Prope initia’ go re STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION rer ea na Ar A AGENCY FOR HEALTH CARE Bt a, ADMINISTRATION, y 7 27 Petitioner, 0 ra Z 2 2, . v es vs. AHCA CASE NO. 2092022201 . | “ ; PROFESSIONAL HEALTH *: one SYSTEMS, INC., Be Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through its undersigned counsel, and files this Administrative Complaint against Respondent, Professional Health Systems, Inc. (hereinafter “PHS”) pursuant to Sections 120.569 and 120.57, Florida Statutes, and as grounds therefore, alleges the following: NATURE OF THE ACTION 1. This is an action to: (a) deny PHS’s license renewal application pursuant to that certain Notice of Intent to Deny letter dated April 29, 2002, a copy of which is attached hereto as Exhibit “A” and incorporated herein by reference; (b} impose an administrative fine in the amount of $179,000 against PHS pursuant to Sections 400.474(2)(a) and 400.484(2)(b) and (c), Florida Statutes; and (c) assess costs related to the investigation of this case pursuant to Section 400.484(3), Florida Statutes, based on five (5) class II deficiencies, two (2) uncorrected class II] deficiencies, and other violations of laws and rules. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. 3. The Agency has jurisdiction over PHS pursuant to Chapter 400 Part IV, Florida Statutes. 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 5. Pursuant to Chapter 400, Part IV, Florida Statutes, and Chapter 59A-8, Florida Administrative Code, the Agency is the regulatory agency responsible for the licensure of home health agencies and for the enforcement of all applicable state laws and rules governing home health agencies. 6. PHS is a home health agency located at 2850 Douglas Road, 2nd Floor, Coral Gables, Florida 33134. PHS is licensed by the Agency to operate a home health agency in Broward and Miami-Dade Counties having been issued license number HHA211970961 (certificate # 9785) with an effective date of August 17, 2001 and an expiration date of February 24, 2002. At all times relevant hereto, PHS is and was a licensed home health agency required to comply with Chapter 400, Part IV, Florida Statutes, and Chapter 594-8, Florida Administrative Code. COUNT I PHS FAILED TO ENSURE THAT THE PHYSICIAL THERAPIST CARRIED OUT HIS OR HER RESPONSIBILIITIES INCLUDING, BUT NOT LIMITED TO, THE FOLLOWING: (1) PROVIDING PHYSICAL THERAPY SERVICES AS PRESCRIBED BY A PHYSICIAN; (2) OBSERVING AND RECORDING ACTIVITIES AND FINDINGS IN THE CLINICAL RECORD; AND (3) REPORTING TO THE PHYSICIAN ANY DEVIATIONS FROM THE PLAN OF CARE. Rule 59A-8.0095(6), Fla. Admin. Code CLASS II DEFICIENCY 7. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 8. From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and a clinical record review of cases receiving physical therapy, a class II deficiency was cited against PHS based upon the findings below involving four (4) patients. 8.1. A review of patient # 2’s clinical record revealed a physician’s order for a physical therapy evaluation and nine (9) physical therapy visits. Patient #2 received the evaluation on the start of care date of January 10, 2002. Upon further review of the record, the Agency surveyor discovered that five (5) out of the nine (9) physical therapy visits were not documented. During an interview with the Agency surveyor, PHS’s Director of Nursing was unable to explain the missing visits. The next day, however, the Director of Nursing provided the Agency surveyor with four (4) visit notes. One (1) physical therapy visit still remained unaccounted for. The patient was discharged from physical therapy on January 29, 2002 without any evidence in the record that the patient had received all nine (9) physical therapy visits as prescribed by the physician. Based on the foregoing, the physical therapist failed to: (a) provide physical therapy services as prescribed by the physician; and/or (b) observe and record activities and findings in the patient’s clinical record; and/or (c) report to the physician any deviations from the plan of care. 8.2. A review of patient #4’s clinical record revealed a physician’s order dated December 27, 2001 for physical therapy for three (3) weeks, three (3) times per week. The physical therapy visits were not conducted in accordance with the physician’s order. During the first week of services, the patient received physical therapy only two (2) times, not three (3) times as per the doctor’s order. During an interview with the patient, the patient informed the surveyor that the physical therapist never returned after the first week of services. The patient was discharged on January 14, 2002 and never received the nine (9) physical therapy visits as prescribed by the physician. Based on the foregoing, the physical therapist failed to: (a) provide physical therapy services as prescribed by the physician; and/or (b) observe and record activities and findings in the patient’s clinical record; and/or (c) report to the physician any deviations from the plan of care. 8.3. A review of patient #7’s clinical record revealed a physician’s order for a physical therapy evaluation. The start of care date was January 26, 2002, and as of the date of the survey, February 4-8, 2002, there was no documentation of a physical therapy evaluation being performed. Based on the foregoing, the physical therapist failed to: (a) provide physical therapy services as prescribed by the physician; and/or (b) observe and record activities and findings in the patient’s clinical record; and/or (c) report to the physician any deviations from the plan of care. 8.4. A review of patient #11’s clinical record revealed a physician’s order for, among other services, physical therapy visits. There was no evidence in the clinical record showing that the patient had received any of the physician ordered physical therapy visits. Based on the foregoing, the physical therapist failed to: (a) provide physical therapy services as prescribed by the physician; and/or (b) observe and record activities and findings in the patient’s clinical record; and/or (c) report to the physician any deviations from the plan of care. 9. Based on all of the foregoing, PHS has violated Rule 59A-8.0095(6), Florida Administrative Code, by failing to ensure that a physical therapist currently licensed in the State of Florida: (i) provides physical therapy services as prescribed by a physician, which can be safely provided in the home and assists the physician in evaluating patients by applying diagnostic and prognostic muscle, nerve, joint and functional abilities tests; (ii) observes and records activities and findings in the clinical record and reports to the physician the patient’s reaction to treatment and any changes in the patient’s condition, or when there are deviations from the plan of care; (iii) instructs the patient and caregiver in care and use of physical therapy devices; (iv} instructs other health team personnel including, when appropriate, home health aides and caregivers in certain phases of physical therapy with which they may work with the patient; and (v) instructs the caregiver on the patient’s total physical therapy program. 