STATE OF FLORIDA C3oor-. AGENCY FOR HEALTH CARE ADMINISTRATION Mew Ps my AGENCY FOR HEALTH CARE bgoce: ADMINISTRATION, 63 -U OR LE : Petitioner, AHCA No.: 2003001001 Return Receipt Requested: Vv. 7000 1670 0011 4849 6426 JULIA RANDOLPH, OWNER/OPERATOR d/b/a RANDOLPH HOME FOR THE ELDERLY, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Julia Randolph, Owner/operator d/b/a Randolph Home for the Elderly (hereinafter “Randolph Home for the Elderly”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2002), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $3,850.00 ($3,500.00 fine + $350.00 survey fee] pursuant to Section 400.419, Florida Statutes (2002), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. 3. Venue lies in St. Lucie County, pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2002), and Chapter 58A-5 Florida Administrative Code. 5. Randolph Home for the Elderly operates a 10-bed assisted living facility located at 1712 Avenue 0, Ft. Pierce, Florida 34950. Randolph Home for the Elderly is licensed as an assisted living facility under license number 9499. Randolph Home for the Elderly 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 RANDOLPH HOME FOR THE ELDERLY IS ASSISTING WITH PRESCRIPTION MEDICATIONS AND NOT NOTING IT ON THE MOR. RULE 58A-5.0185(5) (b), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Based on the biennial re-licensure survey conducted on December 16, 2002 and based on observation, review of the Medication Observation Record, and resident records, it was determined that the facility did not maintain an up-to-date MOR for each resident. The findings include the following. 8. The MOR for Resident #4 did not list the following medications that the facility was assisting this resident with. Resident #4 was being assisted with Zyprexa 10mg TID and Benztropine lmg QD. These medications were not listed as current medications on this resident's MOR record although they were contained in the resident's "Meds on Time" pre-packaged dose. The facility had no health provider’s orders for these prescription medications. The mandated correction date was designated as January 15, 2003. 9. Based on the follow-up survey conducted on January 28, 2003 and based on observation, review of the Medication Observation Record, and resident records, it was determined that the facility did not maintain an up-to-date MOR for each resident. The findings include the following: 10. The MOR for Resident #4 listed the following medications that the facility was assisting this resident with Lithium 300mg, 2 caps BID and Haldol 10mg PRN. The resident was actually being assisted with Zyprexa 10mg TID and Benztropine lmg QD.and Lithium 300mg BID. These medications were not listed as current medications on this resident's MOR record although they were contained in the resident's "Meds on Time" pre- packaged dose. The facility had no health providers’ orders for the Zyprexa and Benztropine prescription medications. 11. The MOR for Resident #3 listed Silvadene Cream 1%. It was signed for daily for the entire month of January as assisted with, but the medication was not available for this resident. The staff member on duty stated she was instructed to sign for this medication as assisted with daily by the owner, even though the medication was not available and assisted with by facility staff. 12. Resident #5 MOR states this resident is to be assisted with Fosinopril 25mg 1 tab daily, Felodipine 1/2 tab daily, ASA. 1 tab daily, Simvastatin 1/2 tab daily. The MOR did not list the doses for each of the medications except for the Fosinopril. The bottles of medications for this resident were completely erased and unreadable, including the resident's name, name of medication and the directions for assistance. This is an uncorrected deficiency from the 12/16/02 report. 13. Based on the foregoing, Randolph Home for the Elderly violated Rule 58A-5.0185(5)(b), Florida Administrative Code herein classified as a Class III violation, which carries an assessed fine of $1,000.00. COUNT II RANDOLPH HOME FOR THE ELDERLY IS ASSISTING RESIDENTS WITH PRESCRIPTION MEDICATIONS WITHOUT A HEALTHCARE PROVIDER’S ORDER IN THE RESIDENT’S RECORDS. RULE 58A-5.024 (3) (c), FLORIDA ADMINISTRATIVE CODE SECTION 400.426(4), FLORIDA STATUTES (RESIDENT RECORD STANDARDS) CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. Based on the biennial re-licensure survey conducted on December 16, 2002 and based on observation, review of the Medication Observation Record, and resident records, it was determined that the facility did not have any health care providers orders for medications which they were providing assistance with the administration. The findings include the following. 