vs. ) Case No. 98-0363
A hearing was held in this case in New Port Richey, Florida, on July 9, 1998, before Arnold H. Pollock, an Administrative Law Judge with the Division of Administrative Hearings.
Maureen L. Holz, Esquire Williams and Holz, P.A.
The issue for consideration in this case is whether Respondent’s license as a nursing home administrator in Florida should be disciplined because of the matters alleged in the Administrative Complaint filed herein.
By Administrative Complaint dated November 16, 1995, the Petitioner seeks to discipline Respondent’s license as a nursing home administrator because, it alleges, in April 1994, Respondent was negligent or incompetent in the practice of nursing home administration, and repeatedly acted in a manner inconsistent with the health, safety, or welfare of the residents of the facility she administered, in violation of Section 468.1755(1)(g) and (k), Florida Statutes, by failing to timely correct numerous deficiencies in the operation of the facility which had been identified by Departmental inspectors. Respondent demanded formal hearing on the allegations and this hearing ensued.
At the hearing, Petitioner presented the testimony of Patti K. Silar, a senior registered nurse supervisor and a
surveyor of nursing homes for the Department of Health; Carole G. Hembree, a health facility evaluator for the Department; and Anthony J. Pileggi, a nursing home administrator and expert in nursing home administration. Petitioner also introduced Petitioner’s Exhibits 1 through 8.
Respondent testified in her own behalf and presented the testimony of Kelley Schild, a nursing home administrator and an expert in nursing home administration. Respondent introduced Respondent’s Exhibits A through F. The parties agreed to the admittance of Joint Exhibit 1.
A transcript of the proceedings was furnished. Subsequent to the receipt thereof, both counsel submitted matters in writing
which were carefully considered in the preparation of this Recommended Order.
At all times pertinent to the issues herein, the Petitioner, Board of Nursing Home Administrators (Board), was the state agency in Florida responsible for the regulation of the nursing home administrator profession in this state and the licensing of nursing home administrators. Respondent, Judith Ortiz, was a licensed nursing home administrator holding license number NH 0002926.
Respondent has an undergraduate degree in science and art, and a master’s degree in Business Administration and Health Care Administration. Subsequent to the award of her graduate degree, she taught in long-term care facilities in Dade County, Florida, during which time she developed an interest in care of the elderly. Ms. Ortiz took and passed the examination for licensure as a nursing home administrator in 1990 and began work as an assistant nursing home administrator for Unicare, a care provider, in 1991. In December 1992, she came to Unicare’s facility in New Port Richey, Richey Manor, as the administrator, and remained there until she was terminated in May 1994. At the time of her termination, she was being paid a salary of $37,500.
Shortly after Respondent assumed the position of administrator at Richey Manor, an inspection of the facility by the Agency for Health Care Administration revealed no significant problem with resident pressure sores. Respondent’s own chronology of events reveals a subsequent series of unfortunate
personnel problems which befell the facility. Only two months after the Respondent was hired, the director of nursing at the facility resigned. It was at that point that Respondent’s problems amplified. A survey of the facility in October 1993 resulted in a citation for insufficient staffing, but the company’s nurse consultant, who visited the facility in
November 1993, concluded the staffing was sufficient. Respondent continued to seek various forms of assistance from her corporation, but in each case, her request was denied. The director of nursing, whom Respondent hired to replace the head nurse who had resigned at the beginning of the year, did not perform well, but Respondent nonetheless retained her on staff.
Ms. Patti K. Silar, a surveyor of nursing homes for the Department of Health Care Administration, has surveyed Richey Manor between six and eight times in the same number of years. In February 1994, as the result of an anonymous complaint filed with the Department, she conducted a survey there during which she found several deficiencies. Specifically, she found that while the number of personnel on duty met minimum license requirements, other factors indicated that staffing was inadequate to meet residents’ needs. This manifested itself in extended delays in responding to patient calls which resulted in resident incontinence and resident falls; failure to maintain resident cleanliness; failure to ensure residents were fed on time; and failure to properly turn bed-ridden patients. All
these deficiencies, which continued over a period of months, resulted in adverse health impacts to the residents.