10. The foregoing violation is a class II violation in that it had a direct adverse effect on the health, safety, or security of the four (4) patients involved. Pursuant to Sections 400.484(2)(b) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $1,000 per patient or per occurrence for a total fine amount of $4,000 ($1,000 x 4 patients) for this class II violation. COUNT II PHS FAILED TO MONITOR AND MANAGE THE SERVICES PROVIDED BY OTHERS UNDER CONTRACTUAL ARRANGEMENTS TO ENSURE THAT SUCH SERVICES WERE BEING DELIVERED IN ACCORDANCE WITH CHAPTER 400, PART IV, FLORIDA STATUTES AND RULES PROMULGATED THEREUNDER Section 400.487(5), Fla. Stat. CLASS II DEFICIENCY 11. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 12. From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and clinical record review, a Class II deficiency was cited against PHS based on the findings below involving five (5) patients. 12.1. A review of patient #12’s clinical record revealed a physician’s order dated January 31, 2002 for a speech therapy evaluation. As of February 6, 2002, the speech-language pathologist had not conducted a speech therapy evaluation. Based on the foregoing, PHS failed to monitor and manage the services provided by the speech- language therapist to ensure the patient received all necessary services. 12.2. A review of patient # 2’s clinical record revealed a physician’s order for a physical therapy evaluation and nine (9) physical therapy visits. Patient #2 received the evaluation on the start of care date of January 10, 2002. Upon further review of the record, the Agency surveyor discovered that five (5) out of the nine (9) physical therapy visits were not documented. During an interview with the Agency surveyor, PHS’s Director of Nursing was unable to explain the missing visits. The next day, however, the Director of Nursing provided the Agency surveyor with four (4) visit notes. One (1) physical therapy visit, however, still remained unaccounted for. The patient was discharged from physical therapy on January 29, 2002 without any evidence in the record that the patient had received all nine (9) physical therapy visits. Based on the foregoing, PHS failed to monitor and manage the services provided by the physical therapist to ensure that the patient received all necessary services. 12.3. A review of patient #13’s clinical record revealed a physician’s order for a physical therapy evaluation and physical therapy visits for three (3) weeks, three (3) times per week. The physical therapy evaluation was conducted on January 25, 2002, the day before the start of care date of January 26, 2002. The is no evidence in the patient’s clinical record showing that the nine (9) physical therapy visits were provided to the patient per the physician’s order. Based on the foregoing, PHS failed to monitor and manage the services provided by the physical therapist to ensure that the patient received all necessary services. 12.4. A review of patient #7’s clinical record revealed a physician’s order for an occupational therapy evaluation and a physical therapy evaluation. The start of care date was January 26, 2002. As of the date of the survey, February 4-8, 2002, there was no documentation in the clinical record of an occupational therapy evaluation or physical therapy evaluation being performed. Based on the foregoing, PHS failed to monitor and manage the services provided by the occupational therapist and physical therapist to ensure that the patient received all necessary services. 12.5. A review of patient #8’s clinical record revealed a physician’s order dated December 12, 2001 for an occupational therapy evaluation. The start of care date was December 12, 2001. The occupational therapy evaluation was not completed by the occupational therapist until January 14, 2002. Based on the foregoing, PHS failed to monitor and manage the services provided by the occupational therapist to ensure that the patient received all necessary services. 13. PHS has contracted with companies and/or individuals to provide speech-language pathology, occupational therapy and physical therapy services to PHS’s patients. Such contractual arrangements include, but are not limited to, arrangements with L’image Physical Therapy and Rehabilitation, Inc., a Florida corporation with a principal address of 9380 SW 72 Street, Suite B222, Miami, Florida 33173 and Affordable Rehab Services, Inc., a Florida corporation with a principal address of 6273 NW 524 Street, Coral Springs, Florida 33067. 14. Based on all of the foregoing, PHS failed to monitor and manage the speech-language, occupational therapy and physical therapy services provided by others under contractual arrangement (e.g., L’image Physical Therapy and Rehabilitation Center, Inc. and Affordable Rehab Services, Inc.) to ensure that PHS’s patients received all necessary services. 15. Based on all of the foregoing, PHS violated Section 400.487(5), Florida Statutes, by failing to monitor and manage the services provided by others other contractual arrangement including speech-language pathology services, occupational therapy services and physical therapy services. 16. The foregoing violation is a class II violation in that it had a direct adverse effect on the health, safety or security of the five (5) patients involved. Pursuant to Sections 400.484(2)(b) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $1,000 per patient or per occurrence for a total fine amount of $5,000 ($1,000 x 5 patients) for this class II violation. COUNT III PHS FAILED TO SUPERVISE AND COORDINATE IN ACCORDANCE WITH THE PLAN OF CARE SKILLED CARE SERVICES PROVIDED TO PATIENTS BY PHS DIRECTLY OR UNDER CONTRACT WITH OTHERS. Section 400.487(6), Fla. Stat. CLASS II DEFICIENCY 17. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 18. From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and clinical record review, a class II deficiency was cited against PHS based upon the findings below involving thirteen (13) patients. 18.1. A review of patient #2’s plan of care revealed a physician’s order for a physical therapy evaluation and nine (9) physical therapy visits. Patient #2 received the evaluation on the start of care date of January 10, 2002. Upon further review of patient #2’s clinical record, the Agency surveyor discovered that five (5) out of the nine (9) physical therapy visits were not documented. During an interview with the Agency surveyor, PHS’s Director of Nursing was unable to explain the missing visits. The next day, however, the Director of Nursing provided the Agency surveyor with four (4) visit notes. One (1) physical therapy visit, however, still remained unaccounted for. The patient was discharged from physical therapy on January 29, 2002 without any evidence in the record that the patient had received all nine (9) physical therapy visits in accordance with the patient’s plan of care. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #2 in accordance with the patient’s plan of care. 18.2. A review of patient # 4’s plan of care revealed a physician’s order for skilled nursing visits, physical therapy visits and home health aide visits. An initial visit was made to the patient on the start of care date of December 31, 2001. The patient was discharged on January 14, 2002. Further review of patient #4’s clinical record revealed that the nurse had recommended changing the frequency of skilled nursing visits from an evaluation and a follow-up visit to three (3) visits for one (1) week and two (2) visits for another week. According to the documentation contained in the clinical record, PHS never sought physician approval to revise the plan of care in order to implement this change As per the physician’s order, the plan of care for physical therapy called for visits three (3) times a week for three (3) weeks. This frequency was not followed. For example, during one week of services, the patient received only two (2) physical therapy visits, not three (3) visits as provided in the patient’s plan of care. Additionally, the patient was discharged on January 14, 2002, prior to the end of the three (3) week period. According to the plan of care, the home health aide visits were to be conducted three (3) times a week for three (3) weeks. The patient received only three (3) home health aide visits, not nine (9) visits as provided in the plan of care. Finally, a review of patient #4’s clinical record revealed four (4) missing laboratory test results. Additionally, there was no evidence in the record that the tests had been performed. PHS failed to obtain the laboratory test results, which results are necessary in evaluating and coordinating the provision of skilled care services to patient #4. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #4 in accordance with the patient’s plan of care. 18.3. A review of patient #7’s plan of care revealed a recommendation for an occupational therapy evaluation and a physical therapy evaluation. The start of care date was January 27, 2002. As of the date of the survey, February 4-8, 2002, there was no documentation in the clinical record of any occupational therapy evaluation or physical therapy evaluation being provided to the patient. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #7 in accordance with the patient’s plan of care. 18.4. A review of patient #8’s plan of care revealed that an occupational therapy evaluation was ordered on the start of care date of December 12, 2001. The initial evaluation was not completed until January 14, 2002. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #8 in accordance with the patient’s plan of care. 18.5. A review of patient #9’s plan of care revealed a physician’s order for daily skilled nursing visits with a start of care date of October 24, 2001. The skilled nursing visits were not provided to patient #9 in accordance with the patient’s plan of care. First, the visits were changed from once a day to two (2) times per day with no documented modification of the physician’s order. Second, on some days, the patient received no skilled nursing visits. During an interview with the consultant and the Director of Nursing, both stated that they were unaware of the fact that the services were not being delivered to the patient in accordance with the plan of care. According to the nurse’s note, the last skilled nursing visit was on January 23, 2002. As of February 8, 2002, there was no indication in the clinical record as to whether the patient was discharged or not. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #9 in accordance with the patient’s plan of care. 18.6. A review of patient #11’s plan of care revealed a recommendation for skilled nursing visits, physical therapy visits and home health aide visits with a start of care date of February 2, 2002. As of the date of the survey, February 4-8, 2002, there was no evidence in the clinical record that the home health aide and physical therapy visits had been provided to the patient. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #11 in accordance with the patient’s plan of care. 18.7. A review of patient #12’s plan of care revealed a recommendation for a speech therapy evaluation and a start of care date of January 31, 2002. According to the documentation contained in the clinical record, as of February 6, 2002, the speech therapy evaluation had not been provided to the patient. Based on the foregoing, PHS failed to supervise and coordinate the provision of skilled care services to patient #12 in accordance with the patient’s plan of care. 18.8. NHP Patient #1 was referred to PHS on February 1, 2002. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. 18.9. NHP Patient #2 was referred to PHS on February 1, 2002. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. 18.10. NHP Patient #3 was referred to PHS on February 1, 2002. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. 18.11. NHP Patient #4 was referred to PHS on February 1, 2002. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. 18.12. NHP Patient #5 was referred to PHS on February 1, 2002. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. 18.13. NHP Patient #6 was referred to PHS on February 1, 2002. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. 19. Based on all of the foregoing, PHS has violated Section 400.487(6), Florida Statutes, by failing to supervise and coordinate, in accordance with the plan of care, skilled care services provided to the patient by PHS directly or under contract with others. 20. The foregoing violation is a class II violation in that it had a direct adverse effect on the health, safety or security of the thirteen (13) patients involved. Pursuant to Sections 400.484(2)(b) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $1,000 per patient or per occurrence for a total fine amount of $13,000 ($1,000 x 13 patients) for this class II violation. COUNT IV PHS FAILED TO PROVIDE CASE MANAGEMENT BY A LICENSED REGISTERED NURSE DIRECTLY EMPLOYEED BY PHS IN CASES INVOLVING ONLY NURSING SERVICES, OR IN CASES REQUIRING NURSING AND PHYSICAL, OCCUPATIONAL OR SPEECH THERAPY SERVICES, Rule 59A-8.008(1), Fla. Admin. Code CLASS IT DEFICIENCY 21. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 22. From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and clinical record review, a class II deficiency was cited against PHS based upon the findings below involving eleven (11) patients. 