STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No.: 2016003411 File No.; 11965797 Provider Type: Assisted Living Facility GOLDEN YEARS ALF, CORPORATION, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent GOLDEN YEARS ALF, CORPORATION (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2016), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine of ten thousand dollars ($10,000.00) and assess a survey fee of five hundred dollars ($500). PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities. Ch, 408, Part II, Ch. 429, Part I, Fla. Stat. (2016); Ch. 58A-5, Fla. Admin. Code. The Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.813, 408.815, 429.14, 429.19, Fla. Stat. (2016). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (2016). 2. The Respondent was issued a license by the Agency to operate an assisted living facility (“the Facility”) located at 321 WEST BLUE HERON BOULEVARD RIVERA BEACH, FL 33404, and was at all times material required to comply with the applicable statutes and rules governing assisted living facilities. COUNTI Resident Care—Supervision 3. Under Florida law: An assisted living facility must provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities must offer personal supervision as appropriate for cach resident, including the following: (a) Monitoring of the quantity and quality of resident diets 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 resident. (c) Maintaining a general awareness of the resident’s whereabouts. The resident may travel independently in the community. (d) Contacting the resident’s health care provider and other appropriate party 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) Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services. Rule 58A-5.0182(1), F.A.C. (2016). 4. Additionally, Florida law provides: (7) The facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and services to treat the condition. § 429.26(7) Fla. Stat. (2016). Facts 5. On or about February 8, 2016 through February 12, 2016 and on or about February 18, 2016, the Agency conducted a survey of the Respondent. 6. Based on record review, interview and observations, the facility failed to provide appropriate supervision to a Limited Mental Health resident suffering from a medical diagnosis affecting the resident's cognitive and behavioral status. The facility failed to provide appropriate supervision to maintain a general awareness of the whereabouts, health, safety, physical and emotional well-being, for 1 of 7 sampled residents (Resident 1). 7. Facility records dated January 29, 2016 stated that Resident 1 has a diagnosis of schizophrenia, but no cognitive or behavioral concerns, nor was he an elopement risk. 8. Resident 1°s case manager stated that Resident 1 suffered from schizophrenia with paranoia, diabetes, high blood pressure, and some form of chronic obstructive pulmonary disease (COPD) because he cannot tolerate too much walking, he has to sit at times, and breathes heavily. 9. Review of Resident 1’s medication observation record (MOR) for October, 2015, through February, 2016, revealed no diagnosis, but did reveal that the resident received antipsychotic, diabetes, and blood pressure medication. 10. Resident 1°s community living support plan and cooperative agreement for Assisted Living Facilities and Mental Health Providers had no date listed. It stated that Resident 1 is always at the facility, does not interact with other residents, and only speaks when spoken to. 11. Resident 1’s Service Plan for Assistive Care Services, dated January 29, 2016, signed by the facility's administrator and the resident, stated that Resident 1 is independent with all activities of daily living; however, staff would continue to provide daily assistance with medications, case manager would provide supervision, daily reminders would continue by staff and daily observation would continue by staff. 12. During an interview with the administrator conducted on or about February 8, 2016, the administrator stated he saw Resident 1 walking down the street at around 1:30 PM on February 1, 2016. The administrator stated that he presumed the resident was going to the local store (approximately 5 minutes walking distance from the facility). 13. When Resident 1 was not at dinner and 8:00 PM medications, the administrator searched the building and property, but did not locate Resident 1. The administrator further stated when he left the facility that night between 8:00 PM and 9:00 PM, Resident 1 had not returned. 14. The administrator stated that when he returned to work the next morning and the resident didn't show up for the 8:00 AM medication, the administrator searched the property and did not locate the resident. The administrator called the local hospitals and jails, notified the police and notified Resident 1's mental health Case Manager. The administrator also filed a One Day Report to the Agency and made an entry in the resident's observation notes. 