STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2017007257 Petitioner, License No.: 12756 File No.: 11968864 vs. Provider Type: Assisted Living Facility MIRACLES HOUSE, INC., d/b/a AMAZING WONDERS, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Miracles House, Inc., d/b/a Amazing Wonders (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2016), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s licensure to operate an assisted living facility, to impose an administrative fine in the amount of thirty-six thousand dollars ($36,000.00) based upon three (3) Class I deficiencies, one (1) Class II deficiencies, and two (2) Unclassified deficiencies pursuant to §429.19(2)(a)(b) and (e), Florida Statutes (2016), and to impose a survey fee of two hundred fifty-eight dollars and eighty-three cents ($258.83) pursuant to §429.19(7), Florida Statutes (2016) for a total assessment of thirty six thousand two hundred fifty eight dollars and eighty three cents ($36,258.83). 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. Page 1 of 45 Ch. 408, Part II, Ch. 429, Part I, Fla. Stat. (2016); Ch. 58A-5, Fla. Admin. Code, and Ch. 59A-35 Fla. Admin. Codes. 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 (#12756) by the Agency to operate an assisted. living facility located at 2323 N.W. 85" Street, Miami, Florida 33147 (“the Facility”), and was at ali times material required to comply with the statutes and rules governing assisted living facilities. Assisted living facilities are residential care facilities that provide housing, meals, personal care and supportive services to older persons and disabled adults who are unable to live independently. These facilities are intended to be a less costly alternative to the more restrictive, institutional settings for individuals who do not require 24-hour nursing supervision. Generally, assisted living facilities provide supervision, assistance with personal care and supportive services, as well as assistance with, or administration of, medications to residents who require such services. 3. As the holder of such a license, the Respondent is a licensee. “Licensee” means “an individual, corporation, partnership, firm, association, or governmental entity, that is issued a permit, registration, certificate, or license by the Agency.” § 408.803(9), Fla. Stat. (2016). “The licensee is legally responsible for all aspects of the provider operation.” § 408.803(9), Fla. Stat. (2016). “Provider” means “any activity, service, agency, or facility regulated by the Agency and listed in Section 408.802,” Florida Statutes (2016). § 408.803(11), Fla. Stat, (2016). Assisted living facilities are regulated by the Agency under Chapter 429, Part I, Florida Statutes (2016), and listed in Section 408.802, Florida Statutes (2016). § 408.802(13), Fla. Stat. (2016). Assisted Page 2 of 45 living facility patients are thus clients. “Client” means “any person receiving services from a provider.” § 408.803(6), Fla. Stat. (2016). The Respondent holds itself out to the public as an assisted living facility that fully complies with state laws governing such providers. 4. The Respondent holds itself out to the public as an assisted living facility that complies with the laws governing assisted living facilities. These laws exist to protect the health, safety and welfare of the residents of assisted living facilities. As individuals receiving services from an assisted living facility, these residents are entitled to receive the benefits and protections under Chapters 120, 408, Part II, and 429, Part I, Florida Statutes (2016), and Chapter 58A-5, Florida Administrative Code. COUNT I Admissions Criteria 5. The Agency re-alleges and incorporates by reference paragraphs 1-4 as if fully set forth herein. 6. Section 429.26, Florida Statutes, states in pertinent part: (1) The owner or administrator of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident’s representative or designee or the resident’s family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the department or the Department of Children and Families, the administrator must notify the appropriate contact person in the applicable department. (4) If possible, each resident shall have been examined by a licensed physician, a licensed physician assistant, or a licensed nurse practitioner within 60 days before admission to the facility. The signed and completed medical examination report shall be submitted to the owner or administrator of the facility who shali use the information contained therein to assist in the determination of the appropriateness Page 3 of 45 of the resident’s admission and continued stay in the facility. The medical examination report shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection or upon request. An assessment that has been completed through the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program fulfills the requirements for a medical examination under this subsection and s. 429.07(3)(b)6. (5) Except as provided in s. 429.07, if a medical examination has not been completed within 60 days before the admission of the resident to the facility, a licensed physician, licensed physician assistant, or licensed nurse practitioner shall examine the resident and complete a medical examination form provided by the agency within 30 days following the admission to the facility to enable the facility owner or administrator to determine the appropriateness of the admission. The medical examination form shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection by the agency or upon request. (6) Any resident accepted in a facility and placed by the department or the Department of Children and Families shall have been examined by medical personnel within 30 days before placement in the facility. The examination shall include an assessment of the appropriateness of placement in a facility. The findings of this examination shall be recorded on the examination form provided by the agency. The completed form shall accompany the resident and shall be submitted to the facility owner or administrator. Additionally, in the case of a mental health resident, the Department of Children and Families must provide documentation that the individual has been assessed by a psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse, or an individual who is supervised by one of these professionals, and determined to be appropriate to reside in an assisted living facility. The documentation