22.1. A review of patient #4’s plan of care revealed a physician’s order for skilled nursing visits, physical therapy visits and home health aide visits. An initial visit was made to the patient on the start of care date of December 31, 2001. The patient was discharged on January 14, 2002. Further review of patient #4’s clinical record revealed that the nurse had recommended changing the frequency of skilled nursing visits from an evaluation and a follow-up visit to three (3) visits for one (1) week and two (2) visits for another week. According to the documentation contained in the clinical record, PHS never implemented this change and the patient was discharged on January 14, 2002. As per the physician’s order, the plan of care for physical therapy called for visits three (3) times a week for three (3) weeks. This frequency was not followed. For example, during one week of services, the patient received only two (2) physical therapy visits, not three (3) visits as provided in the patient’s plan of care. Additionally, the patient was discharged on January 14, 2002, prior to the end of the three (3) week period. According to the physician’s order, the plan of care for the home health aide visits were to be conducted three (3) times a week for three (3) weeks. The patient received only three (3) home health aide visits, not nine (9) visits as provided in the plan of care. Finally, a review of patient #4’s clinical record revealed four (4) missing laboratory test results. There was no evidence contained in the record that the tests had been performed. Based on the foregoing, PHS failed to provide patient #4 with adequate case management by a licensed registered nurse to ensure that: (a) the plan of care was implemented and periodically reviewed; (b) all ordered medical treatment was provided to the patient; (c) the provision of care was supervised and evaluated; (d) all services provided by other health care providers was coordinated with the overall care provided to patient #4; and (e) all activities and findings were documented in the clinical record. 22.2. A review of patient #7’s clinical record revealed a recommendation for skilled nursing services, an occupational therapy evaluation and a physical therapy evaluation. The start of care date was January 26, 2002. As of the date of the survey, February 4-8, 2002, there was no documentation contained in the clinical record showing that the patient had received either the occupational therapy evaluation or the physical therapy evaluation. During an interview with the consultant, the Agency surveyor learned that the patient had been hospitalized and then readmitted to PHS. PHS was unable to determine the date of hospitalization or if any of the ordered services were provided to patient #7. Based on the foregoing, PHS failed to provide patient #7 with adequate case management by a licensed registered nurse to ensure that: (a) the plan of care was implemented and periodically reviewed; (b) all ordered medical treatment was provided to the patient; (c) the provision of care was supervised and evaluated; (d) all services provided by other health care providers was coordinated with the overall care provided to patient #7; and (e) all activities and findings were documented in the clinical record. 22.3. A review of patient #9’s plan of care revealed a physician’s order for daily skilled nursing visits with a start of care date of October 24, 2001. The skilled nursing visits were not provided to patient #9 in accordance with the patient’s plan of care. First, the visits were changed from once a day to two (2) times per day with no documented modification of the physician’s order. Second, on some days, the patient received no skilled nursing visits. During an interview with the consultant and the Director of Nursing, both stated that they were unaware of the fact that the services were not being delivered to the patient in accordance with the plan of care. According to the nurse’s note, the last skilled nursing visit was on January 23, 2002. As of February 8, 2002, there was no indication in the clinical record as to whether the patient was discharged or not. Based on the foregoing, PHS failed to provide patient #9 with adequate case management by a licensed registered nurse to ensure that: (a) the plan of care was implemented and periodically reviewed; (b) all ordered medical treatment was provided to the patient; (c) the provision of care was supervised and evaluated; (d) all services provided by other health care providers was coordinated with the overall care provided to patient #9; and (e) all activities and findings were documented in the clinical record. 22.4. A review of patient #11’s plan of care revealed a recommendation for skilled nursing visits, physical therapy visits and home health aide visits with a start of care date of February 2, 2002. As of the date of the survey, February 4-8, 2002, there was no evidence in the clinical record that the home health aide and physical therapy visits had been provided to the patient. Based on the foregoing, PHS failed to provide patient #11 with adequate case management by a licensed registered nurse to ensure that: (a) the plan of care was implemented and periodically reviewed; (b) all ordered medical treatment was provided to the patient; (c) the provision of care was supervised and evaluated; (d) all services provided by other health care providers was coordinated with the overall care provided to patient #11; and (e) all activities and findings were documented in the clinical record. 20 22.5. A review of patient #12’s plan of care revealed a recommendation for, among other services, skilled nursing services and a speech therapy evaluation. The start of care date was January 31, 2002. According to the documentation contained in the clinical record, the speech therapy evaluation had not been provided to the patient as of February 6, 2002, the date of the record review. Based on the foregoing, PHS failed to provide patient #12 with adequate case management by a licensed registered nurse to ensure that: (a) the plan of care was implemented and periodically reviewed; (b) all ordered medical treatment was provided to the patient; (c) the provision of care was supervised and evaluated; (d) all services provided by other health care providers was coordinated with the overall care provided to patient #12; and (e) all activities and findings were documented in the clinical record. 22.6. NHP Patient #1 was referred to PHS on February 1, 2002. As of February 8, 2002, no licensed registered nurse employed by PHS: (a) had performed an initial assessment of the patient and the patient’s caregiver for the appropriateness of and acceptance of the patient for home health services; or (b) had established a plan of care for the patient. 21 22.7. NHP Patient #2 was referred to PHS on February 1, 2002. As of February 8, 2002, no licensed registered nurse employed by PHS: (a) had performed an initial assessment of the patient and the patient’s caregiver for the appropriateness of and acceptance of the patient for home health services; or (b) had established a plan of care for the patient. 22.8. NHP Patient #3 was referred to PHS on February 1, 2002. As of February 8, 2002, no licensed registered nurse employed by PHS: (a) had performed an initial assessment of the patient and the patient’s caregiver for the appropriateness of and acceptance of the patient for home health services; or (b) had established a plan of care for the patient. 22.9. NHP Patient #4 was referred to PHS on February 1, 2002. As of February 8, 2002, no licensed registered nurse employed by PHS: (a) had performed an initial assessment of the patient and the patient’s caregiver for the appropriateness of and acceptance of the patient for home health services; or (b) had established a plan of care for the patient. 