/ : / EXHIBIT STATE OF FLORIDA _A_ AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2003007641 2003007643 - 2004003102 GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, cd -UlpaS 7 Respondent. a | | l ( 0 > ao ‘es 7 vw / . ie re) ea) ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “Petitioner”), by and through the undersigned counsel, and files this Administrative Complaint against GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, (“Respondent”) pursuant to §§120.569 and 120.57, Fla. Stat. (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose administrative fines totaling $3,000.00, and a survey fee of $500.00, for a full amount of $3,500.00 against the Respondent. 2. The Respondent was cited for violations during a complaint investigation by AHCA, conducted on July 21, 2003, an appraisal survey by AHCA, conducted on or about August 6, 2003, and a biennial survey by AHCA, conducted on or about January 27, 2004. The violations cited were uncorrected and repeat class III violations cited at the time of the follow-up survey to the complaint investigation by AHCA, completed on Page 1 of 18 August 20, 2003, the appraisal revisit survey by AHCA, completed on Sepiember 15, 2003, and the follow-up to the biennial survey by AHCA, completed on March 12, 2004. JURISDICTION AND VENUE 3. AHCA has jurisdiction over the Respondent, pursuant to §§ 120.569 and 120.57, Fla. Stats. 4. Venue is proper in Bay County, FL, pursuant to Chapter 28-106.207, Fla. Admin. Code. Respondent was, at all times material hereto, located in and doing business in Bay County, FL. PARTIES 5. Pursuant to Chapter 400, Part III, Fla. Stat. and Chapter S8A-5, Fla. Admin. Code, AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules. 6. The Respondent is an assisted living facility located at 3409 West 19" Street, Panama City, Florida 32405. The Respondent is and was at-all times material hereto a licensed facility under Chapter 400, Part II, Fla. Stat., and Rule 58A-5, Fla. Admin, Code, having been issued license number 10146. , COUNT I _ THE RESPONDENT FAILED TO MAINTAIN COMPLETE AND ACCURATE MEDICATION RECORDS AND DOCUMENTATION OF SERVICES/TREATMENTS THAT HOSPICE WAS PROVIDING FOR A RESIDENT RECEIVING HOSPICE SERVICES BY FAILING TO MAINTAIN COMPLETE AND ACCURATE DOCUMENTATION OF SERVICES/TREATMENTS THAT HOME HEALTH WAS PROVIDING TO 2 OF 3 SAMPLED RESIDENTS RECEIVING HOME HEALTH SERVICES. § 400.414,. Fla, Stat. §.400.419(1)(c), Fla. Stat. § 400.426(4),. Fla. Stat. § 400.428,. Fla. Stat. Fla. Admin. Code R. 584-5.024(3) Page 2 of 18 7. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 8. On or about July 21, 2003, AHCA conducted a complaint investigation at the Respondent’s facility. AHCA cited the Respondent for a violation, based on the findings below, to wit: Interview with administrator on July 21, 2003, at 11:30 A.M., revealed that she had concerns about the medications being administered by hospice to residents #3 & #4. The administrator stated there was no communication with hospice to ensure that the physician orders were being followed. The facility did not maintain documentation of current physician orders and services hospice provided on each of their visits (which would include the medications that were administered). 9, The Respondent failed to maintain complete and accurate medication records and documentation of services/treatments that hospice was providing for its residents, as required by §400.426(4), Fla. Stat.; and Fla. Admin. Code R. 58A-5.024(3)(c). 10. Maintenance of medical documentation for services and treatments provided to residents admitted into an assisted living facility is required pursuant to the Fla. Stat. and the Fla. Admin. Code, providing in pertinent part as follows: 400.426 Appropriateness of placements; examinations of residents.— (4) If possible, each resident shall have been examined by a licensed physician or a licensed nurse practitioner within 60 days before admission to the facility. The signed and completed medical examination report shall be submitted to the owner or administrator of the facility who shall usg:the information contained therein to assist in the determination of the appropriateness of the resident's admission and continued stay in the facility. The medical examination report shall become a permanent part of the record of the resident at the facility and shall be made available to the agency during inspection or upon request. An assessment that has been completed through the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program fulfills the requirements for a medical examination under this subsection and s. 400.407(3)(b)(6). § 400.426(4), Fla. Stat. 58A-5.024 Records. The facility shall maintain the following written records in a form, place and system ordinarily employed in good business practice and accessible to department and agency staff...