STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Petitioner, )

)

vs. )

) LAKE LADY LLC, d/b/a LADY LAKE ) SPECIALTY CARE CENTER, )

)

Respondent. )

Case Nos. 04-1065

04-0025

)

RECOMMENDED ORDER

A formal hearing was conducted in this case on June 9-10, 2004, in Leesburg, Florida, and on August 26-27, 2004, in Tavares, Florida, before Suzanne F. Hood, Administrative Law Judge with the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Karen L. Goldsmith, Esquire

Jonathan Grout, Esquire Goldsmith, Grout & Lewis, P.A. 2180 Park Avenue North, Suite 100 Winter Park, Florida 32790-2011

For Respondent: Tom R. Moore, Esquire

Agency for Health Care Administration 2727 Mahan Drive, Building III Tallahassee, Florida 32308

STATEMENT OF THE ISSUES

In DOAH Case No. 04-0025, the issue is whether the Agency for Health Care Administrative (AHCA) correctly assigned

conditional licensure status to Lady Lake NH, L.L.C., d/b/a/ Lady Lake Specialty Care Center (Lady Lake) for the period of August 26, 2003, through October 3, 2003. In DOAH Case No. 04- 1065, the issues are as follows: (a) whether Lady Lake committed a violation of 42 C.F.R. Section 483.25, as it relates to care of patients with or who develop pressure sores; (b) whether Lady Lake committed a violation of 42 C.F.R. Section 483.75, as it relates to clinical records; and (c) if so, what, if any, penalty should be imposed.

PRELIMINARY STATEMENT

On or about November 25, 2003, AHCA filed an Administrative Complaint against Lady Lake. The Administrative Complaint alleged that Lady Lake had violated Florida Administrative Code Rule 59A-4.1288, which incorporates 42 C.F.R. Section 483.25(c)(2) by reference. Specifically, the Administrative Complaint asserted that Lady Lake had failed to ensure that a patient did not develop a pressure sore and/or failed to properly care for a patient with a pressure sore, resulting in a class II deficiency, which warranted the assignment of conditional license status.

On or about November 26, 2003, AHCA filed a second Administrative Complaint against Lady Lake. The Administrative Complaint alleged that Lady Lake had violated Florida Administrative Code Rule 59A-4.1288, which incorporates 42

C.F.R. Section 483.25(c)(2) by reference. Specifically, the Administrative Complaint asserted that Lady Lake had failed to ensure that a patient did not develop a pressure sore and/or failed to properly care for a patient with a pressure sore, resulting in an "isolated" class II deficiency, which warranted the imposition of an administrative fine in the amount of

$2,500.00.

On December 9, 2003, Lady Lake filed a Petition for Formal Administrative Hearing and Answer to Administrative Complaint to contest the assignment of a conditional license. On January 5, 2004, AHCA referred the conditional license case to the Division of Administrative Hearings. Hereinafter, the conditional license case shall be referred to as DOAH Case No. 04-0025.

A Notice of Hearing dated January 15, 2004, scheduled DOAH Case No. 04-0025 for hearing on March 25, 2004.

On March 16, 2004, Lady Lake filed an unopposed Motion for Continuance in DOAH Case No. 04-0025. An Order dated March 22, 2004, rescheduled the hearing in DOAH Case No. 04-0025 for April 16, 2004.

On March 25, 2004, Lady Lake filed a Petition for Formal Administrative Hearing and Answer to Administrative Complaint to contest the imposition of an administrative fine. On March 26, 2004, AHCA referred the administrative fine case to the Division

of Administrative Hearings. Hereinafter, the administrative fine case shall be referred to as DOAH Case No. 04-1065.

On March 31, 2004, AHCA filed a Motion to Consolidate, for Leave to File Amended and Consolidated Pleading and to Approve Style, together with an Amended Notice of Assignment of Conditional Licensure Status and Amended Administrative Complaint for Fine in both cases. An Order dated April 2, 2004, consolidated the cases and granted AHCA leave to file an amended pleading in the consolidated cases. The April 2, 2004, Order advised the parties that both cases would be heard on April 16, 2004.