16. There were no health care provider orders for these centrally stored facility assisted medications for these residents. a. Resident #4 was being assisted with Zyprexa 10mg TID and Benztropine lmg QD. b. Resident #5 was being assisted with Atarax 25mg, Flomax 0.4mg, and Lotrisone Creme BID. 17. The mandated correction date was designated as January 15, 2003. 18. During the follow-up survey conducted on January 28, 2003 and based on observation, review of the Medication Observation Record, and resident records, it was determined that the facility did not have any health care providers orders for medications which they were providing assistance with the administration. The findings include the following. 19. There were no health care provider orders for these centrally stored facility assisted medications for this resident: a. Resident #4 was being assisted with Zyprexa 10mg TID and Benztropine lmg QD and Lithium 300mg, 2 caps BID but the MOR stated this resident was to be assisted with Lithium 300mg, 2 caps BID and Haldol 10mg. PRN. There were no physician orders for the Zyprexa and the Benztropine. This resident's last medical assessment dated 1/14/03 stated Lithium 300mg 2 caps BID and Haldol 10mg PRN as the only medications for this resident. 20. This is an uncorrected deficiency from the 12/16/02 report. 21. Based on the foregoing, Randolph Home for the Elderly violated Rule 58A-5.024(3)(c), Florida Administrative Code and Section 400.426(4), Florida Statutes, herein classified as an uncorrected Class III violation which carries an assessed fine of $500.00. COUNT III RANDOLPH HOME FOR THE ELDERLY FAILED TO HAVE AN APPROVED COMPREHENSIVE EMERGENCY MANAGEMENT PLAN. SECTION 400.441(1) (b), FLORIDA STATUTES RULE 58A-5.026(2), FLORIDA ADMINISTRATIVE CODE (EMERGENCY MANAGEMENT) CLASS III 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. Based on the biennial re-licensure survey conducted on December 16, 2002 and based on record review, the facility did not have an emergency management plan submitted and approved by the county emergency management agency. The findings include the following. 24. Based on record review and interview with the administrator on the day of the survey, it was determined that there was no emergency management plan that had been approved by the county emergency management agency available for the surveyor to review. The mandated correction date was designated as January 15, 2003. 25. During the follow-up survey conducted on January 28, 2003 and based on record review, the facility did not have an emergency management plan approved by the county emergency management agency. The findings include the following. 26. Based on record review and interview with the administrator on the day of the survey, it was determined that the emergency management plan had not been approved by the county emergency management agency. The facility was given until 3/18/03 to submit an acceptable plan with the agency's required changes. This is an uncorrected deficiency from the December 16, 2002 report. 27. Based on the foregoing, Randolph Home for the Elderly violated Section 400.441(1)(b), Florida Statutes and Rule 58A- 5.026(2), Florida Administrative Code herein classified as an uncorrected Class III violation, which carries an assessed fine of $500.00. COUNT IV RANDOLPH HOME FOR THE ELDERLY’S STAFF MEMBERS DID NOT HAVE VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE. SECTION 400.4275(4), FLORIDA STATUTES RULE 58A-5.024 (2) (a), FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III 28. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. Based on the biennial re-licensure survey conducted on December 16, 2002 and based on record review and interview it was revealed that the facility did not ensure that staff personnel records contained the required verification of freedom from communicable disease. The findings include the following. 30. Three of three staff records reviewed did not contain any evidence of the required certification that staff were free from communicable disease. The administrator, when requested to by the surveyor, was unable to produce this required information. The mandated correction date was designated as January 15, 2003. 31. During the follow-up survey conducted on January 28, 2003 and based on record review and interview it was revealed that the facility did not ensure that staff personnel records contained the required verification of freedom from communicable disease. The findings include the following. 32. Two of four staff records reviewed did not contain any evidence of the required certification that staff were free from communicable disease. The assistant administrator, when requested to by the surveyor, was unable to produce this required information. This is an uncorrected deficiency from the 12/16/02 report. 