STATE OF FLORIDA macy, AGENCY FOR HEALTH CARE ADMINISTRATION =| ' Mh wets AS LORRAINE A. ARNOLD d/b/a. A HOME AWAY FROM HOME, Petitioner, " ' AHCA No.: 2004010191 vs. : DOAH No.: 05-4030 STATE OF FLORIDA, > £. AGENCY FOR HEALTH CARE | _So = HF ADMINISTRATION, a= Se Pah ‘— aes Respondent. Zs > fr ; / enh 2 ‘ my FINAL ORDER » @ Having reviewed the Notice of Intent to Deny letter dated November 10, 2004, attached hereto and incorporated herein (Ex. 1) and all other matters of record, the State of Florida, Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement (Ex. 2) with the Petitioner in these proceedings, and being otherwise well advised in the the ¢ premises, finds and concludes as follows: ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. 2. The Petitioner agrees to comply with the action and survey process specified within the Agreement. Page 1 of 3 3.1. The Petitioner agrees to the licensure status, and. withdrawal of its renewal of license application, as described and expressly conditioned within the Stipulation and Settlement Agreement. | DONE and ORDERED this M/ day of B2lpeuauy — 2006 in te 1 Tallahassee, Leon County, Florida. ' Alan Levine) Secretary Agency forHealth Care Administration we ' A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL. ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Elizabeth Dudek Eric R. Bredemeyer, Esquire Deputy Secretary Assistant General Counsel Agency for Health Care Admin. Agency for Health Care Admin. 2727 Mahan Drive, Bldg. #1,MS #9 2295 Victoria Avenue, Room 346C Tallahassee, Florida 32308 Fort Myers, Florida 33901 (Interoffice Mail) (Interoffice Mail) Alberta Granger, Manager Peter T. Hickey, Esquire Assisted Living Unit 212 North Park Avenue Bureau of Long Term Care Sanford, Florida 32771 Agency for Health Care Admin. (U.S. Mail) 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (Interoffice Mail) Page 2 of 3 Jeff B. Clark, ALJ Jan Mills, Facilities Intake Unit Division of Admin. Hearings (Interoffice Mail). The DeSoto Bldg. . 1230 Apalachee Parkway Tallahassee, FL 32399-3060 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the S™ day of ___ “na” 2006. Richard Shoop, Agency Clerk Agency for Health Care Administration, , 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 * (850) 922-5873 1 Page 3 of 3 r u * , oF . aun fy wine ALANLEVINE, SECRETARY “JEB BUSH, GOVERNOR ertified Article Number .. RECEIPT REQUESTED © FULD 3901 S648 bisb 8732 a : SENDERS. RECORI November 10,,2004 . , : . , wes Lorraine A. Amold _ A Home Away From Home 2619 El Portal Ave. Sanford, FL 32771 RE: CC# 2004010191 ’ NOTICE OF INTENT TO DENY Dear Ms. Amold: 7 It is the decision of this Agency that A Home Away From Home renewal application foi he assisted living, facility be DENIED. ' _ee application for the . The Specific Basis for this determination is: - The applicant’ fiilure to meet minimum licensure standards pursuant to Section 400.41 i Florida Statute (F.S.). During the biennial licensure renewal survey conducted on fly TS aod twenty-eight de. sciencies were cited. A follow-up survey conducted on September 29 “2004 found eight de!::iencies remained uncorrected and four new deficiencies were cited. These deficiencies we: in the areas, of general license standards, facility records, resident records staffing standari:s, medication standards, nutrition and dietary standards, community living support plan ani: cooperative agreements. The deficiencies identified during the surveys constitute grounus for denial of the renewal application. OO mo EXPLANATION OF RIGHTS Pursuant to Section 120.569, Florida Statutes, (F.S.) you have the sight to request an administrative hearing. In order to obtain a formal proceeding before the Division of - Administrative Hearings under Section 120.57(1), F.S., your request. for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute.. Se ; - EXHIBIT 2727 Mahan Drive # Mail Stop #30 . Tallahassee, FL. 32308 ne A Home Away From Home November 10,2004... 