A follow-up inspection of the facility was done on April 28, 1994. The follow-up was to a survey done on July 23, 1993, and to an investigation done on October 21, 1993, and
February 22, 1994. On this follow-up, the facility’s handling of pressure sores was again found to be inadequate; nursing staffing was determined to be inadequate to meet residents’ needs, resulting in inadequate resident care in several respects; and charge nurses were found not to be fulfilling their responsibilities for the total nursing care of residents in several respects.
The facility’s annual survey was conducted on April 29, 1994. Several additional deficiency areas were addressed in this survey, including the failure of the facility’s transfer paperwork to provide for appeal rights; inappropriate utilization of restraints; failure to meet sufficient quality of life standards; failure to maintain acceptable levels of assessments and personal grooming of residents; and failure to maintain acceptable comprehensive care plans for all residents to avoid deficiencies in such areas as dehydration, restraints, and the like.
This latter survey revealed, as related to pressure sores, not only that those deficiencies previously noted were not improved, but also that residents who came into the facility
without pressure sores developed them while in the facility. There was no plan in place to prevent the development of pressure sores, or to prevent the development of skin breakdown. Simple corrective action, such as the purchase of appropriate mattresses or the frequent turning and repositioning of the resident was not being taken. Ms. Silar concluded that the percentage of residents with pressure sores at Richey Manor was much higher than in other similar facilities, standing at approximately 25% of the residents afflicted, as compared with 7 to 8% in other facilities surveyed.
In addition to the level A areas found to be deficient, there were multiple level B areas, somewhat less serious than level A areas, found to be deficient as well. These included such matters as fluids being added to a resident’s intake without a physician’s orders, or, in the alternative, residents not being provided what a physician ordered. Further, Ms. Silar experienced an inability to reconcile records on seven residents of seven attempted. This is very unusual and showed a repeated failure to carry out doctors’ orders. The responsibility of insuring that all of this is done rests with the administrator who may delegate responsibility, but is not relieved of accountability.
Ms. Silar did not conduct the survey for the purpose of determining the competence of the facility administrator, but she observed significant areas in the operation which were out of
compliance, and residents were at risk as a result thereof. The care she observed being provided by the staff under the supervision of the Respondent was less than acceptable in those areas identified in the survey reports as being deficient.
Overall, the facility was not in compliance.
Whereas the February 1994 survey was abbreviated, the April 1994 survey was a full review for re-certification and re-licensure. As such, it was more comprehensive than the complaint survey. This April 1994 survey was done within one
year of the prior general survey; earlier than normal because of the Department’s serious concerns arising out of the
February 1994 complaint and inspection results.
According to Ms. Silar, Richey Manor, when compared with more than 100 other facilities she has surveyed since 1989, was in the lowest 2 percent. A specific problem she observed there during the February 1994 investigation was the facility’s treatment of bed sores. During the April 1994 survey, Ms. Silar found not only no improvement, but, in fact, a worsening of the conditions. As a result of these surveys, a moratorium was placed on admissions to Richey Manor, and, in fact, disciplinary action was subsequently taken against the facility.
Federal standards enacted in 1987 charge facilities such as Richey Manor with the responsibility of assisting residents to achieve their highest potential over-all. They also encourage facilities to change their emphasis to achieving
practical results rather than concentrating on paper compliance. Ms. Silar found that Richey Manor was placing only minimal emphasis on solving the bed sore problem when she surveyed the facility in February 1994. At that time it was clear that the residents were not being assessed, nor were care plans being developed. When the more comprehensive survey was done in
April 1994, 35 of 36 residents still did not have either appropriate assessments or care plans prepared for them. The facility did not have a comprehensive plan of care, and without that it was impossible to develop individual care plans.
The federal standards as to staffing relate only to “sufficient” staff to meet the needs of residents. Under state requirements, specific minimum ratios are required. A facility may have the minimum number of personnel, but not have enough to meet the needs of the residents. This may also relate to quality of staff or to inappropriate utilization of existing staff. In the instant case, though schedules were prepared to reposition residents, there were not enough staff members to follow the schedule. The staff shortage resulted in staff not responding to resident calls in a timely manner, and physician orders not being followed.
It also was determined that Richey Manor was taking a large number of residents who required more attention and for whom proper care could not be given. Of the more than 111 residents in the facility at the time of the survey, 62 required
assistance with daily living and toileting, and approximately 40 required assistance with dressing.
The above observations were concurred in by Carole G. Hembree, a health facility evaluator with the Agency.
