DIB-Y3B3 Division of Administrative Hearings STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No: 2002019331 Petitioner, Return Receipt Requested 7000 1670 0011 4845 7441 vs. 7000 1670 0011 4845 7465 7000 1670 0011 4845 7458 WEST PALM BEACH HEALTH CARE ASSOCIATES, LLC., f/k/a and d/b/a WEST PALM BEACH REHABILITATION & SPECIALTY CARE, n/k/a and d/b/a AZALEA COURT, Respondent ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against West Palm Beach Health Care Associates, LLC, f/k/a and d/b/a West Palm Beach Rehabilitation & Specialty Care, n/k/a and d/b/a Azalea Court, (hereinafter “Azalea Court”), pursuant to 28-106.111, Florida Administrative Code (2001) (hereinafter “P.A.C”’.), and Chapter 120, Florida Statutes (2001) (hereinafter “Fla. Stat.”), and alleges: NATURE OF ACTION 1. This is an action to impose an administrative fine in the amount of three thousand dollars ($3,000.00), pursuant to Section 400.23, Fla. Stat. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 3. Venue lies in Palm Beach County, pursuant to 120.57, Fla. Stat., and Chapter 28-106.207, F.A.C. PARTIES 4. AHCA is the enforcing authority with regard to nursing home licensure, pursuant to Chapter 400, Part II, Fla. Stat. and Rule 59A-4 F.A.C. 5. Azalea Court is a nursing home located at 5065 Wallis Road, West Palm Beach, Florida 33415 and is licensed under Chapter 400, Part II, Fla. Stat., and Chapters 59A-4, F.A.C.; license number SNF1198096. Azalea Court was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes COUNT I AZALEA COURT FAILED TO NOTIFY A RESIDENT WHEN HIS/HER TRUST ACCOUNT BALANCE WAS WITHIN $200.00 OF THE MEDICAID RESOURCE LIMIT. 42 C.F.R. 483.10(C) (2) (3), incorporated by 59A-4.1288, F.A.C. (PROTECTION OF RESIDENT FUNDS) UNCORRECTED CLASS III DEFICIENCY 6. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 7. Because Azalea Court Participates in Title XVIII or XIX, it must follow the certification rules and regulations found in 42 C.F.R. 483. 8. During the annual survey conducted by the Agency on December 11-13, 2001 and based on review of residents' business records and interview on 12/13/01, between the survey hours of 9:00AM and 10:15 AM, the Agency’s surveyor(s) found that Azalea Court failed to notify a resident when his/her trust account balance was within $200.00 of the Resource Limit. The surveyor found that the facility failed to notify each resident that receives Medicaid benefits when the amount in the resident's account was within $200.00 of the SSI (Supplemental Security Income) resource limit of $2,000.00 for one person. The surveyor identified one resident that this requirement applied to. 9. The surveyor reviewed residents’ records relative to resident trust accounts and found that Resident #2's trust account balance on 11/30/01 was $3,689.02. This balance was $1,689.02 above the resource limit of $2,000.00 allowed by Medicaid (in order to receive benefits). There was no evidence that the facility notified the resident/responsible party when the account reached within $200.00 of the SSI resource limit ($2,000.00), as required. When the surveyor discussed the finding with the Business Office Manager, the Manager stated that she had notified the resident's son twice of the need to spend down the account in order to maintain the resident's Medicaid eligibility, but there was no documentation/record of the contacts to substantiate that this was done. 10. Because this requirement was not followed, the resident was placed at risk of losing Medicaid benefits, representing potential harm to this resident. 11. Additionally, during interview with the Business Office Manage, the surveyor found that Resident Trust Funds were available 7:30 AM to 5:00PM, Monday thru Friday (the hours the Manager is present in the facility). There was no provision/policy in place for residents to access spending money (Trust Funds) after 5:00PM and on weekends. When this was discussed with the Business Office Manager (the availability of Resident Trust Funds on the weekend), the Manager indicated that money would be given on Friday for the residents who needed money for the weekend. The availability of weekend money on Friday was confirmed and corroborated by residents, but there was no provision in place for residents to access funds on the weekend or after 5:00PM, for unplanned needs. Correction time given: 01/13/02. 12. During the follow-up visit conducted on 01/28/02 and based on review of residents' business records and interview on 01/28/02 at 10:50 AM, the surveyor again found that Azalea Court failed to notify a resident when his/her trust account balance was within $200.00 of the Resource Limit. The surveyor determined that the facility failed to notify each resident that receives Medicaid benefits when the amount in the resident's account was within $200.00 of the SS (Supplemental Security Income) resource limit of $2,000.00 for one person. The surveyor identified one resident that this requirement applied to. 13. The surveyor reviewed residents' business records relative to resident trust accounts and found that Resident #12's trust account balance on 01/28/02 (day of the revisit) was $3,027.91. This balance was $1,027.91 above the resource limit of $2,000.00 allowed by Medicaid (in order to receive benefits). There was no evidence that the facility notified the resident/responsible party when the account reached within $200.00 of the SSI resource limit ($2,000.00, as required. When the surveyor discussed the finding with the Administrator, the Administrator confirmed that the required notification was not done (there was no evidence that the resident/responsible party had been notified to reduce the account, in order to maintain the resident's Medicaid eligibility). The Administrator questioned the accuracy of the resident's account balance as truly being the resident’s money, based on a check that was received from the Social Security Administration that was deposited in the resident's trust account in the amount of $2,100.00. Even though the facility questioned the accuracy of the balance on the resident's trust account, there was no evidence that the facility tried to clarify whether or not the money was, in fact, the resident's and, if it was. the resident's, whether or not the resident was eligible for the entire amount or eligible for only a portion of the payment; i.e. would some of the money need to be reimbursed to Medicaid. Record review showed that the resident had a son in Belle Glade and interview with nursing revealed that the resident had a daughter who visits. 