STATE OF FLORIDA Poa AGENCY FOR HEATH CARE ADMINISTRATION-» ,¢ ¢- Tol BAS 2 SAMANTHA R. WILSON AT BAYVIEW, Petitioner, XO Adeava} vs. CASE NO. 01-3809 - : NHOO-161R S AGENCY FOR HEALTH CARE =m : ADMINISTRATION, & : Respondent. a / FINAL ORDER 236 Wi THE PARTIES resolved all disputed issues and executed : a “settlement agreement”, which is incorporated by . reference. The parties are directed to comply with the k. i is terms of the “settlement agreement”. Based on the foregoing, this proceeding is CLOSED. DONE and ORDERED on this the /¢F day of ' 2 : Lalerucatyy , 200%, in Tallahassee, Florida. E Rhonda M. Medows, M.D, tary Agency for Health Care Administration kr b iS a SRE OL TSE ATR ROP IRE A tk i i A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS ~ _ PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL’ IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Peter A. Lewis, Esq. Goldsmith, Grout & Lewis, P.A. 307 West Park Avenue, Suite 200 Tallahassee, Florida 32308 Kim A. Kellum, Esquire Attorney for Agency AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive Fort Knox Building 3, Mail Stop 3 Tallahassee, Florida 32308 Ella Jane P. Davis Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Willie Bivens, Finance and Accounting Mary A. Steward, Medicaid Program Analysis OI oR TERRES ORR RECA R “ =e eR CORRE ET Pre err oer i Se CR TR CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addressees by U.S. Mail on this the /¢ day of — IL ALP , 2008. erry Despre nen Hane Agency¥Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, _ Building #3, Mail Stop 3 Tallahassee, Florida 32308-5403 ep ro corr STATE OF FLORIDA - . DIVISON OF ADMINISTRATIVE HEARINGS SAMANTHA R. WILSON AT BAYVIEW, Petitioner, ‘ vs. > CASE NO: 01-3809 . ' AGENCY FOR HEALTH CARE , ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT Petitioner, Samantha R. Wilson at Bayview, and Respondent, Agency for Health Care Administration (“Agency”), by and through the undersigned counsel and representatives hereby stipulate and agree as follows: 1. The Agency agrees to revise the Petitioner’s Medicaid audit report for fiscal year ended September 30, 1998, in accordance with the attached letter from Maggie Kendrick to Larry Lake, dated November 28, 2001; 2. The Agency agrees to adopt this agreement in a Final Order; 3. Upon the execution of this Agreement by all Parties, the Petitioner shall file with the Agency a dismissal with prejudice of its Petition in this case; 4. Each party agrees to bear their own costs and fees associated with this matter. ; F F . Notwithstanding the provisions of paragraph 4, nothing contained herein shall affect the reporting or allowability of the aforementioned costs or fees for subsequent reporting years. . The Parties stipulate and agree that this Settlement Agreement is a legal and binding document and is fully enforceable in any Court of competent jurisdiction. . The signatories hereto represent and warrant that they are vested with the authority to execute this Settlement Agreement on behalf of their respective principals, and as duly designated representatives, to fully bind such principals. . The Parties recognize and acknowledge that this agreement does not affect the rights and/or obligations of any party other than the parties to this agreement. . This agreement is binding on the parties’ successors and assigns. CORT RR RET TERESI OS oo Seiten ted . 4 te ay Dated this the day of 200K SAMANTHA R. WILSON AT AGENCY FOR HEALTH CARE BAYVIEW ADMINISTRATION TER A. LEWIS KIM A. KELLUM, Esquire GOLDSMITH, GROUT & LEWIS, P.A. Assistant General Counsel P.O. Box 1017 Agency for Health Care 307 West Park Avenue, Suite 200 Administration Tallahassee, Florida 32302-1017 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 STE A. GRIGAS, Esquire Chief Medicaid Counsel } Agency for Health Care / Administration 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 ye” E E oo WILLIAM ROBERTS, Esquire j General Counsel ‘ Agency for Health Care Administration oo. 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 “BOB SHARPE Deputy Secre he | Medicaid — Program ~— Agency for Health Care Administration 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 NOU-23-2881 12:28 AGENCY FOR HEALTH CARE AD 858 413 9313 P.@2 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 386 BUSH, GOVERNOR RUBEN J. KING-SHAW, JIR., SECRETARY November 28, 2001 CERTIFIED MAIL RETURN RECEIPT No. 7000 1530 0000 5396 9158 Mr. Larry Lake 4 Samantha R. Wilson at Bayview" 161 Marine Street St. Augustine, FL 32804 Re: ‘Florida Medicaid Audit Appeal for Cost Report NHO0-161R #202606 Year Ended September 30, 1998 Samantha R. Wilson at Bayview Dear Mr. Lake: Upon further review of the audit adjustments and discussions with Ms. Dawn Segler, the following changes will be made in exchange for dismissal with prejudice of the related audit appeals. Adjustment #7. This adjustment has been removed. Adjustment #9. This adjustment has been removed. Adjustment #30. This adjustment has been increased from (85,667) to ($195,694). Adjustment #41. This adjustment has been removed. : Adjustment #42, This adjustment has been removed. Adjustment #43. This adjustment has been removed. Vistt AHCA Online at 2727 Mahan Drive « Mail Stop 21 www fdhe.siate flus Tallahassee, FL 32308 SOUR RRR TTI ORR eRe eer ere ee » HOU-29-2881 12:26 AGENCY FOR HEALTH CARE AD 838 413 9313 P.@3 = Delta Health Care Center of Tampa July 23, 2001 Page 2 . Adjustment #46. This adjustment has been removed. In addition, we shave removed ‘the Capital Additions and Improvements Adjustment #1, which was ($7, 026. 971) of acquisition costs. The terms of this letter are for settlement purposes ‘only. The assertions made herein 2 are not to, = be considered admissions on the part of the agency. This letter should not be considered a . settlement document unless incorporated into a settlement document. ; The above audit reports will be revised and reissued to reflect appropriate changes necessitated ~ by this agreement. er IRR tm per if these changes are in n accord with : your understanding, please forward this letter to AHCA’s - legal counsel for drafting of a settlement stipulation. Your assistance in bringing this matter to a close is appreciated. 4 If you have any questions, please call me at (850) 488-4476. Sincerely, Maggie Kendrick Audit Review & Evaluation Analyst ORT TEE RTT RRO Pie weer or Seadcciiasaaaumeae /MK cc: Lisa Milton, Administrator of Audit Services, AHCA Kim Kellum, Senior Attomey, AHCA ORE I RET RRR REE ng ore HE reer eer TEE eee Fe Fs TOTAL P.@3

Docket for Case No: 01-003809