On April 14, 2004, the parties filed a Joint Motion for Continuance. That same day, the undersigned issued an Order Granting Continuance and Re-scheduling Hearing for June 9 and 10, 2004.

On June 3, 2004, AHCA filed a Motion for Leave to File Second Amended Pleading, together with the Second Amended Notice of Assignment of Conditional Licensure Status and Second Amended Administrative Complaint for Fine. Specifically, the second amended pleading added Count II in DOAH Case No. 04-1065, alleging that Lady Lake had violated Florida Administrative Code Rule 59A-4.1288, 42 CFR Section 483.75, and/or Section 400.141(21), Florida Statutes (2002), by failing to properly document a patient's medical record.

On June 4, 2004, AHCA filed a Motion for Order Re Burden of Proof and Presentation of Evidence at Hearing.

On June 7, 2004, Lady Lake filed a Response to Motion for Leave to File Second Amended Pleading.

When the hearing commenced as scheduled on June 9, 2004, the undersigned deferred ruling on AHCA's pending Motion for Leave to File Second Amended Pleading. By the close of the day on June 10, 2004, it was clear that the hearing could not be concluded within the scheduled 2-day period.

On June 14, 2004, the undersigned issued an Order Granting Motion for Leave to File Second Amended Pleading.

On June 17, 2004, the undersigned issued an Order Granting Continuance and Re-scheduling Hearing for August 26 and 27, 2004.

On July 6, 2004, Lady Lake filed a Petition for Formal Administrative Hearing and Answer to Second Amended Administrative Complaint.

During the four days of hearing, AHCA presented the testimony of three witnesses in its case-in-chief and three rebuttal witnesses. AHCA offered 24 exhibits that were accepted as record evidence.

Lady Lake presented the testimony of 12 witnesses. Lady Lake offered three exhibits, two of which were voluminous composite exhibits (86 and 146 pages respectively).

The court reporter filed four volumes of transcript on July 13, 2004, and three volumes of transcript on September 20, 2004.

On September 29, 2004, AHCA filed a Motion for Order Regarding the Filing of PROs & Accompanying Brief/Analysis on Evidentiary Issues. The undersigned granted the motion on October 1, 2004.

On October 25, 2004, the parties filed a Joint Motion of Time to File Proposed Recommended Orders. An Order dated October 26, 2004, granted the motion.

On October 28, 2004, Lady Lake filed its Proposed Recommended Order, together with an Appendix.

On October 29, 2004, AHCA filed a Motion for Enlargement of Time and Waiver of Page Limit. That same day, AHCA filed its Proposed Recommended Order and Brief and Analysis of Burden and Standard of Proof in Fine Case. AHCA's Motion for Enlargement of Time and Waiver of Page Limit is hereby granted.

All references hereinafter shall be to Florida Statutes (2003), except as otherwise specified.

FINDINGS OF FACT

1. AHCA is the agency that is responsible for licensing nursing homes and for enforcing Chapter 400, Part II, Florida Statutes, and Florida Administrative Code Chapter 59A-4. This includes enforcement of federal nursing home regulations in the

   Code of Federal Regulations specifically referenced in this case.

2. Lady Lake owns and operates Lady Lake Specialty Care Center (the facility), a 120-bed skilled nursing facility located in Lady Lake, Florida. The facility operates under license # SNF130470994.

3. At all times material here, the facility was licensed under AHCA's authority. Accordingly, the facility was required to comply with all applicable statutes, rules, and regulations.

4. The facility is a long-term care provider under Medicaid and Medicare. As such, it is subject to federal regulation relating to compliance with 42 CFR Section 483.

5. AHCA has the statutory authority and mandated duty, pursuant to Section 400.23(7), Florida Statutes, to evaluate all nursing homes facilities periodically (at least every 15 months). After each such evaluation, AHCA must assign a licensure status of "standard or conditional" to each licensee.

6. On or about August 26, 2003, AHCA conducted a monitoring survey at the facility. As a result of the survey, AHCA cited the facility for a quality of care deficiency. AHCA based the deficiency upon finding of an alleged lack of proper care of one male resident (hereinafter referred to as "the resident").

