STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004011455 Return Receipt Requested: v. 7002 2410 0001 4234 2673 A.J. GOLINO, M.D., OWNER/OPERATOR d/b/a PALM BEACH EYE CLINIC, OS - {002 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against A.J. Golino, M.D. Owner/Operator d/b/a Palm Beach Eye Clinic (hereinafter “Palm Beach Eye Clinic”), pursuant to Chapter 395 and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $3,000.00 pursuant to Sections 400.414 and 400.413, 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 ambulatory surgical centers pursuant to Chapter 395, Florida Statutes (2004). 5. Palm Beach Eye Clinic operates an ambulatory surgical center located at 130 Butler Street, West Palm Beach, Florida 33407. Palm Beach Eye Clinic is licensed as an ambulatory surgical center under license number 1007. Palm Beach Eye Clinic 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 PALM BEACH EYE CLINIC FAILED TO ENSURE THAT NON-PHYSICIAN STAFF HAD TIMELY AND CURRENT RISK MANAGEMENT AND RISK PREVENTION EDUCATION ANNUALLY. SECTION 395.0197(1) (b)1, FLORIDA STATUTES (RISK MANAGEMENT EDUCATION AND TRAINING) 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Palm Beach Eye Clinic was cited with three (3) deficiencies due to the annual risk management survey conducted on July 6, 2004. 8. An annual risk management survey was conducted on July 6, 2004. Based on review of employee personnel files, review of the risk management policies and procedures and interview with the facility Director of Nursing on July 6, 2004, it was determined the facility's Risk Manager did not ensure the non- physician staff had timely and current risk management and risk prevention education and training annually which ircluded the requirements of the current statute. The findings include the following: 9. Review of three staff personnel files for the facility’s Director of Nursing/Circulation Nurse, the facility's Registered Nurse Coordinator, and Surgical Technician/Medical Records staff member revealed annual risk prevention education and training had not been conducted and or provided since 4/15/03. 10. The Director of Nursing was asked on July €, 2004 for a copy of the written plan for risk management education to ascertain if the content included the requirements of the current statute. He/She was unable to provide the information requested. The facility risk manager did not ensure there was a written plan for the content of the risk management education to ensure the content included all requirements of tne current statute. ll. The mandated date of correction was designated as August 6, 2004. 12. A follow-up risk management survey was conducted on August 17, 2004. Based on review of personnel records and interview with the Director of Nursing (DON) at the time of the 8/17/04 revisit, it was determined the facility failed to ensure non-physician staff had received 1-hour Risk Management education annually. The findings are as follows: 13. At the time of the survey, the facility lacked documentation that the DON, the Registered Nurse Coordinator and the Surgical Technician had received the annual i1-hour Risk Management education. 14, Review of the facility plan of correction revealed non-physician staff would have yearly Risk Management training. 4 The DON identified a list of personnel highlighted in yellow as proof of the attendance at Risk management training. The length of the program, presenter, teaching materials and content of the presentation was not identified. 15. The DON presented a copy of the State of Florida Risk Management statute stating at 1:45 P.M. on 8/17/04 that this was the facility's Risk Management policy and procedure. The facility was unable to locate any further informat:on at the time of the survey. The mandated date of correction was designated as September 17, 2004. 16. A second revisit survey was conducted on November 1, 2004. Based on interview and record review it was determined the facility failed to produce proof of Annual Risk Management training for the facility's employees. The findings include the following: 17. Upon request, the facility's administrator was unable to provide evidence to substantiate the correction of the deficient practice originally cited on 07/0€/04. The administrator reported the director of nursing had worked on some of the previous plan of corrections. The administrator stated, "The DON was at home painting and it would take her approximately an hour to come into the facility." The surveyors requested to speak with the risk manager when the administrator was unable to produce the plan of corrections. The administrator reported the risk manager is the physician/owner/surgeon/medical director and he would not be able to speak with the surveyors until he was finished seeing patients. The administrator was not knowledgeable of any corrective actions, which had taken place, and was unable to locate any corrective actions. The Risk Manager became hostile during a meeting with the Surveyors two hours later and the Surveyors had to exit the facility. 18. The surveyors were unable to complete the survey due to the facility's inability to provide, produce or demonstrate evidence of compliance. 19. Based on the foregoing facts, Palm Beach Eye Clinic violated Section 395.0197(1)(b)(1), Florida Statutes (2004), which warrants an assessed fine of $1,000.00. COUNT IT PALM BEACH EYE CLINIC FAILED TO ENSURE THAT THE FACILITY HAD A DOCUMENTED PROCESS IN PLACE TO ADDRESS SEXUAL MISCONDUCT. SECTION 395.0197(1) and (9) and (10), FLORIDA STATUTES (SEXUAL MISCONDUCT) 20. AHCA re-alleges and incorporates parag:-aphs (1) through (5) as if fully set forth herein. 21. An annual risk management survey was conducted on July 6, 2004. Based on review of the facility Policy and Procedures and interview with the Director of Nursing, it was determined the facility had no documented process in place to address sexual misconduct. The findings include the following: 22. Review of the facility policy and procedure manual/book for risk management revealed there was no policy and procedure, which directed the risk manager to investigate and report allegations of sexual misconduct made against a member of the facility's personnel who has direct patient contact. Tnere were no procedures/process to: a. Investigate every allegation of sexual misconduct, which is made against a member of the facility's personnel who has direct patient contact, when the allegation is that the sexual misconduct occurred at the facility or on the grounds of the facility. b. Report every allegation of sexual misconduct to the administrator of the licensed facility; and c. Notify the family or guardian of the victim, if a minor, that an allegation of sexual misconduct has been made and that an investigation is being conducted. 