Ms. Hembree concluded she would not put a loved one in Richey Manor at the time in issue because she did not believe the quality of care given there was adequate.
The survey reports referred to herein were reviewed for the Agency by Anthony J. Pileggi, a nursing home administrator since 1978 and an expert in nursing home administration.
Mr. Pileggi supervises a 120-bed facility and is lead administrator for three other facilities in a care group. He is also licensed as a preceptor for trainees in the field of nursing home administration.
After his review of the survey reports, Mr. Pileggi concluded that during the time in question there was a lack of nursing supervision, a large turnover in nursing staff, poor quality in the nurses on staff, and a lack of preventive measures addressing pressure sores. In his opinion, the administrator did not maintain an awareness of the level of care being provided in the facility through frequent review of indicators such as pressure sores, screening, and treatment. It was his observation that at Richey Manor, during the time in question, there was emphasis on treatment and little effort given to prevention. Respondent’s actions in management were less than competent for a
qualified administrator.
Mr. Pileggi saw what he considered to be an emphasis on admissions based on payor type rather than acuity level at a time when insufficient care was being given to existing residents to prevent the development of pressure sores. When staff is short, it is inappropriate to take more residents who need a high measure of care. To do so compounds the problem. Mr. Pileggi does not believe Respondent did all she could do to solve the problem. Her reliance on budget problems as an excuse for her actions is not, he believes, well placed. In his opinion, budget is not all-controlling. The administrator must strive to provide adequate care within the budget, and must oversee the director of nursing to insure that staff nurses are performing properly.
The appearance of pressure sores is an indicator of other problems. These could include a failure to properly use restraints, improper hydration, and inadequate nutrition. Though Respondent lays blame for the facility’s problems on the nursing staff, as administrator she had the responsibility to ensure there is a proper screening and evaluation of new residents to determine the likelihood of those residents developing pressure sores and to ensure the residents’ skin care is adequate. The administrator must ensure the staff is properly trained and that schedules are developed to provide adequate care. In Pileggi’s opinion, the administrator should perform a weekly review to
ensure the facility is working properly, and if not, make appropriate changes to ensure the residents get proper treatment,
A nursing home administrator is required to provide supervision of resident care - not provide the care herself. Resident care requires more attention than other administrator duties. Administrators should have a general knowledge of how to review a care plan to provide appropriate care for residents and to meet the residents’ needs. It is the responsibility of the nursing home administrator to ensure proper care plans are developed by qualified persons. The failure to have proper care plans has a direct negative impact on the quality of care. Based on Mr. Pileggi’s review of the survey reports, he found that Richey Manor’s care plans were not sufficient.
Respondent points out that in April 1993, she noted a negative trend in patient skin care. Mr. Pileggi does not believe Respondent did enough at that point or thereafter to ensure an appropriate care plan was developed and implemented to combat this trend. Respondent had sufficient authority to act. She could have changed the approach of the various committees towards admissions so as to lower acuity level, but it appeared to Pileggi that she emphasized a payor source admissions policy to conform to budgetary considerations.
Acuity level of the resident is related to what staff is needed to provide the appropriate support. The greater the acuity level, the more staff is required. A nursing home
administrator can manage the resident census by acuity level to ensure that existing staff can provide the level of care needed. Pileggi contends that if the Respondent recognized she did not have adequate staff to provide the appropriate level of care to the residents, she could have stopped admissions or screened prospective admissions for more independent residents who would require less care.
Respondent complained of a lack of corporate support in the areas of staffing and funding; however, Pileggi believes there was much by way of monitoring and supervision of staff she could have done to improve the care provided without more staff or more money. He does not believe Respondent did enough in this regard. To the contrary, if staffing were already inadequate to meet residents’ needs, as Respondent claims, it would negatively impact the health, safety, and welfare of the residents to take in more residents of a high acuity level.
Mr. Pileggi concluded that Respondent showed a strong concern for budgetary considerations of the company. One of her highest priorities appeared to be the effect of any action on operating income. Pileggi contends that a nursing home administrator should use the budget as a tool to provide guidelines for patient care. At those times when line items are not satisfactory, the administrator must look to other budget areas for funds to provide appropriate care. In this case, Pileggi is of the opinion that Respondent’s primary concern
should have been for the residents. This means answering calls, keeping the residents comfortable, and other like activities.