(3) RESIDENT RECORDS. Resident records shall Page 3 of 18 bé maintained on the premises and include...(b) Any health care provider’s orders for medications, nursing services, therapeutic diets, do not resuscitate order, or other services to be provided, supervised, or implemented by the facility that require a health care provider’s order. Fla. Admin, Code R. 58A-5.024(3)(b). 11. For this violation, AHCA provided the Respondent a mandated correction date of August 20, 2003. 12. The foregoing violation constitutes a class III violation, to wit: Class U1 violations are those conditions or occurrences related to the operation and. maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class IIT violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat. 13, On or about August 31, 2003, AHCA conducted a follow-up to the complaint investigation at the Respondent’s facility. AHCA cited the Respondent for an uncorrected violation, based on the findings below, to wit: During the initial tour of the facility on September 15, 2003, at approximately 10:00 AM,, resident #2 was observed to receive services from a nurse. An interview with the nurse at this time confirmed the resident was receiving nursing services from hospice. A review of the medical record did not contain documentation the resident was receiving hospice services. An interview with the administrator on September 15, 2003, at approximately 12:00 P.M., confirmed the current hospice service began seeing the resident on September 5, 2003. The administrator located and showed the surveyor a copy of an order dated September 20, 2003, from the physician for "wound care center evaluation" and a copy of the hospice Interdisciplinary Care Plan dated September 5, 2003. There was no further documentation of physician orders for hospice services. An interview with the administrator on September 15, 2003 at approximately 12:00 P.M., revealed the resident was hospitalized fromm September 31, 2003, until September 5, 2003. Prior to the hospitalization, the resident was receiving home health services. The record did not reveal a discharge order for the home health or an order for the hospice services. The administrator voiced concerns with the communication of services between the facility the physician, hospice, and the home health agency. The hospice "medication profile” revealed on September 5, 2003, the resident listed with 12 medications. A review of the facility medical order record revealed only 2 medications. The interview with the administrator on September 15, 2003 at approximately 12:00, confirmed he/she gives all of the resident's medications and has only given the one routine medication (Synthroid) since September 5, 2003, the other as needed or PRN medication was not given. The administrator confirmed he/she was unaware of the other medications listed by Page 4 of 18 hospice and states "I give what I am given" by the pharmacy. The administrator denied contacting the physician on September 5, 2003, after the resident returned from the hospital to the facility to confirm the resident's medications and orders for hospice services. The facility did not maintain documentation of current physician orders for services and medications. During the initial tour of the facility on September 15, 2003, at approximately 10:00 AM., resident # 1 was observed in his/her room with a bandage to the right foot. An interview was conducted with the resident at this time, and he/she stated he/she was receiving home health from nurses for wound care to the foot. A teview of the medical record revealed no documentation of home health services, An interview was conducted with the administrator at approximately 11:15 A.M. The administrator stated the resident had recently received an evaluation for nursing services from home health but the administrator was unaware the nurses from home health were visiting the resident. The administrator brought the surveyor, from the resident's room, the folder from the home health agency. The folder revealed the resident was receiving home health services for Physical Therapy and Occupational Therapy with a start of care date of March 5, 2003. The administrator confirmed that the therapist is still seeing the resident but he/she was unaware that the therapy was provided through the home health agency. The resident's facility medical record revealed no documentation of the services being received from home health. The facility did not maintain documentation of current physician orders and services. A review of the resident's medical record revealed a folder with copies of visit notes from a home health agency for physical therapy. The record revealed no orders from the physician for home health services or communication between the facility and the home health agency. An interview with the administrator on September 15, 2003, at approximately 12:45 P.M., revealed the administrator was unaware the resident was receiving therapy services from home health. ‘The administrator states he/she questioned the resident concerning therapy and the resident states therapy services have been discontinued. The administrator was unable to provide written documentation from the physician discontinuing home health services. The facility did not maintain documentation of current physician orders and services. 