STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, oe vs. Case No. 2005001282 °., So WOODLAND FIELD, INC., mA = OS DI%9 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “Agency”), by and through its undersigned counsel, and files this Administrative Complaint against Woodland Field, Inc. (“Respondent”) pursuant to Fla. Stat. Sections 120.569, and 120.57 (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose administrative fines upon the Respondent, pursuant to Fla. Stat. Section 400, Part III (2004) and Fla. Admin. Code Chapter 58A-5 (2004). PARTIES 2. AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules, pursuant to Fla. Stat. Chapter 400, Part IIT and Fla. Admin. Code 584-5. 3. The Respondent is a Florida corporation, which operates an assisted living facility located at 6236 Moncrief Dinsmore Road, Jacksonville, Florida. The Respondent is and was, at all times material hereto, a licensed facility under Fla. Stat. Chapter 400, Part III (2004), and Fla. Admin. Code Chapter 58A-5 (2004), having been issued license number 8567. JURISDICTION AND VENUE 4, This Agency has jurisdiction pursuant to Fla. Stat. Chapter 400, Part III, Sections 120.569 and 120.57, and Fla. Admin. Code Chapter 28-106. 5. Venue lies in Duval County, Jacksonville, Florida, pursuant to Fla. Stat. Section 120.57 (2004), Fla. Admin. Code, Rules 58A-5 and 28-106.207 (2004). COUNT I THE FACILITY FAILED TO PROVIDE AGENCY STAFF WITH ACCESS TO RECORDS IN ORDER TO DETERMINE THE FACILITY’S FINANCIAL STABILITY §400.417(3), Fla. Stat. (2004) §400.419(2)(c), Fla. Stat. (2004) 6. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. On or about August 28, 2003, AHCA conducted a biennial survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: A telephone interview with the administrator at 9:25 a.m. on 8/28/03 revealed the administrator was out of town and the records were not in the facility and available for review at the time of the survey. 8. AHCA cited the deficiency as a class III deficiency and mandated that correction of the deficiency be made by September 28, 2003. 9. On or about January 26, 2005, AHCA conducted an appraisal survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: There was not a current financial statement available at the time of the survey. The facility did not make records accessible in order to determine the facility's financial stability. This was confirmed by interview with the Administrator at approximately 11:00AM. 10. The regulatory provisions of the Florida Administrative Code and Florida Statutes that are pertinent to this alleged violation read as follows: §400.417(3), Fla. Stat. (2004) Expiration of license; renewal; conditional license.-- (3) An applicant for renewal of a license who has complied with the provisions of s. 400.411 with respect to proof of financial ability to operate shall not be required to provide further proof unless the facility or any other facility owned or operated in whole or in part by the same person ‘has demonstrated financial instability as provided under s. 400,447(2) or unless the agency suspects that the facility is not financially stable as a result of the annual survey or complaints from the public or a report from the State Long-Term Care Ombudsman Council. Each facility must report to the agency any adverse court action concerning the facility's financial viability, within 7 days after its occurrence. The agency shall have access to books, records, and any other financial documents maintained by the facility to the extent necessary to determine the facility's financial stability. A license for the operation of a facility shall not be renewed if the licensee has any outstanding fines assessed pursuant to this part which are in final order status. §400.419(2)(c), Fla. Stat. (2004) Class “III” violations are those conditions or occurrences related to the operation and maintenance of a facility or the personal care of the residents, which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of the facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class IJ violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class:III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense (emphasis added). 11. The foregoing violation constitutes a repeat class III violation warranting a fine of $500. COUNT II THE RESPONDENT FAILED TO MAINTAIN A DAILY, UP-TO-DATE MEDICATION OBSERVATION RECORD FOR RESIDENTS RECEIVING ASSISTANCE WITY SELF- ADMINISTRATION OF MEDICATIONS Fla. Admin. Code Rule 58A-5.0185(5)(b) (2004) §400.419(2)(c), Fla. Stat. (2004) AHCA repeats, re-alleges, and incorporates paragraphs one (1) through five (5) 12. as if fully set forth herein. 