STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2006004887 CERTIFIED MAIL # LIFE CARE CENTERS OF 7004 1160 0003 3739 1883 AMERICA, INC, d/b/a LIFE CARE CENTER OF ORANGE PARK, Ole UU ADMINISTRATIVE COMPLAINT Petitioner, the Florida Agency for Health Care Administration (“ACA”), through undersigned counsel, files this Administrative Complaint against the above-named Respondent (“‘Respondeanr’) pursuant to Sections 120.569 and 120,57, Florida Statutes (2004)', and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $32,631.00 (the “fine amount”) against Respondent, pursuant to Section 408.040, Florida Statutes, and Florida Administrative Code Rules 59C-1.013 and 59C-1.021. 2. For the calendar year 2004 (the “calendar pear’), Respondent failed to comply with the Medicaid condition upon its Certificate of Need (“CON”), a copy of which is attached to this complaint as Exhibit A. "Unless otherwise noted, al] statutes and rules hereinafter cited are to the indicated year’s version of the statute or rule because this is the controlling year in question. Page | of 9 JURISDICTION AND VENUE 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes, and also Sections 408.03] - 408.045, Florida’s “Health Facility and Services Development Act.” 4. Venue is determined by Florida Administrative Code Rule 28-106.207. PARTIES 5. Pursuant to Chapter 408, Florida Statutes, and Chapter 59C-1, Florida Administrative Code, ANCA is the licensing and enforcing authority with regard to community nursing home Jaws and nules. 6. Respondent is a corporation authorized under the laws of Florida to do business. Respondent operates a community nursing home located at 2145 Kingsley Avenue, Orange Park, Florida 32703 and is the licensee on the CON issued on October 1, 1997, for the construction of 60 beds in addition to the existing 120-bed community nursing home, with the condition that a minimum of 63% of its total annual patient days for the 180-bed facility shall be provided to Medicaid patients, and that a 20-bed subacute care unit, including an 8-bed Respiratory Therapy Suite, shall be established. The CON number is 7737; a copy of the CON is attached to this complaint as Exhibit A. COUNT I Respondent failed to meet its Medicaid condition Section 408.040, Florida Statutes Florida Administrative Code Rule 59C-1.013 Florida Administrative Code Rule 59C-1.021 7. AHCA re-alleges paragraphs 1-6 above. Page 2 of 9 8. Respondent failed to comply with its Medicaid condition as reported to the Agency in its Florida Nursing Home Utilization Report for the year 2004. a copy of which is attached to this complaint as Exhibit B, and its facility report, a capy of which is attached to this complaint as Exhibit C. 9. Respondent failed to comply with the condition set forth in its CON, as required by Section 408.040, Florida Statutes, and Rule 59C-1.013, Florida Administrative Code, which provide, in part, as follows: 408.040 Conditions and monitoring (1)(a) The agency may issue a certificate of need, or an exemption, predicated upon statements of intent expressed by an applicant in the application for a certificate of need. Any conditions imposed on a certificate of need or an exemption based on such statements of intent shall be stated on the face of the certificate of need or in the exemption approval, (b) The agency may consider, in addition to the other criteria specified in 5. 408.035, a statement of intent by the applicant that a specified percentage of the annual patient days at the facility will be utilized by patients cligible for care under Title XIX of the Social Security Act. Any certificate of need issued to a nursing home in reliance upon an applicant's statements that a specified percentage of annual paticnt days will be utilized by residents eligible for care under Title XIX of the Social Security Act must include a statement that such certification is a condition of issuance of the certificate of nced. The certificate-ofneed program shalj notify the Medicaid program office and the Department of Elderly Affairs when it imposes conditions as authorized in this paragraph in an area in which a community diversion pilot project is implemented. (c) A certificate holder or an exemption holder may apply to the agency for a modification of conditions imposed under paragraph (a) or paragraph (b). If the holder of a certificate of need or an exemption demonstrates good cause why the certificate or exemption should he modified, the agency shall reissue the certificate of need or exemption with such modifications as may be appropriate. The agency shall by mile define the factors constituting goad cause for modification. (d) If the holder of a certificate of need oy an exemption fails to comply with a condition upon which the issuance of the certificate or exemption was predicated, the agency may assess an administrative fine against the certificate holder in an amount not to exceed £1,000 per failure per day. Fajlure to annually report compliance with any condition upon which the issuance of the certificate or exemption was predicated constitutes noncompliance. In assessing the penalty, the agency shall take into sccount as mitigation the degree af noncompliance. Proceeds of such penalties shall be deposited in the Public Medicaid Assistance Trust Fund. ee 59C-1.013 Monitoring Procedures (4) Reporting Requirements Subsequent to Licensure or Commencement of Services. All holders of a certificate of need that was issued predicated upon conditions expressed on the face of the certificate of necd shall provide annual compliance reports to the agency, The reporting period shall be January 1 through December 31 of each ycar. The holder of a certificate of need who began operation after January 1 will repor! from the date operation began through December 31. The compliance report shall be submitted no later than April 1 of the subsequent year. (a) The compliance report will contain