© Lm BFY.2 EXHIBIT "A" STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Division of Administrative Hearings STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ? WiaE v8, HCB-H-01-0004 Windmoor Healthcare, Inc. d/b/a Windmoor Healthcare of Clearwater Respondent. i ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this COMPLAINT, the AGENCY FOR HEALTH CARE ADMINISTRATION ("Agency") intends to impose an administrative fine for each day of non-compliance upon Windmoor Healthcare, inc. (H }0-4017) ("Respondent") for viclations involving Prior Year Reports, As grounds for the imposition of this administrative fine, the Agency will show: i, Respondent is a hospital as defined by § 395 .002(12), Florida Statutes and is located at 11300 U.S. 19 North, Clearwater, FL 34624, . +2, Pursuant to Section 402.061(4){a), Florida Statutes, and Rule 59E-5.201, Florida Administrative Code, Respondent is required to file with the Agency within 120 days subsequent to the end of its fiscal year, its Prior Year Report which consists of an original and one copy of its actual report prepared and submitted in compliance with the Florida Hospital Uniform Reporting System Manual on forms adopted by the Agency, two copies of its andited financial statements, and one copy of its Medicare cost report, 3. Respondent failed to submit a complete and accurate Prior Year Report for its 2001 fiscal year by 11/27/2001. Pursuant to Rule $9B-2.024(5), Florida Administrative Code, the Agency sent a deemed nat filed notice to Respondent on 12/06/2001, which specified the corrections needed to bring its report into compliance with statutory and rule requirements, allowed ten (10) working days to provide the agency with the requested information, and gave notice that Respondent would be subject to imposition of an administrative fine if the requested information was not timely filed. A copy of the deemed not filed notice is attached nereto as Exhibit “A” and incorporated herein by reference. The retum receipt card was not returned from the facility. 4, Respondent failed to submit the Prior Year Report, Audited Financial Statements, and Medicare Cost Report to the Agency within ten (10) working days from the date of its receipt of the notice of violation as required therein, and, as of the date of this administrative complaint, has still not complied with the requirements of law and rules as set. forth hercin and in the notice of violation, 5, Based on the foregoing, Respondent has violated: §408.061(4)(a), Florida Statutes and Rule 59E-5.201, Florida Administrative Code, and Respondent is thereby subject to the penalties set forth in Section 408.08, Florida Statutes, which provides that any hospital which refuses to file a report, fails to timely file a report, files a faise report, or files an incomplete report shal! be punished by a fine not to exceed $1,000 per day for each day in violation, to be fixed, imposed, and collected by the Agency. Each day in violation shall be considered a separate offense. 6. Respondent's violations constitute a: second occurrence for the purpose of calvulating fines pursuant to Rule 59B-2.025, Florida Administrative Code. ee ee lemons 7. Pursuant to Rule 59£-2.024(5), Florida Administrative Code, the imposition of an administrative fine will be calculated from October 28", 2001, the original due date of the report, Respondent's failure to file its 2001 Prior Year Report in a timely manner is subject to a fine of $40.00 per day pursuant to Rule 59E-2,025 (1){a), Florida Administrative Code, In addition to the foregoing, if a complete report is not filed prior to the entry of the Order sought herein, Respondent shall be subject to a fine of $25,000 for fuilure to file a Teport as provided in Rule 59E-2.025(c), Florida Administrative Code. 8. YOU ARE FURTHER NOTIFIED that you have a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel or other qualified representative (at your own expense), to take testimony, to call or cross-examine