STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case No. 2005002304 THE PLACE AT MAITLAND, INC., _ f d/b/a PLACE AT MAITLAND (THE), dD 5 . | T U | Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against THE PLACE AT MAITLAND, INC., d/b/a PLACE AT MAITLAND (THE) (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $500.00 based upon one cited uncorrected State Class III deficiency pursuant to §400.419(2)(b) Fla. Stat. (2004). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part III, Florida Statutes, and Chapter S8A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 116-bed assisted living facility located at 740 N. Wymore Road, Maitland, Florida 32751, and is licensed as an assisted living facility, license number 9415. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, newly hired staff shall have 30 days to submit a statement from a health care provider, based on an examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis. Freedom from tuberculosis must be documented on an annual basis. Rule 58A- 5,019(2)(a), Fla. Admin. Code. Further, personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. Rule 58A- 5.024(2)(a), Fla. Admin. Code. 8. That on November 30, 2004, the Agency conducted a complaint investigation of the Respondent facility. 9. That based upon the review of Respondent's files and interview, the Respondent facility failed to ensure that two (2) of four (4) staff personnel files contained a copy of a health care provider's statement documenting that the staff member was free from communicable diseases including tuberculosis (TB) within thirty days of employment in violation of law. 10. That the Petitioner’s representative reviewed four of the Respondent's personnel files on November 30, 2004. il. That two of the personnel files reviewed did not contain a health care provider's statement verifying that the employce was free of signs or symptoms of communicable discases including tuberculosis. The files were identified as the personnel files of employces one and three. 12. That both employees whose personnel files lacked the required health care provider's statement had been in the employ of the Respondent for a period in excess of thirty days. 13. That the Petitioner’s representative asked the Respondent's director of nursing to locate the required health care provider’s statement. 14. That the Respondent’s director of nursing, upon review of the subject personnel files, could not locate the required health care provider's statement. 15. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatencd the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 16. The Agency provided Respondent with a mandatory correction date of December 15, 2004. 17. That on January 19, 2005, the Petitioner Agency conducted a follow-up to the complaint survey of Respondent. 18. That based upon the review of Respondent's files and interview, the Respondent facility failed to ensure that two (2) staff personnel files contained a copy of a health care provider's statement documenting that the staff member was frec from communicable diseases including tuberculosis (TB) within thirty days of employment in violation of law. 19. That the Petitioner’s representative reviewed the Respondent’s personnel files for employees numbered one and three on January 19, 2005. 20. That the personnel files reviewed did not contain a health care provider’s statement verifying that the employee was free of signs or symptoms of communicable diseases including tuberculosis. 21. That both employees whose personnel files lacked the required health care provider's statement had been in the employ of the Respondent for a period in excess of thirty days. 22. That the Petitioner’s representative asked the Respondent’s director of nursing to locate the required health care provider's statement. 23. That the Respondent’s director of nursing, upon review of the subject personnel files, could not locate the required health care provider's statement. 24. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for an uncorrected State Class III deficiency. 25. That the Agency provided Respondent with a mandatory correction date of February 3, 2005. 26. That the same constitutes an uncorrected deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). Respectfully submitted this j day of April, 2005. a Thotnés J. Walsh, II Fla. Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, 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, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7003 1010 0002 4667 0784 on April +, 2005, to Corporation Service Company, Registered Agent, The Place at Maitland, 1201 Hays Street, Tallahassee, Florida 32301-2525, and by U.S. Mail to Paul Mitchell, Administrator, The Place at Maitland, 740 N. Wymore Road, Maitland, Florida, 32751. Jie Thomés J. Walsh, II _Senidr Attorney Copies furnished to: Corporation Service Company | Paul Mitchell Thomas J. Walsh, II Registered Agent Administrator Senior Attorney Place at Maitland (The) Place at Maitland (The) Agency for Health Care Admin. 1201 Hays Street 740 N. Wymore Road 525 Mirror Lake Drive, 330G Tallahassee, FL 32301-2525 Maitland, FL 32751 St. Petersburg, Florida 33701 (U.S. Certified Mail) (U.S. Mail) (Interoffice) nn PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. _in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. The Place at Maitland 2005002304 Facility Name AHCA No.

Docket for Case No: 05-001747

Orders for Case No: 05-001747