STATE OF FLORIDA FILED AGENCY FOR HEALTH CARE ADMINISTRATION “ 00 JUN TG PMI2? SO AGENCY FOR HEALTH CARE TION, , DIVISION OF ADMINISTRATION ADMINISTRATIVE it Ay Petitioner, HEARINGS -vs- AHCA No. 08-00-02-HHA EDMUND N. JACKSON d/b/a ELITE HEALTH . CARE SERVICES, INC., (0-2 uM Respondent. “ / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from the receipt of this complaint, the Agency intends to impose a fine in the amount of three thousand six hundred dollars ($3,600.00) upon the Respondent. As grounds for the imposition of this fine, the Agency alleges as follows: (1) The Agency for Health Care Administration, State of Florida, has jurisdiction over the Respondent by virtue of the provisions of Chapter 400, Part ~ IV, Florida Statutes. _.(2) | The Respondent is licensed to operate the above named facility at 1299 Highway 17 South, Arcadia, Florida 33821, as an home health agency in : ~~ gompliance with Chapter 400, Part IV, Florida Statutes. (3) | The Respondent has violated minimum licensure standards, as _ evidenced by each deficiency set forth below, as found to exist during the annual survey of May 7, 1999, ‘recited at the first revisit survey conducted on July 26, 1999, and tags H 072, H 103, H 104, H 215 and H 230 cited May 17, 1999 and Ww . oo A recited at the July 26, 1999 survey and second revisit survey of September 27, 1999. The Respondent failed to timely correct the deficiencies as follows: - (a) H 060 -— This Standard is not met as evidenced based upon review of the policy and procedure manual and interview with the administrator, it was determined that the agency did not designate in writing a qualified representative to serve in the administrator’s absence. This was cited at the Annual Survey of May 17, 1999, and recited at the revisit of July 26, 1999. This deficiency is in violation of Rule 59A-8.0095(1), Florida Administrative Code. This is'a Class Ill deficiency. Fine amount: $400.00. (b) H 072 — This Standard is not met as evidenced based upon Interview, it was determined that the agency did not establish and conduct an ongoing Quality Assurance Program. This was cited at the Annual Survey of May 17, 1999, and recited at the revisit of July 26, 1999. This deficiency is in violation of Rule 59A-8-0095(2), Florida Administrative Code. This is a Class lll deficiency. Fine amount: $400.00. (c) H 080 — This Standard is not met as evidenced based upon record review and interview, it was determined that the registered nurse did not notify the physician of changes or deviations from the Plan of Treatment for two of three patients. This was cited at the Annual Survey of May 17, 1999, and recited at the revisit of July 26, 1999. This deficiency is in violation of Rule 59A-8.0095(3), Florida Administrative Code. This is a Class Ill deficiency. Fine amount: $400. 00. : id H 103 — “This ‘Standard i is ‘not met a as ‘evidenced based upon ; __ interview with the administrator, it was determined that the ‘Home Health Aides did not receive 12 hours of in- service per year. This was cited at the Annual Survey of May 17, 1999, ; and recited at the revisit of July 26, 1999. This deficiency is in violation of | Rule 59A-8.0095(5), Florida _ Administrative Code. This is a Class Ill deficiency. Fine amount: $400.00. —~ — oe fe) H104- This Standard is not met as evidenced based upon record review and interview with the administrator, it was determined that the agency did not ensure that the Home ae Health Aides maintained records of care for two patient records reviewed. This was cited at the Annual Survey of May 17, 1999, and recited at the revisit of July 26, 1999. This deficiency is in violation of Rule 59A-8.0095(5), Florida Administrative Code. This is a Class Ill deficiency. Fine amount: $400.00. (f) H 181 — This Standard is not met as evidenced based upon record review, policy and procedure manual review, and interview with the administrator, it was determined that the agency did not ensure the Plan of Care for patients was reviewed by the physician every 62 days or when there are deviations to a patient’s condition. This was cited at the May 17, 1999 Annual Survey, and recited at the revisit of July 26, 1999. This deficiency is in violation of Section 400.487m Florida Statutes. This is a Class III deficiency. Fine amount: $400.00. (g) H 215 —- This Standard is not met as evidenced based upon record review and interview, it was determined the agency did not follow the required Plan of Care and all updates for two of three patients, nor did they provide signed and dated clinical or service notes. . This was cited at the May 17, 1999 Annual Survey, and recited at the revisit of July 26, 1999. This deficiency is in violation of Rule 59A-8.022, Florida Administrative Code. This is a Class Ill deficiency. Fine amount: $400.00. (h) H 221 — This Standard is not met as evidenced based upon clinical record review and interview, it was determined that the agency