STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004004054 Return Receipt Requested: v. 7002 2410 0001 4237 7279 7002 2410 0001 4237 7286S IT’S JUST LIKE HOME, INC. d/b/a IT’S JUST LIKE HOME, Respondent. ; O U . 3 ( | v ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against It's Just Like Home, Inc. d/b/a It’s Just Like Home (hereinafter “It’s Just Like Home”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $6,350.00 [$6,000.00 fine + $350.00 survey fee] pursuant to Sections 400.414 and 400.419, Florida Statutes 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 Palm Beach 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 (2003) and Chapter 58A-5 Florida Administrative Code. 5. It's Just Like Home operates an 8-bed assisted living facility located at 3815 Russell Place. It’s Just Like Home is licensed as an assisted living facility under license number 9936. It’s Just Like Home 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 IT’S JUST LIKE HOME’S ADMINISTRATOR ALLOWED A RESIDENT TO BE SOLELY IN CHARGE OF OTHER RESIDENTS ON THE WEEKENDS. RULE 58A-5.019(1) (a) 2, FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. It’s Just Like Home was cited with one (1) Class I deficiency and one (1) Class II deficiency due to a complaint investigation conducted on April 1, 2004. 8. Based on a complaint investigation conducted on April 1, 2004 and based on interviews with residents and staff, the facility administrator allowed a resident to be solely in charge of other residents on the weekends. The findings include the following. 9. On 4/1/04, Residents #2, #3, #5, #7 and #8 were interviewed. All residents interviewed verified that Resident #2 was left in charge of the residents on weekends. The residents as well as the House Manager verified that this resident was left in charge of providing meals, medication assistance and supervision to all other residents on weekends. Resident #2 stated that this was a deal with the owner in exchange for a reduced housing payment. Review of the resident's record revealed that the resident had been at the facility since 3/3/04 and had not had a health assessment done, CPR certification or first aid, medication assistance training or training in food preparation. The House Manager also verified that the resident did not have any credentials. 10. Based on the foregoing, It’s Just Like Home violated Rule 58A-5.019(1)(a)2, Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $5,000.00. COUNT II IT’S JUST LIKE HOME’S ADMINISTRATOR FAILED TO MAKE EVERY REASONABLE EFFORT TO PROVIDE MEDICATIONS THAT WERE PRESCRIBED TO RESIDENTS BY A PHYSICIAN. RULE 58A-5.0185(7) (£), FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS II VIOLATION 11. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. Based on a complaint investigation conducted on April 1, 2004 and based on record review and interviews with staff and residents, the facility failed to make every reasonable effort to provide medications that were prescribed to residents by a physician. The findings include the following. 13. Resident #5 was interviewed on 4/1/04 and stated that the facility had recently switched pharmacies due to difficulty in obtaining prescribed medications in a timely manner. The resident stated that in relation to the change, the resident was unable to receive Geodon, a prescribed medication for approximately 3 days. This was also noted in the medication record on 3/15/04 and 3/16/04. Resident #2 was also interviewed and verified that medications were not available for some time. This resident was not provided a prescribed medication for 18 days in March according to the medication record. The House Manager was interviewed and verified that the change in pharmacy caused some residents to go without prescribed medications for approximately 3 days. She also stated that Resident #2 did not receive medication for 18 days because the family had not delivered any and that the physicians were not notified of these incidences. 14. Based on the foregoing, It’s Just Like Home violated Rule 58A-5.0185(7) (f£), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $350.00 has been assessed in this case 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 It’s Just Like Home on Counts I and II. 2. Assess an administrative fine of $6,000.00 against It's Just Like Home on Counts I and II for the violations cited above. 3. Assess a survey fee of $350.00 against It’s Just Like Home pursuant to Section 400.419(10), 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 (2003). 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 Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAk ORDER BY THE AGENCY. Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 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 I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Joseph A. Lupo, Administrator, It’s Just Like Home, 3815 Russell Place, West Palm Beach, Florida 33405; Joseph A. Lupo, Registered Agent, 3815 Russell Place, West Palm Beach, Florida 33405 on this 4, \day of Faye ; 2004. 7 Matgaret 1

Docket for Case No: 04-002718