HOW13-2862 15:47 AHCA LEGAL DEPARTMENT P.B2 STATE OF FLORIDA bn. AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, gs aT Petitioner, a AO i X | . vs. AHCA No:2002007581 3. Bow, : c ga ° Return Receipt Re 1 i Ay et le C.H.R. ASSOCIATES, INC., 7000 1670 OO11 4846°2339 + oy ered ‘ d/b/a CLARIDGE HOUSE NURSING 7000 1670 0011 4846 2322. 3 ae) AND REHABILITATION CENTER, ae c on “- . _ Respondent . ~ / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Amended Administrative Complaint against C.H.R. Associates, Inc., d/b/a Claridge House Nursing & Rehabilitation Center (hereinafter “Claridge House”) pursuant to 28-106.111, Florida Administrative Code (2001) (F.A.C.), and Chapters 120 and 400, Florida Statutes (Fla. Stat.) hereinafter alleges: NATURE OF ACTION l. This is an action to impose an administrative fine in the amount of $7,500.00 pursuant to Section 400.23, Fla. Stat. HOW-13-2862 15:49 ARCA LEGAL DEPARTMENT P.O3 JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 3. Venue lies in Dade 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 rursing home licensure law pursuant to Chapter 400, Part II, Fla. Stat., and Rules 59A~4, F.A.C. 3, Claridge House Nursing and Rehabilitation Center is a nursing home located at 13900 NE 3°° Court, North Miami, Florida 33161, and is licensed under Chapter 400, Part II, Fla. Stat., and Chapter 59A-4, F.A.C. COUNT I CLARIDGE HOUSE FAILED TO DEVELOP AND IMPLEMENT WRITTEN POLICIES THAT PROHIBIT MISTREATMENT, NEGLECT AND ABUSE OF RESIDENTS AND MISAPPROPRIATION OF RESIDENT PROPERTY 483.13(c), C.F.R., and 415.102, Fla, Stat. (STAFF TREATMENT OF RESIDENTS) CLASS II 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During a survey conducted on December 11, 2001 and based on medical record review and staff interview, the facility willfully did not protect one of four residents (Resident #1) from harm related to the falsification of MOW-13-2882 15:47 AHCA LEGAL DEPARTMENT P.@4 his/her medical record; transfer from a facility and staff with which he/she was familiar without medical indication; and caused the staff to call the resident by a false name. The facility created a medical record for a fictitious resident and then transferred that Resident to a sister facility. Based on community standards, the Resident could be expected to suffer the loss of comfort and security related to being transferred to an unfamiliar location and staff; having a false identity should he/she be involved in an accident during the transfer; not having past medical history available if the need for treatment by a hospital or physician were to occur; and the indignity of being called by someone else's name during his/her 2 month stay at the other facility. Evidence includes: A. Resident #1 is severely cognitively impaired, dependent upon staff for all Activities of Daily Living, and fed by tube. The Resident is non-verbal. The Resident has resided at the facility since 2/06/97. According to the Admission/ Discharge record kept by Social Services, the Resident was discharged from the facility on 10/01/01 by ambulance and was to go home. Comparison of Resident #1's medical record with the medical record of resident #2 at Regents Park Nursing Home revealed that Resident #2 was admitted to the facility from "home" by ambulance. The NOW-13-2882 15:47 AHCA LEGAL DEPARTMENT Resident had a different name and social security number than Resident #1 from Claridge House. Resident #2 had a state facility to facility transfer form (3008) saying he/she came from home. Resident #2 had Physician's Progress Notes dated 10/15/01 and 11/9/01 (with no resident name) that were identical to Progress Notes in Resident #1's medical record. According to the Admission/Discharge record, Resident #1 was readmitted from home to Claridge House on 12/03/01 by ambulance. Resident #2 was transferred from Regents Park by ambulance to be readmitted to Claridge House on 12/03/01 as Resident #1. The state facility-to~facility transfer form (3008) listed the nearest relative as Resident #2'S nearest relative. 8. The Administrator of Claridge House was interviewed at 8:55 AM on 12/12/01. He stated Resident #1 and 42 were one and the same person. When asked about his knowledge of the false record, he stated he had "perimeter knowledge" and that this was done at the request of the relative who made decisions for the Resident. 9. Based on the foregoing, Claridge House violated 483.13 (c) (1) (i), C.F.R., and 415.102, Fla. Stat., herein classified as a Class II violation, which carries, in this NOW-13-2002 15:47 ARCA LEGAL DEPARTMENT P.65 case an assessed fine of $2,500.00 pursuant to Section §400.23(8) (b), Fla. Stat. (2001). COUNT II CLARIDGE HOUSE FAILED TO BE ADMINISTERED IN A MANNER THAT ENABLES IT TO USE IT RESOURCES EFFECTIVELY TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING OF EACH RESIDENT 483.75, C.F.R., and 400.141, Fla. Stat. (ADMINISTRATION) CLASS II 10. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. li. During the survey of 12/11/01 and based on medical record review and staff interview, administrative staff of the facility were aware of and involved in the creation of a fraudulent medical record; transfer of Resident #1 from familiar surroundings and caregivers to an unfamiliar sister facility where the Resident was called by a fictitious name. The Resident was totally dependent on the facility to protect him/her from physical, mental, and psychosocial, harm. 12. Based on the foregoing Claridge House violated 483.75, C.F.R., and 400.141, Fla. Stat. herein Classified as a Class II violation, whichcarries in this case an assessed fine of $2,500.00 to Section 400.23(8) (b), Fla. Stat. (2001). NOU-13-+20B2 15:47 AHCA LEGAL DEPARTMENT COUNT III CLARIDGE HOUSE FAILED TO MAINTAIN CLINICAL RECORDS ON EACH RESIDENT IN ACCORDANCE WITH ACCEPTED PROFESSIONAL STANDARDS AND PRACTICES 483.75(1) (1), C.F.R., and 400.1415(1), Fla. Stat. (ADMINISTRATION) Class II 13. AHCA re-alleges and incorporates Paragraphs (1) through (5) as if fully set forth herein. 14. During the survey conducted on December 11, 2001 and based upon accepted professional standards, Claridge House failed to maintain the records for one (Resident #1) of four records reviewed, The facility created a medical record for a fictitious resident and then transferred that Resident to a sister facility. The facility caused the Resident the loss of security and comfort related to being cared for by staff he/she was familiar with in familiar surroundings; the loss of dignity and identity related to being called by someone else’s name during his/her 2 month stay at the other facility; the risk of harm related to the loss of identity should he/she be involved in an accident during the transfer; and not having Past medical history available if the need for treatment by a hospital or physician were to occur. Evidence includes: A. Resident #1 is severely cognitively impaired, dependent upon staff for all Activities of Daily Living, and fed by tube. The Resident is non-verbal. The Resident has NOQU-13-2682 15:47 AHCA LEGAL DEPARTMENT resided at the facility since 2/06/97. According to the Admission/ Discharge record kept by Social Services, the Resident was discharged from the facility on 10/01/01 by ambulance and was to go home. Comparison of Resident #1's medical record with the medical record of resident #2 at Regents Park Nursing Home revealed that Resident #2 was admitted to the facility from "home" by ambulance. The Resident had a different name and social security number than Resident #1 from Claridge House. Resident #2 had a state facility to facility transfer form (3008) saying he/she came from home, Resident #2 had Physician’s Progress Notes dated 10/15/01 and 11/9/01 (with no resident name) that were identical to Progress Notes in Resident #1's medical record. According to the Admission/Discharge record, Resident #1 was readmitted from home to Claridge House on 12/03/01 by ambulance. Resident #2 was transferred from Regents Park by ambulance to be readmitted to Claridge House on 12/03/01 as Resident #1. The state facility-to-facility transfer form (3008) listed the nearest relative as Resident #2's nearest relative. 15. The Administrator of Claridge House was interviewed at 8:55 AM on 12/12/01. He stated Resident #1 and #2 were one and the same person. When asked about his knowledge of the false record, he stated he had "perimeter knowledge" and that P.@ NOW-13-28@82 15:47 AHCA LEGAL DEPARTMENT this was done at the request of the relative who made decisions for the Resident. 16. Based on the foregoing Claridge House violated 483.75(1) (1), C.F.R., and 400.1415(1), Fla. Stat. herein classified as a Class II violation which, carries, in this case, an assessed fine of $2,500.00 pursuant to Section 400.23(8) (b), Fla. Stat. (2001). PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Enter a recommended order in favor of the Agency for Health Care Administration against Claridge House Nursing and Rehabilitation Center. B. Assess against Claridge House Nursing and Rehabilitation Center an administrative fine for $7,500.00 pursuant to Section 400.23(8) (b), Fla. Stat, Cc. Award the Agency for Health Care Administration costs related to the investigation and prosecution of the case pursuant to §400.121(10), Fla. Stat, E. Grant such other relief as the court deems is just and proper. P.@3 NOW-13-2082 15:48 AHCA LEGAL DEPARTMENT 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, 4355 Nw 53° Street, Miami, Florida 33166; Nelson Rodney, Assistant General Counsel. 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. Nelson Rodney Assistant General Counsel Agency for Health Care Administration 8355 NW 53°¢ Street Miami, Florida 33166 Copy to: Nelson Rodney, Assistant General Counsel Agency for Health Care Administration Manchester Building 8355 NW 53% Street Miami, Florida 33166 MOU~13-2882 15:48 RHCA LEGAL DEPARTMENT Elizabeth Dudek, Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive, MS#9 Tallahassee, Florida CERTIFICATE OF SERVICE I. HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by Fax and U.S. to Eddie y. Bursztyn, Administrator, Claridge House Nursing and Rehabilitation Center, 13900 N.E, 3*% Court, North Miami, Plorida 33161, and to Mare Birnbuam, Registered Agent, 1031 Ives Dairy Road, Suite 2238, Miami, Florida 33179 on , 2002, al Rédtey P.il

Docket for Case No: 03-000781