22 22.10. NHP Patient #5 was referred to PHS on February 1, 2002. As of February 8, 2002, no licensed registered nurse employed by PHS: (a) had performed an initial assessment of the patient and the patient’s caregiver for the appropriateness of and acceptance of the patient for home health services; or (b) had established a plan of care for the patient. 22.11. NHP Patient #6 was referred to PHS on February 1, 2002. As of February 8, 2002, no licensed registered nurse employed by PHS: (a) had performed an initial assessment of the patient and the patient’s caregiver for the appropriateness of and acceptance of the patient for home health services; or (b) had established a plan of care for the patient. 23. Based on all of the foregoing, PHS has violated Rule 59A-8.008(1), Florida Administrative Code, by failing to provide case management by a licensed registered nurse employed by PHS in cases of patients requiring nursing services only, or in cases requiring nursing services and physical therapy, occupational therapy and speech therapy services. 24. The foregoing violation is a class II violation in that it had a direct adverse effect on the health, safety or security of the eleven (11) patients involved. Pursuant to Sections 400.484(2)(b) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $1,000 per patient or per occurrence for a total fine amount of $11,000 ($1,000 x 11 patients) for this class II violation. 23 COUNT V PHS FAILED TO ASSURE THAT EACH PATIENT ACCEPTED FOR SERVICE RECEIVED SERVICES AS DEFINED IN THE SPECIFIC PLAN OF CARE INCLUDING ASSURING THAT EACH PATIENT RECEIVED ALL ASSIGNED VISITS. Rule 59A-8.020(1), Fla. Admin. Code CLASS II DEFICIENCY 25. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 26. From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and clinical record review, a class II deficiency was cited against PHS based upon the findings below involving thirteen (13) patients. 26.1. PHS accepted patient #2 as a patient for service. A review of patient #2’s plan of care revealed a physician’s order for a physical therapy evaluation and nine (9) physical therapy visits. Patient #2 received the evaluation on the start of care date of January 10, 2002. Patient #2 was discharged from physical therapy on January 29, 2002 without any evidence in the record that the patient had received all nine (9) visits in accordance with the plan of care. Based on the foregoing, PHS failed to assure that patient #2 received services as defined in the plan of care and failed to assure that patient #2 received all assigned visits. 24 26.2. PHS accepted patient #4 as a patient for service. A review of patient #4’s plan of care revealed a physician’s order for skilled nursing visits, physical therapy visits and home health aide visits. An initial visit was made to the patient on the start of care date of December 31, 2001. The patient was discharged on January 14, 2002. Further review of patient #4’s clinical record revealed that the nurse had recommended changing the frequency of skilled nursing visits from an evaluation and a follow-up visit to three (3) visits for one (1) week and two (2) visits for another week. According to the documentation contained in the clinical record, PHS never obtained physician approval to revise the plan of care to implement this change. The patient was discharged on January 14, 2002. As per the physician’s order, the plan of care for physical therapy called for visits three (3) times a week for three (3) weeks. This frequency was not followed. For example, during one week of services, the patient received only two (2) physical therapy visits, not three (3) visits as provided in the patient’s plan of care. Additionally, the patient was discharged on January 14, 2002, prior to the end of the three (3) week period. According to the plan of care, the home health aide visits were to be conducted three (3) times a week for three (3) weeks. The patient received only three (3) home health aide visits, not nine (9) visits as provided in the plan of care. 25 Based on the foregoing, PHS failed to assure that patient #4 received services as defined in the plan of care and failed to assure that patient #4 received all assigned visits. 26.3. PHS accepted patient #7 as a patient for service. A review of patient # 7’s plan of care revealed a physician’s order for an occupational therapy evaluation and a physical therapy evaluation. The start of care date was January 26, 2002. As of the date of the survey, February 4-8, 2002, there was no documentation contained in the clinical record showing that the patient had received either the occupational therapy evaluation or the physical therapy evaluation. Based on the foregoing, PHS failed to assure that patient #7 received services as defined in the plan of care and failed to assure that patient #7 received all assigned visits. 26.4. PHS accepted patient #8 as a patient for service. A review of patient #8’s plan of care revealed that a physician ordered an occupational therapy evaluation on the start of care date of December 12, 2001. The initial evaluation was not completed until January 14, 2002. Based on the foregoing, PHS failed to assure that patient #8 received services as defined in the plan of care and failed to assure that patient #8 received all assigned visits in a timely fashion. 26 26.5. PHS accepted patient #9 as a patient for service. A review of patient #9’s plan of care revealed a physician’s order for daily skilled nursing visits with a start of care date of October 24, 2001. The skilled nursing visits were not provided to patient #9 in accordance with the patient’s plan of care. First, the visits were changed from once a day to two (2) times per day with no documented modification of the physician’s order. Second, on some days, the patient received no skilled nursing visits. During an interview with the consultant and the Director of Nursing, both stated that they were unaware of the fact that the services were not being delivered to the patient in accordance with the plan of care. According to the nurse’s note, the last skilled nursing visit was on January 23, 2002. As of February 8, 2002, there was no indication in the clinical record as to whether the patient was discharged or not or whether the patient had received all ordered skilled nursing visits. Based on the foregoing, PHS failed to assure that patient #9 received services as defined in the plan of care and failed to assure that patient #9 received all assigned visits. 26.6. PHS accepted patient #11 as a patient for service. A review of patient #11’s clinical record revealed a start of care date of February 2, 2002. The patient’s plan of care called for skilled nursing visits, physical therapy visits and home health aide visits. There was no evidence in the clinical record that the home health aide and physical therapy visits had been made. 27 26.7. PHS accepted patient #12 as a patient for service. A review of patient #12’s clinical record revealed that the patient’s plan of care required a speech therapy evaluation. The start of care date was January 31, 2002. However, as of February 6, 2002, the speech therapy evaluation had not been conducted. 