STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 2m CEC 20 Psy AGENCY FOR HEALTH CARE voce ADMINISTRATION, BLS Petitioner, AHCA No. 2004007279 (Cond. Lic.) vs. AHCA No. 2004007277 (Fine) HQM OF PORT ST. JOE, LLC, d/b/a BAY ST. JOSEPH CARE ean AND REHABILITATION CENTER, [ l| me [ \ (\ 5 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “A gency”), by and through the undersigned counsel, and files this Administrative Complaint against HQM OF PORT ST. JOE, LLC, d/b/a BAY ST. JOSEPH CARE AND REHABILITATION CENTER (“Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose conditional licensure statues upon Respondent, pursuant to Section 400.23(7)(b), Florida Statutes, and an administrative fine of SEVEN THOUSAND FIVE HUNDRED DOLLARS ($7,500) upon Respondent, pursuant to Section 400.23(8)(b), Florida Statutes. JURISDICTION AND VENUE 2. AHCA and the Division of Administrative Hearings upon a request for formal hearing, have jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. Administrative Complaint 2004007279 & 2004007277 Page 1 of 9 3. Venue shall be determined pursuant to Rule 28-106.207, Fla. Admin. Code. PARTIES 4. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes; and Chapter 59A-4, Fla. Admin. Code, respectively. 5. Respondent, HQM OF PORT ST. JOE, LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, BAY ST. JOSEPH CARE AND REHABILITATION CENTER (“Facility”), is a 120-bed nursing home located at 220 Ninth Street, Port St. Joe, Florida 32456. Respondent is licensed as a skilled nursing facility, having been issued licensed number 1038096 and was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and tules.' COUNT I CLASS Il WIDESPREAD VIOLATION FOR FAILURE TO IMPOSE A MORATORIUM ON NEW ADMISSIONS WHEN MINIMUM STAFFING REQUIREMENTS WERE NOT MET Section 400.23(7)(b), Florida Statutes Section 400.23(8)(b), Florida Statutes Section 400.141(15)(d), Florida Statutes 6. AHCA te-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 1 The Standard license subsequent to Exhibit A is Standard license number SNF 1038096, certificate number 11679, with an effective date of 8/26/04, and a license expiration date of 3/23/05. This original assigned standard license is attached as Exhibit B. Administrative Complaint 2004007279 & 2004007277 Page 2 of 9 7. The regulatory provision of the Florida Statutes that is pertinent to this alleged violation, reads as follows: 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: 2K (15) Submit semiannually to the agency, or more frequently if requested by the agency, information regarding facility staff-to-resident ratios, staff turnover, and staff stability, including information regarding certified nursing assistants, licensed nurses, the director of nursing, and the facility administrator. For purposes of this reporting: RK (d) A nursing facility that has failed to comply with state minimum-staffing requirements for 2 consecutive days is prohibited from accepting new admissions until the facility has achieved the minimum-staffing requirements for a period of 6 consecutive days. For the purposes of this paragraph, any person who was a resident of the facility and was absent from the facility for the purpose of receiving medical care at a separate location or was on leave of absence is not considered a new admission. Failure to impose such an admissions moratorium constitutes a class II deficiency. 8. AHCA surveyors conducted a survey of Respondent’s facility on May 26, 2004, which revealed the following: Based on interview and record review the facility failed to impose a moratorium on new admissions for 6 days when minimum staffing requirements were not met for 2 consecutive days in April and May 2004. Specific findings were: a). A review of the form “Calculating Staffing for Long Term Care Facilities” which was completed by the facility for the dates of April 1, 2004 thru May 25, 2004, revealed a failure to meet the minimum requirements for nursing staff. The facility failed to meet minimum staffing requirement for 2 consecutive days for the following dates: » April 10 and April 11 » April 22 and April 23 * April 26, April 27, April 28 » May 13, May 14, May 15 » May 21, May 22, May 23 b). An interview with the Administrator at 2:30 p.m. on 5/26/04 revealed he/she was new to the position and unaware of a self-imposed moratorium on new admissions. An interview with the Risk Manager at this same time revealed he/she was aware of a current Administrative Complaint 2004007279 & 2004007277 Page 3 of 9 moratorium and a moratorium in April 2004. He/She was unaware of the dates and the facility was unable to provide proof of this self-imposed moratorium. 9. Respondent’s failure to impose a moratorium on new admissions when minimum staffing requirements were not met is a violation of Section 400.141(15)(d), Florida Statutes. 10. | AHCA classified the nature and scope of this violation as a class II “widespread” violation. Pursuant to Section 400.23(8)(b), this classification constitutes grounds for the imposition of an administrative fine of SEVEN THOUSAND FIVE HUNDRED DOLLARS ($7,500). A class II violation is defined as one that “the agency determines has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services,” which also gives rise to conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes.” 11. Respondent's failure to impose a moratorium on new admissions when minimum staffing requirements were not met constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(b). DISPLAY OF LICENSE 12. Pursuant to Section 400.25(7), BAY ST. JOSEPH CARE AND REHABILITATION CENTER shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. 2 HQM OF PORT ST. JOE, LLC, d/b/a BAY ST. JOSEPH CARE AND REHABILITATION CENTER, AHCA Case No. 2004007279 is a conditional licensure status case, pursuant to §400.23(7), Florida Statutes, [T]he Agency [AHCA] shall {emphasis added]... assign a licensure status of standard or conditional to each nursing home. ...{b) A conditional licensure status means that a facility, due to the presence of one or AHCA Case No. 2004007279, ,is the assignment ofa more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. The burden of proof in a conditional licensure case upon the Agency is a preponderance of the evidence standard. Administrative Complaint 2004007279 & 2004007277 Page 4 of 9 13. The Conditional License is attached hereto as Exhibit “A”. The subsequent Standard License is attached hereto as Exhibit “B” CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of the Agency on Count I. 2. Uphold the imposition of conditional licensure status. 3. Imposition of an administrative fine of SEVEN THOUSAND FIVE HUNDRED DOLLARS ($7,500). 4. Such other relief as this Court deems is just and proper. DISPLAY OF LICENSE eo Pursuant to Section 400.23(7), Florida Statutes, Destin Healthcare and Rehabilitation Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit “B”.° OE — 3 The original Conditional license attached hereto as Exhibit B is Conditional license number SNF 1038096, certificate number 11678, with an effective date of 5/26/04, and a license expiration date of 3/23/05. Administrative Complaint 2004007279 & 2004007277 Page 5 of 9 NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569 and 120.57, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSTITUTE AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted this 2 4 day of So@ tole, , 2004. Respectfully submitted. Eric R. Bredemeyer Fla. Bar. No. 318442 Senior Attorney Agency for Health Care Administration Office of the General Counsel 2727 Mahan Drive Ft. Knox, Building #3, MS #3 Tallahassee, FL 32308 (850) 922-5873 Administrative Complaint 2004007279 & 2004007277 Page 6 of 9 CERTIFICATE OF SERVICE AHCA, by and through its undersigned counsel, hereby certifies that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Explanation of Rights Under Section 120.569, F.S.A. form, have been forwarded by certified mail, return receipt requested (receipt no. 7003 1010 0000 9716 0366), to: Jane C. Davis, Administrator, Bay St, Joseph Care and Rehabilitation Center, 220 Ninth Street, Port Saint Joe, Florida 32456, this 23 day of Septem ef , 2004. Sue Eric R. Bredemeyer, Esquire Assistant General Coun sel a“ Administrative Complaint 2004007279 & 2004007277 Page 7 of 9

Docket for Case No: 04-004505