7. More specifically, the citation was for an alleged violation of 42 CFR Section 483.25(c), which pertains to quality of care as it relates to pressure sores. A violation of 42 CFR Section 483.25(c) is commonly referred to as a Tag F-314 deficiency.

8. AHCA determined that the scope of the Tag F-314 deficiency was isolated. AHCA also determined that the nature of the Tag F-314 deficiency was a Class II violation.

9. Pursuant to leave granted, AHCA also charged Lady Lake with violating 42 CFR Section 483.75(l)(1), and/or Section 400.141(21), Florida Statutes, by failing to properly document treatment and care. This violation is commonly referred to as a Tag F-514 deficiency.

10. AHCA determined that the scope of the Tag F-514 deficiency was isolated. AHCA concluded that the Tag F-514 deficiency was a Class II violation.

11. AHCA assigned conditional licensure status to the facility for the period August 26, 2003, to October 3, 2003. AHCA seeks to impose an administrative fine in the amount of

    $2,500 for the Tag F-314 deficiency and $2,500 for the Tag F-514 deficiency.

12. Lady Lake admitted the 81-year-old resident to the facility on July 31, 2003. At that time, the resident was severely contracted and bedridden. He had much comorbidity,

    including but not limited to, severe dementia, severe cardiac disease, peripheral vascular disease, end-stage Parkinson's disease, incontinence, cancer, and diabetes mellitus. The resident was non-verbal, non-ambulatory, and emaciated.

13. The resident's records include a Transfer Summary from the Marion County Hospice, dated July 30, 2003. The Transfer Summary indicates that the resident's legs were contracted, that his skin was intact, and that he was using a low-air mattress.

14. When the resident was a patient at the Marion County Hospice, he suffered a number of pressure sores on his feet and legs and at least one Stage III pressure sore on his coccyx. These pressure sores developed at the hospice even though the resident received appropriate care because they were unavoidable given his physical condition.

15. The resident was at "high risk" for pressure sores.

    
    

    He scored a "9" on the Braden Scale for evaluating such risks. A score below "12" is a "high risk" patient.

16. Pressure sores are classified as follows: (a) in Stage I as a persistent area of skin redness (without a break in the skin) that cannot be blanched and which does not disappear within 30 minutes when pressure is relieved; (b) in Stage II as a partial loss in the thickness of skin layers that presents clinically as an abrasion, blister, or shallow crater; (c) in Stage III as a loss of a full thickness of skin layers, exposing

    the subcutaneous tissues and presenting a deep crater with or without undermining adjacent tissue; and (d) in Stage IV as missing a full thickness of skin and subcutaneous tissues, exposing the muscle and/or bone.

17. Upon admission to the facility, the resident had a red area on the plantar region of the foot below and toward the outer aspect of the great right toe. This red area was a pressure sore in the initial stage with undetermined damaged below. In fact, the resident could have suffered pressure trauma during transit from the hospice to the facility, causing damage to the foot.

18. The facility's Assistant Director of Admissions (ADON) instructed the admission nurse to document the resident's pressure sore so that the facility would not be blamed. However, the admission nurse did not record the red area as a Stage I pressure sore. Instead, she noted that there was no skin impairment with the exception of a reddened area on the outer aspect of the right great toe. She also noted that sheepskin heel protectors were in place. The first charge nurse to attend the resident on the day of his admissions made the same observations.

19. There is no way to determine at the time of a Stage I pressure sore how much underlying tissue has been damaged and how large the wound may become. A wound may look very small,

    but within a short period of time become huge because there is underlying tissue damage. Additionally, a reddened area on one spot may surface as an open area somewhere else due to underlying tissue damage. The damaged tissue must be removed before new tissue can fill the wound. Tissue damage equates to tissue death.

20. A pressure sore may unavoidably escalate to a Stage III or Stage IV due to tissue damage beneath the skin. This is especially true in cases where the patient, such as the resident here, has severe peripheral vascular disease and lack of adequate blood supply.