14. The foregoing violation constitutes an uncorrected class III violation, and warrants a fine of $500.00, to wit: Class III violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations, A class I violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. §.400.419(1)(c), Fla. Stat, Page 5 of 18 COUNT I THE FACILITY FAILED TO MAINTAIN AN UP TO DATE MEDICATION RECORD (MOR) FOR 1 OF 5 SAMPLED RESIDENTS Fla. Admin. Code R. S84-5.0185(5)(b) 16. | ACA repeats, re-alleges and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 17. On or about August 6, 2003, AHCA conducted an appraisal investigation at the Respondent’s facility. The Respondent was cited for a violation, based on the findings below, to wit: MEDICATION STANDARDS For residents who receive assistance with self-administration or medication administration, the facility must maintain a daily up-to-date, medication observation record (MOR) for each resident. 58A-5.0185(5)(b), Fla.Admin.Code This standard is not met as evidence by: Based on record review and staff interview the facility failed to maintain an up to date medication record (MOR) for 2 of 2 sampled (#1,2) residents. The findings are: Record review of the ALF July MOR for resident #1 indicates the resident receiving the following medications: Synthroid 0.5 milligrams daily, which was signed as given by the facility from 7/1/03 until 7/10/03. From 7/10/03 until the end of the month MOR lacked evidence the medication was given by the facility. Record review of Hospice MOR indicated the synthroid was signed as given by Hospice from 7/10/03 until 7/21/03 at which time Hospice was discontinued per Power of Attorney. Interview with the owner/caregiver of the ALF on 8/5/03 at 6:00 PM indicated that Hospice was in charge of giving medications, Record review of the residents chart at the ALF indicated a contract signed by the Power of Attorney and the owner/caregiver indicating Hospice was tesponsible for medications, Review of Hospice records indicate the resident has physician orders for: Lortab 5/500 milligrams every 6 hours as needed for pain, Ambien 10 milligrams every night, Zoloft 50 milligrams every day, Senna-S 1-4 everyday as needed, Duragesic patches 25 milligrams every 72 hours, Vitamin daily, Vitamin C daily, Zinc daily and Macrobid 100 mailligrams two times a day and Roxanol 0.25 milligrams every two hours as needed for pain. Record review of the ALF July MOR for resident #2 indicates the resident receiving the following medications: Flomax 0.4 milligrams daily, Coumadin 2 milligrams daily 2 and ¥% pills, Risperdal 0.25 milligrams daily, Lortab. 5/500 milligrams as needed, and Vitamin Page 6 of 18 daily. Review of Hospice records indicate the resident has physician orders for: Ambien 10 milligrams, Senokot-S, Duragesic patch 50 milligrams, Atropine Sulfate, Protonix-L 40 milligrams and Toprol XL 25 milligrams. Interview with ALF staff on 8/5/03 at 6:00 PM indicated Hospice is in charge of the medications and didn’t think the resident needed the pain medication. Record review of Hospice MOR indicated the resident was receiving pain medication. 18. The Respondent failed to maintain an up to date medication record (MOR) for 2 of 2 sampled residents, pursuant to Fla. Admin. Code R. 58A-5.0185(5)(b), which reads in pertinent part as follows: 2003. (5) MEDICATION RECORDS. ke (b) For residents who receive assistance with self-administration or medication administration, the facility shall maintain a daily up-to-date, medication observation record (MOR) for each resident. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name of each medication prescribed, its strength, and directions for use; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. 19. A correction date of September 6, 2003 was mandated. 20, An appraisal revisit survey was conducted on or about September 15, The Respondent was re-cited for a violation, based on the findings below, to wit: For residents who receive assistance with self-administration or medication administration, the facility must maintain a daily up-to-date, medication observation record (MOR) for each resident. 