14. The facility’s Plan of Correction (POC) read: "B.O.M. (Business Office Manager) will review all resident trust accounts on a monthly basis, any account found to be within $200 limit for any resident receiving medical (Medicaid) funds will be identified. B.O.M. will report in writing to ED (Executive Director) any account that remains over funds and/or failure of res/responsible party response to notification on a monthly basis. ED will follow up with resident/responsible party and record this interaction in resident financial record. For any resident without family/responsible party support, the S.W. (Social Worker) will assist resident in purchasing personal items to reduce resident trust account. This activity will also be noted in the resident financial records. ED/BOM will continue to review all resident trust account balance on a monthly basis for ongoing compliance." Even though the facility's POC indicated this deficiency would not be corrected until 01/13/02, the surveyor asked the Administrator if resident trust accounts were reviewed in December, as outlined in the POC. The Administrator indicated the resident trust accounts had been reviewed in late December, but was unable to find the facility's record/documentation of the review for the surveyor to review. 15. On 01/31/02 at 11:30 AM, the surveyor spoke with a supervisor from the Department of Children and Families (DCF) with the Institutional Care Program. This individual confirmed that the resource limit for the resident was $2,000.00 and indicated that the resident/responsible party had 10 days from receipt of the income to report the income from Social Security Disability to the Department of Families and Children. He further explained that the resident would have had 9 days to spend the money below the resource limit allowed by Medicaid ($2,000.00), in order to remain eligible for Medicaid (no back- money would have been due to Medicaid if the change in income was reported within the 10 days, but now an overpayment by Medicaid has occurred because the income was not reported timely - the overpayment occurred because the patient's responsibility changed 10 days after the money was received). Additionally, the DCF supervisor stated that it was important for the resident/responsible party to report the income because of the patient's/resident's responsibility to the facility (the responsibility would have changed going forward from the date the money was received, not retroactive back to the date the money was approved - in this case May, 2001). The surveyor observed a notice from the Social Security Administration dated 10/17/01 sent to the facility that read: "We are writing to give you new information about the disability benefits which you received on this Social Security record. We can pay you beginning May 2001." “You will soon receive a check for $2,110.00, which is the money you are due through September 2001. Your next scheduled payment of $422.00, which is for October 2001, will be received on or about the fourth Wednesday of November, 2001. After that you will receive $422.00 on or about the fourth Wednesday of each month." 16. Because the notification requirement was not followed (notifying the resident/responsible party when the trust account was within $200.00 of SSI resource limit), the resident was placed at risk of losing his/her Medicaid benefits, representing harm/potential harm to this individual. 17. Based on the foregoing, Azalea Court violated 42 C.F.R. 483.10(c) (2) (3), incorporated by 59A-4.1288, F.A.C., herein classified as an isolated uncorrected Class TII deficiency, pursuant to 400.23(8)(c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT II AZALEA COURT FAILED TO MAINTAIN A SANITARY, CLEAN AND COMFORTABLE ENVIRONMENT. 400.141(8), Fla. Stat., and/or 59A-4,.122, F.A.C. (PHYSICAL ENVIRONMENT) UNCORRECTED CLASS III DEFICIENCY 18. AHCA re~alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. During the annual survey conducted by the Agency on December 11-13, 2001 and based on observation and interview, the Agency’s surveyor found that Azalea Court failed to maintain a Sanitary, clean, and comfortable environment. The surveyor found that the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior on two of the four wings of the facility. The surveyor’s findings include: (a) During the orientation tour on 12/11/01 of the 200 wing, the resident in room #202 stated that he/she could not get his/her heat to work. The Surveyor observed the A/C unit on the wall under the window and found that the knob was broken, and the unit could not be turned on. The surveyor brought this to the attention of the nurse. (b) On 12/12/01, at 1:30PM, the surveyor observed the bathroom of room #214. Inside the bathroom, the Hoyer lift was being stored. Observation of this Hoyer lift revealed that the base ledges, and