26.8. NHP Patient #1 was referred to PHS on February 1, 2002 and PHS accepted the patient for service. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. Based on the foregoing, PHS failed to assure that the patient received services as defined in a specific plan of care. 26.9. NHP Patient #2 was referred to PHS on February 1, 2002 and PHS accepted the patient for service. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. Based on the foregoing, PHS failed to assure that the patient received services as defined in a specific plan of care. 26.10. NHP Patient #3 was referred to PHS on February 1, 2002 and PHS accepted the patient for service. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. Based on the foregoing, PHS failed to assure that the patient received services as defined in a specific plan of care. 28 26.11. NHP Patient #4 was referred to PHS on February 1, 2002 and PHS accepted the patient for service. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. Based on the foregoing, PHS failed to assure that the patient received services as defined in a specific plan of care. 26.12. NHP Patient #5 was referred to PHS on February 1, 2002 and PHS accepted the patient for service. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. Based on the foregoing, PHS failed to assure that the patient received services as defined in a specific plan of care. 26.13. NHP Patient #6 was referred to PHS on February 1, 2002 and PHS accepted the patient for service. As of February 8, 2002, no initial evaluation or plan of care had been established for this patient. Based on the foregoing, PHS failed to assure that the patient received services as defined in a specific plan of care. 27. Based on all of the foregoing, PHS has violated Rule 59A-8.020(1), Florida Administrative Code, by failing to assure that each patient accepted for service received services as defined in a specific plan of care and received all assigned visits. 29 28. The foregoing violation is a class II violation in that it had a direct adverse effect on the health, safety or security of the thirteen (13) patients involved. Pursuant to Sections 400.484(2)(b) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $1,000 per patient or per occurrence for a total fine amount of $13,000 ($1,000 x 13 patients) for this class II violation. COUNT VI PHS FAILED TO ENSURE THAT A REGISTERED NURSE LICENSED IN THE STATE OF FLORIDA WAS: (1) THE CASE MANAGER IN ALL CASES INVOLVING NURSING OR BOTH NURSING AND THERAPY CARE; (2) RESPONSIBLE FOR THE CLINICAL RECORD FOR EACH PATIENT RECEIVING NURSING CARE; AND (III) ASSURING THAT PROGRESS REPORTS WERE MADE TO THE PHYSICIAN FOR PATIENTS RECEIVING NURSING SERVICES WHEN THE PATIENT’S CONDITION CHANGES OR THERE ARE DEVIATIONS FROM THE PLAN OF CARE. A REGISTERED NURSE MAY ASSIGN SELECTED PORTIONS OF PATIENT CARE TO LICENSED PRACTICAL NURSES AND HOME HEALTH AIDES BUT ALWAYS RETAINS FULL RESPONSIBILITY FOR THE CARE GIVEN AND FOR MAKING SUPERVISORY VISITS TO THE PATIENT’S HOME. Rule 59A-8.0095(3), Fla. Admin. Code UNCORRECTED CLASS III DEFICIENCY 29. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 30. On or about August 30, 2001 a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and review of seven (7) patient records, a class III deficiency was cited against PHS based on the findings below. 30 30.1. Each of the seven (7) patient records reviewed by the Agency surveyor did not have a plan of care containing a specific list of goals. 30.2. Each of the seven (7) patient records reviewed by the Agency surveyor did not have an initial assessment of the patient’s needs. 30.3. During the survey, “key” PHS personnel admitted to an Agency surveyor that none of the seven (7) clinical records reviewed by the surveyor contained a plan of care or initial assessment. 31. Based on all of the foregoing, PHS has violated Rule 59A-8.0095(3), Florida Administrative Code, by failing to ensure that a registered nurse currently licensed in the State of Florida is: (i) the case manager in all cases involving nursing or both nursing and therapy care; (ii) responsible for the clinical record for each patient receiving nursing care; and (iii) assuring that progress reports are made to the physician for patients receiving nursing services when the patient’s condition changes or there are deviations from the plan of care. A registered nurse may assign selected portions of patient care to licensed practical nurses and home health aides but always retains full responsibility for the care given and for making supervisory visits to the patient’s home. 32. The foregoing violation is a class II] violation in that it had an indirect adverse effect on the health, safety or security of the seven (7) patients involved. 31 33. PHS was given written notification of the cited class III violation with a mandated correction date of September 30, 2001. 34, From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and clinical record review, the following uncorrected class III deficiency was cited against PHS based on the findings below involving three (3) patients. 34.1. A review of patient # 4’s plan of care revealed a physician’s order for skilled nursing visits, physical therapy visits and home health aide visits. An initial visit was made to the patient on the start of care date of December 31, 2001. The patient was discharged on January 14, 2002. Further review of patient #4’s clinical record revealed that the nurse had recommended changing the frequency of skilled nursing visits from an evaluation and a follow-up visit to three (3) visits for one (1) week and two (2) visits for another week. According to the documentation contained in the clinical record, PHS never obtained physician approval to revise the plan of care in order to implement this change As per the physician’s order, the plan of care for physical therapy called for visits three (3) times a week for three (3) weeks. This frequency was not followed. For example, during one week of services, the patient received only two (2) physical therapy visits, not three (3) visits as provided in the patient’s plan of care. Additionally, the patient was 32 discharged on January 14, 2002, prior to the end of the three (3) week period. According to the plan of care, the home health aide visits were to be conducted three (3) times a week for three (3) weeks. The patient received only three (3) home health aide visits, not nine (9) visits as provided in the plan of care. Finally, a review of patient #4’s clinical record revealed four (4) missing laboratory test results. Additionally, there was no evidence in the record that the tests had been performed. PHS failed to obtain the laboratory test results, which results are necessary in evaluating and coordinating the provision of skilled care services to patient #4. Based on the foregoing, PHS failed to