STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. AHCA No. 2019019335 SOVEREIGN HEALTHCARE OF WEST PALM BEACH, LLC., d/b/a BOULEVARD REHABILITATION CENTER, Respondent. / ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against the Respondent, Boulevard Rehabilitation Center (‘the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine of $2,000.00 against a nursing home based upon criminal background screening violations. PARTIES 1. The Agency is the licensing and regulatory authority that oversees nursing homes in Florida and enforces the applicable state statutes and rules governing such facilities. Ch. 408, Part Il, Ch. 400, Part I, Fla. Stat. (2019); Ch. 59A-4, Fla. Admin. Code. 2. The Respondent was issued a license by the Agency to operate a nursing home (“the Facility”) and was at all times material required to comply with the applicable statutes and rules governing nursing homes. COUNT I Criminal Background Screening -- Clearinghouse 3. Under Florida law, the Agency shall require level 2 background screening for personnel as required in Section 408.809(1)(e), Florida Statutes, pursuant to Chapter 435 and Section 408.809. § 400.215, Fla. Stat. (2019), The criminal background screening results of such personnel shall be reviewed by the Agency and the qualifying or disqualifying status of the person named in the request shall be maintained in a database. § 408.809(3), Fla. Stat. (2019). The Care Provider Background Screening Clearinghouse was created and providers are required to register with the Clearinghouse and comply with its statutory and rule provisions. § 435.12, Fla. Stat (2019); Fla. Admin. Code R. 59A-35.090. Among other requirements, employers must maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. § 435.12(2)(c), Fla. Stat. (2019). An employer must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee for electronic fingerprint submission to the Department of Law Enforcement. § 435.12(2)(d), Fla. Stat. (2019). 4. On or about 08/29/19 the Agency conducted a survey of the Facility. 5. Based on record review and staff interview, the Facility failed to ensure that initial employment or change in employment status was reported to the Care Provider Background Screening Clearinghouse employee roster within 10 days as required for 4 of 14 employees sampled (Staff A, B, C, and D). 6. Record review revealed Staff A, Registered Dietitian (contracted worker) with a hire date of 10/03/2018, was not included on the facility's roster in the Background Screening Clearinghouse. 7. Record review revealed Staff B, Registered Dietitian (contracted worker) with a hire date of 05/15/2019, was not included on the facility's roster in the Background Screening Clearinghouse. 8. Record review revealed Staff C, Dietary Technician (contracted worker) with a hire date of 02/21/2019, was not included on the facility's roster in the Background Screening Clearinghouse. 9. Record review revealed Staff D, Registered Dietitian (contracted worker) with a hire date of 07/22/2019, was not included on the facility's roster in the Background Screening Clearinghouse. 10. ‘In an interview conducted on 08//29/19 at 12:40 PM, the Director of Nursing acknowledged all findings. Relief 11. Under Florida law, the Agency may impose an administrative fine against a nursing home, not to exceed $500 per violation per day for the violation of any provision of part Il of chapter 400, part II of chapter 408, or the applicable rules. § 400.121, Fla. Stat. (2019). 12. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for cach violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2019). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $2,000.00 against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks an order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. Respectfully Submitted, OSES] D. Carlton Enfinger IT, Senior Attorney Florida Bar No. 793450 Office of the General C Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3658 Facsimile (850) 922-9634 Email: Carlton.Enfinger(@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 designated on this 4 day of January, 2020. ‘ id. (i ran D. Carlton Entinger II, Senj omey Florida Bar No. 793450 Office of the General Céunsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3658 Facsimile (850) 922-9634 Email: Carlton.Enfinger@ahca.myflorida.com Administrator Boulevard Rehabilitation Center 2839 S Seacrest Blvd Boynton Beach, FL 33435-7994 (U.S. Certified Mail) 9469 OOF0 O02? £048 0495 77 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: SOVEREIGN HEALTHCARE OF WEST ACHA No. 2019019335 PALM BEACH, LLC., d/b/a BOULEVARD REHABILITATION CENTER 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: USPS Tracking® Tracking FAQs Track Another Package + Track Packages Anytime, Anywhere Get the free Informed Delivery® feature to receive automated notifications on your packages Learn More Remove Tracking Number: 9489009000276048089577 Your item was delivered to an individual at the address at 1:55 pm on January 11, 2020 in BOYNTON BEACH, FL 33435. Status: Delivered January 11, 2020 at 1:55 pm Delivered, Left with Individual BOYNTON BEACH, FL 33435 Get Updates Delivered

Docket for Case No: 20-003421