the handle and ledges around this area were coated with dust, debris, and particles of black and yellow. This was brought to the attention of the nurse, who asked the certified nursing assistant (CNA) to clean it. Observation of the Hoyer lift on 12/13/01 revealed that the Hoyer lift was in the tub/shower room and remained dirty. (c) The surveyor observed the tub/shower room on 12/12/01 at 10:15AM, and found that there were three Hoyer lifts and a chair scale stored in the room. The two Sara 2000 Hoyer lifts were dirty, with brown and black specks, dust, stains on the legs and base (approximate size: 2 feet by 1 and 1/2 feet). The Marisa Hoyer lift was coated with dust around its base. The base of the chair scale was dirty, with stains and covered with particles of dust. The base and legs of this chair were also very rusty. There was also a bedside table against the wall, and it was speckled with a white substance on the base and leg (up to about 8 - 10 inches). The bathtub, to the left side as you enter the tub room, was covered with a white substance around its base. The shower scale had black mold-like substance around the base tiles and on the floor. The drain had a broken stainless steel cover over it, and this had a collection of dust 10 and dry debris in it. There were also black, dry-looking lumps lying on the floor. The surveyor brought this to the attention of the staff developer, who stated, "This is disgusting". 20. During the annual survey on 12/11/01, the surveyor observed ants crawling around a doorframe. The surveyor was conducting an initial tour on the low 100 hall, and observed ants crawling around the outside doorframe of room #106, at 8:54 a.m. At 9:17 a.m., the surveyor went back to room #106, and observed that the ants were still present. The surveyor asked the nurse to accompany her to room #106, and the nurse observed the ants also. The nurse spoke with the Director, and pest control was called. 21. During the group interview on 12/12/01, 5 of 11 residents corroborated the surveyor’s observations and stated that they have had ants in their rooms within the past 12 months. Also, all eleven residents reported two incidents of flies in the dining room within the last 12 months. 22. During a tour of the facility at approximately 10:00 a.m. on 12/11/01, the surveyor observed resident 10's room and found about seven ants crawling on a shelf by an empty milk carton. In addition, the surveyor observed an empty milkshake carton, three dirty utensils and a cup of warm orange liquid in the bedroom, on various’ shelves. Correction time given: 01/13/02. 23. When the follow-up visit was conducted on 01/28/02 and based on observation and interview, the surveyor again found that Azalea Court failed to maintain a sanitary, clean, and comfortable environment. The surveyor determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 24. During the revisit survey conducted on 01/28/02, the surveyor noted the following observations during the observation tour of the facility: 25. The hallway floor carpets throughout the 3 nursing units were soiled, heavily stained, and smelled of urine. The surveyor interviewed the facility’s director of housekeeping on 01/28/02 and was told that the carpets were old and could no longer be cleaned properly. 26. The ceiling tiles located in the shower/tub room of the 200 hall were mold-laden. 27. A resident lift (Sara 2000 Hoyer), located in room #312, was noted to be soiled, stained, and the base of the lift was covered with dust and dirt particles. 28. A resident lift (Sara Hoyer 2000), located outside of room #313, was found to have soiled nursing tape hanging from the shaft area. 29. The floor of room #412 was found to be soiled and stained, and had dry particles and dust around the bed and bedside table. The bathroom floor of room #412 was soiled and stained with a brownish substance. 30. A shower chair located in the shower stall bathroom of room #313 was found to have rusted wheels, a broken right arm vest, and a left arm rest that had old tape wrapped around it that was soiled and brownish in color. 31. Based on the foregoing, Azalea Court violated 400.141(8), Fla. Stat., and/or 59A-4,.122, F.A.C., herein classified as a patterned uncorrected Class III deficiency, pursuant to 400.23(8)(c), Fla. Stat., which carries, in this case, an assessed fine of $2,000.00. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration, requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and II, B. Assess an administrative fine of $3,000.00 against Azalea Court for the uncorrected Class III deficiencies in Counts I and II, in accordance with Section 400.23(8) (c), Fla. Stat. Cc. Award the Agency for Health Care Administration costs related to the investigation and prosecution of this case, in accordance with Section 400.121(1), Fla. Stat., and D. Grant such other relief as this Court deems is just and proper. Respondent 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 and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 Nw 53°? Street, Miami, Florida 33166; Kathryn F. Fenske. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, oni ¥ Fenske Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 NW 53*° Street Miami, Florida 33166 (305) 499-2165 Copy to: Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Gloria Collins, Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Maria Viola, Administrator, Azalea Court, 5065 Wallis Road, West Palm Beach, Florida 33415, West Palm Beach Health Care Associates, LLC, 400 Perimeter Center Terrace, Suite 650, Atlanta, GA 30346, and to c.T. Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on Jf.3 » 2002. ; Kathryn F. Fenske 15

Docket for Case No: 02-004243