must be in the facility within 30 days after the mental health resident has been admitted to the facility. An evaluation completed upon discharge from a state mental hospital meets the requirements of this subsection related to appropriateness for placement as a mental health resident providing it was completed within 90 days prior to admission to the facility. The applicable department shall provide to the facility administrator any information about the resident that would help the administrator meet his or her responsibilities under subsection (1). Further, department personnel shall explain to the facility operator any special needs of the resident and advise the operator whom to call should problems arise. The applicable department shall advise and assist the facility administrator where the special needs of residents who are recipients of optional state supplementation require such assistance. (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 Page 4 of 45 provider, the necessary care and services to treat the condition. (11) No resident who requires 24-hour nursing supervision, except for a resident who is an enrolled hospice patient pursuant to part IV of chapter 400, shall be retained in a facility licensed under this part. § 429.26(1, 4, 5, 6, 7, 11), Fla. Stat. (2016). 7. Rule 58A-5.0181, Florida Administrative Code, states in pertinent part: (1) ADMISSION CRITERIA. (a) 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: 1. Be at least 18 years of age. 2. Be free from signs and symptoms of any communicable disease that is likely to be transmitted to other residents or staff; however, an individual who has human immunodeficiency virus (HIV) infection may be admitted to a facility, provided that the individual would otherwise be eligible for admission according to this rule. 3. Be able to perform the activities of daily living, with supervision or assistance if necessary. 4. Be able to transfer, with assistance if necessary. The assistance of more than one person is permitted. 5. Be capable of taking medication, by either self-administration, assistance with self-administration, or by administration of medication. a. If the resident needs assistance with self-administration, the facility must inform the resident of the professional qualifications of facility staff who will be providing this assistance. If unlicensed staff will be providing assistance with self- administration of medication, the facility must obtain written informed consent from the resident or the resident’s surrogate, guardian, or attorney-in-fact. b. 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 service to the resident. 6. Not have any special dietary needs that cannot be met by the facility. 7. Not be a danger to self or others as determined by a physician, or mental health practitioner licensed under Chapter 490 or 491, F.S. 8. Not require 24-hour licensed professional mental health treatment. 9. Not be bedridden. 10. Not have any stage 3 or 4 pressure sores. A resident requiring care of a stage 2 pressure sore may be admitted provided that: a. Such resident either: (1) Resides in a standard licensed facility and contracts directly with a licensed home health agency or a nurse to provide care, or (ID Resides in a limited nursing services licensed facility and services are provided pursuant to a plan of care issued by a health care provider, or the resident contracts directly with a licensed home health agency or a nurse to provide care; b. The condition is documented in the resident’s record and admission and Page 5 of 45 discharge log; and c. If the resident’s condition fails to improve within 30 days as documented by a health care provider, the resident must be discharged from the facility. 11. Not require any of the following nursing services: a. Oral, nasopharyngeal, or tracheotomy suctioning; b. Assistance with tube feeding; c. Monitoring of blood gases; d. Intermittent positive pressure breathing therapy; or e. Treatment of surgical incisions or wounds, unless the surgical incision or wound and the condition that caused it, has been stabilized and a plan of care developed. 12. Not require 24-hour nursing supervision. 13. Not require skilled rehabilitative services as described in Rule 59G-4.290, F.AC. 14. Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator must base the decision on: a. 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; b. The facility’s admission policy and the services the facility is prepared to provide or atrange in order to meet resident needs. Such services may not exceed the scope of the facility’s license unless specified elsewhere in this rule; and c. The ability of the facility to meet the uniform fire safety standards for assisted living facilities established in Section 429.41, F.S. and Rule Chapter 69A-40, F.A.C. * * * (2) HEALTH ASSESSMENT. As part of the admission criteria, an individual must undergo a face-to-face medical examination completed by a health care provider as specified in either paragraph (a) or (b) of this subsection. (a) A medical examination completed within 60 calendar days before to the individual’s admission to a facility pursuant to Section 429.26(4), F.S. The examination must address the following: 1. The physical and mental status of the resident, including the identification of any health-related problems and functional limitations; 2. An evaluation of whether the individual will require supervision or assistance with the activities of daily living; 3. Any nursing or therapy services required by the individual; 4. Any special diet required by the individual; 5. A list of current medications prescribed, and whether the individual will require any assistance with the administration of medication; 6. Whether the individual has signs or symptoms of Tuberculosis, Methicillin Resistant Staphylococcus Aureus, Scabies or any other communicable disease, which are likely to be transmitted to other residents or staff; 7. A statement on the day of the examination that, in the opinion of the examining health care provider, the individual’s needs can be met in an assisted living facility; and 8. The date of the examination, and the name, signature, address, telephone number, and license number of the examining health care provider. The medical Page 6 of 45 examination may be conducted by a health care provider licensed under Chapters 458, 459 or 464, F.S. (b) A medical examination completed after the resident’s admission to the facility within 30 calendar days of the admission date. The examination must be recorded on AHCA Form 1823, Resident Health Assessment for Assisted Living Facilities, October 2010. The form is hereby incorporated by reference. AHCA Form 1823 may be obtained http://www.flrules.org/Gateway/reference.asp?No=Ref-04006. Faxed or electronic copies of the completed form are acceptable. The form must be completed as instructed. 