information necessary for an assessment of compliance with conditions on the certificate of need, utilizing measures, such as a percentage of patient days, that are consistent with the stated condition. The following information shall be provided in the holder's annual compliance rcport: 1. The time period covered by the measures: 2, The measure for Page 3 of 9 assessing compliance with each of the conditions identified and described on the face of the certificate of need; 3. The way in which the conditions were evaluated by applying the measures; 4. The data sources used to generate information about the conditions that were measured; 5. The person and position responsible for supplying the compliance report; 6. Any other information necessary for the agency to determine compliance with conditions; and 7. If applicable, the reason or reasons, with supporting data, why the certificatc of need holder was unable to meet the conditians set forth on the face of the certificate of need, (b) A change in the licensee for a facility or service docs not affect the obligation for that facility or service to continue to mect conditions impased on a certificate of need and to provide annual condition compliance reports, (c) Conditions imposed on a certificate of need may be modified consistent with Rule 59C- 1.019, FAC, (5) Violation of Certificate of Need Conditions. Health care providers found by the agency to be in noncompliance with conditions set forth in their certificate of need shall be fined ag defined in Rule 59C-},021, F.A.C. 10. The foregoing violation warrants imposition of the above-mentioned fine amount pursuant to Florida Administrative Code Rule 59C-1.021, which provides, in part: §9C-1.021 Penalties, (1) General Provisions, The agency shall initiate administrative proceedings for revocation of a certificate of nced for violation of paragraphs 408.040(2)(a) and (b), F.S., or the assessment of admunistrative fines for failure to comply with conditions placed on a certificate of need as specified under Rule 59C-1.013, F.A.C sue (3) Penalties for Failure to Comply with Certificate of Need Conditions. The agency shall review the annual compliance report submitted by the health care providers who arc licensed and operate the facilities or services and other pertinent data to assess compliance with certificate of need conditions. Providers who are not in compliance with certificate of uced conditions shall be fined, For community nursing homes or hospital-based skilled nursing units certified as such by Medicare, the first compliance report on the status of conditions must be submitted 30 calendar days following the eighteenth month of operation or the first month where an 85 percent occupancy is achieved, whichever comes first. The schedule of fines is as follows: (a) Facilities failing to comply with any conditions set forth on the Certificate of Need will be assessed a fine, not to exceed 41,000 per failure per day. In assessing the penalty the agency shall take into account the degree of noncompliance, (b) The assessed fine shall be paid to the agency wilhin 45 calendar days after written notification of assessment hy certified mail or within 30 calendar days after final agency action if an administrative hearing has been requested. Ta health care provider desires it may remit payment according to a payment schedule accepted by the agency. The health care provider must submit the schedule of payments to the agency within 30 calendar days after the date of receipt of the notification of assessment or 21 calendar days after final agency action. The final balance will be due no Jater than 6 months after the health care provider has been notified in wziting by the agency of the amount of the assessed fine or 6 months after final agency action, ll. AHCA, in determining the penalty imposed, considered the degree of noncompliance. Page 4 of 9 WHEREFORE, AHCA demands the following relief: (1) enter factual and legal findings as set forth in Count I; (2) impose the above-mentioned fine amount for the violatian; and (3) impose such other relief as this tribunal may find appropriate. NOTICE RESPONDENT is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action aré 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, 2727 Mahan Dr., Bldg. 3, MS #3, Tallahassee, Florida, 32308; Attention: Agency Clerk. RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Submitted as of the date indicated on the below Certificate of Service. o> Donna &( Plante, Senior Attorney Fla. Bar No. 0966193 Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3, MS #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-9313 Page 5 of 9 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the original Administrative Complaint, Explanation of Rights form, and Election of Rights form have been sent by U.S. Cerlifted Mail, Return Reccipt Requested (receipt # 7004 1160 0003 3739 1881) to Respondent, Attention: Administrator, Life Care Center of America d/b/a Life Care Center of Orange Parl, at 2145 Kingsley Avenue, Orange Park, Florida 32703 on-this bkdey of June = Donna et Zi Attorney Page 6 of 9 STATE OF FLORIDA By, be AGENCY FOR HEALTH CARE ADMINISTRATION l / p Bos 4 RE: Life Care Center of Orange Park Case No. ahi, 4s oe TE ROH, ELECTION OF RIGHTS FOR PROPOSED 4GENCY. ACTION® . PLEASE SELECT ONLY | OF THE 3 OPTIONS OPTION ONE (J). T do not dispute the allegations of fact contained in the proposed agency action and waive my right to object or to be beard. | understand that by waiving my rights, a final order wil} be issued that adopts the proposed agency action and imposes the sanctions sought. OPTION TWO (2) Ido not dispute and admit the allegations of fact contained in the proposed agency action, but { do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time I will be permitted to submit ora) and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) I do dispute the allegations