witnesses, to have subpoena and/or subpoena duces tecum issued, and to present written evidence or argument if you request a hearing, Chapter 59-1, Part I, Florida Administrative Code, constitutes the Agency's procedural rule for administrative proceedings. resulting from this complaint. In order to obtain a formal proceeding under Section 120.57(1), Florida Stanites, your request for an administrative hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, and must set forth with specificity disputed issues of material fact. Failure to set forth such disputed issues of material fact may be treated by the Agency as an election by you of an informal proceeding . under §120.57(2), Florida Statutes. All requests for a hearing shall be made to: Agency for Health Care Administration, MS #3, Bldg. #3, 2727 Mahan Drive, Tallahassee, Florida 32308, Attention: Office of the General Counsel, Agency Clerk, copies to Christopher J. Augsburger, Regulatory Analyst Supervisor, Bureau, Health Facility Regulation. 9. All payments of administrative fies shall be by check or money order payable to the Agency for Health Care Administration. Reference shall be made to Respondent's _ hame, facility number, and the case number on this Complaint, and shall be sent to the Agency for Health Care Administration, Bureau Health Pacility Regulation, Fort Knox Office Plaza, Building #1, MS #28, 2727 Mahan Drive, Tallahassee, Florida 32308, Attention: Christopher J, Augsburger, Regulatory Analyst Supervisor, Bureau, Health Facility Regulation, 10. YOU ARE FURTHER NOTIFIED that failure to request a hearing within twenty-one (21) days of service 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. I HEREBY CERTIFY that a tue copy hereof was sent by U. 8, Certified Mail, Return Receipt Requested to C. William Brett, Chief Executive Officer, Windmoor Healthcare of Clearwater, 11300 U.S. 19 North, Clearwater, FL 34624 this 9" day of August 2002, - AugsBurger Regulatory"Analyst Supervisor Bureau Health Facility Regulation Agency for Health Care Administration pie STATE OF FLORIDA HCA AGENCY FOR HEALTH CARE ADMINISTRATION JER BUSH, GOVERNOR, RHONDA M. MEDOWS, ML, FAAFP, SECRETARY CERTIFIED MaqL December 6, 2001 C. William Brett tae Es h Lb: t ht Chief Executive Officer Windmoor Healthcare of Pineifas Park, Inc. mo, 11300 U.S. 19 North Clearwater, FL 34624 RE: 2001 Prior Year Report, FYE: 06/30/01 HL 104017 Deemed Not Filed Notice of Violation Dear Mr. Brett: Pursuant to rule 59E-2.024, 59B-5,103, 59E+5.204 and 590-5,206 F.A.C., the above referenced report has been found incomplete and deemed not filed for the following reason(s) ‘~~ Prior Year Actual Report Pursuant to rule 59B-5.201 and $9E-5.206 F.A.C., your hospital is required to submit to the Agency its actual report in electronic format, Please submit 0) 3.5, Inch diskette pursuant to the formatting requirements provided in Rule 59E~5.206, a” Audited financial statements Pursuant to rule 59E-5.201 F.A.C., your hospital is required to submit the hospital’s audited financial statements, Plonse submit (1) copy of the audited financial statements. Draft copies are not accepted, ce Medicare Cost Report Pursuant to rule $9E-5,.201 F.A.C., your hospital is required to submit (1) capy of the Medicare Cost Report. Please submit (1) copy of the Medicare Cost Report. 2727 Mahan Drive - Mall Step #28 Fratr ABCA Online af Taliahessec, FL 323092 www Fatho.rtare. Jt. as Pursuant to rule 59B-2.024(5), please submit the required information within 10 working days from the date you receive this letter. Any subsequent administrative fines will be imposed from the due date of the report. Section 408.08 of the Florida Statutes provides that any hospital which refuses to file on a timely basis reports or other information, required to be filed with the Agency, shall be punished by a fine not to exceed $1,000 per day for each day in violation. Failure to provide these corrections will result in the matter being forwarded to our legal counsel for