1. Items on the form that may have been omitted by the health care provider during the examination do not necessarily require an additional face-to-face examination for completion. The facility may obtain the omitted information either orally or in writing from the health care provider. 2. Omitted information must be documented in the resident’s record. Information received orally must include the name of the health care provider, the name of the facility staff recording the information, and the date the information was provided. 3. Electronic documentation may be used in place of completing the section on AHCA Form 1823 referencing Services Offered or Arranged by the Facility for the Resident. The electronic documentation must include all of the elements described in this section of AHCA Form 1823. (c) Any information required by paragraph (a) that is not contained in the medical examination report conducted before the individual’s admission to the facility must be obtained by the administrator using AHCA Form 1823 within 30 days after admission. * * * (f) Any orders for medications, nursing, therapeutic diets, or other services to be provided or supervised by the facility issued by the health care provider conducting the medical examination may be attached to the health assessment. A health care provider may attach a DH Form 1896, Florida Do Not Resuscitate Order Form, for residents who do not wish cardiopulmonary resuscitation to be administered in the case of cardiac or respiratory arrest. (g) A resident placed on a temporary emergency basis by the Department of Children and Families pursuant to Section 415.105 or 415.1051, F.S., is exempt from the examination requirements of this subsection for up to 30 days. However, a resident accepted for temporary emergency placement must be entered on the facility’s admission and discharge log and counted in the facility census; a facility may not exceed its licensed capacity in order to accept such a resident. A medical examination must be conducted on any temporary emergency placement resident accepted for regular admission. 8. The Agency conducted a complaint survey at the Respondent Facility from May 25, 2017 to June 09, 2017. Deficiencies were found at the time of surveys. 9. Based on observation, interview and record review, the Assisted Living Facility (ALF) failed to ensure that 2 of 6 sampled residents met the admission criteria (Residents #1 and Page 7 of 45 #2). 10. — Resident #1 was non-ambulatory, could not use his hands because his extremities were contracted beyond use, and required total care upon admission to the ALF. 11. Resident #2 needed 24-hour psychiatric care. 12. The ALF also failed to ensure a comprehensive Health Assessment was properly completed for 3 out of 6 sampled residents (Residents #2, #4, and #5) within 60 days prior to or 30 days after admission to the facility. 13. Upon arrival to the facility on May 25, 2017, at 11:30 a.m., Staff B was observed caring for a census of four residents. 14. _ During the tour, Staff B reported that room #3 was occupied by Resident #1, who had passed away. 15. Room #4 was occupied by Resident #2, who had eloped from the facility. 16. Resident #4, who Staff B stated did not live at the facility, was observed asleep in bed. Resident 1 17. On May 25, 2017, at 11:50 a.m., the Agency observed that there was no resident record onsite at the facility for Resident #1. 18. The facility did not have an admission and discharge log onsite. 19. | There was no documentation available to indicate Resident #1 had lived at the facility. 20. On May 25, 2017, at 11:47 am., Staff B stated regarding Resident #1, "I do not have his file because [another state agency] took it with them. They have a lot of paper, all his papers, with them.” 21. A review of the progress notes from the state agency (received from the facility's Page 8 of 45 legal representative via email days after the inspection) showed that Resident #1, age 64, was admitted from a group home for persons with severe disabilities sometime in October 2016 or November of 2016. 22. According to the other Agency’s progress notes, the resident was described as: [I]n need of total care services. He is not able to bathe himself. He cannot walk without assistance. He has a walker but is unstable. He is very aggressive and defiant to the staffmembers. He constantly throws his diapers off either wet or dry. He likes to be without clothes. He verbally curses the staff upon helping him. He is assisted with all of his meals. The food must be soft for him to eat. 23. | Areview of records from a December 2016 hospitalization showed the resident had two pressure ulcers, at the root of the helices bilaterally (ear wound). On the right, it measured 0.7x0.3 cm (centimeters). On the left it measured 3x0.7cm. The resident also had a large sacral wound (a wound in the area of the sacrum, the wedge shaped vertebra at the inferior end of the spine), with measurements not stated in the record. The resident was also diagnosed with Dysphagia (defined as difficulty swallowing), Urinary Tract Infection (defined as an infection of the urinary system to include the kidney, bladder or urethra), unspecified Psychosis (defined as a mental disorder characterized by a disconnection from reality), Extrapyramidal movement disorder (defined as drug induced side effects for persons who receive antipsychotic medications), Seizures (defined as a a sudden surge of electrical activity in the brain possibly causing convulsions or a change in behavior for a short time), Hypothyroidism (defined as a condition in which the thyroid gland doesn't produce enough thyroid hormone, Hypertension (defined as a condition where the force of blood against the artery wall is too high), and Hyperlipidemia (defined as high levels of fat particles/lipids in the blood). 