was required to comply with the applicable state statutes and rules. 5. Per their respective license applications submitted to the Agency, the Respondent and Hollywood Pavilion are each owned 100% by High Ridge Management Corp. 6. Per their respective license applications submitted to the Agency, the Respondent and Hollywood Pavilion are each under the direction of the same President and corporate officer, Leonore Kallen. 7. As a result of their common ownership, the Respondent and Hollywood Pavilion share common controlling interests as defined by Section 408.803 (7), Florida Statutes (2013), 8. As a result of their common president and corporate officer, the Respondent and Hollywood Pavilion share common controlling interests as defined by Section 408.803(7), Florida Statutes (2013). COUNTI Adverse Action Against Any Other Licensed Facility With a Common Controlling Interest 9. Under Florida law, the Agency may deny an application, revoke or suspend a license, and impose an administrative fine, not to exceed $500 per violation per day for the violation of any provision of part I of chapter 400, part II of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest: (a) A violation of any provision of part II of chapter 400, part II of chapter 408, or applicable rules; or (b) An adverse action by_a regulatory agency against any other licensed facility that has a common controlling interest with the licensee or - applicant against whom the action under this section is being brought, If the adverse action involves solely the management company, the applicant or licensee shall be given 30 days to remedy before final action is taken. If the adverse action is based solely upon actions by a controlling interest, the applicant or licensee may present factors in mitigation of any proposed penalty based upon a showing that such penalty is inappropriate under the circumstances, § 400.121(1), Fla. Stat. (2013) (emphasis supplied). 10, The Agency re-alleges the allegations that are common to all counts. 11. On the service date of this Administrative Complaint, the Agency initiated an adverse action against Hollywood Pavilion (AHCA Case No. 2014001019) seeking license revocation based upon its for cause termination from the Medicare program. 12, The Administrative Complaint against Hollywood Pavilion is an adverse agency action by a regulatory agency against any other licensed facility that has a common controlling interest with the Respondent. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license. COUNT IE Involuntary Termination from the Medicare/Medicaid Program 13. Under Florida law, 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: ... (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other . State, or the Medicare program, § 408.815(1)(e), Fla. Stat. (2013). 14, The Agency re-alleges the allegations that are common to all counts, 15. On April 3, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a letter informing Hollywood Pavilion that its Medicare privileges were being revoked and that the subjection action would result in the termination of its provider agreement. Hollywood Pavilion was afforded appeal rights within the letter. Ex. A. 16. On September 12, 2013, CMS issued a letter revoking Hollywood Pavilion’s Medicare billing privileges and terminating it from the Medicare program. Ex. A. 17. As a result of the for cause termination of Hollywood Pavilion from the Medicare program by CMS, all Agency licensed facilities that have common controlling interests with Hollywood Pavilion are subject to license revocation. § 408.815(1)(e), Fla. Stat. (2013). They are also subject to application denial. § 408.815(4), Fla. Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a final order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief sought in the Administrative Complaint. Respectfully submitted on this ¥ day of February, 2014. Bradford C. Herter, Senior Attorney Florida Bar No. 69060 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308 Telephone: 850-412-3639 Facsimile: 850-922-6484 NOTICE OF RIGHTS Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120,57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28-106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21° day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form have been served to the below named persons at the address stated by the method designated on this of day of February, 2014. Bradford C. Herter, Senior Attorney Florida Bar No. 69060 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL 32308 Telephone: 850-412-3639 Facsimile: 850-922-6484 Jay Adams, Esquire Douglas Manheimer, Esquire Broad and Cassel 215 South Monroe Street, Suite 400 Tallahassee, FL 32301 Certified Mail — 7012 1010 0003 2438 1050 Administrator Hollywood Hills Rehabilitation Center, LLC 1200 North 35" Avenue Hollywood, FL 33021 (Certified Mail - 7012 1010 0003 2438 1128) Clyde Hamstreet, Court Appointed Receiver Hamstreet & Associates o/b/o Hollywood Hills Rehabilitation Center One SW Columbia Street, Suite 1000 Portland, OR 97258 Certified Mail — 7012 1010 0003 2438 1074 John H. Hough, Registered Agent o/b/o Hollywood Hills Rehabilitation Center 11300 US Highway One, Suite 401 Palm Beach Gardens, FL 33408 (Certified Mail ~ 7012 1010 0003 2438 1081 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Hollywood Hills Rehabilitation Center, LLC AHCA No. 2014000953 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. The Election of Rights form 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 received the Administrative Complaint. If your Election of Rights form with your selected option (or request for hearing) is not timely received by the Agency Clerk, the right to an administrative hearing to contest the proposed agency action will be waived and an adverse Final Order will be issued. In addition, please send a copy of this form to the attorney of record who issued the Administrative Complaint. (Please use this form unless you, your attorney or your qualified representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) The address for the Agency Clerk is: Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I waive the right to a hearing to contest the allegations of fact and conclusions of law contained in the Administrative Complaint. 