7 mo , , Page.2. ~ : : : . “SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS Sincerely, ; ‘assisted Livine g 2 Unit ; Bureau: of Long Term Care Services cy AG/mb~ Orlando Field Office -07 Administrator, District 07, Dept. of Children and Families LTCOC District 07 ; ; ’ DOEA, Tallahassee | Wendy Adams, General Counsel Office - Copy to:. STATE OF FLORIDA mane AGENCY FOR HEALTH CARE ADMINISTRTION _ FILED : Nb WAR Ib AH 08 _ DIVISION OF ADMINISTRATIVE HEARINGS ' \ LORRAINE A. ARNOLD d/b/a A HOME AWAY FROM HOME, 8 Petitioner vs. ' AHCA Case No. 2004010191 STATE OF FLORIDA, AGENCY FOR ' HEALTH CARE ADMINISTRATION, Respondent. STIPULATION AND SETTLEMENT AGREEMENT Respondent, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter "AGENCY" or “AHCA”), and LORRAINE ‘A:. ARNOLD, d/b/a A HOME AWAY FROM HOME (hereinafter “Petitioner,” “Facility,” or “A HOME AWAY FROM HOME”), pursuant to Section: 120.57(4), Florida: Statutes (2005), ‘by and through their undersigned representatives, hereby enter into this Stipulation and Settlement Agreement (hereinafter “Agreement”) and agree as follows: WHEREAS, Petitioner was an assisted living facility licensed pursuant to Chapter 400, Part Il, Florida Statutes, and Chapter 58A-5, Florida Administrative Code (2005); and WHEREAS, the AGENCY issued a Notice of Intent to Deny the Renewal Application in Case Number 2004010191 on or about November 10, 2004, through which it expressed its intention to deny the license renewal application previously submitted by the Petitioner; and WHEREAS, the Agency during surveys on or about July 15, 2002; June 26, 2003; September 30, 2003; January 14, 2004; July 19, 2004; July 29, 2004; and September 29, 2004, at which times the Agency alleged various deficiencies some of which, but not necessarily all, EXHIBIT _=2 te 239 338 2372 Pa art rere constituted the Agency’s basis for issuing its aforementioned Notice of Intent to Deny (the purpose of listing the varions surveys is in order to include all the Vatious surveys both relevant to, and . prior to the date of the aforementioned Notice of Intent to Deny); and WHEREAS, Tepresentatives of the AGENCY and A HOME. AWAY FROM HOME have reviewed the issues to be presented in this matter, and desire to amicably resolve the pending j issues ‘raised i in this matter, . Pa Now THEREFORE, in consideration of the mutal covenants contained l herein, and other valuable consideration, the sufficiency of which js acknowledged by all Parties, it is hereby stipulated and agreed by and between the Parties intending to be legally bound as follows; Ad. All recitals teferred to in the matters referred to above, are true and correct, expressly incorporated herein, and binding findings of the parties, Upon full execution of this Agreement, Petitioner agrees: a) to forego any administrative review of the referenced Notice Intent to Deny (and the notification correspondence teferenced below in Paragraph’ #3: and to withdraw any such review sought duiing the pendency of the fall execution hereof, including, but not limited to, any request under §120.569, Florida Statutes, for an informal Proceeding under $120.57 (2), or for a formal proceeding under §120,57 (1), any appeal under §120.68, Florida Statutes, and any declaratory relief or relief sought through any writ, of or from any court or administrative tribunal of competent jurisdiction; b) to waive any and all appeals or further proceedings regarding this matter; c) to waive any objections as to the form of the Final Order (e.g, regarding the presentation of findings of fact and conclusions of law), 2. The Petitioner agrees that it will undergo a full licensure survey with deficiencies identified, if any, to be corrected within 30 days, or sooner if required by statute or Tule, and thereafter the Petitioner agrees to be surveyed again (hereinafter called “final survey”) to verify all Page 2 of 10 7 Anum 239 338 2372 P.@4 Aree CE er er, deficiencies have been corrected and the facility is‘in compliance with the ‘minimum , license standards of §400.414(1)(i), Florida Statutes: and ; - 3. If after the Anal survey, the Petitioner has not met the minimum license standards of §400.414(1)@), Florida Statutes, the Agency shall so advise the Petitioner in person and send to the Petitioner (care of Petitioner's below signed Counsel) via U.S: Certified Mail (Regular First Class. Mail Certified Return Receipt or Express Mail Certified Return Receipt, at the exclusive discretion of the Agency as to which forrn of U.S. Certified Mail) Notice that the Petitioner has not met these minimum standards along with a courtesy photocopy of this agreement, The Petitioner shall be deemed to have received a copy of the Notice that it has not met these aforementioned standards on the “Date of Delivery” indicated on the U.S. Certified Mail Return Receipt... If no date has been recorded under the heading “Date of Delivery” on the U.S, Certified Mail Return Receipt, the Petitioner shall be deemed to have received a copy of the Notice on the date reflected-on the: Track & Confirm service available on the United States Postal Service's S website. ia Following signature by all parties designated below as signatories, the Agency shall send to the Petitioner (care of the Petitloner’s below. signed Counsel) via U.S. Certified Mail (Return Receipt Requested) 4 copy of this fully executed Agreement. The