Respondent claims she devoted 20% of her time to marketing. This time could have been better spent, according to Pileggi, dealing with problems. In short, Respondent should have spent more time in supervising preventive care, rather than seeking additional residents.
Evidence presented at hearing indicates that the Director of Nursing at Richey Manor at the time of Respondent’s incumbency was performing poorly, and Respondent advertised for a replacement. Proof of the director’s incompetence, in Pileggi’s opinion, was the deterioration of resident skin condition. Pileggi is satisfied that Respondent’s awareness of this situation was demonstrated by her seeking to replace the director. However, in his opinion, merely seeking to replace the incompetent employee was not enough. Respondent should have worked around her to correct a situation which was obviously of long standing. The development of pressure sores does not come about over-night.
Mr. Pileggi would not state that Respondent repeatedly acted contrary to the health, safety, and welfare of the residents of Richey Manor, but because of the existence of the pressure sore problem, a condition which takes a significant time to develop, Respondent’s decision to admit more high acuity level
residents indicates that she intentionally failed to act in the best interests of the residents.
In summary, Mr. Pileggi concluded that Respondent’s actions constituted neglect or incompetence in that she did not ensure the facility had adequate staff, and she did not take adequate measures to treat and prevent pressure sores on the residents. The magnitude of the pressure sore problem was, for Mr. Pileggi, proof positive of the failure of Respondent to perform properly. His opinion would not change even if it were shown that Respondent authorized and was trying to hire more staff when, at the same time she was actively seeking to admit more patients who required a high level of care.
Ms. Ortiz is adamant in her denial of the allegations that she acted in an incompetent or negligent manner while serving as administrator at Richey Manor. When she went to the facility as its administrator, she was confronted with a director of nursing who had been there for more than a year and who had a management style which conflicted radically with the more structured style of the Respondent. As a result, the director of nursing became disgruntled and resigned in February 1993. Respondent claims she immediately placed an advertisement in area papers for a replacement but got no response. She discussed this problem with her supervisor, Unicare’s regional director of operations, who gave her some recruiting suggestions. Respondent also requested monetary assistance to advertise out-of-state, but
this request was denied. Nonetheless, in June 1993, Respondent was able to hire a director of nursing.
In the interim, while the hiring search was going on, the assistant director of nursing filled in and Unicare’s regional office sent in a temporary director from another area. In June 1993, Respondent hired Ms. Paderoff, a woman over 60 years old, as director of nursing. However, though her performance at first was good, Ms. Paderoff began to fail to show up for work, and the assistant director would not support her. Her effectiveness was, therefore, diminished.
Ms. Paderoff was an experienced nurse - knowledgeable and capable. While she worked at Richey Manor, she was given goals for the nursing department and immediately began implementing them. She was supportive and worked well until the end of 1993. At that time the facility’s personnel problems began to take their toll on her and she threatened to resign. Respondent attempted to support Ms. Paderoff, and Ms. Paderoff withdrew her resignation, but it shortly became apparent her performance had deteriorated badly. Respondent felt that additional supervision was necessary and met weekly with
Ms. Paderoff and the other department heads to evaluate their expectations. Ultimately, Paderoff terminated employment.
In mid-February 1994, Respondent was able to hire an assistant director and a month after Paderoff left, Respondent hired a very experienced director of nursing. At that point,
finally, both the director and assistant director were qualified in their jobs. The problems faced by the facility continued, however, and in May 1994, Respondent was fired. In October 1995, the Agency sought to impose an administrative fine of $1,575 against Unicare for the deficiencies relating to insufficient staff and improper handling of pressure sores identified during the tenure of Respondent but still uncorrected by February 2, 1995.
Respondent contends that at the very beginning of her employment at Richey Manor she recognized the staffing problems and sought to correct them. She contacted the local community college’s nursing department to attempt to recruit, as did the director of nursing, who also served as nurse consultant to the college. She sent recruitment letters to over 100 nurses without any response. She encouraged nursing students to perform their rotations at Richey Manor, and she tried to get a pay raise approved for certified nursing assistants (CNA). She also tried to retain and supplement the existing nursing staff by introducing CNA helpers, instituted perfect attendance bonuses, established a recruitment and retention committee to brainstorm ways to get and keep nursing staff, and had two licensed nurses mentor new nursing employees. She also had plans for offering continuing education units in the area, and looked into the possibility of developing an in-house CNA training program.