assure that a registered nurse: (a) provided case management; (b) maintained a complete and accurate clinical record; and/or (c) made a progress report to the physician when there were deviations from the plan of care. 34.2. A review of patient #7’s plan of care revealed a recommendation for skilled nursing services, an occupational therapy evaluation and a physical therapy evaluation. The start of care date was January 27, 2002. As of the date of the survey, February 4-8, 2002, there was no documentation in the clinical record of any occupational therapy evaluation or physical therapy evaluation being provided to the patient. Based on the foregoing, PHS failed to assure that a registered nurse: (a) provided case 33 management; (b) maintained a complete and accurate clinical record; and/or (c) made a progress report to the physician when there were deviations from the plan of care. 34.3. PHS accepted patient #9 as a patient for service. A review of patient #9’s plan of care revealed a physician’s order for daily skilled nursing visits with a start of care date of October 24, 2001. The skilled nursing visits were not provided to patient #9 in accordance with the patient’s plan of care. First, the visits were changed from once a day to two (2) times per day with no documented modification of the physician’s order. Second, on some days, the patient received no skilled nursing visits. During an interview with the consultant and the Director of Nursing, both stated that they were unaware of the fact that the services were not being delivered to the patient in accordance with the plan of care. According to the nurse’s note, the last skilled nursing visit was on January 23, 2002. As of February 8, 2002, there was no indication in the clinical record as to whether the patient was discharged or not or whether the patient had received all ordered skilled nursing visits. Based on the foregoing, PHS failed to assure that a registered nurse: (a) provided case management; (b) maintained a complete and accurate clinical record; and/or (c) made a progress report to the physician when there were deviations from the plan of care, 34 35. Based on all of the foregoing, PHS has violated Rule 59A-8.0095(3), Florida Administrative Code, by failing to ensure that a registered nurse currently licensed in the State of Florida is: (i) the case manager in all cases involving nursing or both nursing and therapy care; {ii) responsible for the clinical record for each patient receiving nursing care; and (iii) assuring that progress reports are made to the physician for patients receiving nursing services when the patient’s condition changes or there are deviations from the plan of care. A registered nurse may assign selected portions of patient care to licensed practical nurses and home health aides but always retains full responsibility for the care given and for making supervisory visits to the patient’s home. 36. The foregoing violation is a class III violation in that it had an indirect adverse effect on the health, safety or security of the three (3) patients involved. Pursuant to Sections 400.484(2)(c) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $500 per patient or per occurrence and $500 per day for each day the uncorrected deficiency exists. Based on the foregoing, the Agency seeks a total fine amount of $65,000 (($500 x 3 patients = $1,500) + ($500 x 127 days (10/01/01 to 2/04/02) = $63,500)) for this uncorrected class III violation. 35 COUNT VII PHS FAILED TO MAINTAIN FOR EACH PATIENT WHO RECEIVES SKILLED CARE A COMPLETE CLINICAL RECORD THAT INCLUDES PERTINENT PAST AND CURRENT MEDICAL, NURSING, SOCIAL AND OTHER THERAPEUTIC INFORMATION, THE TREATMENT ORDERS, AND OTHER SUCH INFORMATION AS IS NECESSARY FOR THE SAFE AND ADEQUATE CARE OF THE PATIENT. Section 400.491(1), Fla. Stat.; Rule 59A-8.022(5) and (6), Fla. Admin. Code UNCORRECTED CLASS II DEFICIENCY 37. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 38. On August 30, 2001 a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and review of seven (7) patient records, a class III deficiency was cited against PHS based on the findings below. 38.1. Seven (7) of the seven (7) clinical records reviewed did not contain documentation of past or current medical, nursing and other therapeutic information as necessary for the safe and adequate care of the patient. 38.2, During the survey, “key” personnel admitted to an Agency surveyor that none of the seven (7) clinical records reviewed by the surveyor had documentation of past or current medical, nursing and other therapeutic information. 36 39. Based on the foregoing, PHS has violated: (a) Section 400.491(1), Florida Statutes, by failing to maintain for each patient who receives skilled care a clinical record that includes pertinent past and current medical, nursing, social and other therapeutic information, the treatment orders, and other such information as is necessary for the safe and adequate care of the patient; and (b) Rule 59A-8.022(5) and (6), Florida Administrative Code, by failing to maintain for each patient a complete clinical record with all twelve (12) types of information as stated in the rule. 40. The foregoing violation is a class III violation in that it had an indirect adverse effect on the health, safety or security of the seven (7) patients involved. 41. PHS was given written notification of the cited class IH violation with a mandated correction date of September 30, 2001. 42. From on or about February 4, 2002 to on or about February 8, 2002, a survey team from the Agency’s Area 11 Office conducted a survey at PHS. Based on interviews and clinical record review, an uncorrected class III deficiency was cited against PHS based upon the findings below involving nine (9) patients. 42.1. A review of patient #1’s clinical record revealed that it did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #1. Based on the foregoing, PHS failed to 37 maintain a complete clinical record for patient #1 containing, among other information, reports of case conferences. 42.2. A review of patient # 2’s clinical record revealed that five (5) out of the nine (9) physician ordered physical therapy visits were not documented. The next day, the Director of Nursing provided the Agency surveyor with four (4) visit notes. PHS’s staff informed the Agency surveyor that the physical therapy company failed to provide the notes in a timely fashion. One (1) physical therapy visit, however, still remained unaccounted for. The patient was discharged from physical therapy on January 29, 2002 without any evidence in the record that the patient had received all nine (9) visits. A further review of patient #2’s clinical record revealed that it did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #2. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #2 containing, among other information, reports of case conferences and clinical and services notes, signed and dated by the staff member providing the service which notes include services rendered. 38 42.3. A review of patient #3’s clinical record revealed that it did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #3. