STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, CASE NO: 2003004915 vs. HOUSING AUTHORITY OF CITY OF TAMPA (THE) d/b/a PALM TERRACE ALF Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against HOUSING AUTHORITY OF CITY OF TAMPA (THE) d/b/a PALM TERRACE ALF (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of Five hundred dollars ($500) pursuant to Section 400.419(1) (c) Florida Statutes. 2. The Respondent is cited for the deficiency set forth below as a result of a follow-up visit completed on July 7, 2003. The violation cited is one (1) uncorrected Class III deficiency, originally cited on or about April 29, 2003. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 4. Venue lies in Hillsborough 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 5121 East Serena Drive, Tampa, Florida 33617. 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 RESPONDENT FAILED TO ENSURE AT LEAST ONE STAFF MEMBER WHO IS TRAINED IN FIRST AID AND CPR, WAS IN THE FACILITY AT ALL TIMES, VIOLATING RULE 58A-5.019(4) (b)4, FLORIDA ADMINISTRATIVE CODE UNCORRECTED CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. A complaint survey was conducted on April 29, 2003. 9. On that date, based on a review of the facility staffing schedule, time sheets and nine personnel records, the facility did not ensure that at least one staff was in the facility at all times who was certified in First Aid and CPR. 10. A Class III deficiency was cited against Respondent based on the findings below: Of nine records reviewed (CB, GD, AR, CB, AD, MS, HW, BF, MC), none had documentation of certification in CPR and First Aid. Two of the staff (AD & CB) were verified as working on shift duty together, neither had proof of CPR and First Aid. 11. These observations were cited as a Class III deficiency and were to be corrected by May 29, 2003. 12. A follow-up survey was conducted on July 7, 2003. 13. On that date, based upon a review of the facility staffing schedule, and three (3) personnel records on 7/7/03, the facility did not ensure that at least one staff was in the facility at all times who was certified in First Aid and CPR. 14. Specifically, the findings include: A review of the staff schedule provided by the administrator, three staff who were scheduled to work on the 3 p.m. to 11 p.m. shift together did not have documentation on file that they were certified in CPR and/or First aid. Staff (H.P. & C.B.) worked together on Sunday, 7/6/03. Both of these staff did not have CPR and First Aid certification in their personnel records. 15. This is a violation of Rule 58A-5.019(4) (a)4, Florida Administrative Code which requires at least one staff member who is trained in First Aid and CPR, as provided under Rule 58A- 5.0191, shall be within the facility at all times when residents are in the facility. 16. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of five hundred dollars ($500) is authorized pursuant to Section 400.419(1)(c) Florida Statutes (2002). ADDITIONAL FEE UNDER SECTION 400.419(9), FLORIDA STATUTES 17. The Respondent has been cited for one (1) uncorrected Class III deficiency as a result of a complaint and therefore is subject to a survey fee of $150.00 pursuant to Section 400.419(9), Florida Statutes. 18. Notice was provided in writing to the Respondent of the 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 and survey fee against the Respondent pursuant to Section 400.419(1)(c) and (9) Florida Statutes in the amount of six hundred and fifty dollars (S650). 