Petitioner shall be deemed to have received 4 copy of this fully executed Agreement on the “Date of Delivery” indicated on the U.S. Certified Mail Return Receipt sent care of the Petitioner’s Counsel, If no date has been tecorded under the heading “Date of Delivery” on the U.S, Certified Mail Return Receipt, the Petitioner shall be deemed to have received a Sopy of this fully executed Agreement on the date reflected on the Track & Confirm service available on the United States Postal Service! $ website, 5, Upon the full execution of this Agreement, the Petitioner agrees that it shall perform each and all of the following: Page 3 of 10 6. Licens or fine ue 239 338 2372 P. os Hy a Within oné (1) day following Petitioner's receipt of correspondence notifying the Petitioner of its failure to meet the minimum standards pursvant to $400.414(1)(i), Florida Statutes, 9s described i Paragraph #3 above, Petitioner agrees to provide to al! residents at Petitioner’s facility written notice of termination of residency as required by $400.428(1)(k), Florida Statutes (2005). Copies of all such notices shall be provided to the Agency within two (2) days following Petitioner’s receipt of the notification Correspondence. Such written notice shal! provide that termination of residency shall be effective forty-five (45) days following the date of the notice of termination, However, if §400.428(1)(k) requires a shorter notice period for any residenit, the written notice provided to such resident ‘shall specify a shorter notice period, Furthermore, any and all residents who can be placed at another licensed facility, and who request or do not object to such placement, shall be transferred to such facility at the earliest practicable date possible for such transfer, However, any such transfer shall occur prior to the. expiration of the 45-day period described above, b. The Petitioner aprees to comply with any and all applicable statutes, tules, and regulations conceming Medicaid Participation and reimbursement. Nothing in this Agreement shall in any way absolve or relieve the Petitioner for a failure to comply with such statutes, tules, and regulations, cs. _. Upon full execution of this Agreement, Petitioner agrees to withdraw in its entirety the Petitioner's previously submitted License Renewal Application, By virtue of such withdrawal, the Petitioner’s license to Operate as an assisted living facility shall he deemed to expire one (1) day after the 45-day period set forth in Paragraphs #5.a. above and #6,, immediately below, of this Agreement, . Upon full execution of this Agreement, at which time Petitioner’s withdrawal of ¢ Renewal Application shall be deemed effective, the Agency agrees not to sanction the Petitioner, or Lorraine A. Amold for the unlicensed operation of an assisted living facility unless the Petitioner, or Lorraine A. Amold continue to operate as an assisted living facility beyond the 45-day termination of Tesidency date established pursuant to Page 4 of 10 we or ew Lor AR 239 338 2372 P.@6 Paragraph #5.a.. If the Petitioner by the time of final survey, as described in Paragraph #20 above, has met the minimum license standards of §400.414(1)(i), Florida Statutes, the Agency shall so advise the Petitioner and the Petitioner’s License Renewal Application will be deemed to be'then reinstated for conclusion of any remaining ministerial Tequirements, as if the application had not been withdrawn. ‘The Petitioner shail cooperate with any . , Fequests of the Agency to assist in completing these ministerial requirements, as necessary. . 7, Petitioner and Lorraine A. Arnold agtee to comply with, and the Agency shall tetain the authority to enforce, any and all applicable refund Provisions, including but not limited to those set forth i in §400.424(3)(a),(b),and (c), Florida Statutes (2005), Should the Petitioner, Lorraine A. Amol, or any agent or employee thereof, fail to comply with applicable refimd provisions, the Petitioner and Lorraine A. Amold shall be subject to any and all penalties-and sanctions permitted and/or authorized by law. Be some Nothing in this Agreement shall be deemed a waiver by the Agency ofits duty and obligation to enforce any and all statutory and regulatory Provisions concerning the unlicensed operation of a health care facility over which the Agency the maintains jurisdiction, Should the Petitioner, Lorraine A. Amold, or any agent or employee thereof, engage in any such unlicensed activity subsequent to the 45-day termination of residency date established pursuant to Paragraph #5.a. of this Agreement, the Petitioner and Lorraine 4. Amold shall be subject to any and all penalties and sanctions permitted and/or authorized by law. 9. Nothing in this Agreement shall be deemed a waiver by the Agency of its duty and obligation to enforce any and all statutory and regulatory provisions conceming the operation of a licensed or unlicensed assisted living facility. Until such time as the Petitioner’s license to Operate an assisted living facility is deemed expired, as detailed in Paragraph #5.a, above, the Page 5 of 10 i te, Teo _ 239 338.2372 P.a? ive ie ' AMG Petitioner and Lorraine A. Amol shall be subject to all laws governing assisted living facilities, If the Petitioner by the time of final survey, as described in Paragraph #2 above, has met the minimum license standards of §400. 