appropriate action. Thank you very much for your cooperation, If you have any questions, please contact me at 850- 922-7434, oo, . . Sincerely, af . Paul Dyin * Regulatory Analyst COMPOSITE EXHIBIT “B” WORKSHEET A ACTUAL Xx BUDGET TRANSMITTAL AND CERTIFICATION OF BUDGET/PRIOR YEAR ACTUAL REPORT eee E 10 sep 25 2002 iysis OlficeAGENCY FOR HEALTH CARE ADMINISTRATION 325 John Knox Road The Atrium, Suite 301 Tallahassee, Florida 32303-4115 Con/Financial Ana Mail Stop 28 FROM WINDMOOR HEALTHCARE OF PINELLAS PARK, INC. dibla WINDMOOR HEALTHCARE OF CLEARWATER 4037, (NAME OF HOSPITAL) (HRS LICENSE NO.) 11300 US HIGHWAY 19 NORTH 10-4017 (STREET ADDRESS) \ (AHCA NUMBER) CLEARWATER 33764 727) 541-2646 {CITY AND ZIP CODE) (TELEPHONE) PERIOD FROM: 07/01/2000 TO: 06/30/2001 }HEREBY CERTIFY THATI HAVE EXAMINED THE ACCOMPANYING WORKSHEETS AS A PART OF THE STATE OF FLORIDA UNIFORM REPORT AND SUCH OTHER WORKSHEETS AND FORMS INCLUDED FOR YOUR INFORMATION FOR THE ABOVE PERIOD, INACCORDANCE WITH AND SUBJECT TO THE PROVISIONS OF SECTION 407.51(4). F.S, TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE INFORMATION CONTAINED IN THE REPORT SUBMITTED 1S TRUE, ACCURATE AND COMPLETE AND HAS BEEN PREPARED FROM THE HOSPITAL'S BOOKS AND RECORDS, EXCEPT AS NOTED. CHIEF EXECUTIVE OFFICER: C. WILLIAM BRETT (TYPE OR PRINT) - (SIGNATUR 5h 5/62 (DATE) CHIEF FINANCIAL OFFICER: WENDY MERSON (TYPE OR PRINT) Phi pl be (DATE) A Sent By: WINDMOOR - CLEARWATER ; 7275414402; 3 FINANCIAL SYSTEMS wors/5C-WoH oR WOMDOR HRALTNCARE HEALTH ‘ PREPARED @/ 1/2002 murs REPORT Te REQUIRED BY TA (42 DBC assby; 42 CPR 423-2000)). FAILURE 70 REPORT CAN RESULT TH ALL IWTakih PAYMENTS MADE SINCE ‘ie BEGINNING OF THE REPOR! PERIOD BEING DEEMED OVERPAYMENTS (42 vec 13959). ROSPITAL AND HOSPITAL WEALTH 1 pRovaprR NO; I PERIOD: t CARE COMPLEX 20-4017 y yrom 7/1/2000 I cost REPORT CERTIFICATION I I 70 6/30/2002 £ AND A&E! BURGTARY I 1 zt MANUALLY SUBMITTED COST REPORT PART 7 ~ CERTIFICATION MISREPRESENTATION oR GRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, IDENTIFIED BY TAIS REPORT WERE oy A KICKSACK OF WHERE AND /OR TMERISIONMENT MAY RRBULT. XNTORMATION CONTALNED TX SETS COS’ REPORT PINE AND/OR IMPRISONMENT UNDER THROUGH THE CRIMINAL, CIViL AND ADMINISTRATIVE ACTION, PINKS Sep-18-02 11:48AM; Page 2/2 e2t- 2552-96 (05/1998) X LIEU OF FORM FORM ABPROVED oma NO. 938-0050 WORKSHEET 5 vyaRte I 6 ii PATE RECEIVED: iif THTERMEDIARY NO: HAM yay BR PONTHHABLE BY FEDERAL LAW- FURTORRHORE , PAYMENT DIRECTLY OR CERTIFICATION BY OFEICESA OR ADMINIGTRATOR OF PROVIDER (3) 1 REREBY CERTIFY THAT y SUBMITTED CORT REPORT AND THE or 1024017 SEERT AND 6' ‘THCABE FOR THE COAT REPORT PRRZOD BEGINNING 1/ 34/2000 AD ENDING BELIEF, IT IS A TRUE, CORRECT, and wit APPLICABLE INSTRU REOREDING THE PROVISION OF ECEIVE SEP 25 2002 Con/Financial Analysis Office 6/30/2001 ; awd THAT IT KAVE READ HE ABOVE BTATIHENT AMD gnAT 1 HAVE EXAMINED THE ACCOMPANYING ELECTRONICALLY FILED OR REVENDE AND EXPENSES PREPARED BY: BOOKS AND Mait Stop 28 PART Il ~ SETTLEMENT BUMAARY TITLE QLTLE TITLE v XVIIT ‘XI% a Ld i 2 a 1 ROSPITAL 0 62,433 44,323 0 100 TOTAL ° 82,433 44,323 0 ——— NOE FROM THE APPLICABLE PROGRAN FOR 7H ELEMENT OF THE WAOVE COMPLEX INDICATED THE ABOVE aunts REPRESENT pur to" OR Ton Bat BF 1995, The valid OMB control number for a, and complete and review the "9500 Bacurity pevievard, N2~16-26, Bal and Budget, To parsons are required to respond to & CO: this information eollection 4p 0936-0050. par remponge, information collimation. Taeotion At information unless At the tine time to review dnatruct.one, Tf you have any comments Centers for Medicare & Anotuding the form, please write to: and to the Office of the Information and COMPOSITE EXHIBIT “B” COMPOSITE EXHIBIT “B” SEP 25 2002 Con/Financial Analysis Office Mail Stop 28 cee ‘WINDMOOR HEALTHCARE OF PINELLAS PARK, INC d/b/a Windmoor Healthcare of Clearwater FINANCIAL STATEMENTS JUNE 30, 2001 a Berkowitz & Berkowitz Certified Public Accountants

Docket for Case No: 02-003948