58A-5.0185(5)(b), Fla. Admin. Code This Standard is not met as evidence by: Based on record review and staff interview the facility failed to maintain an up to date medication record (MOR) for 1 of 5 sampled residents. (#2) The findings include: A review of the facility MOR for September 2003 revealed only 2 medications listed. These medications were; Propoxphene/APAP 100/650 every 8 hours with a hand written note. beside. the medication D/C’d (discontinued) 5/03.” There were no notations of this medication being given. The other medication listed was Synthroid 0.05 mg once a day; the medication was initialed as given 9/7/03 through 9/14/03. An interview with the administrator on 9/15/03 at approximately 12:00 P.M. confirmed he/she gives all of the resident’s. mediations and has only given the Synthroid since 9/7/03; the other medication was not given. The administrator states he/she wrote the discontinue date on the MOR. A review of a “medication profile” dated 9/5/03 by the hospice lists 12 medications. The rnedications include: Zoloft 50 mg once a day, Ambien 10 mg at bedtime, Page 7 of 18 Synthroid 50 mcg once a day, Lortab 5, 1-2 tabs every 3-5 hours, Ensure three times a day, Duragesic 25 meg every 72 hours, Tequin 400 mg once a day, Laniseptic to all areas of skin breakdown, Enema as needed, Sterile water 30-60 cc as needed to foley, Lortab elixir 1 teaspoon — 2 teaspoon every 4 hours, and Mouth Kote as needed. The hospice “Tnterdisplinary Care Plan” lists the following mediations; Lortab 5 1-2 tabs every 3-4 hours, Lortab elixir 1-2 teaspoon every 4 hours, Duragesic 25 meg every 72 hours, Laniseptic to skin breakdown, Sterile water 30-60 cc as needed to foley, enema prn, Senna-S 1-4 tabs twice a day and Mouth Kote spray as needed. The administrator confirmed he/she was. unaware of the other medications listed by hospice and states, “I give what I am given: by the pharmacy and again confirms hospice does not give the resident any medications because of problems the administrator had previously with another hospice organization. A review of the medical record revealed the resident was hospitalized 8/31/03 to 9/5/03. The administrator denied contacting the physician on 9/5/03 after the resident returned from the hospital to the facility to confirm any new orders or changes to the resident’s medications. . The administrator denies knowledge of the other medications listed on hospice records and states “They just copied” from an old record. The. administrator voiced concerns with the communication between the physician, hospice and the facility. The facility did not maintain documentation of current physician orders for medications. 21. The foregoing violation constitutes a repeated class IIT violation, to wit: Class IIT violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class I violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat. This violation warrants the imposition of a $500.00 fine. COUNT Hil THE RESPONDENT FAILED TO PROVIDE A PHYSICIAN ORDER AND CONSENT FOR FULL SIDE RAILS FOR A RESIDENT. § 400.414, Fla.. Stat. § 400.419(1)(c),. Fla. Stat. § 400.428, Fla. Stat. Fla. Admin. Code R. 58A-5.0182(6)(h) 22. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. Page 8 of 18 23. On or about August 6, 2003, AHCA conducted an appraisal survey at the Respondent’s facility. AHCA cited the Respondent for a violation, based on the findings below, to wit: Observation while on tour revealed resident #1 lying in bed with full side rails up. Interview with staff on August 6, 2003 at 9:00 AM indicated the use of side rails came when the resident was trying to get out of bed after a fall resulting in hip fracture (March 2003). Record review lacked evidence of Power of Attorney consent and a physician’s order. Record review. indicated the resident had been receiving Hospice since June 2003, and the plan of care lacked evidence that side rails were addressed. Further record review lacked any mention of the side rails. 24. The Respondent failed to provide a physician order and consent for full side rails for one resident, as required by Fla. Admin. Code R. 58A-5.0182(6)(h). 25. Under the Fla. Admin. Code, appropriate resident care standards for an assisted living facility are required, stating as follows: 58A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility...(6), RESIDENT. RIGHTS. AND. FACILITY PROCEDURES...(h) Pursuant to Section 400.441, F.S., the use of physical restraints shall be limited to half-bed rails, and only upon the resident’s representative. . Any. device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance shall not be considered a physical restraint. Fla. Admin. Code R. S8A-5.0182(6)(h). 