414(1)(i), Florida Statutes, the Agency shall so advise. the Petitioner and the Petitioner” 8. License Renewal Application will be deemed to be then reinstated - for conclusion of any remaining ministerial requirements, as if had not been. withdrawn. The. Agency agrees that it will not impose any further penalty against the Petitioner, as a result of the survey(s)conducted on or about July 15, 2002; “June 26, 2003; September 30, 2003; January 14, 2004; July 19, 2004; July 29, 2004; and September 29, 2004; and the two surveys (survey and final survey) described in Paragraph #2., above; however, no agreement made herein shall preclude the Agency from imposing a penalty apainst the Petitioner for any deficiency/violation of statute or rule identified in a future (not referenced above) survey of the Petitioner’s facility which, constitutes a “repeat” deficiency from the surveys referenced herein above. ‘ ‘ 10. . Petitioner and Lorraine A, Amold further agree that such party and individual: 2, Shall not apply for a new license, or attempt to acquire an existing license to operate any health care facility, including an assisted living facility, i in the State of Florida for a period of two (2) years, commencing ‘on the date a Final Order is rendered in this matter, unless by the time of the final survey, as described in Paragraph #2 above, the Petitioner has met the minimum license standards of §400.414(1)(), Florida Statutes; and , b. Shall not be involved or employed, directly or indirectly, as an administrator of any nursing home, skilled nursing facility, assisted living facility, adult family care home, or any other health care facility in the State of Florida for a period of two (2) years, commencing on the Page 6 of 10 Url (26a lb ed +. 4 HACH 239 338 2372 P.8a date a Final Order is rendered in this matter, unless by the time ofthe final survey, the Petitioner has met the minimum license standards of §400.414(1)(i), Florida Statutes; and _ 6. If either the Petitioner, or Loraine A. Amold, subsequent to the two ' (2) year exclusion period described in. Paragraph #10. a. and b, immediately above, apply for licensure to operate any health care facility an ‘in the State of Florida, the Agency may deny such license application if the Petitioner, or Lorraine A. Amold, as an officer, director, agent, or "|" managing.employee of the Petitioner or 4s an affiliated person, partner, ; ot shareholder having an ownership interest equal to 5 percent or greater ' ue in the Petitioner, unless the application meets all requirements for such application. 11. For so long as the Petitioner or Lorraine A. Amold refrain from engaging.in unlicensed ¢ operation of any type of health care facility regulated by the Agency, the-Agency agrees to waive its right to impose any fines against Petitioner for violations cited during surveys-of Petitionér’s, facility on or about July 15, 2002; June 26, 2003; September 30, 2003; January 14, 2004; July 19, 2004; July 29, 2004; and September 29, 2004; and the two surveys (survey and final survey) described in Paragraph #2., above. However, no Agreement made herein shall preclude. ...... the ‘Agency from pursuing the imposition of fines, injunctive relief or referral to law enforcement - for investigation criminal activities of or upon the Petitioner for the violations cited during the aforementioned surveys should the Petitioner engage in any unlicensed activity subsequent to the 45-day termination of residency date established pursuant to Paragraph #5.a. of this Agreement. 