15. | The administrator confirmed he did not attempt to file a missing person report with law enforcement until nearly 24 hours after Resident 1 was last seen. The administrator confirmed it was facility policy for facility staff to wait until the following morning to make any official reports. He confirmed facility staff did not make any efforts to search the neighboring area or any of the several stores Resident 1 was known to frequent. 16. During interviews conducted with Resident 1's case manager and next of kin, it was revealed the facility delayed notification for almost 24 hours. During an interview conducted on or about February 10, 2016, Resident 1's case manager stated that she was notified on February 2, 2016, at 11:40 AM. In an interview conducted on or about February 10, 2016, Resident 1's family member and emergency contact stated she found out he was missing when she made her weekly telephone call to Resident 1 on February 3, 2016. She further stated she had not been contacted by the facility since that time. 17. The local police report stated that a missing person report was filed by the facility on February 2, 2016 at 2:10 PM. The report disclosed that the administrator told police that Resident 1 walked off the property on February 1, 2016, during lunch time. The report further stated that Resident 1 normally walks to a local residential community or local store. The report also stated that Resident 1 has been known to visit his girlfriend in Delay Beach. 18. During interviews conducted with residents and facility staff members, interviewees stated that Resident 1 always returned from his daily trips on the same day and they were not aware that Resident | had a girlfriend. 19. Review of facility records revealed a Day One report was filed on February 3, 2016. The entire narrative of the report stated “Resident #1 left facility without signing out or notifying staff. Resident #1 did not return. A missing report was made." 20. Resident 1's observation notes stated "Resident left to go to the store on 2/1/16. Resident did not return to facility, policy report made." 21. The facility's written Policy and Procedures for Elopement provide: a. "Should a resident not sign-out in the facility's Sign-Out/Sign-In log (Temporary Absence Log) indicating the Date, Time and Reason for temporary absence, it is therefore understood by the facility that the resident left the facility without following the policy and procedures. Although, the resident may travel independently in the community, the assisted living staff are responsible for knowing the whereabouts of all resident. When a resident is determined missing or whereabouts is unknown, the facility shall make every attempt as quickly as possible to locate the resident." Page 1. b. "Elopement is when a resident leaves the facility without following the facility's policies and procedures." Id. c. “If the missing resident is still not discovered during search of the property, the Administrator must be notified. The Administrator or Designee then assumes responsibility for the notification of outside agencies, such as the local police department ..."/d. d. "Family members or, in the absence of family, other responsible persons will be notified by the Administrator or Designee after the search and within one hour determining that the resident has eloped/is missing." Page 2. 22. Review of the facility's sign in/out sheet titled, "Temporary Absences Log” revealed that since April 15, 2015, only seven residents used the sign in/out sheet. The administrator confirmed that residents have left the facility on days other than those on the sign in/out sheet, including an instance where Resident 4 eloped from March 20, 2014 before returning to the facility on April 22, 2014. The administrator acknowledged resident confusion as to when they are required to sign out/in. 23. Further record review revealed no documentation showing a thorough investigation was conducted and steps were implemented by the facility (including attempts to locate Resident 1, areas searched, persons notified, etc.) to prevent recurrence of an incident of this type. There was no documentation showing facility staff made any attempts to search for Resident 1, other than to check the facility and facility property. There was no documentation showing facility staff contacted local hospitals, jails, homeless shelters, or other places Resident 1 could be. Low temperatures for the period of February 1, 2016 through February 11, 2016 ranged from 57 to 58 degrees. 