24. A review of the facility's record for Resident #1 showed that there was no documentation of an admission date, contract between the resident and the facility, or any other move-in documents, including power of attorney. Further review of the notes from the other state Page 9 of 45 agency showed, the resident's brother was his legal guardian. There was no documentation in the file that the guardian had given consent for Resident #1 to move to the ALF. Further review of the resident record showed, there was no documentation that the resident was receiving home health services for his pressure ulcers. 25. A review of the staff records revealed no documentation that the administrator or any staff person was a licensed medical professional trained to care for Resident #1's sacral wound or the other two pressure ulcers. 26. A review of hospital records revealed Resident #1 died on April 7, 2017. 27. The resident had been receiving medication administration and nutrition through a PEG tube (Percutaneous Endoscopic Gastrostomy, a tube in the stomach to provide a means of feeding for people who have Dysphagia/difficulty swallowing) by unlicensed ALF staff for three days before being hospitalized with sepsis (a potentially life-threatening infection). Resident 2 28. A review of Resident #2's health assessment provided by the facility on May 25, 2017, revealed the document was undated. The assessment indicated that the resident needed 24- hour psychiatric care and supervision with all activities of daily living. 29. The resident’s diagnoses included Cellulitis to bilateral lower extremities (defined a bacterial skin infection), Schizophrenia (defined as a disorder that affects a persons ability to think, feel and behave clearly), Chronic Alcohol Use and smoking and an elopement risk. 30. The assessment did not indicate if the resident needed assistance with medication or what kind of assistance (self-administration or medication administration). 31. The Administrator provided a second health assessment on May 26, 2017. This assessment was dated February 15, 2017 and indicated the resident was independent. Page 10 of 45 32, On May 25, 2017, at 11:47 am., Staff B reported that Resident #2 walked away (eloped) after living at the facility for a month or two. He further stated, "Resident #2 was admitted on February 15, 2017, and left. I believe that in March he left and the police brought him back to the house, He was here in the month of April until May 13, 2017, and he walked away again." 33. Staff B further stated, "The resident does not have a MOR (medication observation record) for May 2017 because he ran away. He did not have SSI (social security income) or insurance, so there was no way to get his medication.” Resident 4 34, On May 25, 2017, at 11:35 a.m., Staff B reported that room #3 was a private room where Resident #1 lived before he passed away, but that this room was now occupied by Resident #4. He further stated, "I'm fixing her bed now—that's why the bed does not have linen. She is not an ALF resident, she is here temporarily for a few days because the other house where she lives has a tent." Resident # 4 was observed leaving the bedroom to sit in the living room. The resident was not able to be interviewed. 35. A review of the facility records revealed no documentation that Resident #4 was living in the home and sleeping in room #3. A review of the resident records revealed no records for Resident #4. 36. An observation of the medication cabinet revealed Resident #4's medications were present. A review of the Medication Observation Records (MOR) showed there was an MOR for Resident #4, for the month of April 2017. The resident was prescribed Divalproex 500 mg (milligrams), Benzetropine 2mg, Chlorpromazine 200 mg, Lorazepam | mg and Propranolol 10 mg ordered at 7:00 a.m., 3:00 p.m. and 11:00 p.m. According to the Mayo Clinic, Divalproex is described as an anticonvulsant used to treat the manic phase of bipolar disorder or seizures. Chlorpromazine is described as a phenothiazine, a medication used to treat serious mental and Page 11 of 45 emotional disorders. Lorazepam is used to treat anxiety. Propranolol is used to treat high blood pressure, chest pain or irregular heartbeat. Benzetropine used to treat Parkinson’s disease and side effects of other drugs. 37. On May 25, 2017, at 12:16 p.m., Staff B reported that Resident #4 was independent, but needed 24-hour supervision and assistance. He further stated, "I do assist her with medication and all Activities of Daily Living (ADL).” 38. On May 25, 2017, at 1:04 p.m., the Administrator stated, "Resident #4 does not belong to this house. She moved from [another state agency's] group home to the ALF. She is a free client. We are helping her without any payment." At 1:09 p.m., the Administrator stated, "yesterday we went to the hospital and they did not refill her medications. They are going to give her a shot." 39. A review of a document found in the facility not connected to a resident record revealed that the facility acted as payee for Resident #4's social security benefit payments. Resident 5 40. On May 25, 2017, at 1:10 p.m., Staff B and the Administrator reported that Resident #5 was independent. 41. A review of Resident #5's record revealed an Assisted Living Facility (ALF) admission and financial Agreement for the monthly amount of $680.00 and a waiver of $1200.00 (dated July 1, 2015), resident weight sheet, assistance with medication, and a signed informed consent (dated July 1, 2015). 42. There was no documentation of a face to face health assessment (AHCA 1823) done within 60 days prior to the admission or 30 days after the admission date to indicate diagnoses and what kind of assistance the resident needed (including with her medications). 43. Further review of the record showed documents from an earlier state hospitalization Page 12 of 45 identifying the resident as being at high risk of elopement, displaying dangerous behaviors to other residents, and needing assistance with medication. 44. During an interview on May 25, 2017, at 3:40 p.m., Resident #5 stated, "I have my medication with me." The resident picked up her purse from the floor and showed two bottles of prescribed medication. 45. | The Agency determined that the above constitutes grounds for the imposition of a Class I violation. 46. — Class “I” 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 present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24-hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. §408.813(2)(a) Fla. Stat. (2016). 