13. On or about August 28, 2003, AHCA conducted a biennial survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: 1. Staff stated that medications are given at breakfast at 8:30 a.m., noon on the days that residents stay at the facility and at bedtime around 7 p.m. 2. The August 2003 medication observation record (MOR) for Resident #1 listed that this resident had received the evening dose of Temazepam 15 mg capsule. The MOR was reviewed at noon. Resident #1 was also listed as receiving Quinine in the afternoon, but no such medication was on the premises. Staff stated that the resident did not take that medication any longer. The July 2003 MOR had Quinine crossed out and replaced with Propoxyphene-N 100 with apap. The August MOR did not have Propoxyphene-N 100 listed. In addition, Patanol 0.1% ophthalmic solution was not listed on the August 2003 MOR. 3. Resident #2 had a bottle of Clonazepam 1 milligram (mg) tablets with directions to take one pill by mouth four times a day. The August 2003 MOR listed that Clonazepam was to be given | pill by mouth in the morning, three pills at noon and one pill in the evening for a total of five pills. Divalproex 500 mg was to be given one tablet three times a day. The MOR listed that the resident had received the evening dose for August 28, 2003. Glyburide 5 mg tablet was to be given orally twice a day. The MOR listed that only the evening dose was to be given at the facility. Staff stated that the resident used to take the morning pill with him/her to the day treatment center, but now takes it at the facility. 4. The August 2003 MOR Resident #3 had not been updated since 8/23/03. According to the MOR, the resident last received a dose of Haloperidol 10 mg on 8/23/03. Hctz was last taken on 8/23/03. Doxepin Hydrochloride 50 mg was missing from the MOR and according to the bottle was last filled on 8/25/03. The following medications were last received on 8/22/03: Zyprexa 15 mg, Trileptal 300 mg, Certagen (a vitamin). 14. | AHCA cited the deficiency as a class III deficiency and mandated correction of the deficiency be made by August 31, 2003. 15. | Onor about January 26, 2005, AHCA conducted an appraisal survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: 1.Review of the medication observation records for Residents #1, #2, and #3 on the day of the survey revealed that the medication, number of pills and time of observation were noted, but the milligrams in the medication were not. This does not accurately reflect the amount of medication the resident is receiving. 2. Review of the medication for Resident #1 revealed that the resident had a container of Glyburide Smg. with instructions to give one pill two times a day. The medication observation record revealed this resident was receiving the medication one time a day. This same resident had a container of Olanzapine 10mg. with instructions to give one pill at bedtime. The medication observation record indicated the resident was receiving this medication in the morning. 16. The regulatory provisions of the Florida Administrative Code and Florida Statutes that are pertinent to this alleged violation read as follows: Fla. Admin. Code Rule 58A-5.0185(5)(b) (2004) Medication Practices -- (5) MEDICATION RECORDS (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. §400.419(2)(c), Fla. Stat. (2004) Class “III” violations are those conditions or occurrences related to the operation and maintenance ‘of a facility or the personal care of the residents, which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of the facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense (emphasis added). The foregoing violation constitutes a repeat class III violation warranting a fine of $500. COUNT Il THE RESPONDENT FAILED TO ENSURE THAT THERAPEUTIC DIETS ARE PREPARED AND SERVED AS ORDERED BY THE HEALTH CARE PROVIDER Fla. Admin. Code Rule 58A-5.020(2)(e)(2004) $400.419(2)(c)(2004) 18. | AHCA repeats, re-alleges, and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 19. On or about August 28, 2003, AHCA conducted a biennial survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: A review of the facility menus that had been reviewed by a registered dietitian revealed the menus were regular menus only. A review of the record for Resident #2 revealed the diet specified by the health care provider on the DOEA HA Form, 1823 was a low salt and diabetic diet. Further review of the DOEA 1823 revealed that Resident #2 has a diagnosis of Diabetes Mellitus. Lastly, a review of the medications prescribed for Resident #2 revealed the resident has a prescription for an oral medication for the control of diabetes. An interview with the staff person in charge revealed this individual is responsible for the preparation of meals and has access to regular meals only. 20. | ACHA cited the deficiency as a class III deficiency and mandated correction of the deficiency be made by September 28, 2003. 21. On or about January 26, 2005, AHCA conducted an appraisal survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: Review of the medical record for Resident #1 revealed that the resident was to receive a diabetic diet. There was no diabetic menu extension and interview with staff indicated the resident was receiving a regular diet. 22. The regulatory provisions of the Florida Administrative Code and Florida Statutes that are pertinent to this alleged violation read as follows: $500. 23. Fila. Admin. Code Rule 58A-5.020(2)(e)(2004) Food Service Standards (2) DIETARY STANDARDS (e) Therapeutic diets shall be prepared and served as ordered by the health care provider. 