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #3 containing, among other information, reports of case conferences. 42.4. A review of patient #4’s clinical record showed an order to have blood drawn every Monday and Wednesday. The documentation contained in the clinical record revealed that it was drawn on the initial visit only. There was no other documentation showing that the blood was drawn again. On February 7, 2002 PHS’s staff provided a memorandum to the Agency surveyor. According to the memorandum, the patient was going to a physician’s office to have blood drawn. There was no further evidence in the clinical record that PHS obtained the test results from the physician’s office in order to re-evaluate, reassess, and patient coordinate care. A further review of patient #4’s clinical record revealed that it did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #4. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #4 containing, among other information, reports of case conferences and an accurate assessment of the patient’s needs. 39 42.5. A review of patient #5’s clinical record showed that it was missing a discharge summary. A further review of patient #5’s clinical record revealed that it also did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #5. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #5 containing, among other information, reports of case conferences and a termination summary including the date of the first and last visit, the reason for the termination of services, an evaluation of established goals at the time of termination, the condition of the patient on discharge and the disposition of the patient. 42.6. A review of patient #7’s clinical record showed that it was missing a discharge summary. A further review of patient #7’s clinical record revealed that it also did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #7. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #7 containing, among other information, reports of case conferences and a termination summary including the date of the first and last visit, the reason for the termination of services, an evaluation of established goals at the time of termination, the condition of the patient on discharge and the disposition of the patient. 40 42.7. A review of patient #8’s clinical record showed that it was missing a discharge summary. A further review of patient #8’s clinical record revealed that it also did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #8. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #8 containing, among other information, reports of case conferences and a termination summary including the date of the first and last visit, the reason for the termination of services, an evaluation of established goals at the time of termination, the condition of the patient on discharge and the disposition of the patient. 42.8. A review of patient #9’s clinical record showed that it was missing a discharge summary and several skilled nursing notes. There were no skilled nursing notes for a period of ten (10) days. At the time of the record review on February 4, 2002, the plan of care reflected daily nursing visits. There were a total of twenty (20) nursing notes that were missing from the clinical record. Based on the foregoing, PHS failed to maintain in patient #9’s clinical record clinical and services notes, signed and dated by the staff member providing the service which notes include initial assessments and progress notes, services rendered, observations, and instructions to the patient and caregiver or guardian. 4 42.9. A review of patient #13’s clinical record revealed that it did not contain reports of case conferences. During an interview with the Agency surveyor, PHS’s Director of Nursing admitted that case conferences were not being conducted for patient #13. Based on the foregoing, PHS failed to maintain a complete clinical record for patient #13 containing, among other information, reports of case conferences. 43. Based on all of the foregoing, PHS has violated: (a) Section 400.491(1), Florida Statutes, by failing to maintain for each patient who receives skilled care a clinical record that includes pertinent past and current medical, nursing, social and other therapeutic information, the treatment orders, and other such information as is necessary for the safe and adequate care of the patient; and (b) Rule 59A-8.022(5) and (6), Florida Administrative Code, by failing to maintain for each patient a complete clinical record containing all twelve (12) types of information as stated in the rule. 44. The foregoing violation is a class III violation in that it had an indirect adverse effect on the health, safety or security of the nine (9) patients involved. Pursuant to Sections 400.484(2)(c) and 400.474(2)(a), Florida Statutes, the Agency is authorized to impose a fine against PHS in the amount of $500 per patient or per occurrence and $500 per day for each day the uncorrected deficiency exists. Based on the foregoing, the Agency seeks a total fine amount of $68,000 (($500 x 9 patients = $4,500) + ($500 x 127 days (10/01/01 to 2/04/02) = $63,500)) for this uncorrected class III violation. 42 CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make factual and legal findings in favor of the Agency on Counts I through VII; 2) Impose a fine in the amount of $179,000; 3) Uphold the Agency’s denial of PHS’s license renewal application; 4) Assess costs related to the investigation of this case pursuant to Section 400.484(3), Florida Statutes (2001); and 5) Any other general and equitable relief as deemed necessary in the furtherance of justice. NOTICE Respondent hereby is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. All requests for a hearing shall be sent to the Lori C. Desnick, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida, 32308. PHS IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 43 Respectfully submitted on this 29' day of April, 2002. Lori C. Desnick Senior Attorney Florida Bar No. 0129542 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32303 (850) 921-0071 (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint has been served via hand delivery to Adela C. Nunez, Administrator, or her designee, Professional Health Systems, Inc., 2850 Douglass Road, 274 Floor, Coral Gables, Florida 33134 and via certified mail return receipt requested (return receipt # 7106 4575 1294 2049 9146) to Raul E. Garcia, Esquire, Registered Agent, 9200 South Dadeland Boulevard, Suite 316, Miami, Florida 33156, on this 29 day of April, 2002. kine CC. Dusprwech, Lori C. Desnick, Esquire Copies furnished to: Lori C. Desnick Senior Attorney Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 44 Elizabeth Dudek, Deputy Secretary Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #9 Tallahassee, Florida 32308 (via Interoffice Mail) Anne Menard Home Care Unit Manager Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #34 Tallahassee, Florida 32308 (via Interoffice Mail) 45

Docket for Case No: 02-002324