47. Class “I” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class ] violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. §429.19(2)(a) Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine against the Respondent in the amount of ten thousand dollars ($10,000). COUNT II Continued Residency 48. The Agency re-alleges and incorporates by reference paragraphs 1-4 and Count I as if fully set forth herein. Page 13 of 45 49. Rule 58A-5.0181, Florida Administrative Code, states in pertinent part: (4) CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility must 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 health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change 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 accordance with that paragraph. (a) The resident may be bedridden for up to 7 consecutive days. (b) A resident requiring care of a stage 2 pressure sore may be retained provided that: 1. The resident contracts directly with a licensed home health agency or a nurse to provide care, or the facility has a limited nursing services license and services are provided pursuant to a plan of care issued by a health care provider; 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 health care provider, the resident must be discharged from the facility. (c) 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 that coordinates and ensures the provision of any additional care and services that may be needed; 2. Continued residency is agreeable to the resident and the facility; 3. An interdisciplinary care plan, which specifies the services being provided by hospice and those being provided by the facility, is developed and implemented by a licensed hospice in consultation with the facility; and 4. Documentation of the requirements of this paragraph 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 at all times. (e) A hospice resident that meets the qualifications of continued residency pursuant to this subsection may only receive services from the assisted living facility’s staff within the scope of the facility’s license. (6 Assisted living facility staff may provide any nursing service permitted under the facility’s license and total help with the activities of daily living for residents admitted to hospice; however, staff may not exceed the scope of their professional licensure or training. (g) Continued residency criteria for facilities holding an extended congregate care license are described in Rule 58A-5.030, F.A.C. (5) 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 health care provider, the resident must be discharged in accordance with Section 429.28, F.S. Page 14 of 45 Fla. Admin. Code R 58A-5.0181(4) and (5) (2016). 50. The Agency conducted a complaint survey at the Respondent Facility from May 25, 2017 to June 09, 2017. Deficiencies were found at the time of surveys. 51. Based on interview and record review, the facility failed to determine ongoing appropriateness for continued residency for 2 of 6 sampled residents (Residents #1, and #2). The facility failed to meet the increased care needs for Resident #1 who experienced a decline in health with dysphagia resulting in a percutaneous endoscopic gastrostomy (PEG) tube being placed. Resident #2 eloped from the facility three times, with facility staff making no interventions between clopements. Resident 1 52. | Areview of records from another state agency found that Resident #1 was admitted to the Assisted Living Facility (ALF) sometime in October 2016 or November of 2016. The resident needed total care upon admission to the ALF. The resident's extremities were contracted beyond use. The resident had diagnoses to dysphagia, Diabetes Mellitus II, and a wound on the sacrum and the great toe of the right foot. The resident’s hospital records did not identify the stage of these wounds, but described the sacral wound as “very large.” 53. A review of facility records revealed no records on-site for Resident #1. The facility's legal representative emailed a copy of the record to the Agency and the original record was later obtained from another state agency. After the records were obtained, they revealed that the facility failed to document that the resident had been hospitalized several times. 54. On June 6, 2017, at 3:56 p.m., Resident #1's caseworker from another state agency reported: a. He went to the hospital several times. For example, on December 22, 2016, our agency received an incident report that the resident was transferred to Page 15 of 45 an emergency room; on January 9, 2017, he was transferred to a hospital; and on February 6, 2017, he was discharged to the ALF. I went to the ALF to visit him. On March 8, 2017, my client went to the hospital and on March 27, 2017, he was discharged back to the ALF. 55. A review of the hospital records revealed, Resident #1 was hospitalized multiple times before his death. 56. A/January 14, 2017, hospital record revealed Resident #1 was admitted for a decline in function. The resident had aspiration pneumonia, sepsis with ESBL (Extended Spectrum Beta Lactamases-an enzyme produced by bacteria) Escherichia Coli pneumonia, altered mental status, Diabetes Mellitus II, malnutrition, hypothyroidism, hyperglycemia, seizure disorder, urinary tract infection and dementia. Further review shows that the resident developed an Ileus. The resident had two pressure ulcers, at the root of the helices bilaterally. On the right, it measured 0.7x0.3 cm (centimeters). On the left it measured 3x0.7cm. The resident also had a large sacral wound, with measurements not documented in the record. The resident was in the intensive care unit and was eventually transferred to another hospital for continued treatment prior to returning to the ALF. 57. A March 10, 2017, hospital record revealed Resident #1 was hospitalized until March 26, 2017, for functional decline and altered mental status. The resident had a decreased appetite, was unable to follow commands and required total assistance with all bed mobility. The resident was unable to sit, stand or transfer. A PEG (Percutaneous Endoscopic Gastrostomy) Tube was installed to facilitate the resident's receipt of nutrition directly into his stomach due to difficulties swallowing. 58. According to hospital records, upon discharge on March 26, 2017, the resident needed placement at a skilled nursing facility and was discharged via stretcher. Instead of being sent to anursing home, Resident #1 was returned to the assisted living facility. The resident needed Page 16 of 45 continuous PEG tube feedings at 65cc (cubic centimeters) per hour, with clear water flushes at 300cc every 4 hours. 