mmmscamsin 4 / Oe U STATE OF FLORIDA . f ! L E PD AGENCY FOR HEALTH CARE ADMINISTRATION OOMAY 26 AM 10:15 STATE OF FLORIDA, AGENCY FOR ALTH CARE ADMINI: DIVISION OF HE CARE ADMINISTRATION, ADUINISTRAL IVE Petitioner, AHCA CASE NO.: 04-00-009-ALF RINGS vs. JONES SHELTER & CARE INC. } : oo-aald Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY notified that after twenty-one (21) days from receipt of this Administrative Complaint, the Agency for Health Care Administration (hereinafter referred to as the “Agency”) intends to impose a civil penalty in the amount of $2,300.00 upon JONES SHELTER & CARE INC., (hereinafter referred to as “Respondent”). As grounds for the imposition of this civil penalty, the Agency alleges as follows: (1) The State of Florida, Agency for Health Care Administration has jurisdiction over the Respondent by virtue of the provisions to Chapter 400 Part III, Florida Statutes (1999) and Section 58A-5, Florida Administrative Code. (2) Respondent is licensed to operate as an Assisted Living Facility at 509 Palmetto Street, Jacksonville, Florida, 32202, in compliance with Chapter 400 Part II, Florida Statutes, and Rule 58A-5, Florida Administrative Code. (3) The Respondent has violated the provisions of Chapter 400 Part II, Florida Statutes, and provisions of Rule 58A-5, Florida Administrative Code, in that it was cited for seven (7) classified III deficiencies and two (2) classified IV deficiencies during a biennial licensure and limited mental health inspection conducted on December Peper ne i j a | ov) 14, 1999. These deficiencies set forth below, were previously cited during a biennial licensure inspection conducted on November 24, 1997, and constitute, repeat deficiencies. (a) (A100) The Respondent failure to maintain a complete and accurate records that clearly outline the operations of the business, including resident trust funds and other property. 7 This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.021(1) Florida Administrative Code. Class IW deficiency. Fine: $300.00. (b) (A208) The Respondent emergency management plan had not been submitted to the local emergency management agency at the time of the inspection. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.024(1)(j), Florida Administrative Code. Class IV deficiency. Fine: $100.00. (c) (A306) Residents who were receive OSS funds do not have on file the HRS Form, 1003. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.024(2)(a) 11, Florida Administrative Code. Class EV deficiency. Fine: $100.00. (d) (A513) The Respondent did not ensure that there is at least one staff member on duty at all times who has certification in an approved first-aid and CPR course. Personnel record review disclosed that the Respondent does not have 24 hours coverage. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58a- 5.019(5)(f), Florida Administrative Code. Class III deficiency. Fine: 300.00. (e) (A520) The Respondent did not ensure that all staff persons who have been employed longer than 30 days have documentation from a health care provider stating \e/ | w) they are from the signs and symptoms of communicable disease. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- . 5.019(5)(h), Florida Administrative Code. Class lI deficiency. Fine: $300.00. (f) (A608) The Respondent did not ensure that an accurate Medication Administration Record was maintained. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.0182(6)(c), Florida Administrative Code. Class III deficiency. Fine: $300.00. (g) (901) The Respondent did not ensure the interior and exterior of the building and grounds was reasonably attractive. Loose, cracked or peeling paint was not promptly replaced, repaired or repainted to provide a satisfactory surface finish. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.022(1)(b), Florida Administrative Code. Class III deficiency. Fine: $300.00. (h) (902) The Respondent did not ensure the furnishing were clean, in good repair and reasonably attractive. This is a violation of Section 400.419(1)(c), Florida Statutes (1999), and Rule 58A- 5.022(1)(c), Florida Administrative Code. Class III deficiency. Fine: $300.00. @ (A1024) The Respondent did not have a satisfactory fire safety inspection completed within the last 365 days. This is a violation of Section 400.419(1)(c), and Section 400.441(1)(a) 2, Florida Statutes (1999). Class II deficiency. Fine: $300.00. (4) Notice was provided in writing to the Respondent of the above violations and the time frame correction. The agency is authorized to impose this fine pursuant to \aw/ : WH Chapter 400.419(1)(c), and Chapter 400.441, Florida Statutes (1999), and Rule 58A-5, Florida Administrative Code. (5) Respondent is notified that it has a right to request an administrative hearing pursuant to 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. Chapter 59-1, Part II, Florida Administrative Code, constitutes the Agency’s procedural tule for administrative proceeding under Section 120.57(1), Florida Statutes, your request for an administrative hearing, must conform to the requirements in Rule 28-5. 201, Florida Administrative Code, and must state which issues of material fact you dispute. Failure to dispute material issues of the fact in your request for a hearing may by treated by the Agency as election by you of an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency for Health Care Administration, and delivered to Agency for Health Care Administration, Building 3, Suite 343 L 2727 Mahan Drive, Tallahassee, Florida 32308; Attention: Michael O. Mathis, Senior Attorney. Payment of fines shall be sent to the Agency for Health Care Administration, P.0. Box 13749, Tallahassee, Florida 32317-3749. (Please reference the case number and facility name on the front of your check). (6) Respondent is Further Notified that failure to request a hearing within twenty- one (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. VY CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereby was sent by U.S. Certified Mail, Return Receipt Requested, to Abdullah Shah, Administrator, Jones Shelter and Care, Inc., 509 E. Palmetto Street, Jacksonville, Florida 32202 this 27 Baay A, rv | 2000. Copies furnished to: Michael O. Mathis, Esquire Senior Attorney Agency for Health Care Administration 2727 Mahan Drive Bldg. 3, Suite 3408-D Tallahassee, Florida 32308 Abdullah Shah, Administrator Jones Shelter and Care, Inc. 509 E. Palmetto Street Jacksonville, Florida 32202 bd a Karen Swann : Area 4 Office Supervisor Division of Health Quality Assurance Agency for Health Care Administration 921 North Davis St., A-115 Jacksonville, Florida 32209 Karen Swann Area 4 Office Supervisor Health Quality Assurance Agency for Health Care Administration 921 North Davis St., A-115 Jacksonville, Florida 32209 Finance & Accounting Agency for Health Care Administration Bldg. 2, 2nd Floor 2727 Mahan Drive Tallahassee, Florida 32308

Docket for Case No: 00-002219