24. During an interview conducted February 9, 2016, the Administrator confirmed another resident had eloped prior to Resident 1 a few years ago. The Administrator stated he followed the same practice with Resident 4 as he did with Resident 1. The administrator stated he had planned to revise the elopement policy after Resident 4 had eloped in 2014, but he never did. 25. During a tour of the facility conducted February 8, 2016 with the administrator present, the Agency observed that the facility property is completely enclosed by metal and concrete fences with three gates on the front side of the property. During an interview conducted at the time of observation, the administrator stated that two gates were kept locked at all times, unless there was a specific reason for them to be unlocked and they were re-locked immediately afterward. The third gate was locked daily from 10:00 PM until 6:00 AM. 26. The Agency observed there was no doorbell or other means of announcing one's presence at the gate when it was locked. In an interview conducted at that time, the administrator stated either the person at the gate would need to call the facility's telephone number or sometimes residents were present on the front patio and could get the staff person on duty holding the gate key to let the person in. 27. In interviews with several residents and an employee (separately), when asked what residents do if they come home after 10:00 PM (when no one is present on the front patio) and they cannot call the facility, all responded that the resident would, "jump the fence.” The fence referenced is a 6' tall concrete block wall located on the front of the facility's property. 28. ‘In an interview conducted on February 12, 2016, the administrator was asked about the locked gate with no door bells or other means of announcing one's presence and stated "the neighborhood is not safe" and he "can install something in five minutes.” 29. During an interview with the administrator on February 18, 2016, it was revealed Resident 1 was located by a staff member at a bus stop near the facility. According to the administrator, the resident was attempting to return home, but became tired and sat down to rest at a bus stop when he was located by a staff member. Police were notified and the resident was taken to the hospital for further treatment and evaluation. 30. The Respondent’s actions or inactions constituted a violation of Section 429.26(7), Florida Statutes (2016), and Rule 58A-5.0182(1), Florida Administrative Code (2016). Sanction 31. Under Florida law, the Respondent as the licensee is legally responsible for all aspects of the provider operation. § 408.803(9), Fla. Stat. (2016). 32. Under Florida law, in addition to the requirements of part I of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any provision of this part, part Il of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or for the actions of any facility employee: an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. § 429.14(1)(a), Fla. Stat. (2016). 33. Under Florida law, “Class H” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2016). 34. Under Florida law, the Agency shall impose an administrative fine for a cited Class If violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of five thousand dollars ($5,000.00) against the Respondent. COUNT II Elopement Standards 35. Under Florida law: (8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention must be directed towards residents assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease or related disorders assessed at high risk. 2, At a minimum, the facility must have a photo identification of at risk residents on file that is accessible to all facility staff and law enforcement as necessary. The facility’s file must contain the resident’s photo identification within 10 days of admission or within 10 days of being assessed at tisk for elopement subsequent to admission. The photo identification may be provided by the facility, the resident, or the resident’s representative. (b) Facility Resident Elopement Response Policies and Procedures. The facility must develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures must provide for: 1. An immediate search of the facility and premises; 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities; 3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to subparagraph (8)(b)1.; and 4. The continued care of all residents within the facility in the event of an elopement. (c) Facility Resident Elopement Drills. The facility must conduct and document resident elopement drills pursuant to Sections 429.41(1)(a)3. and 429.41(1)q), F.S.. Rule 58A-5.0182(8), F.A.C., (2016). 36. Under Florida law: (3) Licensed facilities shall provide within 1 business day after the occurrence of an adverse incident, by electronic mail, facsimile, or United States mail, a preliminary report to the agency on all adverse incidents specified under this section. The report must include information regarding the identity of the affected resident, the type of adverse incident, and the status of the facility’s investigation of the incident. §429.23(3) Fla. Stat. (2016). Facts 37. | The Agency re-alleges and incorporates by reference all of the facts listed in Count I of this complaint. 38. Based on record review and interviews, the facility failed to develop and implement adequate elopement response policies and procedures. The facility failed to implement an elopement response policy and procedure when Resident 1 went missing. 39. Review of the facility's written Policies and Procedures for Elopement revealed there were no provisions requiring staff to make “a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number” nor “the continued care of all residents within the facility in the event of an elopement.” 