23. Interview with the facility Director of Nursing on 7/6/04 revealed she was not aware of any procedure or policy that was in place at the facility to address allegations of sexual misconduct. 24. The mandated date of correction was designated as August 7, 2004. 25. A follow-up survey was conducted on August 17, 2004. Based on review of the facility documentation and interview with the DON conducted at the time of the 8/17/04 survey, it was determined the facility failed to ensure there was a policy in accordance to Florida Statute 395.0197(1) and (9) and (10) for the investigation of sexual misconduct made against a member of the facility's personnel who has direct patient contact. The findings are as follows: 26. At the time of the survey, the facility lacked documentation of a Policy and Procedure for the implementation of a process to ensure the investigation of allegation(s) of sexual misconduct made against a member of the facility's personnel who has direct patient content. The plan of correction for the deficient practice cited 7/6/04 identified that the facility will create a policy. 27. The DON stated at 1:30 P.M. that the copy of the State of Florida statute is the facility policy. 28. The mandated date of correction was designated as September 17, 2004. 29. A second revisit survey was conducted on November 1, 2004. Based on interview and record review it was determined the facility failed to produce proof of Sexual Misconduct Policy for the facility. The findings include the following: 30. Upon request the facility's administrator was unable to provide evidence to substantiate the correction of the deficient practice originally cited on 07/06/04. The administrator reported the director of nursing had worked on some of the previous plan of corrections. The administrator stated, "The DON was at home painting and it would take her approximately an hour to come into the facility." The surveyors requested to speak with the risk manager when the administrator was unable to produce the plan of corrections. The administrator reported the risk manager is the physician/owner/surgeon/medical director and he would not be able to speak with the surveyors until he was finished seeing patients. The administrator was not knowledgeable of any corrective actions, which had taken place, and was unable to locate any corrective actions. The Risk Manager became hostile during a meeting with the Surveyors two hours later and the Surveyors had to exit the facility. 31. The surveyors were unable to complete the survey due to the facility's inability to provide, produce or cGemonstrate evidence of compliance. 32. Based on the foregoing facts, Palm Beach Eye Clinic violated Section 395.0197 (1) and (9) and (10), Florida Statutes, which warrants an assessed fine of $1,000.00. COUNT III PALM BEACH EYE CLINIC FAILED TO ADOPT AND IMPLEMENT A PATIENT SAFETY PLAN. SECTION 395.1012(1), FLORIDA STATUTES (PATIENT SAFETY PLAN) 33. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 34. Section 395.1012(1), Florida Statutes (2003), mandates that a plan be adopted to implement the requirements of 42 Code of Federal Regulations 482.21(Quality Assurance and Performance Improvement Plan). 35. An annual risk management survey was conducted on July 6, 2004. Based on review of the facility policies and procedures and interview with the Director of Nursing on July 6, 2004, it was determined the facility did not adopt and implement a Patient Safety Plan. The findings include the followine: 36. Review of the facility policies and procedures for Risk Management, Quality Assurance and Governing Body and interview with the Director of Nursing on July 6, 2004 revealed the facility did not establish or develop a Patient Safety Plan, adapted to implement the requirements according to 42 Code of Federal Regulation 482.21. 37. The mandated date of correction was designated as August 6, 2004. 10 38. A follow-up risk management survey was ccnducted on August 17, 2004. Based on review of facility documentation and interview with the DON conducted during the 8/17/04 survey, it was determined the facility failed to ensure a patient safety plan had been adopted. The findings are as follows: 39. At the time of the 8/17/04 revisit the facility failed to demonstrate a patient safety plan had been developed. 40. On 8/17/04, the facility was given a mandated date of correction of September 17, 2004. 41. A second revisit survey was conducted on November 1, 2004. Based on interview and record review it was determined the facility failed to produce proof of a patient safety plan had been adopted. The findings include the following: 42. Upon request the facility's administrator was unable to provide evidence to substantiate the correction of the deficient practice originally cited on 07/06/04. The administrator reported the director of nursing had worked on some of the previous plan of corrections. The administrator stated, "The DON was at home painting and it woulé take her approximately an hour to come into the facility." The surveyors requested to speak with the risk manager when the administrator was unable to produce the plan of corrections. The administrator reported the risk manager is the physician/owner/surgeon/medical director and he would not be able to speak with the surveyors 11 until he was finished seeing patients. The administrator was not knowledgeable of any corrective actions, which had taken place, and was unable to locate any corrective actions. The Risk Manager became hostile during a meeting with the Surveyors two hours later and the Surveyors had to exit the facility. 43. The surveyors were unable to complete the 11/1/04 survey due to the facility's inability to provide, produce or demonstrate evidence of compliance. 44, Based on the foregoing facts, Palm Beach Eye Clinic violated Section 395.1012(1), Florida Statutes, which warrants an assessed fine of $1,000.00. 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 Palm Beach Eye Clinic on Counts I through III. 2. Assess an administrative fine of $3,000.00 against Palm Beach Eye Clinic on Counts I through III for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 12 4, 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 end 120.57, Florida Statutes (2004). 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 FINAL ORDER BY THE AGENCY. Aho wr ane 7 ourdes A. Naranjo, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6801 13 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) Ambulatory Surgical Center 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 cosy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Diane Stollmar, Administrator, Palm Beach Eye Clinic, 130 Butler Street, West Palm Beach, Florida 33407 on — this (6 Ty of | TEG. , 2004. Lists eles, 14

Docket for Case No: 05-001002