21. The healing of the resident's pressure sore was negatively impacted by its location on the foot. The resident's peripheral vascular disease caused a decreased amount of blood circulation to the foot. Further, the resident was not active and therefore was not achieving a good heart rate, which meant that the cardiac output was low. Cardiac output is important in providing blood with oxygen, hemoglobin, and red blood cells to the wound to assist in the healing process.

22. Between the time that the resident was admitted and August 7, 2003, there was no physician order for specific treatment of the reddened area on the resident's foot. There is no persuasive evidence that any such treatment was required.

23. The Weekly Skin Review dated August 7, 2003, identified the damaged tissue on the resident's foot as a pressure sore. The August 7, 2003, Skin Grid indicates that it was a new site of skin impairment that was not present on admission. The pressure sore was documented as a new site of skin impairment because it was no longer just a reddened area typical of Stage I, but had progressed to Stage II, clearly visible as a black/blue area, 3 cm by 3 cm, with no depth or drainage.

24. On August 7, 2003, the resident's doctor ordered a skin preparation to be applied to his right plantar foot region three times daily. At that point in time, the nurses transferred the order to the Treatment Administration Record (TAR), which is just one of the places that the facility uses to document treatment. On the day it was ordered, the treatment was rendered to the resident one time. This is most likely because the facility had to secure the doctor's order and receive the product from the pharmacy before treatment could begin.

25. On August 8, 2003, the nurses on two shifts recorded the skin preparation treatment on the TAR. On August 9 and 10, 2003, all three shifts noted the skin preparation treatment on the TAR.

26. On August 11, 2003, two nurses noted the skin preparation treatment on the TAR. The third nurse presented credible testimony that she provided the treatment even though she did not record it on the TAR.

27. On August 11, 2003, the doctor issued an order for the pressure sore to be cleaned daily, treated with TAO, and covered with non-stick telfa. The TAR reflects that the nurses changed the dressing once on August 12, once on August 14, twice on August 15, once on August 16, twice on August 18, and once on August 20. However, the greater weight of the evidence indicates that the facility's staff complied with the doctor's orders even through they did not always document their treatments.

28. On August 13, 2003, the Weekly Skin Review identified no new areas of skin impairment. The August 14, 2003, Skin Grid notes that the Stage II pressure sore had not changed in size, but was pink in color.

29. On August 20, 2003, the Weekly Skin Review identified no new areas of skin impairment. The August 20, 2003, Skin Grid notes that the Stage III pressure sore had not changed in size or color but had some drainage and minimal odor.

30. On August 21, 2003, the resident's doctor issued an order for the pressure sore to be treated twice a day with Santyl in the middle and TAO on the edges then wrapped with

    curex until healed. The facility's staff complied with the doctor's orders and recorded the treatments on the TAR twice a day until the doctor discontinued them on August 27, 2003.

31. The resident was placed on the facility's Magnolia Wing. The facility usually places Medicare patients on this wing.

32. The nurses on the Magnolia Wing use Medicare documents such as the forms for Daily Skilled Nursing Notes (DSNN). Because the resident was a private-pay patient, the nurses were not required to document his condition on the Medicare forms on a daily basis. In fact, the nurses were not required to fill out the DSNN at all. They were only required to chart his progress on a weekly basis or when there was a significant change that required charting. The use of the DSNN was at the facility's discretion.

33. Under the facts of this case, the nurses were not expected to check off every box on the DSNN that was relevant or to write a comment on each shift. They were expected to "document by exception," noting anything on their shift that was out of the ordinary for the resident. It is acceptable practice in long-term care nursing to "chart by exception" as it would be insurmountable to chart every thing that a resident does on a daily basis. While the records reflect that some nurses charted

    routine care of the resident, that charting is indicative of the nurses' training or experience in another setting.

34. The facility's system of documentary communication included, but was not limited to, Nurse's Notes, TAR, and Medication Administration Record (MAR). Other documentary forms were used for skin assessments and wound care treatment. The facility's staff also communicated with each other about the resident's condition by conducting shift-change meetings and nurses' rounds and by checking the dates and nurses' signatures on bandages. These methods of communication met the community standard for good nursing.