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 the allegations of fact contained in the Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where | may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine, sanction or other agency action should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Administrative Complaint and 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 7 received by the Agency Clerk at the address above within 21 days of your receipt of this 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 representative 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 statenient of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (Optional) eee I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: SS EER EEEEEEEReeeeenee DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30309 * CENTERS FOR MEDICARE & MEDICAID SERVICES September 12, 2013 Hollywood Pavilion 1201 N 37 Avenue Hollywood, Florida 33021-5414 Re: CMS Certification Number (CCN) 10-4015 Dear Provider: The Centers for Medicare and Medicaid Services (CMS) was notified by Wisconsin Physicians Service (WPS) that the agency’s Medicare billing privileges were revoked pursuant to 42 CFR 424.545(a). This action also terminates your corresponding Medicare provider agreement per 489.53, Your provider agreement is terminated retroactive to the date of revocation, May 3, 2013, A public notice of termination will be published in a local newspaper. If you believe this action is not correct, please refer to the letter which was sent to you on April 3, 2013 by WPS, notifying you of the revocation of your Medicare enrollment. This letter included your rights to appeal. If you have questions, please contact Jackie Whitlock at 404-562-7437 or Jacqueline.whitlock@cms,hhs.gov. Sincerely, | ‘T’ Sandra M. Pace Associate Regional Administrator Division of Survey and Certification cc: Florida Agency for Healthcare Administration WPS Florida Medicaid ex A yz Medicare April 3, 2013 Current CEO or Ms. Karen Kallen-Zury, CEO Hollywood Pavilion conan 1201 N. 37" Ave. Hollywood, FL 33021-5414 RE: Provider DBA Name: Hollywood Pavilion Provider Number/CMS Certification # (CNN): 10-4015 NPI: 1326027723 Dear Current CEO: This is to inform you that your Medicare privileges are being revoked effective May 3, 2013. Pursuant to 42 CFR §424.545(a), this action will also terminate your corresponding provider agreement. FACTS: On January 3, 2013 and January 25, 2013, letters were sent to your facility advising the United States Postal Service was returning mail sent to your facility. In researching the returned mail, our staff was advised the facility’s address had changed. These letters requested you file a CMS-855A application to update your address in your Provider Enrollment record, No response was received, On February 20, 2013, a letter was sent advising if the application was not received by March 6, 2013, we would place your facility on a suspension of payments until the application was received. No application was received; therefore, the facility is on a suspension of payment. To date, no application to update your practice location address has been received. Because you have failed to comply as requested, according to 42 CFR §424.535(a)(9), this revocation is being issued. If you believe that you are able to correct the deficiencies and establish your eligibility to participate in the Medicare program, you may submit a corrective action plan (CAP) within 30 calendar days after the postmark date of this letter. The CAP should provide evidence that you are in compliance with Medicare requirements. The reconsideration request must be signed and dated by the authorized or delegated official within the entity. CAP requests should be sent to: Centers for Medicare & Medicaid Services Division of Provider & Supplier Enrollment 7500 Security Blvd. Mailstop: C3-02-16 Baltimore, MD 21244-1850 Wisconsin Physicians Service Insurance Corporation serving as a CMS Medicare Contractor P.O. Box 1787 # Madison, WI 53701 Phone 608-221-4711 HEALTH INSURANCE? If you believe that this determination is not correct, you may request reconsideration before a contractor hearing officer. The reconsideration is an independent review and will be conducted by a person who was not involved in the initial determination. You must request the reconsideration in writing to this office within 60 calendar days of the postmark date of this letter. The request for reconsideration must state the issues, or the findings of fact with which you disagree and the reasons for disagreement. You miay submit additional information with the reconsideration request that you believe may have a bearing on the decision. The reconsideration request must be signed and dated by the authorized or delegated official within the entity. Failure to timely request reconsideration is deemed a waiver of all rights to further administrative review. The request for reconsideration should be sent to: Centers for Medicare & Medicaid Services Division of Provider & Supplier Enrollment 7500 Security Blvd. Mailstop: C3-02-16 Baltimore, MD 21244-1850 If you have any questions regarding this matter, please contact me at 1-866-734-9444 extension 50332. Sincerely, Nic Chesnut Supervisor, Provider Enrollment Medicare Provider Enrollment Wisconsin Physicians Service ce: Ms. Patricia Pearson Centers for Medicare & Medicaid Services ATTN: CQISCO 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 Ms. Janis Williamson Agency for Health Care Administration 2727 Mahan Drive, Mailstop 31 Tallahassee, FL 32308 Version: 2.0 Modified: 08/27/12 2 of 2 werNDER: COMPLETE THIS. SECTION “COMPLETE THIS SECTION ON DELIVERY @ Complete items 1, 2, and 3. Also complete A. Signature Item 4 if Restricted Dellvery is desired. & Print your name and address on the reverse so that we can return the card to you, ® Attach this card to the back of the mallpiece, or on the front if space permits. 1. Afticle Addressed to: £7 Agent D Addressee ‘| C. Date of Detivery B. Received by ( Printed Nar ‘e) { \fo ~ D. Is delivery address different from item 1? © Yes If YES, enter delivery address below: C1 No Jay Adams, Esquire Douglas Manheimer, Esquire Broad and Cassel 215 South Monroe Street, Suite 400 Tallahassee, FL 32301 3. Sepvice Type Certified Mail (1 Express Mall O Registered Ofeturn Recelpt for Merchandise O Insured Mail ~=OC.0.p, 4, Restricted Delivery? (Extra, Fee) *f 702 LOMO 0003 2438 1Os0 ; PS Form 3811, February 2004 Domestlo Return Recelpt 102595-02-M-1840 Jay Adams, Esquire Douglas Manheimer, Broad and Cassel Ret (ena 215 South Monroe Street, Suite 400 Tallahassee, FL 3230] Esquire Restrle (Endors: Total Postage & Foes | ?O12 1010 0003 2434 1050

Docket for Case No: 14-004352