26. For this violation, AHCA provided the Respondent a mandated correction date of September 6, 2003. 27. The foregoing violation constitutes a class II violation, to wit: Class UT violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class I violations. A class I violation is subject to an administrative fine of not less than $500 and not exceeding * $1,000 for each violation. § 400.419(1)(c), Fla. Stat. Page 9 of 18 28. On September 15, 2003, AHCA conducted an appraisal revisit survey at the Respondent’s facility. AHCA cited the Respondent for an uncorrected violation, based on the findings below, to wit: During the initial tour on September 15, 2003, at approximately 10:00 A.M., the resident was observed in a hospital bed with full side rails in place on both sides of the bed. A review of the medical record revealed no order from the physician for full side rails. An interview was conducted with administrator on September 15, 2003, at approximately 12:00 P.M., which revealed the resident has a health care surrogate. The administrator was unable to locate documentation of the physician order for side rails and consent of the health care surrogate for side rails. 29. The foregoing violation constitutes an uncorrected class III violation, and warrants a fine of $500.00, to wit: Class III violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class I violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat. COUNT IV THE RESPONDENT FAILED TO MEET MINIMUM STAFFING HOURS. § 400.414, Fla.. Stat. § 400.419(1) (o),. Fla.. Stat. § 400.428, Fla. Stat. Fla. Admin. Code R. 58A-5.019(4)(a)(L) 30. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 31. On or about January 27, 2004, AHCA conducted a biennial survey at the Respondent’s facility. AHCA cited the Respondent for a deficiency, based on the findings below, to wit: Based on a review of the January 2004 staffing pattern, the facility scheduled only two staff for total of 12 hours a day and 84 hours a week. Also no staff was scheduled to care for residents after 7:00 P.M., Monday through Sunday. Review of the facility’s December schedule revealed the same staffing pattern. The minimum weekly staffing hours for a resident census of 15 is 212 hours. Page 10 of 18 In interview with the administrator on J: anuary 27, 2004, around 10:00 A.M., she affirmed that these were the facility staffing hours during December 2003, and January 2004. 32. The Respondent failed to maintain minimum staffing hours, as required by Fla, Admin. Code R. S8A-5.019(4)(a)(1). 33. Minimum staffing hours for assisted living facilities must be maintained as follows: 58A-5.019 Staffing Standards (4) Staffing Standards. (a) Minimum staffing: 1, Facilities shall maintain the following minimum staff hours per week: Number of Residents Staff Hours/Week 0-5 168 6-15 212 16-25 253 26-35 294 36-45 335 46-55 375 56-65 416 66-75 457 76-85 498 86-95 539 For every 20 residents over 95 add 42 staff hours per week. Fla. Admin. Code R. 58A-5.019(4)(a)(1). 34. For this deficiency, AHCA provided the Respondent a mandated correction date of February 27, 2004. 35. The foregoing violation constitutes a class III violation, to wit: Class II violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class TI violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. §.400.419(1)(c), Fla. Stat. Page 11 of 18 36. On March 12, 2004, AHCA conducted a follow-up to the biennial survey at the Respondent’s facility. AHCA cited the Respondent for an uncorrected violation, based on the findings below, to wit: From review of staffing schedule of March which occurred during the follow-up survey of March 12, 2004, around 10:00 A.M., the schedule revealed that there were only 217 staff hours on the schedule for both weeks of March 1- 12, on average. The administrator cannot be noted "on call" but has to be on the schedule. Review of the schedule done by the surveyor on March 12, 2004, around 10:00 A.M., did not reveal that the administrator was on the schedule. {n interview with the administrator, she affirmed that this was the staff schedule for the facility. The interview with the administrator occurred around 10:00 A.M. on March 12, 2004. 37. The foregoing violation constitutes an uncorrected class III violation, and warrants a fine of $500.00, to wit: Class Ii violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class DL violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat. COUNT V THE RESPONDENT FAILED TO PROVIDE A SECURE PLACE FOR A RESIDENT’S MEDICATION. § 400.414, Fla.. Stat. §. 400.419(1) (c),. Fla. Stat. § 400.428, Fla. Stat. Fla, Admin. Code R. 58A-5.0185(6)(a) 38. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 39, On or about January 27, 2004, AHCA conducted a biennial survey at the Respondents facility. AHCA cited the Respondent for a violation, based on the findings below, to wit: Page 12 of 18 a) An initial tour of the facility was conducted on January 26, 2004 at approximately 10:30 A.M. CST. During the tour surveyors observed that residents #1 and #7 had medication in their rooms which were not secured and in plain view. 40. The Respondent failed to provide a secure place for its residents? medications, as required by Fla. Admin. Code R. 5 8A~-5.0185(6)(a). 41. Medications for assisted living facility residents must be secured as follows: 58A-5.0185 Medication Practices (4)(a) MEDICATION STORAGE AND DISPOSAL. (a) In order to accommodate the needs and preferences of residents and to encourage residents to remain as independent as possible, a resident may keep his/her medication, both prescription and over ~the-counter, on his/her person both on or off the facility premises; or in his/her room or apartment which must be kept locked when the resident is absent unless the medication is in a secure place within the room or apartment; or in some other. secure place which is out of sight of other residents... Fla. Admin. Code R. 58A-5.0185(6)(a) 42. For this deficiency, AHCA provided the Respondent a mandated correction date of February 27, 2004. 43. The foregoing violation constitutes a class II violation, to wit: Class II violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class TI violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. : § 400.419(1)(c), Fla. Stat. 44, On March 12, 2004, AHCA conducted a follow-up to the biennial survey at the Respondent’s facility. AHCA cited the Respondent for an uncorrected violation, based on the findings below, to wit: Surveyor observed on March 12, 2004 around 11:00 A.M., resident #6 having Diazepam and Darvocet medications in an unlocked yellow box which was not only accessible to the resident but other residents. The resident’s room did not have a lock on it. The yellow box was located on the floor just inside her door, in plain view. Page 13 of 18 Resident #6, in interview on March 12, 2004, around 11:00 A.M., affirmed that the medications were kept in the yellow box, which was not locked, and her door to her room was not locked, because there was no lock on the door. 45, The foregoing violation constitutes an uncorrected class III violation, and warrants a fine of $500.00, to wit: Class III violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class It violations. A class I violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat. COUNT VI THE RESPONDENT FAILED TO PROVIDE EVIDENCE THAT THE ADMINISTRATOR HAD REVIEWED ITS EMERGENCY MANAGEMENT PLAN. § 400.414, Fla. Stat. § 400.419(1)(c), Fla. Stat.. § 400.428, Fla. Stat. § 400.441(1)(b),. Fla.. Stat. Fla, Admin. Code R. 58A-5.026(2)(c) 46. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 47. On or about January 27, 2004, AHCA conducted a biennial survey at the Respondent’s facility. AHCA cited the Respondent for a violation, based on the findings below, to wit: Surveyor found on January 26, 2004, around 1:30 pm, that the administrator had not reviewed the emergency management plan in the past 365 days. There was no documentation indicting this had been done. In interview with the administrator, around 1:30 pm., on January 26, 2004, she was not able to supply documentation that this review had been done. 48. The Respondent failed to provide evidence that the administrator had reviewed its emergency management plan, as required by § 400.441(1)(b), Fla. Stat., and Fla. Admin. Code R. 58A-5.026(2)(c). Page 14 of i8 49. Annual review of an assisted living facility’s emergency management plan is required as follows: 400.441 Rules establishing standards, — (1) It is the intent of the Legislature that rules published and enforced pursuant to this section shall include criteria by which a reasonable and consistent quality of resident care and quality of life may be ensured and the results of such resident care may be demonstrated. Such rules shall also ensure a safe and sanitary environment that is residential and noninstitutional in design or nature. It is further intended that reasonable efforts be made to accommodate the needs and preferences of residents to enhance the quality of life in a facility. In order to provide safe and sanitary facilities and the highest quality of resident care accommodating the needs and preferences of residents, the department, in consultation with the agency, the Department of Children and Family Services, and the Department of Health, shall adopt rules, policies, and procedures to administer this part, which must include reasonable and fair minimum. standards in relation to... (b) The preparation and annual