35. The nurses and their assistants were not required to document every time they turned and repositioned the resident because it was not an "activity of daily living" for charting purposes. The nurses noted on the TAR that the resident needed to be turned every two hours. They made this notation merely as a reminder to turn the resident. There was no doctor's order to accomplish this task. There was a bear symbol on the resident's door to remind the staff that he needed skin precautions, including turning and repositioning. In any event, turning and repositioning the resident would have had no effect on the foot wound because his foot was not on the bed.

36. Reviewing the MAR, TAR, Nurses' Notes, and DSNN together, there is consistent documentation of treatment being

    rendered in accordance with the doctor's orders. There is no persuasive evidence that any lack of documentation in the resident's medical records adversely impacted the resident's health and welfare or constituted a deficiency. Lady Lake substantially complied with the requirement to document the care and treatment of the resident.

37. The resident was admitted to the facility on a pressure reduction mattress. The facility provided him with a low-air mattress on August 21, 2003. His mattress was upgraded on two occasions. Providing a long-term care patient like the resident with a pressure-relieving mattress is such a routine intervention that it does not require charting or a doctor's order. Regardless of the type of mattress provided, it did not impact the pressure sore because the resident's foot did not rest on the mattress.

38. On August 26, 2003, AHCA's surveyor asked to observe the resident's wound. A nurse removed the dressing from the resident's foot. AHCA's surveyor had to pry the resident's right foot from where it pressed against his left leg in order to observe the Stage III pressure sore on the ball of the resident's right foot. The wound was crater-like, with irregular edges that were red and meaty looking. The surveyor was unable to determine its depth due to what appeared to be drainage. The bandage could not be reapplied because the nurse

    assisting the surveyor did not have a key to the medication cart.

39. On August 26, 2003, the wound was covered with a slimy or gelatinous material, which could be attributed at least in part to the Santyl treatment. Santyl is a collagenase debriding agent that dissolves necrotic tissue without causing any harm to the new healing tissue. The use of Santyl can cause a wound to appear gelatinous and green or brown.

40. It would not have been appropriate, at the time of the survey, to remove the gelatinous material from the wound to determine its depth. Because healing starts at the base of the wound, it should not be forcibly cleaned or rubbed.

41. A wound can be left undressed for a period of time if it has not dehydrated. There was no evidence that the resident's wound became dehydrated on August 26, 2003, or at any other point in time.

42. The resident's pressure sore never became infected.

    
    

    An infection would have been likely if he had not received appropriate treatment for the wound.

43. The surveyor did not see any pillows on the bed or in the resident's room. However, the greater weight of the evidence indicates that the resident would have had many more skin problems if the facility staff had not been turning and repositioning him with pillows every two hours.

44. Without pillows, the facility's staff would not have been able to position the resident on his back to feed him. The staff used pillows to separate the resident's legs to relieve the pressure on the foot to the extent possible. Repositioning with pillows is a standard procedure in long-term care facilities. The bandage on the pressure sore acted as padding to eliminate any friction on the pressure sore.

45. The resident's pressure sore never progressed to Stage IV, which requires exposed bone or muscle. The only record of a Stage IV pressure sore is found in the Minimum Data Set (MDS). It is necessary to record a pressure sore as Stage IV on the MDS when it has a blister and the depth cannot be determined. Furthermore, there is no difference in the care rendered to a patient with a Stage III or Stage IV pressure sore.

46. The resident's pressure sore changed to a Stage II before he was transferred out of the facility. The greater weight of the evidence indicates that the resident's ability to reach his highest practicable mental, physical and psychosocial well-being was not compromised by Lady Lake in regard to the quality of care provided or in regard to documenting his condition.

    CONCLUSIONS OF LAW

    
    

47. The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of this

    proceeding pursuant to Sections 120.569 and 120.57(1), Florida Statutes (2004).

48. The regulatory provision that is pertinent to the Tag F-314 deficiency is 42 CFR Section 483.25, which states as follows in relevant part:

    § 483.25 Quality of Care.

