STATE OF FLORIDA O7 map 0 AGENCY FOR HEALTH CARE ADMINISTRATION ae 437 OM igie ' STATE OF FLORIDA, AGENCY FOR HEALTH ADMINIS Rage CARE ADMINISTRATION, HEARIRAL VE Petitioner, AHCA No.: 2006006541 Return Receipt Requested: v. 7002 2410 0001 4235 1064 7002 2410 0001 4235 1071 GOOD FAITH ASSISTED LIVING FACILITY, INC. d/b/a GOOD FAITH ALF, OT ; (U (4 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Good Faith Assisted Living Facility, Inc. d/b/a Good Faith ALF (hereinafter “Good Faith ALF”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2005), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $5,000.00 and a survey fee of $287.00 pursuant to Sections 400.414 and 400.419, Florida Statutes (2005) for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2005) and Chapter 28-106, Florida Administrative Code (2005). 3. Venue lies in Broward County pursuant to Section 120.57, Florida Statutes (2005) and Rule 28-106.207, Florida Administrative Code (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, Florida Statutes (2005) and Chapter 58A-5 Florida Administrative Code (2005). 5. Good Faith ALF operates a 5-bed assisted living facility located at 3405 Knolls Road, Miramar, Florida 33025. Good Faith ALF is licensed as an assisted living facility under license number 10662. Good Faith ALF was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT TI GOOD FAITH ALF FAILED TO PROVIDE PERSONAL SUPERVISION, INCLUDING GENERAL AWARENESS OF A RESIDENT’S WHEREABOUTS AND FAILED TO PROVIDE A SAFE LIVING ENVIRONMENT FREE FROM NEGLECT. RULE 58A-5.0182(1) (c}, FLORIDA ADMINISTRATIVE CODE SECTION 400.428(1) (a), FLORIDA STATUTES (RESIDENT CARE STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Good Faith ALF was cited with one (1) Class I deficiency during a complaint investigation conducted on June 20, 2006. Section 400.419(2) (a), Florida Statutes, provides, in pertinent part, that: Class “I” violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines present an imminent danger to the residents or guests of the facility or a substantial probability that death or serous physical or emotional harm would result therefrom. 8. Based on interview and record review, the Agency determined that the facility failed to provide personal supervision to Resident #1, including general awareness of the resident's whereabouts and failed to provide a safe living environment free from neglect for the resident. The findings include the following: 9. According to record review, the resident was admitted to the facility on 04/06/06. The Resident's file contained a Florida Department of Children and Families Patient Transfer and Continuity of Care Form (Form ID# CF-MED3008, Oct. 96) signed and dated by an examining physician (date unknown) which reflected that the resident’s principle diagnosis is diabetes and the secondary diagnosis is dementia (mild) and HTN. 10. During interview with the Administrator, it was reported that on 06/03/06 at approximately 2:15 PM, Resident #1 informed Employee #2 that he/she was taking a walk to the corner store, near the facility. It was reported that the resident left the premises and did not return to the facility by dinnertime. At approximately 6:00 PM, the Administrator reportedly got into her car and drove around the vicinity of the facility in search of Resident #1, but was unsuccessful. 11. During a further interview, the Administrator reported that it was not until the morning of 06/04/06 that she contacted the local police department to inform them that Resident #1 was missing. The Administrator neglected to file a missing person's report on the actual day that the resident was determined to be missing in an effort to obtain knowledge of the resident's whereabouts, safety, and well-being. Furthermore, the Administrator confirmed that the facility staff provided assistance to the resident with his/her self-administered medications and that the resident's medications were on the premises of the facility and the resident did not have his medications at hand. 12. The Administrator reported that after notifying the police department, an officer arrived at the facility and a "missing person" report was filed on behalf of Resident #1 (Case #06-06-796). 13. The Administrator reported that as of 06/20/06, the day of the complaint investigation, Resident #1's whereabouts remained unknown. 14. During the exit conference conducted at approximately 3:45 PM, the Administrator acknowledged the findings. 15. Based on the foregoing facts, Good Faith ALF violated Rule 58A-5.0182(1)(c), Florida Administrative Code (2005), and Section 400.428(1) (a), Florida Statutes (2005), herein classified as a Class I violation, which warrants an assessed fine of $5,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida Statutes (2005), AHCA may assess a survey fee to cover the cost of monitoring visits. A survey fee of $287.00 has been assessed in this case. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Good Faith ALF on Count I. 2. Assess an administrative fine of $5,000.00 against Good Faith ALF on Count I for the violation cited above. 3. Assess a survey fee of $287.00 against Good Faith ALF pursuant to Section 400.419(10), Florida Statutes. 4. Assess costs related .to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2005). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. Opes tn. Rodecyses/ Alba M. Rodriguez, Es Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Hyacinth Banton-Doyley, Administrator, Good Faith ALF, 3405 Knolls Road, Miramar, Florida 33025; G Woode Financial Consulting, Inc., 901 S. State Road 7, Suite 315, | Hollywood, Florida 33023 on this 9*4 day of October, 2006. ' oO Alba M. th he mo i) ADMINIS “HEARIAL SENDER: COMPLETE THIS SECTION Complete items 1, 2, and 3, Also complete. " tom 4 if Restricted Delivery is isdesired. , m Print your name and address on she reverse fa od “he 4 so that we can return the card to you. TPB. Receive rinited Nat . Date c ws Attach this card to the back of the mailplece, tee ak See Ser or on the front if space permits. ae : tes ics aetna -O Yes HYES, enter avery ecraee bola O.No --} 8, Service Type % “ Ci certified Mail, C1 Express Mall Oi Registered. . O Patum Receipt for Merchandise Oi insured Mail’ 1 C.0.D. 7002 2 it} po03, 4235 Sot (Transter trom service label) peed : q PS Form 3811, August 2001 Domeate Roum Receipt GD ” Co att 2ACPRI-03-2-0985 “ma meee hi, pre eee a,

Docket for Case No: 07-001483