STATE OF FLORIDA ae AGENCY FOR HEALTH CARE ADMINISTRATION £2 PH 4:95 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. HCB-H-01-0013 Gulf Pines Hospital, Inc. d/b/a Gulf Pines Hospital Trees + Respondent. ZoOZEAG Al, 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 Gulf Pines Hospital, Inc. (H 10-0027) ("Respondent") for violations involving Prior Year Reports. As grounds for the imposition of this administrative fine, the Agency will show: 1. Respondent is a hospital as defined by § 395.002(12), Florida Statutes and is located at 102 20" Street, Port St. Joe, FL 32456. 2. Pursuant to Section 408.061(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 audited 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 09/30/2001. Pursuant to Rule 59E-2.024(5), Florida Administrative Code, the Agency sent a deemed not filed notice to Respondent on 10/05/2001, 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 hereto as Exhibit “A” and incorporated herein by reference. Respondent received the deemed not filed notice on 10/09/2001. 4. The Agency sent a second notice of delinquent filing to the hospital on 11/01/2001 which was received by the respondent on 11/07/2001. A copy of this notice is attached hereto as Exhibit “B”. 5. 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 herein and in the notice of violation. 6. 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 false report, or files an incomplete report shall 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. 7. Respondent's violations constitute a: second occurrence for the purpose of calculating fines pursuant to Rule 59E-2.025, Florida Administrative Code. -'4 8. Pursuant to Rule 59E-2.024(5), Florida Administrative Code, the imposition of an administrative fine will be calculated from September 30", 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 failure to file a report as provided in Rule 59E-2.025(c), Florida Administrative Code. 9. 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 II, 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 Statutes, 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. 10. All payments of administrative fines shall be by check or money order payable to the Agency for Health Care Administration. Reference shall be made to Respondent's name, facility number, and the case number on this Complaint, and shall be sent to the Agency for Health Care Administration, Bureau Health Facility 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. . ll. 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 true copy hereof was sent by U. S. Certified Mail, Return Receipt Requested to Hubert E. Steeley, Chief Executive Officer, Gulf Pines Hospital, Inc., 102 20" Street, Port St. Joe, FL 32456.this 9"" day of August 2002. Regulatory Arfalyst Supervisor Bureau Health Facility Regulation Agency for Health Care Administration sa) —_—_—_— STATE OF FLORIDA pic AGENCY FOR HEALTH CARE ADMINISTRATION JEB BUSH, GOVERNOR . RHONDA M. MEDOWS, MD, FAAFP SECRETARY CERTIFIED MAIL October 5, 2001 Hubert E. Steeley _ Chief Executive Officer E h: L ‘ f Gulf Pines Hospital rH, 102 20" Street Port St. Joe, FL 32456 RE: 2001 Prior Year Report Hospital Number 10-0027 FYE: 05 Deemed-not-Filed Notice of Violation Dear Mr. Steeley: Pursuant to rule S9E-2.024, 59E-5.103, 59E-5.204 and 59E-5.206 F.A.C., the above referenced report has been found incomplete and deemed not filed for the following reason(s): . a Prior Year Actual Report Pursuant to rule 59E-5.201 and 59E-5.206 F.A.C., your hospital is required to submit to the Agency its actual report in electronic format. Please submit (1) 3.5 inch diskette pursuant to the formatting requirements provided in Rule 59E-5.206. [2 Audited financial statements Pursuant to rule 59E-5.201 F.A.C., your hospital is required to submit the hospital’s audited financial statements. Please submit (1) copy of the audited financial statements. Draft copies are not accepted. [Medicare Cost Report Pursuant to rule 59E-5.201 F.A.C., your hospital is required to submit (1) copy of the Medicare Cost Report. Please submit (1) copy of the Medicare Cost Report. Visit AHCA Online at 2727 Mahan Drive « Mail Stop #28 www.fdhe state fl.us Tallahassee, FL 32308 Oo Other Pursuant to rule 59E-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. Sincerely, COMPLETE THIS SECTION ON DELIVERY A. Recelved by (Please Print Clearty) Roce AN C, Signature ™ Complete items 1, 2, and 3. Also complete itern 4 if Restricted Delivery Is desired. m Print your name and address on the reverse so that we can return the card to you, ™ Attach this card to the back of the mailpiece, B. Date of Delive -O or on the front if space permits. ((— doe} 1, Article Addressed to: Bw} Cras eset If YES, enter delivery address below: a 3. Service Type (Certified Mail CJ Express Mail Ci Insured Mail ~— 1 C.0.D. . Your St. hos, HK 3240 2. “Ty Number (Copy from service label) xX: Ye CSS. Er Agent dress: D. Is delivery address different from item 17, Ne: lo Ss OO Registered 1 Return Receipt for Merthandi: 4, Restricted Delivery? (Extra Fee) - O Yes i GbO Obed (P2¢ W2os 3323 O] DAF | PS Form 3 i i rm 3811, July 1999 Domestic Ratu Receipt 102595-00-M-085 + STATE OF FLORIDA ( ; nl IA HCA Qh or AGENCY FOR HEALTH CARE AGENCY FOR HEALTH CARE ADMINISTRATION a9) rm JEB BUSH, GOVERNOR RHONDA M. MEADOWS, MD, FAAFP SECRETARY . Certified Mail November 1, 2001 Hubert E. Steeley £ y |. L : L (3 Chief Executive Officer Gulf Pines Hospital 102 20" Street Port St. Joe, FL 32456 . . . RE: 2001 Prior Year Report FYE: 05 AHCA#: 10-0027 Dear Mr. Steeley: Please be advised that the Agency has not received the above referenced report which was due in our office September 28, 2001. On October 5, 2001 you were notified by certified letter of the hospital’s noncompliance with this filing requirement and our certified mail receipt indicates you received the notice on October 9, 2001. Rule 59E-2.024 of the Florida Administrative Code allows the hospital 10 working days after the receipt of the notice to file the delinquent report. Section 408.08 of the Florida Statutes provides that any hospital which refuses to file or fails to file a report when required by the Agency, shall be punished by a fine not to exceed $1,000 per day for each day it is late. Unless you respond immediately, this office will file an administrative complaint against the facility in order to gain your compliance. You may contact Paul Kennedy at (850) 922-7434 to receive assistance in resolving this issue. Be iw) dO LHOIY SH1 OL: 3dOTAANA JO'dOL LV e3MOUS BOW Id SENDERS COMPLETE THIS: SECTIUW a | mi Complete items 1, 2, and 3. Also complete * ! item 4 If Restricted Delivery is desired. istopher J. Augsburger @ Print your name and anaress on the reverse + so that we can return the card to you. Regulatory Analyst Supervisc lm Attach this card to the back of the mailplece, or on the front if space permits. /6-( 02." COMPLETE THIS SECTION ON DELIVERY = Recely pu fe Ae Clearly) |B. Date of Oo} Y--°) c. = x Renae aRiies D. Is delivery 25 different from item 47 C1 Yes if YES, enter delivery address below: 0 1. Article Addrassed to: Ty Dis. Auspib? 3. Service Type Certified Mat 1 Express Mail Registered 1 Return Receipt for Merchan 2727 MAHAN DRIVE, MAIL 8? , Otnsured Mat 01. 0.0.D. TALLAHASSEE, FL 32308 } FSI FL 329Sb 4. Restricted Delivery? (Extra Fee} 0 Yes Article Hoyt vice fabel) ~ . — = parare Rp e PS Y Gos CYS Ol od DU , -00-M De Farm BAT sIuly 1999 Domestic Return Receipt . 102595

Docket for Case No: 02-004143