59. During interview on June 8, 2017, at 2:01 p.m., the Administrator reported Resident #1 was discharged from the hospital with a catheter in place and that a nurse from the hospital came to the facility on the evening of March 26, 2017, to remove the catheter and to teach the staff how to administer the resident's medication and nutrition through the PEG tube. 60. The Administrator reported that the facility staff fed the resident through the PEG tube four or five times per day. 61. The Administrator reported that Staff B and Staff C were administering medication and nutrition to Resident # 1 through the PEG tube every day from March 26 through 29, 2017, until he returned to the hospital. 62. The administrator confirmed, neither Staff B nor Staff C was a nurse or other licensed medical professional. 63. The Administrator reported, she did not know that the facility staff could not administer medications, or food through the PEG tube. 64. The March 10, 2017, hospital record stated that Resident #1 needed continuous PEG tube feedings at 65cc per hour, with clear water flushes at 300 cc every 4 hours and the following medications were prescribed for the resident: Aspirin, baby, 81 mg (milligrams) by mouth; Benzetropine .5 mg by mouth twice daily; Bisacodyl 10 mg rectally as needed; Famotidine 20 mg oral; Lactobacillus Acidophilus Three times a day with meals; Levetiracitam 500 mg by mouth every 12 hours; Levothyroxine 0.125 mg by PEG tube daily; Magnesium Citrate 300 mi (milliliters) by mouth once only, if constipated within 48 hours; Polyethelene Glycote 3350, 17 gm(grams), oral, once daily; Quetiapine 100mg, oral HS(hour of sleep); Temazepam 7.5 mg, oral, PRN(as needed); Jevity 1.5 mg, tube feeding, with goal of 65cc per hour. Page 17 of 45 65. The ALF did not have any documentation that the resident was receiving home health agency care from qualified health professionals to administer the tube feeding for nutrition and medications through the PEG tube. 66. During interview on June 8, 2017 at 2:05 p.m., the Administrator reported that Resident #1 was able to swallow. The administrator showed a photo in her personal cellular phone that showed Resident #1 drinking from a cup. She stated: The hospital always said he had trouble swallowing, but I know my residents. He was constantly asking for something to drink or eat, so we gave it to him. When asked how she thought these drinks or meals affected the Residents' diagnosis of Dysphagia, she stated, the hospitals could never agree on whether he really had the condition or not. She further reported, once the PEG tube was inserted, they no longer gave Resident #1 food or drink by mouth. 67. A review of the hospital records showed Resident #1 was returned to the hospital on 03/29/17, because he was severely constipated for four days, and was dehydrated. His hospital diagnoses included, Ileus (a disruption of the normal action of the intestines, where food or waste no longer progresses through the intestines); Small Bowel Obstruction, Acute Kidney Injury and Chronic Kidney Disease (stage 3, secondary to dehydration), severe protein calorie malnutrition (likely from poor oral intake), and bilateral lower extremity edema (likely secondary to hyperglobulinemia, Dysphagia, Sepsis, Diabetes, Psychiatric disorder not specified, mental retardation, seizures, and thyroid disease). 68. The resident died on April 7, 2017. Resident 2 69. During an interview on May 25, 2017, at 11:47 a.m. Staff B reported, Resident #2 was living here at the house for a month or two and he walked away. Staff B stated, "I don't know where he is at this moment, we filed a police report.” Staff B revealed that Resident #2 was admitted on February 15, 2017, and subsequently eloped. Staff B further stated “I believe, in March 2017, he left and the police brought him back to the house. He was here in April 2017 until Page 18 of 45 May 13, 2017, at 6:30 p.m., then he walked away again.” 70. Staff B reported that resident did not have a medication observation record (MOR) for the month of May 2017 because he did not have medication. The resident had to go back to the hospital for an appointment to refill his medication. Staff B reported, “I made the appointment for May 18, 2017 and he ran away on May 13th." Staff B further stated that Resident #2 was without medication from May 1 through May 13, 2017, when he ran away. Staff B reported, the resident did not have insurance or income, and there was no way to get his medications. 71. A review of Resident #2's health assessment provided by the facility on May 25, 2017, revealed the document was undated. The assessment showed that the resident needed 24- hour psychiatric care and supervision with all activities of daily living. The diagnoses included: Cellulitis to bilateral lower extremities (defined a bacterial skin infection), Schizophrenia (defined as a disorder that affects a persons ability to think, feel and behave clearly), Chronic Alcohol Use, smoking and an elopement risk. The assessment did not indicate if the resident needed assistance with medication, or what kind of assistance (self-administration or medication administration). 72. The Administrator provided a second health assessment on May 26, 2017. This assessment was dated February 15, 2017, and indicated that the resident was independent. 73. The resident's record did not have documentation of the three elopements except for the police report number for a missing person's report for two of the episodes. 74. The Facility's elopement policy states: a. Each individual will be assessed for risk of elopement during the referral and admissions process. Assessment may also occur after admission due to demonstration of elopement behavior. b. The policy further stated that individuals identified to be at risk will receive identification on their person or possibly their wheelchair stating the Page 19 of 45 individual's name, name of facility, address, and phone numbers. c. The policy also provides that individuals identified to be at risk will have a photo identification for use by all agency personnel, other agencies as necessary and law enforcement. d. Per the policy, the photo identification will be obtained upon admission and/or within 10 calendar days. 75. A review of the resident records showed, there was no documentation of an elopement assessment for any resident and no photos of residents were in the files. 