    
    

    Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

    
    

    * * *

    
    

    1. Pressure sores. Based on the comprehensive assessment of a resident, the facility must ensure that--

       
       

       1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and

          
          

       2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

          
          

49. The regulatory provision that is pertinent to the Tag F-514 deficiency is 42 CFR Section 483.75, which states as follows in relevant part:

    § 483.75 Administration.

    
    

    A facility must be administered in a manner that enables it to use its resources

    effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

    
    

    * * *

    
    

    (l) Clinical Records.

    (1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are--

    1. Complete;

    2. Accurately documented;

    3. Readily accessible; and

    4. Systematically organized.

    
    

50. Section 400.141, Florida Statutes, provides as follows in relevant part:

    400.141 Administration and management of nursing home facilities.--Every licensed facility shall comply with all applicable standards and rules of the agency and shall:

    
    

    * * *

    
    

    (10) Keep full records of resident admissions and discharges; medical and general health status, including medical records, personal and social history, and identity and address of next of kin or other persons who may have responsibility for the affairs of the residents; and individual resident care plans including, but not limited to, prescribed services, services frequency and duration, and service goals. The records shall be open to inspection by the agency.

    
    

    * * *

    
    

    (21) Maintain in the medical record for each resident a daily chart of certified nursing assistant services provided to the resident. The certified nursing assistant

    who is caring for the resident must complete this record by the end or his or her shift. This record must indicate assistance with activities of daily living, assistance with eating, and assistance with drinking, and must record each offering of nutrition and hydration for those residents whose plan of care or assessment indicates a risk for malnutrition or dehydration.

    
    

    DOAH Case No. 04-0025

    
    

51. AHCA has the burden of proving by a preponderance of the evidence that Lady Lake should be given conditional license status pursuant to Section 400.23(7), Florida Statutes. See Beverly Enterprises - Florida v. Agency for Health Care

    Administration, 745 So. 2d 1133 (Fla. 1st DCA 1999); Florida Department of Transportation v. J.W.C. Company, Inc., 396 So. 2d 778 (Fla. 1st DCA 1981). AHCA has not met its burden.

52. The greater weight of the evidence indicates that the resident had a Stage I pressure sore upon his admission to the facility. Thereafter, the facility provided appropriate treatment to promote healing, to prevent infection, and prevent new sores from developing. There is no persuasive evidence, under any standard, that the facility's treatment of the pressure sore compromised the resident's highest practicable mental, physical and psychosocial well-being. Under the facts of this case, there is no need to determine the classification of a Tag F-314 deficiency that did not exist.

    DOAH Case No. 04-1065

    
    

53. AHCA has the burden of proving by clear and convincing evidence that Lady Lake is subject to an administrative fine for violating 42 CFR Section 483.25(c) and 42 CFR Section 483.75(l). See Department of Banking and Finance, Division of Securities and Investor Protection v. Osborne Stern Company, 670 So. 2d 932 (Fla. 1996). AHCA has not met its burden.

54. As stated above, the facility provided appropriate care for the resident's pre-existing pressure sore. Additionally, the greater weight of the evidence indicates that the facility maintained the resident's medical records in accordance with accepted professional standards and practices.

55. To the extent that the facility failed to document treatment, it was in substantial compliance with the requirement to do so. 42 CFR Section 488.301 defines "substantial compliance" as "a level of compliance with the requirements of participation such that any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm."

56. There is no persuasive evidence, under any standard, that the facility's failure to document treatment, if any, caused any potential for harm, much less any actual harm. Under the facts of this case, there is no need to determine the classification of a Tag F-514 deficiency that did not exist.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is

RECOMMENDED:

That AHCA enter a Final Order dismissing the Administrative Complaints in both cases.

DONE AND ENTERED this 15th day of December, 2004, in Tallahassee, Leon County, Florida.

S

SUZANNE F. HOOD

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 15th day of December, 2004.

COPIES FURNISHED:

Karen L. Goldsmith, Esquire Goldsmith, Grout & Lewis, P.A. 2180 North Park Avenue, Suite 100 Post Office Box 2011

Winter Park, Florida 32790-2011

Tom R. Moore, Esquire

Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308-5403

Charlene Thompson, Acting Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.

Docket for Case No: 04-000025

Orders for Case No: 04-000025