Ms. Ortiz claims her time as administrator was spent
evaluating the activities of eight departments in the facility. She spent a lot of time with hiring and replacing staff, including department heads. She started her work day at
7:00 a.m., and her day would end at around 5:30 or 6:00 p.m. She would also periodically come in on weekends to show support for the staff and to see what was going on, and would attend the monthly family dinners hosted by the facility.
During January and February 1993, as a result of the weekly reports of the nursing staff, Respondent sent reports of resident pressure sores to the company’s regional and national office. As she became more acquainted with the problem, she set goals to address it, starting in March or April 1993. She instructed the director of nursing, when she first came on board, to look into and assess the program in effect and to make recommendations to improve the system. Though Respondent claims this worked well, in fact, the problem continued.
Respondent claims that in July 1993 she developed a skin-care program at Richey Manor to address the problem and it appeared the director of nursing was enthusiastically supporting it. In a letter to the company dated November 12, 1993, Respondent outlined the local actions taken regarding skin-care and observed that the facility had experienced a “marked decrease in in-house acquired decubes,” but this apparently was not so.
In addition, Respondent contends that Unicare’s skin care policy and procedures were followed at Richey Manor. This policy
includes a risk assessment program and continuing observations of factors bearing on the potential for developing decubetes - all
the things Respondent claimed she had implemented in her referenced letter to the company.
Notwithstanding those efforts, from November 1993 to February 1994, residents who already suffered from pressure sores continued to be admitted to the facility, and it was also during this time that the performance of the director of nursing deteriorated, as previously described. Nonetheless, from February 1994 onward, more emphasis was placed on staff to deal with the pressure sore problem, and the corporate office got more involved as well. The company stepped into the picture because at a meeting at the regional office which she attended in
January 1994, she requested the approval of an incontinence care product, and the provision of nurse consultants to train the local staff. Both requests were denied by the company. At a similar meeting held in February or March 1994, the request for this product was again made and again denied. All during this time, Respondent believed she was being attentive to the needs of her residents. She was open to and sought suggestions from staff on the issues confronting the facility, and contacted corporate staff to discuss the problems with them.
Apparently, the Agency was not satisfied with Respondent’s efforts and concluded the facility no longer merited
a regular license. On May 12, 1994, the Agency changed the rating for Richey Manor to conditional, and, as was noted previously, Respondent was dismissed shortly thereafter.
Mr. Pileggi characterized Respondent’s emphasis on recruiting high acuity level residents as being an example of mismanagement. As a for-profit institution, corporate policy sought achievement of a certain levels of resident census and income/profit. Corporate goals called for a resident census of between 95 and 97 percent of capacity. Consistent therewith, Respondent sought to obtain more private pay residents. While Respondent admits to seeking to obtain private pay/insurance pay residents, she categorically denies at any time seeking to admit more high acuity level residents, or of admitting a resident over the objection of the director of nursing. The decision of admission to Richey Manor was a collegial decision of a committee with Respondent having final authority. Petitioner has failed to demonstrate any correlation between the source of payment and acuity level, and Ms. Schild, also a nursing home administrator and owner, categorically indicates there is none. Though Respondent may not have sought high acuity level residents, she also did not seek to reduce the case load by declining to admit residents who required a high level of care.
The documents considered by Mr. Pileggi and the Board were also reviewed by Kelly Schild, a nursing home administrator
and expert in nursing home administration. Based on her review of the documents and what she heard at hearing regarding the Respondent’s actions, she concluded that Respondent took all steps necessary to address the items listed in the Administrative Complaint. Respondent had a care plan in place and made repeated but unfulfilled requests to her corporate headquarters to redress her staffing problems. In her opinion, Respondent had a more than adequate plan for identifying residents at risk from pressure sores and did everything a prudent nursing home administrator could do to address the issues confronting her in light of the lack of financial and other support from her company. Ms. Schild does not believe Respondent repeatedly acted in a manner contrary to the health, safety, and welfare of her residents. To the contrary, Respondent repeatedly addressed the issue of insufficient staff and the pressure sore problem.
Respondent was hampered in the performance of her duties by her corporate hierarchy which prevented her from taking appropriate corrective action. Even in light of corporate resistance, Respondent did all a reasonable and prudent nursing home administrator could do.
