a . : . : . we) aot _ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, . Petitioner, vs. AHCA NO: 10-00-019-ALF ST. ANN’S RETIREMENT HOME, Respondent. / , ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of $1,900.00 upon St. Ann’s Retirement Home. As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1, The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part Il, Florida Statutes. 2. Respondent, St. Ann’s Retirement Home, is licensed by the Agency to operate an assisted living facility at 10000 NW 41° Street, Hollywood, Florida 33024 and . is obligated to operate the assisted living facility in compliance with Chapter 400 Part Dl, F lorida Statutes, and Rule 58A-5, Florida Administrative Code. 3. On April 28, 1999, a survey team from the Agency’s Area 10 Office , conducted a complaint investigation. There were three Class III and one Class II- deficiencies cited. 3A. written admis: . i ; oe Pursuant to Rule 58A-5.024(1)(a), F.A.C., the facility shall maintain a sion and discharge record of all residents, including temporary emergency shelter and services placements, apart from the resident’s file. This Standard was not met ‘as evidenced by the following observation: 3B. (1) During the tour of the facility a resident was observed watching television. The resident reported having moved to the facility a few days before. During a review of the admission and discharge record, it was noted that this resident was not listed. (2) Based on observation and record review, it was determined that the facility violated Rule 58A-5.024(a)(a), F.A.C., for failing to maintain an accurate admission and discharge record. Pursuant to Rule 58A-5.024(1)()2,¢, F.A.C., the facility shall develop and follow a written Comprehensive Emergency Management Plan for emergency care during an internal or external disaster in accordance with Ch. 252, F.S. The plan shall be appropriate for the size and location of the facility and for the service needs of the residents. The plan shall be submitted for review and approval to the county emergency management agency in accordance with the developed schedule. This standard was not met as evidenced by the following observation: 3C. the supervision of an administrator who is responsible for all personnel and services- (1) During record review it was revealed that the facility did not have an Emergency Management plan approved by the local authority, the Broward County Emergency Managernent Division. (2) Based on record review, it was determined that the facility violated Rule 58A-5.024(1)(@)2,e, F.A.C., for failing to have an ‘approved Emergency Management Plan. ; Pursuant to Rule 58A-5.019(1) and (3), F.A.C., the facility shall be under within the facility. This standard was not met as evidenced by the following observation: vo. ne? (1) During the entrance conference, the surveyor asked the staff member to contact the administrator. The staff member reported she had only been at the facility for five days. She then called the facility next . door reporting she was trying to contact the administrator at that facility. (a) As she was not there, the staff member then spoke with another individual who requested to speak with the surveyor. However, this iridividual refused to identify herself, or to speak with the surveyor. Finally the staff member was able to contact the administrator of record. ; (b) The administrator was interviewed by telephone and reported that she did not know why her staff was trying to contact the administrator of the adjacent facility, as she was the administrator. (c) | She was advised to contact the surveyor to discuss the findings of the investigation since she was unable to be present during the survey. Based on the findings, the facility is not being supervised. (2) Based on the findings, it was determined that the facility violated Rule 58A-5.019(1) and (3), F.A.C., for the administrator failing to provide the appropriate supervision to the staff and residents of the facility. 3D. Pursuant to Rules 58A-5.0182(6)(c) and 58A-5.024(1)(c), F.A.C., the facility shall maintain an accurate up-to-date medication administration record (MAR). This standard was not met as evidenced by the following observations: (1) During a review of the medication administration records (MAR’s) for Resident #5, it was revealed that the resident was supposed to be ~"eeéiving Cogentin on a daily basis. There were no entries from April 22 until April 26 on the MAR. (a) During an interview with the staff member present, it was revealed that the facility was out of the medication at that time. (2) Resident #1 was supposed to be receiving Premarin on a daily basis, however, there were no entries on the MAR from April 20 until the day of the investigation documenting that the resident had received it. Re 4. Ww . wo (a) The resident was supposed to be receiving Fosamax on a daily basis, but again, there was no documentation that the resident received it on April 22, April 25 or April 26. The staff member reported that they were out of the medication at that time. (3). - During a review of Resident #3’s medications, it was noted that the prescription label documented that the resident was to receive Risperdal 3mg, 1 tab 3 times a day. However, on the MAR, the order was for Risperdal 3mg, 2 tabs 2 times a day. (a) The staff member was unable to explain the discrepancy or report which dosage the resident was actually receiving. (4) During a review of the MAR for Resident #4, it was noted that there were no entries for April 23 and April 24. The staff member reported being out of the medications at that time. (5) Based on record reviews, it was determined that the facility violated Rules 58A-5.0182(6)(c) and 58A-5.024(1)(c), F.A.C., for failing to maintain an accurate up-to-date medication administration record for four out of six residents. On July 1; 1999, a survey team from the Agency’s Area 10 Office conducted a revisit survey. There were three Class HI and one Class II uncorrected deficiencies cited. 