33. Based on the foregoing, Randolph Home for the Elderly violated Section 400.4275(4), Florida Statutes and Rule 58A- 5.024(2) (a), Florida Administrative Code herein classified as an uncorrected Class III violation, which carries an assessed fine of $500.00. COUNT V RANDOLPH HOME FOR THE ELDERLY FAILED TO OBTAIN AN UPDATED ANNUAL LIVING SUPPORT PLAN FOR THREE (3) LIMITED MENTAL HEALTH RESIDENTS. RULE 58A-5.029(2) (c)3, a.vii, FLORIDA ADMINISTRATIVE CODE (COMMUNITY LIVING SUPPORT PLAN) CLASS III 34. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 35. Based on the biennial re~licensure survey conducted on December 16, 2002 and based on record review, the community 10 living support plan was not updated annually. The findings include the following. 36. Based on record review and interview with the administrator on the day of the survey, it was determined that three of three limited mental health resident files reviewed did not contain a community living support plan that had been updated on an annual basis. The mandated correction date was designated as January 15, 2003. 37. During the follow-up survey conducted on January 28, 2003 and based on record review, the community living support plan was not updated annually. The findings include the following. 38. Based on record review and interview with the administrator on the day of the survey, it was determined that three of four limited mental health resident files reviewed did not contain a community living support plan that had been updated on an annual basis. The Assistant Administrator stated they were completed but were not as yet delivered. This is an uncorrected deficiency from the 12/16/02 survey report. 39. Based on the foregoing, Randolph Home for the Elderly violated Rule 58A-5.0029(2) (c)3,a.vii, Florida Administrative Code herein classified as an uncorrected Class III violation, which carries an assessed fine of $500.00. COUNT VI RANDOLPH HOME FOR THE ELDERLY’S STAFF MEMBERS DID NOT HAVE DOCUMENTATION OF FREEDOM FROM COMMUNICABLE DISEASE. RULE 58A-5.019(2) (a), FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III 40. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 41. Based on the biennial re-licensure survey conducted on December 16, 2002 and based on record review and interview it was revealed that the facility did not ensure that staff personnel records contained the required annual verification of freedom from tuberculosis. The findings include the following. 42. Three of three staff records reviewed did not contain any evidence of the required annual certification that staff were free from tuberculosis. The administrator, when requested to by the surveyor, was unable to produce this required information. The mandated correction date was designated as January 15, 2003. 43. During the follow-up survey conducted on January 28, 2003 and based on record review and interview it was revealed that the facility did not ensure that staff personnel records contained the required annual verification of freedom from tuberculosis. The findings include the following. 12 44, One of four staff records reviewed did not contain any evidence of the required annual certification that staff were free from tuberculosis. The assistant administrator, when requested to by the surveyor, was unable to produce this required information. This is an uncorrected deficiency from the 12/16/02 report. 45. Based on the foregoing, Randolph Home for the Elderly violated Rule 58A-5.019(2) (a), Florida Administrative Code herein classified as a Class III violation, which carries an assessed fine of $500.00. SURVEY FEE Pursuant to Section 400.419(9), Florida statutes, AHCA may assess a survey fee to cover the cost of initial complaint investigations. A survey fee of 350.00 was assessed in this instance. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Randolph Home for the Elderly on Counts I through VI. 13 2. Assess an administrative fine of $3,500.00 against Randolph Home for the Elderly on Counts I through VI for the violations cited above. 3. Assess a survey fee of $350.00 against Randolph Home for the Elderly pursuant to Section 400.419(9), Florida Statutes. 4, Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. 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 (2002). 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, 2727 Mahan Drive, Building #, Mail Stop #3, Tallahassee, Florida 32308, attention Lealand McCharen, Agency Clerk, telephone # (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS oP RECEIPT 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. Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration Alba M. Rodriguez, Est Assistant General Counsel Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE NE DD ERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.s. Certified Mail, Return Receipt Requested to Julia Randolph, Owner/operator, Randolph Home for the Elderly, 1712 Avenue 0, Ft. Pierce, Florida 34950; on this 5 day of Aopen bor), 2003. Qobe, mM: Bo dre Alba M. Rodrigueé, Esq. 16

Docket for Case No: 03-004689