STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, ao Petitioner, re AHCA NO: 2002000521 vs. ae rane an Sats! HARBOR VIEW MANOR INC. Respondent. i a [ae] ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Harbor View Manor Inc. (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of three thousand dollars ($3,000) pursuant to Sections 400.414 (1) (e) and 400.419(1) (c), Florida Statutes. 2. Respondent is cited for the deficiency set forth below as a result of the annual survey on or about December 20, 2001. Same or similar deficiencies were cited in the annual survey on or about February 28, 2000. The deficiencies are repeated Class III deficiencies. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Charlotte County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. PARTIES S. AHCA, Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 315 Addison Drive, Port Charlotte, FL. Respondent, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNT I AND RULE 58A-5.0185(5) (b), F.A.C. CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. Based on record review it was determined that Respondent failed to maintain accurate and updated Medication Observation Records (MOR) for 2 (Residents #1 and #4) of 5 active residents. Respondent failed to give Resident #4’s physician-ordered medication to the resident. Respondent failed to follow physician’s orders for an “as needed” medication by giving the medication every night at 6 P.M. daily without orders from the physician to make the medication routine. 9. This is a violation of Section 400.4256(3) (f), Florida Statutes which requires Respondent to keep a record of when a resident receives assistance with self- administration of medication; and Rule 58A-5.0185(5) (b), Florida Administrative Code which requires Respondent to maintain daily up-to-date, medication observation record (MOR) for residents who receive assistance with self- administration or medication administration. 10. The above referenced violation constitutes the grounds for the imposed Class III deficiency and for which a fine of seven hundred and fifty dollars ($750) is authorized pursuant to Sections 400.414 (1) (e) and 400.419(1) (c), Florida Statutes. ll. Notice was provided in writing to Respondent of the above violation and the time frame for correction. COUNT II RESPONDENT FAILED TO ADEQUATELY STORE MEDICATION VIOLATING RULE 58A-5.0185(6) (b)1., F.A.C. CLASS III DEFICIENCY 12. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 13. Based on interview and observation it was determined that Respondent failed to store the prescription medication in a central location by leaving the medication for Resident #5, who had expired, on the resident’s shelf in the bathroom. When interviewed, the Administrator stated that the medication should have been stored in the medication cart. 14. This a violation of Rule 58A-5.0185(6)(b)1., Florida Administrative Code which requires centrally stored medication to be stored in a locked cabinet, locked cart, or other locked storage receptacle, room, or area at all times. 15. The above referenced violation constitutes the grounds for the imposed Class III deficiency and for which a fine of seven hundred and fifty dollars ($750) is authorized pursuant to Sections 400.414 (1) (e) and 400.419(1) (c), Florida Statutes. 16. Notice was provided in writing to Respondent of the above violation and the time frame for correction. COUNT III RESPONDENT FAILED TO OBTAIN ADEQUATE PHYSICIAN ORDERS FOR “AS NEEDED” MEDICATION FOR RESIDENTS VIOLATING RULE 58A- 5.0185(7) (c), F.A.C. CLASS III DEFICIENCY 17. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 18. Based on record review of the Medication and Observation Records (MOR) and staff interview it was determined that Respondent failed to request specific instruction from the health care provider when orders were obtained for Residents #1 and #4 medication that stated “as needed.” 19. This is a violation of Rule 58A-5.0185(7) (c), Florida Administrative Code which requires if the directions for use are “as needed” or “as directed” the health care provider shall be contacted and requested to provide revised instructions. 20. The above referenced violation constitutes the grounds for the imposed Class III deficiency and for which a fine of seven hundred and fifty dollars ($750) is authorized pursuant to Sections 400.414 (1) (e) and 400.419(1) (c), Florida Statutes. 21. Notice was provided in writing to Respondent of the above violation and the time frame for correction. COUNT Iv RESPONDENT FAILED TO OBTAIN ADEQUATE EMPLOYEE DOCUMENTATION IN A TIMELY MANNER VIOLATING RULES 58A-5.019(2) (a), and 58A-5.024(2) (a) ,F.A.c. CLASS III DEFICIENCY 22. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 23. Based on record review and interview with the Administrator it was determined that Respondent’s staff, Employees #2 and #4, failed to submit a statement to the facility from a health care provider within 30 days of hire documenting the employee’s freedom from tuberculosis and other communicable diseases. When interviewed, the Administrator confirmed the statements of freedom from communicable diseases for Employees #2 and #4 had not been submitted to the facility in a timely fashion. 24. This is a violation of Rule 58A-5.019(2) (a), Florida Administrative Code which requires newly hired staff to submit a statement from a health care provider, based on an examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis; and Rule 58A-5.024(2) (a), Florida Administrative Code which requires at a minimum a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. 25. The above referenced violation constitutes the grounds for the imposed Class III deficiency and for which a fine of seven hundred and fifty dollars ($750) is authorized pursuant to Sections 400.414 (1) (e) and 400.419(1) (c), Florida Statutes. 26. Notice was provided in writing to Respondent of the above violation and the time frame for correction. WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order relief with a fine against the Respondent pursuant to Sections 400.414(1)(e) and 400.419(1) (c), Florida Statutes in the amount of three thousand dollars ($3,000) as to Counts I, II, III, and Iv. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one Page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Dennis L. Godfrey, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO 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. Respectfully submitted, nis L. Godfrey, E ite AHCA - Senior Attorney FBN: 0158100 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 (727) 552-1525 0 ns < My ~ I HEREBY CERTIFY that a true copy hereof has been ‘Sent : Phe! 2. to Respondent’s Registered Agent by U.S. Certifieg/Mait | 2g Return Receipt No. 7001 2510 0007 5976 5506, at Amerilawyet Chartered 343 Almeria Ave., Coral Gables, FL 33134, and U.S. mail, prepaid postage, to Administrator, Harbor View Manor Inc., 315 Addison Drive, Port Charlotte, FL 33953, the Ie aay of March, 2002. Copies furnished to: Amerilawyer Chartered Registered Agent for Harbor View Manor, Inc. 343 Almeria Ave. Coral Gables, FL 33134 (Certified U.S. Mail) Administrator Harbor View Manor Inc. 315 Addison Drive Port Charlotte, FL 33953 (U.S. Mail) Dennis L. Godfrey AHCA - Senior Attorney 525 Mirror Lake Drive Suite 3107 St. Petersburg, Fl 33701

Docket for Case No: 02-002770