40. In addition to those provisions referenced in Count I, the facility’s Policy and Procedures for Elopement provide that “If elopement would place the resident at risk of harm or injury, within one (1) business day after preliminary investigation, of the eloped/missing resident incident the Administrator will ensure the Agency for Health Care Administration is notified upon completion of the 1 DAY ADVERSE INCIDENT REPORT form by faxing the completed form to the Agency's Adverse Incident reporting office as required 429.23(3) F.S.. In addition to faxing, the administrator shall also ensure that the report is sent via United States Mail." Page 2. 41. In addition to the facility having inadequate elopement response policies and procedures, the facility did not even comply with those policies and procedures, as evinced by the late notice to both the resident’s family and the Agency. 42. The Respondent's actions or inactions constituted a violation of Sections 429.174 and 408.809, and Chapter 435, Florida Statutes (2016). Sanction 43. Under Florida law, the Respondent as the licensee is legally responsible for all aspects of the provider operation. § 408.803(9), Fla. Stat. (2016). 44, Under Florida law, in addition to the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in chapter 120 against a licensee for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under s. 408.809, or for the actions of any facility employee: an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. § 429.14(1)(a), Fla. Stat. (2016). 45. Under Florida law, “Class II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2016). 46. Under Florida law, the Agency shall impose an administrative fine for a cited Class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of five thousand dollars ($5,000.00) against the Respondent. COUNT I Survey Fee 47. Under Florida law: (7) In addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 429.28(3)(c) to verify the correction of the violations. § 429.19(7) Fla. Stat. (2016). 12 48. The Agency re-alleges and incorporates by reference all of the facts listed in Counts I and II of this Administrative Complaint. 49. In response to a complaint, the Agency conducted a complaint survey of the Respondent’s facility. 50. As aresult of the complaint survey, the Respondent was cited for violations. 51. The basis for the violations alleged in this Administrative Complaint arise from the initial complaint and complaint survey. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to assess a survey fee of five hundred dollars ($500) against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Renders findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Respectfully Submitted, > Antonio Lozada, Assistant General Counsel Florida Bar No.: 112613 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3699 Facsimile (850) 922-9634 Email: Antonio.Lozada@ahca.myflorida.com NOTICE 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 21st 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 were served to the below named persons/entities by the method lh ’, r designated on this 20 day of _ Ani lA A 2017. / ha bn B <2 ) Wi - : Antonio Lozada, Assistant General Counsel Florida Bar No.: 112613 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3699 Facsimile (850) 922-9634 Email: Antonio.Lozada@ahca.myflorida.com | Arlene Mayo-Davis, Field Office Manager Agency for Health Care Administration Agency Field Office (Electronic Mail) Administrator Golden Years ALF, Corporation 321 West Blue Heron Boulevard Rivera Beach, FL 33404 Via Certified Mail: 91 71959 9991 7033 6372 8450 Laura Manville, Unit Manager Assisted Living Unit Agency for Health Care Administration (Electronic Mail) 15 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: GOLDEN YEARS ALF, CORPORATION ACHA No. 2016003411 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but_must_be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form 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 SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged 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 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 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. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: 17 USPS Tracking Results Tracking FAQs Track Another Package + Remove X Tracking Number: 9171999991 703363728450 SE ee ee CO(clivered Product & Tracking Information See Available Actions Postal Product: Features: Certified Mail™ DATE & TIME STATUS OF ITEM LOCATION April 3, 2017, 1:19 pm Delivered, Front Desk/Reception WEST PALM BEACH, FL 33404 Your item was delivered to the front desk or reception area at 1:19 pm on April 3, 2017 in WEST PALM BEACH, FL 33404. April 3, 2017, 10:23 am In Transit to Destination April 2, 2017, 3:23 am Departed USPS Facility WEST PALM BEACH, FL 33416 April 1, 2017, 5:11 pm Arrived at USPS Facility WEST PALM BEACH, FL 33416 See More \/

Docket for Case No: 17-005309