76. During interview on June 8, 2017, at 1:23 p.m., the Administrator reported that Resident #2 was found wandering the street and did not know how to get back to the facility after his first elopement. She stated that the police took him to the hospital. The Administrator futher reported that when Resident #2 ran away in May 2017, the police found him in the Florida Keys, and put him in jail on an old warrant. She further stated: The person who referred Resident #2 from the hospital told me that he is a problem. I spoke with Resident #2; he showed me his arm and told me that he is a drug addict. He stated he robbed things to get money to buy drugs. I did nothing to prevent the elopement, because they can walk away if they want. 77. The Administrator also stated that she does not have photos on record nor identification for residents to wear when they leave the facility. 78. During the survey from May 25 through June 21, 2017 the Administrator stated that she did not have any knowledge about the ALF regulations and how these problems can be corrected. 79. The Agency determined that the above constitutes grounds for the imposition of a Class I violation. 80. Class “I” violations are those conditions or occurrences related to the operation and Page 20 of 45 maintenance of a provider or to the care of clients which the agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24-hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. §408.813(2)(a) Fla. Stat. (2016). 81. Class “I” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. §429.19(2)(a) Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine against the Respondent in the amount of ten thousand dollars ($10,000). COUNT I Staffing Standards—Administrators 82. | The Agency re-alleges and incorporates by reference paragraphs 1-4 and Counts I and I! as if fully set forth herein. 83. Rule 58A-5.019, Florida Administrative Codes, states in pertinent part: (1) ADMINISTRATORS. Every facility must 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 appropriate care to all residents as required by Part II, Chapter 408, F.S., Part I, Chapter 429, F.S., Rule Chapter 59A-35, F.A.C., and this rule chapter. Fla. Admin. Code R. 58A-5.019(1) (2016). 84. Based on observations, record review, and interviews, the Administrator failed to maintain the general oversight of the daily operation of the Assisted Living Facility. 85. The Administrator also failed to ensure the appropriateness of admission and Page 21 of 45 continued residency for at least 3 of 7 residents (Residents #1, #2, and #4) and failed to ensure that qualified staff were providing adequate care and services to the residents. 86. The Administrator failed to ensure that resident records were completed for 6 out of 7 sampled residents (Residents #1, #2, #3, #4, #5, and 6). 87. The Administrator failed to ensure that residents received medications timely, and failed to maintain updated medication observation records (MOR). The Administrator failed to have complete staff records that included an employment application, an eligible level 2 background screening for staff A, B and C. 88. The Administrator failed to maintain an admission and discharge log, progress notes, or elopement drill records for 7 out of 7 residents (Residents #1, #2, #3, #4, #5, #6, and #7). 89. The Administrator failed to file adverse incident reports with the Agency after Resident #2 eloped three times from the facility and was hospitalized. 90. During a survey from May 25 through June 21, 2017, the Administrator stated that she did not have any knowledge about assisted Living Facility (ALF) regulations and how her facility’s problems could be corrected. 91. During a tour of the facility on May 25, 2017, at 11:30 a.m., Staff B revealed that room #3 was occupied by Resident #1, who passed away, and Room #4's empty bed was occupied by Resident #2, who eloped from the facility. 92. A review of resident records revealed that there were no records for Resident #1. 93. A review of resident records revealed there were no progress notes or incident reports regarding Resident #2's elopement. Resident 1 94. A review of hospital records and records from another state agency showed that Resident #1 was admitted approximately in November of 2016, the resident needed total care when Page 22 of 45 he was admitted to the assisted living facility (ALF), and the resident's extremities were contracted beyond use. The resident had diagnoses to include dysphagia, Diabetes Mellitus Il, a wound on the sacrum and right foot great toe. The hospital records did not identify the stage of these wounds, but described the sacral wound as ‘very large." 95. Resident #1 was discharged from the hospital on March 26, 2017, by stretcher, to the ALF even though skilled nursing was identified by the physician as being the needed level of care. The diagnoses on the hospital admission a few days before the residents death included, Ileus (a disruption of the normal action of the intestine, where food and waste no longer progress through the intestines), Bowel Obstruction, Acute Kidney Injury and Chronic Kidney Disease (Stage 3, secondary to dehydration), severe protein calorie malnutrition (likely from poor oral intake) and bilateral lower extremity edema (likely secondary to hyperglobulinemia), Dysphagia, Sepsis, Diabetes, Psychiatric disorder not specified, mental retardation, seizures, and thyroid disease. 96. Between March 16 and 26, 2017, the resident was hospitalized and a PEG (Percutaneous Endoscopic Gastrostomy) tube was inserted. During this period, a facility caretaker who wasn't a licensed professional administered his medication and food through the PEG tube. Flushes of the PEG tube were prescribed 3 times daily. During an interview with the ALF Administrator, it did not appear she had knowledge that unlicensed staff couldn't perform this type of care. 97. On June 8, 2017, at 2:01 p.m., the Administrator reported Staff B and staff C were feeding and administering Resident #1 medication and food through the PEG tube. Staff B acknowledged he did not have a professional license authorizing him to administer medication and tube feeding through the PEG tube. 98. Resident #1 was admitted to the hospital on March 29, 2017 with severe Page 23 of 45 constipation, dehydration, and other diagnoses listed above. 