STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 26 BEC | onal TAMPA BAY RETIREMENT CENTERS, INC., d/bia OAKWOOD PARK SU CASA, Petitioner, vs. AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER THE PARTIES resolved all disputed issues and executed a Settlement Agreement, which is attached and incorporated by reference. The parties are directed to comply with the terms of the attached Settlement Agreement. Based on the foregoing, this file is CLOSED. \ DONE and ORDERED this 1Jasay of Leena , 2004, in Tallahassee, Leon County, Florida. an Levine, Secretary Agency for Health Care Administration APARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH AGENCY CLERK AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, IN THE DISTRICT COURT OF APPEAL WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Theodore E. Mack, Esquire Powell & Mack 803 North Calhoun Street Tallahassee, Florida 32303 (U.S. Mail) Sarah D. Cyrus, Esq. Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 (Interoffice Mail) Lawrence P. Stevenson Administrative Law Judge The Desoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Lisa Milton Administrator of Audit Services Medicaid Program Analysis 2727 Mahan Drive, MS #21 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE is. ee I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) by U.S. Mail, or the method designated, on this the / 2 day of LLCENIALS, 2004. Duce dts, x ( — 2727 Mahan Drive, Building #3 FL S Agengy Clerk / ( Agency for Health Care Administration Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION TAMPA BAY RETIREMENT CENTERS, INC., d/bla OAKWOOD PARK SU CASA, Petitioner, Case No. 04-1264MPI vs. NHO03-184F AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT The Agency for Health Care Administration (““AHCA” or “the Agency”), and Petitioner, Tampa Bay Retirement Centers, Inc. d/b/a/ Oakwood Park Su Casa (“PROVIDER”), stipulate and agree as follows: 1. This Agreement is entered into between the parties to resolve disputed issues arising from audit engagements. 2. The PROVIDER is a Medicaid provider in the State of Florida operating a facility that was audited by the Agency. 3. In audit engagement number NH03-184F, AHCA audited the PROVIDER’S cost report for the audit period ending July 31, 2001. In its Audit Report issued on March 5, 2004, AHCA notified the PROVIDER that Medicaid reimbursement principles required adjustment of the cost allocations stated in the report. The Agency further notified the PROVIDER of the adjustments AHCA was making to the cost report. 4. In response to the Audit Report, the PROVIDER filed a timely petition for administrative hearing that was assigned DOAH case number 04-1264MPI. 5. Subsequent to the petition for administrative hearing, AHCA and the PROVIDER exchanged documents and discussed the disputed adjustments. 6. Asa result of the aforementioned exchanges, the parties agree to accept all of the Agency’s adjustments that were subject to these proceedings as set forth in the audit report, except for the following changes: Audit Adjustment #5, Agency Data: RN costs from $4,974 to $6,121 LPN costs from $(113,086) to $(15,405) CNA costs from $(199,687) to $(47,821) Total adjustment from $(307,799) to $(57,105) 7. In order to resolve this matter without further administrative proceedings, the PROVIDER and AHCA expressly agree the adjustment resolutions, as set forth in paragraph 6 above, completely resolve and settle this case and this agreement constitutes the PROVIDER’S withdrawal of its petition for administrative hearing, with prejudice. 8. The PROVIDER and AHCA further agree the Agency shall recalculate the per diem rate for the audit period ending July 31, 2001, and issue a notice of the recalculation. Where the PROVIDER was overpaid, the PROVIDER will reimburse the Agency the full amount of the overpayment within thirty (30) days of such notice. Where the PROVIDER was underpaid, AHCA will pay the PROVIDER the full amount of the underpayment within forty-five (45) days of such notice. 9. Payment shall be made to: AGENCY FOR HEALTH CARE ADMINISTRATION Medicaid Accounts Receivable Post Office Box 13749 Tallahassee, FL 32317-3749 Notices to the PROVIDER shall be made to: Tampa Bay Retirement Centers, Inc. d/b/a Oakwood Park Su Casa 1514 East Chelsea Street Tampa, Florida 33610 Payment shall clearly indicate it is pursuant to a settlement agreement and shall reference the audit/engagement number. 10. | The PROVIDER agrees that failure to pay any monies due and owing under the terms of this Agreement shall constitute the PROVIDER’S authorization for the Agency, without further notice, to withhold the total remaining amount due under the terms of this Agreement from any monies due and owing to the PROVIDER for any Medicaid claims. 11. AHCA is entitled to enforce this Agreement under the laws of the State of Florida, the Rules of the Medicaid Program, and all other applicable law. 12. This settlement does not constitute an admission of wrongdoing or error by the parties with respect to this case or any other matter. 13. Each party shall bear their respective attorneys’ fees and costs, if any. 14. The signatories to this Agreement, acting in their respective representative capacities, are duly authorized to enter into this Agreement on behalf of the party represented. The parties further agree a facsimile or photocopy reproduction of this Agreement shall be sufficient for the parties to enforce the Agreement. The PROVIDER agrees, however, to forward a copy of this Agreement to AHCA with original signatures, and understands a Final Order may not be issued until said original Agreement is received by AHCA. 15. This Agreement shall be construed in accordance with the provisions of the laws of Florida. Venue for any action arising from this Agreement shall be in Leon County, Florida. 16. This Agreement constitutes the entire agreement between the PROVIDER and AHCA, including anyone acting for, associated with, or employed by them, respectively, concerning all matters and supersedes any prior discussions, agreements, or understandings; there are no promises, representations, or agreements between the PROVIDER and AHCA other than as set forth herein. No modification or waiver of any provision shall be valid unless a written amendment to the Agreement is completed and properly executed by the parties. 17. This is an Agreement of settlement and compromise, recognizing the parties may have different or incorrect understandings, information and contentions, as to facts and law, and with each party compromising and settling any potential correctness or incorrectness of its understandings, information, and contentions as to facts and law, so that no misunderstanding or misinformation shall be a ground for rescission hereof. 18. The PROVIDER expressly waives in these matters its right to any hearing pursuant to §120.569 or §120.57, Florida Statutes, the making of findings of fact and conclusions of law by the Agency, and all further and other proceedings to which it may be entitled by law or rules of the Agency regarding these proceedings and any and all issues raised herein, other than enforcement of this Agreement. The PROVIDER further agrees the Agency shall issue a Final Order, which adopts this Agreement. 19. This Agreement is and shall be deemed jointly drafted and written by all parties to it and shall not be construed or interpreted against the party originating or preparing it. 20. To the extent any provision of this Agreement is prohibited by law for any reason, such provision shall be effective to the extent not so .prohibited, and such prohibition shall not affect any other provision of this Agreement. 21. This Agreement shall inure to the benefit of and be binding on each party’s successors, assigns, heirs, administrators, representatives, and trustees. Petitioner/Provider Tampa Bay Retirement Centers, Inc. d/b/a Oakwood Park Su Casa (signature) By its en (title) 7 AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive, Mail Stop #3 Tallahassee, FL Ppp (UMW Dated: laf it iss , 2004 Tomas W. Amold, Deputy Secretary, Medicaid ay 4 SLE a elle. be Dated: pvt 7 , 2004 Valda Clark Christian, General Counsel val, L Cruse Dated: , 2004 Sarah D, Cyrus, Assisfant General Counsel

Docket for Case No: 04-001264MPI