Nonetheless, Ms. Schild notes that if she had confronted the problems Respondent was having with pressure sores, she would not have admitted any new residents with the same problem. In fact, she would not admit any new residents if she had insufficient staff to support the existing resident
census. It is in this area that Respondent’s actions fell most below acceptable standards.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter in this case. Section 120.57(1), Florida Statutes.
The Board seeks to discipline Respondent’s license as a nursing home administrator, alleging that she was negligent or incompetent in the practice of nursing home administration; and repeatedly acted in a manner inconsistent with the health, safety and welfare of the residents of her facility, in violation of Section 468.1755(1)(g), Florida Statutes, by failing to timely correct numerous deficiencies in the operation of the facility which had been identified by department inspectors.
The burden rests upon the Petitioner to establish the misconduct of the Respondent by clear and convincing evidence. Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987). The courts have clearly stated that both the statute dealing with the operation of nursing homes and that dealing with the licensing of nursing home administrators define an administrator’s responsibility as “. . . essentially to shelter and protect the health and well being of physically and often mentally infirm patients.” Magnolia Nursing and Convalescent Center v. Dept. of Health and Rehabilitative Services, 438 So. 2d 421 (Fla 1DCA 1983).
The evidence is clear that the number of residents at Richey Manor with pressure sores increased to unacceptable proportions during the incumbency of the Respondent as administrator. The unacceptable incidence of pressure sores was not, however, the only indication of alleged neglect or incompetence on the part of Respondent. The surveyors noted numerous other deficiencies, such as inadequate hydration; a failure to properly respond to resident calls; falls and other injuries; and a series in incidents which, absent other explanation, evidence a failure of proper management.
In addition, the evidence revealed that at the time of the 1994 surveys in issue herein, more than a year after the Respondent became administrator at the facility, 35 of 36 residents did not have either assessments or appropriate care plans, notwithstanding Respondent’s assertion of a care plan in her November 1993 letter to her corporate headquarters. Further, it appears that at the time better than 50% of the residents of the facility needed assistance with daily living, and more than one third of the residents needed assistance with dressing.
These deficiencies appeared to exist from shortly after Respondent began working at Richey Manor until several months after her departure.
Respondent urges that she made every effort to properly staff the facility during a time when a qualified director of nursing was not available, and her recruitment efforts were
singularly unsuccessful. If her claims are to be believed, and there is no evidence to the contrary, she appears to have traveled all reasonable avenues available for personnel recruiting.
In addition, she claims, her efforts to obtain financial and personnel assistance from her corporate headquarters were equally unsuccessful. She justifies her recruitment of additional residents from the rolls of private pay or insured patients as being dictated by the budgetary requirements of her corporation. In one regard, her defense of
self is accurate. There is no correlation between the payment status of residents and their acuity level, as argued by Petitioner. Nonetheless, she was successful in obtaining some
financial support from her corporation which she used to fund raises for CNAs, rather than hiring additional staff.
license to practice her profession. Petitioner also recognizes, however, that Respondent has little management experience. It seeks to restrict her unsupervised practice through the imposition of a two-year period of probation under the supervision of a more experienced preceptor, and the imposition of a $2,000 administrative fine. In light of the evidence presented herein, the requirement for probation under supervision in exactly correct. However, in light of the fact that Unicare, clearly a contributing factor in the situation confronting the Respondent, paid an administrative fine in the amount of $1,575 for deficiencies discovered during the tenure of the Respondent, it would appear inequitable to assess a greater fine against Respondent.
Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Board of Nursing Home Administrators enter a Final Order in this matter imposing an administrative fine of $1,575 on Respondent, and placing her license as a nursing home administrator on probation for a period of two years, under such terms and conditions relating to restriction of her practice to only supervised employment as the Board deems appropriate.
DONE AND ENTERED this 28th day of August, 1998, in Tallahassee, Leon County, Florida.
ARNOLD H. POLLOCK
Filed with the Clerk of the Division of Administrative Hearings this 28th day of August, 1998.
John O. Williams, Esquire Maureen L. Holz, Esquire Williams and Holz, P.A.
Suite No. 101-A Tallahassee, Florida 32312
Angela T. Hall, Agency Clerk Department of Health
All parties have the right to submit written exceptions within 15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.