99. Resident #1 died on April 7, 2017. Resident 2 100. During an interview on May 25, 2017, at 11:47 a.m., Staff B reported that Resident #2 was living at the facility for a month or two before eloping. Staff B further reported that Resident #2 was admitted on February 15, 2017 and he left sometime in March 2017, with the police bringing him back to the house. Staff B stated that the resident was present at the ALF from April 2017 until May 13, 2017, when he eloped again. 101. Resident #2's record revealed a health assessment requiring 24-hour psychiatric care and supervision with all activities of daily living. Resident #2's diagnoses included Cellulitis bilateral lower extremities, Schizophrenia, Chronic Alcohol Use, smoking and an elopement risk. The health assessment did not have indication if the individual needs assistance with the medication and what kind of assistance (self-administration or medication administration). 102. The resident’s records did not have documentation of the events surrounding the times when the resident had left the facility. The facility only had the police report number. 103. On May 25, 2017, at 1:28 p.m. on May 25, 2017, the Administrator stated, "I do not have a complete record for Resident #2. He had a different situation because a hospital sent him here." 104. Review of the facility's elopement/missing person policy and procedures revealed the facility did not follow its own procedures regarding wandering behavior. 105. Staff did not demonstrate an understanding and competency of the policy and procedures. There was no documentation that residents were assessed for their risk of elopement during the referral and admissions process. 106. The residents identified to be at risk did not receive identification on their person Page 24 of 45 that included the following: the individual's name, name of the facility, address, and phone numbers. 107. The residents identified to be at risk did not have a photo identification obtained upon admission and/or within 10 calendars days of admission. 108. On May 25, 2017, at 3:20 p.m., the Administrator reported no elopement drill was done. She stated, she did not file one day and fifteen day adverse incident reports with the Agency. 109. Staff B reported this resident did not have a medication observation record (MOR) for the month of May 2017 because he did not have medication. Staff B stated that the resident had to go back to the hospital for an appointment to refill his medication, but the resident eloped before his appointment. Staff B reported that Resident #2 was without medication from May 1 through May 13, 2017, when he ran away. Staff B reported that the resident did not have insurance and there was no way to get his medications. Resident 4 110. On May 25, 2017, at 11:45 A.M, Staff B reported that Resident #4 occupied room #3, 111. The Administrator and Staff called this resident a “free client.” The Administrator stated that the resident did not belong to her facility. She stated that the resident was a client that belonged to another facility. 112. Record review revealed that Resident #4 did not have a file; however, a payment from a federal agency showed the facility as the payee for Resident #4. 113. The resident’s medication observation record (MOR) was found for the month of April 2017. The list of medications was included, Divalproex 500 mg (milligrams), Benzctropine 2mg, Chlorpromazine 200 mg, Lorazepam 1 mg and Propranolol 10 mg ordered at 7:00 a.m., 3:00 p.m. and 11:00 p.m. Page 25 of 45 114. Bottles of these medications with Resident #4's name on them were found in the facility's locked medication cabinet. Resident 5 115. A review of records for Resident #5, referred to as "independent resident" by facility staff, revealed an ALF admission and financial Agreement, a resident weight sheet, an assistance with medication, and informed consent form signed and dated on July 1, 2015. 116. There was no face to face health assessment (AHCA 1823) done within 60 days prior to the admission and/or 30 days after the admission to indicate diagnoses and what kind of assistance the resident needed with her medication. 117. The resident record did not contain documentation or progress notes. Medications 118. On June 8, 2017, at 12:53 p.m., the medications locked inside of the facility's cabinet located in the kitchen were reviewed with the Administrator and Staff B to establish why certain medications were still at the facility. OTC (over the counter) medications without resident names were observed to include, Fish oil 1200 mg, Pepto-Bismol 5, Vitamin C 500 mg, two bottles of Sentry multivitamin supplement, Qvar 80 mceg(micrograms), Senior advanced therapy. 119. Resident #1, who passed away on 04/07/17, still had medications in the medication cabinet for the month of February 2017 and included, Lithium Carb 450 mg, Levothyroxin 50 mg, Famotidine 20 mg, Benztropine 0.5 mg, Levetiraceta 500 mg, Aspirin 81 mg and Quetiapine 25 mg. 120. On June 8, 2017, at 12:55 p.m., the Administrator reported that Resident # 7 had left the facility for a long time. Her medications found in the locked medication cabinet were: Nexium 40 mg, Rivastigmine cap 4.5 mg, Amlodipine 10 mg, Montelukast 10 mg, Escitalopram 5 mg., over the counter medications and Alendronate 70 mg. Page 26 of 45 121. The Administrator stated that she did not have knowledge that OTC medications needed to be labeled with the resident names and couldn't be shared with others residents. 122. The Administrator reported she did not have knowledge of how to discard medications after residents left the facility. 123. A review of Resident # 3's medication observation record (MOR) revealed a list of medications to include, Atorvastatin 40 mg, Gabapentin 300 mg, Hydroxyzine 50 mg, Nuedexta 20-10 mg, Quetiapine Fumarate 50 mg, and Zolpidem. Medications were not initialed on May 23, 24, and 26, 2017, by staff and the medication blister pack was punched open. 124, Areview of Resident #6's MOR showed that, scheduled at 9:00 a.m., Valsartan 80 mg was not initialed for May 25, 2017. At 9:00 a.m., Vitamin D 3 and Baclofen 10 mg was not initialed for May 24 and 25, 2017. At 9:00 a.m. Atorvastatin 40 mg, Brimonidine 0.2 eye drop, Latanoprost 0.005 eye drops, Quetiapine Fumarate 100 mg, Baclofen 10 mg and Gabapentin 100 mg were also not initialed on dates from May 23 through May 25, 2017. 125. On May 25, 2017, at 11:57 a.m., Staff B acknowledged the MORs were not initialed for a few days and asked to sign the MOR after the fact. Facility Records 126.