4A. Pursuant to Rule 58A-5.024(1)(a), F.A.C., the facility shall maintain a written admission and discharge record of all residents, including temporary emergency shelter and services placements, apart from the resident’s file. This Standard was not met as evidenced by the following observation: (1) On the day of the revisit the admission and discharge record was feviewed and listed four residents. However, during an interview with the ’ staff member present, it was revealed that one of the residents had been discharged two weeks ago. (2) Based on record review and interview, it was determined that the- facility violated Rule 58A-5.024(a)(a), F.A-C., for again failing to maintain an accurate admission and discharge record. BR te 4B, Pursuant to Rule 58A-5.024(1)(9)2,¢, F.AC., the facility shall develop and follow a written Comprehensive Emergency Management Plan for emergency care during an internal or external disaster in accordance with Ch. 252, F.S. The plan shall be residents. The plan shall be submitted for review and approval to the county emergency : _ appropriate for the size and location of the facility and for the service needs of the management agency in accordance with the developed schedule. This standard was not met as evidenced by the following observation: 4c. (1) During record review it was revealed that the facility did not have an Emergency Management plan approved by the local authority, the Broward County Emergency Management Division. (2) Based on record review, it was determined that the facility violated Rule 58A-5.024(1)(f)2,¢, F.A.C., for again failing to have an approved Emergency Management Plan. Pursuant to Rule 58A-5.019(1) and (3), F.AC., the facility shall be under the supervision of an administrator who is responsible for all personnel and services within the facility. This standard was not met as evidenced by the following observation: (1) On the day of the revisit survey, the surveyor spoke with the administrator by telephone. The individual identified himself as the new administrator and reported he has only been employed by the facility for tie week, and so was not aware of the outstanding deficiencies. (a) He also reported that he would have to contact the owner and named an individual not currently listed as the owner. He was’ “advised of the requirement to notify the Agency if the facility changed owners and administrators. (2) Based on the findings, it was determined that the facility violated Rule 58A-5.019(1) and (3), F.A.C., for the administrator again failing to provide the appropriate supervision to the staff and residents of the facility. eee re ¢ ; 7 i iw) . o a wo 4D. Pursuant to Rules 58A-5.0182(6)(c) and 58A-024(1)(c), F.A.C., the facility shall maintain an accurate up-to-date medication administration record. ‘This Standard was not met as evidenced by the following observations: (1) On the day of the revisit survey a review was completed of the resident’s MARs. There was no MAR for Resident #3. The staff member present was interviewed and reported that the resident self-administers his medication. (a) Further record review revealed that the resident’s mode of administration is “B”, requiring supervision. (2) Duringa review of the MAR for Resident #2, it was revealed that the staff did not record on the MAR that the resident received the June 30, 1999 evening dose of Benztropine. (3) Based on record reviews and interview with staff, it was determined that the facility violated Rules 58A-5.0182(6)(c) and 58A- 024(1)(c), F.A.C., for again failing to maintain an accurate’ up-to-date - medication administration record for two of three residents in the sample. 5. Based on the foregoing, St. Ann’s Retirement Home has violated the following: - (@)__ Tag A203 incorporates Rule 584-5.024(1)(a), F.A.C. (b) Tag A208 incorporates Rule 584-5.024(1)@)2,¢, F.A.C. (c) Tag A500 incorporates Rule 58A-5. 019(1) and (3), FAC. © Tag A608 incorporates 58A-5.0182(6)(c) and 58A-024(1)}(c), ‘or the aforementioned violations The above referenced violations ¢ ‘constitute grounds to 0 levy this ‘civil : penalty pursuant to Section 400.419, Florida Statutes, and Rule 58A-5.033, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a ad : : oa WwW : violation of the minimum standards, rules, and regulations for the operation of an Assisted Living Facility. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: R.S. Power, Agency Clerk, Senior ‘Attomey, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403, with a copy sent to Christine T. Messana,Bsquie, — All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. All payment of fines should be sent to the Agency for Health Care Administration, Attention: Christine T. Messana, Staff Attorney, General Counsel’s Office, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403. Vv gg RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO a REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Issued this ]3 day of__ YVVIAVCH 2000. snc eu anf ridia Feeney > Supervisor, Area 10 Agency for Health Care Administration Health Quality Assurance 1400 W. Commercial Blvd., Suite 110 Ft. Lauderdale, Florida 33309 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint was sent by U. S. Mail, Return “ . Receipt Requested, to: Administrator, St Ann’s Retirement Home, 10000 nwa Street, Hollywood, Florida 33024 0 on n this i 3 day of m is Re Ht Christine T. Messana, Esquire Office of the General Counsel BS ws Copies furnished to: Christine T. Messana Staff Attorney Agency for Health Care Administration 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308-5403 Pete J. Buigas, Deputy Director Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403 Areal0 Office... Jean Lombardi, Finance & Accounting i » F

Docket for Case No: 00-001678