1. Facilities that offer residents a variety of food choices through a select menu, buffet style dining or family style dining are not required to document what is eaten unless a health care provider’s order indicates that such monitoring is necessary. However, the food items which enable residents to comply with the therapeutic diet shall be identified on the menus developed for use in the facility. 2. The facility shall document a resident’s refusal to comply with a therapeutic diet and notification to the resident’s health care provider of such refusal. If a resident refuses to follow a therapeutic diet after the benefits are explained, a signed statement from the resident or the resident’s responsible party refusing the diet is acceptable documentation of a resident’s preferences. In such instances daily documentation is not necessary. §400.419(2)(c), Fla. Stat. (2004) Class “IIT” violations are those conditions or occurrences related to the operation and maintenance of a facility or the personal care of the residents, which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of the facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected, If a class IH violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense (emphasis added). The foregoing violation constitutes a repeat class III violation warranting a fine of COUNT IV THE RESPONDENT FAILED TO ENSURE THAT FREEDOM FROM TUBERCULOSIS IS DOCUMENTED ON AN ANNUAL BASIS FOR EMPLOYEES 24, Fla. Admin. Code R. 58A-5.019(2)(a)(2004) $400.419(2)(c), Fla. Stat. (2004) AHCA repeats, re-alleges, and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 25. On or about August 28, 2003, AHCA conducted a biennial survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: A review on 8/28/03 of the employee record for the administrator revealed the documentation of freedom from tuberculosis was dated 1/3/02. A review of the record for an employee with a hire date of 2/7/01 revealed no documentation of freedom from tuberculosis. 26. AHCA cited the deficiency as a class III deficiency and mandated correction of the deficiency be made by September 28, 2003. 27. On or about January 26, 2005, AHCA conducted an appraisal survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: Not all facility staff had documentation on file that they were free from tuberculosis on an annual basis. Two employees did not have an annual TB screening. This was confirmed by interview with the Administrator at approximately 11:00AM. 28. The regulatory provisions of the Florida Administrative Code and Florida Statutes that are pertinent to this alleged violation read as follows: $500. 29. Fla. Admin. Code R. 58A-5.019(2)(a)(2004) Staffing Standards (2) STAFF. (a) Newly hired staff shall have 30 days to submit a statement from a health care provider, based on a 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. A person with a positive tuberculosis test must submit a health care provider’s statement that the person does not constitute a risk of communicating tuberculosis. Newly hired staff does not include an employee transferring from one facility to another that is under the same management or ownership, without a break in service. If any staff member is later found to have, or is suspected of having, a communicable disease, he/she shall be removed from duties until the administrator determines that such condition no longer exists. §400.419(2)(c), Fla. Stat. (2004) Class “III” violations are those conditions or occurrences related to the operation and maintenance of a facility or the personal care of the residents, which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of the facility residents, other than class I or class II violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense (emphasis added). The foregoing violation constitutes a repeat class III violation warranting a fine of WHEREFORE, AHCA demands the following relief: 1. Entry of factual and legal findings as set forth in the allegations of all counts of this Administrative Complaint. H 2. Imposition of administrative fines totaling $2,000.00. Sm - a ia Submitted on this ! P day of Mosrch 2005 on behalf of the Agency for Health Care, en Administration by, NN J . Rosenthal Assistant General Counsel Fla. Bar. No. 540129 Agency for Health Care Administration 2727 Mahan Drive Bldg. 3, MSC #3 Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 413-9313 (fax) NOTICE OF RIGHTS Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120,57, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. 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, Mail Stop #3, Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING, WHICH MUST BE RECEIVED BY THE AGENCY WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT, WILL RESULT IN ENTRY OF A FINAL ORDER BY THE AGENCY WHICH FINDS THAT SUCH FAILURE CONSTITUTES AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT. CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights form have been sent by U.S. Certified Mail, Return Receipt Requested, on the | [t day of March 2005 to Harriett Wallace, Administrator, Woodland Field, Inc., 8236 Moncrief Dinsmore Road, Jacksonville, FL 32219 and to Harriett Wallace, Registered Agent, Woodland Field, Inc., 2438 Grand Street, J; acksonville, FL 32208. Jani§L. Rosenthal Assistant General Counsel

Docket for Case No: 05-002159