did not follow the policy on medications for two of three patients reviewed. This was cited at the Annual Survey of May 17, 1999, and recited at the revisit of July 26, 1999. ~ This deficiency is in violation of Rule 59A-8.024, Florida Administrative Code. This is a Class Ill deficiency. Fine amount: $400.00. (i) H 230 — This Standard is not met as evidenced based upon “review of policies and procedures ‘and interview, it was determined that the agency did not have written policies or procedures regarding Advanced Directives or any documentation in two of three records reviewed. This was cited at the Annual Survey of May 17, 1999, and recited at the revisit of July 26, 1999. “This deficiency is in violation of Rule 59A-8.0245, Florida Administrative Code. This is a Class Ill deficiency. Fine amount: $400.00. ; (4) The above referenced violation constitutes grounds to levy the ‘indicated fine(s) pursuant to Sections 400.471, 400.474, Florida Statutes, in that the above referenced conduct of the Respondent constitutes violations of the minimum standards, rules, and regulations for the operation of an home health agency. . (5) Notice was provided in writing to the Respondent of the above violations and a time frame was given for correction. HEARING RIGHTS AND PROCEDURE (READ CAREFULLY) IN GENERAL. You have the right to request an administrative hearing pursuant to Section 120.569, Florida Statutes, to be represented by counsel (at ‘your expense), to take testimony, to call or cross-examine witnesses, to have subpoena and subpoena duces tecum issued, and to present written evidence or argument if you request a hearing. The Uniform Rules found at Chapter 59-28-1 06, Florida ‘Administrative Code, are the Agency’s procedural rules for administrative proceedings resulting from this complaint. ; HEARING REQUESTS. A request for a hearing shall be made to o the Agency for Health Care Administration, 6800 N. Dale Mabry Highway, Suite 220, Tampa, Florida 33614. Attention: Thomas Caufman, Senior Attorney. “420.57(2), VA a! ee oe a) re An individual owner, corporation, or partnership requesting a hearing must submit a written request signed by the individual owner; a corporate officer or director; a partner; an attorney; or another person having written authorization to represent the owner, corporation, or partnership. A copy of the authorization must be submitted with the hearing request. A request for a hearing must be in writing and should include your address, and a . telephone number where you may be reached during weekdays. FORMAL HEARINGS. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, the request for an administrative hearing must conform to the requirements in Rule 28-106.201, Florida Administrative Code, and must state which issues of material fact are in dispute. FAILURE TO DISPUTE MATERIAL ISSUES OF FACT IN THE REQUEST WILL BE DEEMED A WAIVER OF “THE RIGHT TO A FORMAL HEARING, AND AN ELECTION FOR AN INFORMAL HEARING UNDER SECTION 120.57(2), FLORIDA STATUTES. INFORMAL HEARINGS. A request for an informal hearing under Section Florida Statutes, 106.301, Florida Administrative Code. By requesting an informal hearing you agree to the existence of the facts cited in this administrative complaint. At an informal hearing you will be permitted to present questions of law and any mitigating circumstances you wish the administrative law judge to consider; however, no must conform to the requirements in Rule 28: ae _ ADMINISTRATIVE evidence disputing the existefi¢é of the violations may be presented. REPRESENTATION BY NON-ATTORNEY. A non-attorney seeking to represent the owner of a facility in a formal proceeding must be qualified by the administrative law judge as provided in Rule 28-106.107, Florida Administrative Code. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO FILE A REQUEST FOR 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. PAYMENT OF FINES. _ Fines should be mailed: to the Agency for Health Care Administration, Finance & Accounting Department, P.O. Box 13749, Tallahassee, FL 32317-3749. Attention: Jim Mitchell. To insure proper credit, you must attach the payment form on the last page of this complaint with your payment. FOR CLARIFICATION AFTER YOU HAVE READ THE COMPLETE LAINT, CALL THOMAS CAUFMAN AT (813) 871-7402. | HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt Requested to, Registered Agent of Elite Health Care Services, Inc., Edmund elie ~ Ww. _ rw) N. Jackson, 1682 NE Turner Avenue, Arcadia, Florida 34266, this /Y day of Copies to: Agency for HeAl g State Regional Servi¢e Center 2295 Victoria Avenue, Room 346 Fort Myers, Florida 33901 Home Health Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Thomas Caufman Senior Attorney Agency for Health Care Administration 6800 N. Dale Mabry Highway, Suite 220 Tampa, Florida 33614 Elite Health Care Services, Inc. 1299 Highway. 17 South Arcadia, Florida 33821

Docket for Case No: 00-002464