) . @ Certified Mail Receipt (7004 1160 0003 3739 8620) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, : AHCA NO.: 2005009267 VS. LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/a HENDERSON HOUSE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel; and files this Administrative Complaint against LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, (“Henderson House”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2005), alleges: NATURE OF THE ACTION 1. This is an action to impose one (1) administrative fine in the amount of Five Hundred Dollars ($500.00), against Henderson House for one (1) uncorrected class II] deficiency, pursuant to Section 400.419(2){(c), Fla. Stat. (2005) and Section 58A-5.026(2), Fla. Admin. Code (2005). JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 400, Part III and Section Sections 120.569 and 120.57, Fla. Stat. (2005). 3. Venue lies in Lake County, Eustis, Florida, pursuant to Section 120.57 Fla: Stat. (2005); Rule 58A-5, Florida Administrative Code (2005), and Section 28,106,207, Fla. Stat. (2005). PARTIES 4. AHCA, is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Fla. Stat. and Rules 58A-5, Florida Administrative Code (2005). 5. Henderson House is a for-profit corporation, whose 39-bed assisted living facility is located at 907 E. Orange Avenue, Eustis, FL 32726. Henderson House is licensed as an assisted living facility license #.AL6622; certificate number #15394,’ effective November 08, 2003 through November 07, 2005. Henderson House was at all times material hereto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. . COUNTI | HENDERSON HOUSE CONTINUES NOT TO HAVE AN APPROVED EMERGENCY MANAGEMENT PLAN IN PLACE FOR THE FACILITY. STATE TAG A900-EMERGENCY MANAGEMENT Section 400.419(2)(c), Fla. Stat. (2005) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Section 400.441(1)(b), Fla. Stat. (2005) RULES ESTABLISHING STANDARDS Section 58A-5.026(2), Fla. Admin. Code (2005) EMERGENCY PLAN APPROPVAL Nw 6. AHCA te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about October 04, 2005, AHCA conducted a bi-annual survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a. * On or about August 02, 2005, Henderson House failed to ensure that the facility's comprehensive emergency plan was submitted for review and approval to the county emergency Management agency. b. On or about September 13, 2005, Henderson House failed to have an approved comprehensive emergency plan in place for the facility. Cc. On ot about October 04, 2005, Henderson House continues not to have an approved comprehensive emergency plan in place for the facility. The Findings include: On October 4, 2005, review of the documentation provided by the facility revealed that the facility had submitted a proposed Emergency Management Plan to the Lake County Department of Public Safety, Emergency Management Division, on August 31,.2005, 23 days after the Biennial Licensure Survey was conducted. Interview with the staff at the Emergency Management Division (EMD) at 2 PM on October 4, 2005 revealed that the Lake County Emergency Management Plan requires that all facility emergency plans be submitted and reviewed annually. The staff member stated that all facilities are reminded when their plans are approved that they are to resubmit the plans at least 60 days before the expiration of the approval period. Reviewing the compliance history for this facility, the staff member indicated that the last approved Emergency Management Plan was October 2001. The current plan has gone back and forth between EMD and the facility and, until EMD was called by the AHCA surveyor on August 1, 2005, the EMD had not seen the plan since it had been returned to the facility for corrections on December 15, 2003. At that time it had still not been approved. rvs The staff member stated that the plan submitted to them on August 31, 2005 was the same plan, with some corrections, that had been returned to the facility in December 2003. On September 21, 2005, the proposed plan was again returned to the facility for corrections. 8. The regulatory provisions of the Fla. Stat. (2004), that are pertinent to this alleged violation read as follows: 400.419 Violations; imposition of administrative fines; grounds. ~ (2)(c) Class "III" violations are those conditions or occurrences telated to the operation and maintenance of a facility or to the personal care of 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. 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. * * *” 400.441 Rules establishing standards.— (1)(b) The preparation and annual update of a comprehensive emergency management plan. Such standards must be included in the rules 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. - ek 58A-5.026 Physical Plant Procedures. ~ (2) Emergency Plan Approval. The plan shall be submitted for review and approval to the county emergency management agency. ek OF 9. The violation alleged herein constitutes an uncorrected class III deficiency, 4 and warrants a fine of $500. © WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $500. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2005). 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, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. A ~ onal Respectfully Submitted this 3 day of Hansen 2005,.Leon County, Tallahassee, Florida. Michael O. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg..3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (B50) 921-0158 (fax) CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served al Hh. j by certified mail on 3” day of verbs ‘4 2005 to Richard Evelyn, Administrator, Henderson House, 907 E. Orange Avenue, Eustis, FL 32726. | NVAeaiNiive= Michael O. Mathis, Esq. hau 385 aI o Oo + Se0y 2 GBzjsc4q jRIOL $ a B {painbey yatwessopua} r - Bey Alenjeg payasay a aujNbay jwawesigpuy) BIGH & iWapey Lumsy Q BOLUS, o ¥ 7 UM vo bby Paya o uJ eGuysog 8 us eel uJ pen) ir Cc mW o yjs9ey Winjey oysewog "(002 Isniny "LL@E Wwo4 Sd eu jorsoen) a > SBqUUNN aijpy *z sO (ee 2x3) Aionyed paylysay “y ‘oo Os ileW pansy G SS|PUBYOURW 40} Jdjeoey WN}SH pausysjGey [y : JEW sseudxa C] EW Paywe adAl agjuag ‘pe aH unhapeve Hl iad ATLES JA THI8 . mig 2 LSb SIO Ussve pve} : vee ‘ubqeng preety 30} Passeuppy soy *| “syjuued aords 4) juU0y 84y UO JO ‘eoaidyfeu 84) Jo-YORq ayy OF pueO SiN LORY mw " "NO€ o}-pueo eu; WuNje: UED am jyely os @SJ8A8! BU] UO SseJppe PUB BLEU INOA JU me ‘pal|sep S| Alenl9aq Payopysay J] p Wis}! Byejdwos.os|y ‘¢ pun ‘Z ‘| suey ae{dWoD » ON [] ~~ ‘Moj8q Sseuppe Avanyjep seque ‘G3, 4 Se, (] é} Wis} Waly yueleyp sseipps Alenyep S| ‘q Meal (SEN Pal ) £q panjaogy “g sesseippy | NOILOZS SIHL SLFIdWO9 *H30NAS

Docket for Case No: 05-004578