update of a comprehensive emergency management plan. Such standards must be included in the tules adopted by the department after consultation with the Department of Community Affairs, At a minimum, the rules must provide for plan components that address emergency evacuation transportation; adequate sheltering arrangements; postdisaster activities, including provision of emergency power, food, and water; postdisaster transportation; supplies; staffing; emergency equipment; individual identification of residents and transfer of records; communication with families; and responses to family inquiries. The comprehensive emergency management plan is subject to review and approval by the local emergency management agency. During its review, the local emergency management agency shall ensure that the following agencies, at a minimum, are given the opportunity to review the plan: the Department of Elderly Affairs, the Department of Health, the Agency for Health Care Administration, and the Department of Community Affairs. Also, appropriate volunteer organizations must be given the opportunity to review the plan. The local emergency management agency shall complete its review within 60 days and either approve the plan or advise the facility of necessary revisions. §.400.441(1)(b), Fla. Stat. 58A-5.026 Emergency Management (2) EMERGENCY PLAN APPROVAL. The plan shall be submitted for review and approval to. the county. emergency management agency...(c) The facility shall review its emergency management plan on an annual basis. Any substantive changes must be submitted to the county emergency agency for review and approval. Fla. Admin. Code R. 58A-5.026(2)(c). 50. For this violation, AHCA provided the Respondent a mandated correction date of February 27, 2004. 51. The foregoing violation constitutes a class III violation, to wit: Page 15 of 18 Class If violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class HI violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat. 32. On March 12, 2004, AHCA conducted a follow-up to the biennial survey at the Respondent’s facility. AHCA cited the Respondent for an uncorrected violation, based on the findings below, to wit: From record review on March 12, 2004, around 1:00 P.M., surveyor found no documentation that administrator had reviewed the current emergency management plan. In interview with the administrator on March 12, 2004, around 1:00 P.M., she stated that she had no current documentation that she reviewed the facility’s emergency management plan in the last 365 days. 53. The foregoing violation constitutes an uncorrected class III violation, and warrants a fine of $500.00, to wit: . Class JIL violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class If violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation. § 400.419(1)(c), Fla. Stat.(2004). COUNT VI A SURVEY FEE IN THE AMOUNT OF $500.00 IS IMPOSED UPON THE RESPONDENT. § 400.419 (9), Fla. Stat. 54. | AHCA repeats, re-alleges, and incorporates paragraphs one (1) through five (6) as if fully set forth herein. 55. The above cited survey fee is imposed pursuant to, § 400.419(9), Fla. Stat., stating as follows: Page 16 of 18 In addition to any administrative fines imposed, the agency may assess a survey fee, \ equal to the lesser of one half of the facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 400.428(3)(c) to verify the correction of the violations. § 400.419 (9), Fla. Stat. (2004) WHEREFORE, AHCA demands the following relief: 1. Entry of factual and legal findings as set forth in the allegations of Counts I through VI of this Administrative Complaint; 2. Imposition of fines totaling $3,000.00; and 3. Imposition of a $500.00 survey fee. 4. Any such other relief this Court finds necessary and proper. Submitted on this 8 day of November 2004. Agency for Health Care Administration 2727 Mahan Dr., Bldg 3, MSC 3 Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 413-9313 (fax) NOTICE The Respondent, GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE INN, is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Fla. Stat. (2003). 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 the Agency for Health Care Administration, 2727 } Mahan Dr., Bldg. 3, MSC 3,Tallahassee, Florida, 32308; Attention: Agency Clerk. Page 17 of 18 THE RESPONDENT JS FURTHER NOTIFIED, IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. . CERTIFICATE OF SERVICE IMEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Retum Receipt Requested, Receipt No. 7003 1010 0000 9716 1240 to Gold Key Development, Inc., d/b/a Carriage Inn; 3409 West 19" Street, Panama City, Florida 32405; Panama City, Florida 32405, Submitted on this_ 8 day of November 2004. Page 18 of 18 .

Docket for Case No: 04-004632