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: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, AHCA - Senior Attorney Fla. Bar No. 0136440 525 Mirror Lake Drive North, 330L St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Lucia M. Pena, Administrator, Palm Terrace ALF, 5121 East Serena Drive, Tampa, FL 33617, Return Receipt No. 7002 2030 0007 8499 6478 by U.S. Certified Mail on September Lwe, 2003. Li LLG Wayne (. Knight, Copies furnished to: Lucia M. Pena, Administrator Palm Terrace ALF 5121 East Serena Drive Tampa, FL 33617 (Certified U.S. Mail) Wayne D. Knight, Esq. Senior Attorney 525 Mirror Lake Drive Suite 330L St. Petersburg, Fl 33701 TARIASHED FOR = ve ne 1 HAYWOt ® z "se re z 3 2 2 z z By gee BR gee gs 368 - &3 4982 Ss 528 38 s5R J a6 gg6 zy 28 332 23 48 855 a¢€ 4 pul gdze 2 #84; 2 ibgigee s8 ogess 33 bobseae gig 28 8028F Sez Bege Beso ERLE S85 §ske £83 SES a&as 23228 VOTER REGISTRATION IDENTIFICATION CARD/TARJETA OE IDENTIFICACION ELECTORAL LEGAL RESIDENCE / DOMICILIO PERMANENTE ONI, HAYWOOD MARK SR ARTEL FLECTOR POLLING PLACE/CENTAO DE VOTACION 617 : D PRECINGT/PRECINTO: ae PARTY / PARTIDO: REGISTRATION DATE DATE OF BIRTH |_FECHA DE INSCRIPCION IGNATURE OF CERTIFIED NURSING ASSISTANT FECHA DE NACIMIENTO | | tO NUMBER NUM DE IDENTIFICACION * * ‘You are eligible to vote for the representatives Ud. es elegible para votar por los representantes de los CONGRESS STATE SENATE STATE HOUSE DATE ISSUED FECHA DE EXPEDICION COUNTY COMMISSION CONGRESO | SENADO ESTATAL | CAMARA ESTATAL | COMISION DE CONDADO ee SCHOOL BOARD JUNTA DE EDUCACION PAM I1ORIO © Supervisor of Elections * TAMPA CITY COUNCIL CONCEJO DE LA CIUDAD Hillsborough County “py American Heart Associations Fighting Heart Disease and Stroke Heartsaver CPR . This card gfrtifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the-Ame Heart Association isSue Date ot free Ht [fi He AN Ke S/OSHA. UPDATE ; Soe, Paget this 23" ofJu june, 2003 03 ACT 29 Pi kt 23 m—— The Sunshine State — ENSE E ORIVER Lic! CLASS f 5 Associations Fighting Heart Disease and Stroke Heartsaver CPR Carol 1. barrou) This card certifies that the above individual has Successfully completed the national Cognitive and skills evaluations in accordance with the curriculum of the AHA for the Heartsaver CPR Program. Adult CPR/ Rediatio CR Adut CBRL AED __G-02 2-24 Issue Date Recommended Renewal Date American Heart Fighting Heart Disease and Stroke Healthcare Provider This card certifies t Recommended Renewal AHA Region FLORIDA Commun 5 Star Training Center Communit styt Teaining Center _ (304) 94 8141 Training y Site Instructor Holder's Signature ($2000 American Heart Assocanon Tarverog with tus card wad ater ts appearence 70-2919 70-2915 9-00 TRAINING CERTIFICATE PRESENTED TO CAROL L. BARROW Has successfully completed a 2 hour training course for FIRST AID Presented this 12" Day of MAY, 2003 RN 2144142 seat aay i Beit a Brittany Hae pevcourse for a American Heart Association. Fighting Heart Disease and Stroke Healthcare Provider accordance with the curriculum of the American Heart Association for the BLS tor Hegtthcare Providers Program, Ri Al SMA O83 SE Lpafo Issue Date Recommended Renewal Date AHA Region FEQPIOA “et Community Training Center wp dad Olat Training Site ay-- - instructor fo) Holder's Signature ©2000 American Heait Assocwtion — Tampersig will thus card wil atte ds appearance 10 2915 70-2915 9-00 TRAINING CERTIFICATE PRESENTED TO MARIA T. SMITH. Has successfully completed a 2 hour training course for FIRST AID Presented this 12' Day of MAY, 2003 linda Lube b SIGNED RN 2144142 TRAINING CERTIFICATE PRESENTED TO MARIA SMITH Has successfully completed a 2 hour training course for RESIDENT CARE & SIGNIFICANT CHANGES Presented this 8" of August, 2003 4 TRAINING CERTIFICATE PRESENTED TO MARIA SMITH Has successfully completed the 2hour training course for INFECTION CONTROL Presented this 23°” 6 July, 2003 , Instructor’s Signature TRAINING CERTIFICATE PRESENTED TO MARIA SMITH Has successfully completed a 1 hour training course for HIPAA Presented this 12" of August, 2003 TRAINING CERTIFICATE PRESENTED TO. Maria Smit} Has successfully completed a 3 hour training course for HIV/AIDS/OSHA UPDATE Presented this 2"° Day of June, 2003 TRAINING CERTIFICATE PRESENTED TO { ° S ° tl - Has successfully completed a 2 hour training course for Infection Control and Safety Presented this 2" Day of June, 2003 Conlea.

Docket for Case No: 03-003855