of fact contained in the proposed agency action and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes, you must ALSO file a request for a formal hearing ihat conforms to the requirements of Rule 28-106.201, Florida Administrative Code. The hearing request MUST contain: - The name and address of each agency affected and each agency’s file or identification number; ~ Your name, address, and telephone number, and the name, address, and telephone number of your representative, if any, in this proceeding; - An explanation of how your substantial interests will be affected by the Agency’s proposed action; - A statement of when and how you received notice of the Agency’s proposed action; , - A statement of all disputed issues of material fact; - A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency’s proposed action; - & statement of the specific rules or statuies you contend require reversal or modification of the Agency’s proposed action; and ? Proposed agency action refers to cither the Notice of Intent or Administrative Complaint that you reecived from the Agency along with this Election of Rights. Page 7 of 9 - A statement of the relief you are seeking, stating exactly what action you wish the Apency to take with respect to its proposed action. , In order to preserve your right to a hearing, the Election of Rights form (AND the request for a formal hearing if you have chosen OPTION THREE (3)) in this matter must be received by AFICA within twenty-one (21) days from the date you received the proposed agency action. If the election of rights form with your selected option is not received by ANCA within twenty-one (21) days from the date of your receipt of the proposed apency action, you will have waived your right to contest the Agency’s proposed action and a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought. If_you have elected e ver OPTION TWO (2) or THREE (3) above and are interested in discussing a settlemen: of this matter with the Agency, please also mark and check this block. ia) Mediation under Section 120.573, Florida Statutes, is available in this matter if the Agency agrees, SEND NO PAYMENT NOW - REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. Please sign and fil] in your current address. Licensee: eee Licensee’s Representative (if any): Address: License No, and facility type: Telephone No.: PLEASE RETURN YOUR COMPLETED FORM TQ: Agency for Health Care Administration, Attention: Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32208. Page 8 of 9 EXHIBITS EXEIBIT “A” — Respondent's CON # 7737, requiring that a minimum of 63% of the fotal ; annual patient days in the 180-bed facility be provided to Mcdicaid patients. EXHIBIT “B”— Florida Nursing Home Utilization Report for Year 2004 EXHIBIT “C”— Respondent’s facility report (All are copies) Page 9 of 9 Ra Lee e “H/ ieeeh May ‘86Lb WHOS Fer bey / : aan we yNeqNs pod Oz = Ys|iqeisa jeys jueaijdde oy 1 {z) pue ‘squaped ebblsAep fenuue.se10) 57] Jo %¢9 jo sanjay Vv (}) isNorliaNnoo erent) oe re : jt be'hs pue UO}ONIsuOD Meu 404389 ops‘ 9} UO} PPE euay Buysinu pays pag gg e “ c1pRisidans .: “Lolisia 16S :3LVa ANSs} TBES. 7LSOD LOZPOUd 0. 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BRUCE McHKIBBEN ATTORNEY.AT Law 1435 € Pledmont Drive; Sulte 214 » Tallahassee, FL 32308 « 650.942.8585 « 450.949.8594 (For) = romlaw@earthlink net February 23, 2006 ot, ony o Mr. Jumes McLemore ° “4 Sy Health Services & Facilities Consultant es * Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, FL 32308 FEB 24 ange | Re: CON 7737 Con/Financiel Analysis Office Life Care Center of Orange Park Mall Stop 28 CON Condition compliance (2004) DE ORE WE Dear James: Please accept this letter and attachment as the amended and updated report by Life Care Center of Orange Park concerning its CON Condition Compliance for calendar year 2004, The following information is submitted for purposes of compliance with Rule 59C+1 0194), Florida Administrative Code: The: time period covered by this report is Ii snuary ~ December. 2004, ; The measure for assessing compliance. with the Medicaid condition is to determine total patient days-for the year and divide by the number, of Medicaid patient days for the year. The data.used was the facility’ s internal census tracking information generated on a monthly basis, The compliance report is being submitted by the undersigned under the authority of the facility administrator and licensee of the facility. Requirement for 20-bed Subacute Unit/Respiratory Unit Please see attached floor plan of the facility indicating the existence of the Subacute Unit. The facility actually has 60 beds certified for Medicare of which 20 (rooms 223 through 232) are designated as the “subacute” unit. Each of these rootns is equipped to handle al) subacute residents, including ventilator patients. The facility has designated rooms 223, 224, 225 and 226 as its “Respiratory Suite.” Requirement for 63% Medicaid Patient Days . During calendar year 2004, the facility had a Medicaid. census of about 589% (36,409 Medicaid days out of 63,462 total patient days). See attached report, All residents -whose care was paid by Medicaid — even if they were hospice ~ are.inchided, in the Medicaid figures. In addition to the traditional Medicaid days, there were a large number of Medicare residents whose eligibility for Medicaid places them in the Medicaid category for purposes of the CON. Based upon the foregoing, it appears Life Care Center of Orange Park is in full compliance with the subacute condition and substantial compliance with its Medicaid Condition. Please let me know if anything further is required in order to satisfy the reporting requirements for calendar year 2004, Thank you again for your assistance and attention to this matter. Sincerely, re nace R. Bruce McKibben, Jr. Enclosure ce: Executive Director, Life Care Center of Orange Parl (w/o attach)

Docket for Case No: 06-002446