12. No agreement made herein shall preclude the Agency ftom denying Petitioner or its principals, including Lorraine A. Arnold, licensure or renewal of a license that allows, or is “necessary, for the operation of a health care facility in State of Florida. The Agency shall be Page 7 of 10 - + to , .89 DEL-“Yr-20> lbi es ‘RHC j 233 338 2372 Pp authorized to base such denial upon any applicable provision in law. 13. | Each party shall bear its own costs and attomey’s fees. 14. The parties stipulate'and agree that this Stipulation and Settlement Agreement is a legal and binding document and is ‘fully enforceable against all parties in any coust of competent jurisdiction. However, any action to enforce the terms of this Agreement or the Final Order pursuant hereto shall be brought in the Circuit Court in Leon County, Florida, The signatories hereto represent and warrant that they are vested with the authority to execute this Stipulation and Settlement Agreement on behalf of their respective principals and to fully bind such Principals. 15, Bach party to this proceeding shall bear its own attorney's fees and costs, 16. The Petitioner, including but not limited to Lorraine-A; Amoid; for itself and for its related or resulting organizations, its successors or transferee, attomeys, heirs, and executors or administrators, does hereby discharge the AGENCY, and its agents, representatives, and attomeys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arlsing out of or in any way related to this matter and the Agency’s actions, including but not limited to, any claims that were or may be asserted in any federal or sate court or administrative forum including any claims arising out of this agreement and/or any and all surveys enumerate by Paragraphs #2, #11 or otherwise contemplated as related to this matter , by or on behalf of the Petitioner or related entities. 17, | The AGENCY, for itself and for its related or resulting organizations, its successors or transferees, attomeys, heirs and executors or administrators, does hereby discharge the Petitioner, including but not limited to Lorraine A. Amold,, and its agents, representatives, and atiomeys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Petitioner’s actions, including but not limited to, any claims that were or may be asserted in any federal or state court ot administrative foram, including any claims arising out of this Page 8 of 10 DEC-NP-2885 15:26 AHCA oo . 239 338 2372 P.ig - agreement. and/or any and all surveys enumerate by Paragraphs #2, #11 or otherwise contemplated as related to this matter, by or on behalf of the AGENCY or related entities. 18. This Agreement will, in all respects, be interpreted, enforced and governed. under the laws of the State of Florida. The language of all parts of this Agreement will, in all cases, be construed as a whole, according to its fair ; meaning, and not strictly for or against either party nor against the AGENCY as the initial author of this Agreement, ‘19. " Both parties agree that this Agreement does not waive. the Agency’s ability to enforce a Final Order, or any portion thereof, based upon this Settlement Agreement pursuant to panes, 69, Florida Statutes. 0, " ‘Upon full execution of this Agreement, the Agency shall enter .a Final. Order - adopting and incorporating the terms of this Agreement and that the above-styled case be dismissed. 21, This Agreement contains and incorporates the entire understandings ‘and agreements ‘of the parties, ; . 22. This Agreement supersedes any prior oral or written agreements between the parties. 23. This Agreement may not be amended except in writing, Any attempted assignment of this Agreement shall be void. 24. The parties agree that AHCA is authorized to and shall submit a Final ‘Order adopting ard incorporating the terms and conditions of this Settlement Agreement: without either notice of hearing or another Election of Rights being provided the Petitioner, and that this Settlement Agreement shall be attached to the Final Order, 25. Further, Petitioner authorizes atid consents to the Respondent’s filing a Motion to Remand, Abate and/or any motion necessary to implement the Settlement Agreement, 26, This Agreement is not effective and binding until executed by all parties hereto. This Agreement may be executed simultaneously in two or more counterparts, each of which shall bs deemed to be an original, but all of which together shall constitute one and the same instrument. Page 9 of 10 = * DEC-@7-2885 15:28 ' AHCA ee a2 : rote 239 '338 2372, P.14 27. ¥Facsimiles of signatures shall be deemed to be the same as otiginal signatures. Health Quality Assprance Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL, 32308 DATED:_<7BY/ BOL Chef Calessos Christa Calamas General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 FL Bar No: 0142123 ‘ “DATED: 7 [2+[0¢ a ta Page 10 of 10' Owner and. Administrator ‘A Home Away From Home | DATED: Jay bv los” Git, FT Yedg- Peter Hickey Counsel for the Petitioner 212 North Park Ave. , Sanford, FL 32771 FL Bar No: 09177174 DATED: /- 6 - 06 TOTAL P.1t

Docket for Case No: 05-004030