STATE OF FLORIDA Be AGENCY FOR HEALTH CARE ADMINISTRATION nee Soe STATE OF FLORIDA, AGENCY FOR. BBE HEALTH CARE ADMINISTRATION, Be. Zz. Petitioner, ™ vs. CaseNo. 2007000646 FLORIDA HHC, INC., d/b/a MARTHA’S HOME, LD 7 ly al Respondent. / . ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against FLORIDA HAC, INC., d/b/a MARTHA’S HOME (hereinafter Respondent), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00), pursuant to Section 429.19(2)(c), Florida Statutes (2006), based upon the existence of one (1) repeat Class III violation. JURISDICTION AND VENUE (2006). The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 429.07, Florida Statutes 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 429, Part I, Florida Statutes and Chapter 58A-5 Florida Administrative Code, respectively. 4. Respondent operates a 16-bed assisted living facility located at 3586 — 53" Avenue N., St. Petersburg, Florida 33714, and is licensed as an assisted living facility, license number 5336. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7 That pursuant to Florida law, assisted living facilities shall maintain minimum staffing hours per week as follows: 6-15 residents, 212 staff hours per week; 16-25 resident, 253 staff hours per week... R. 58A-5.019(4)(a), Florida Administrative Code. 8. That on August 11, 2006, the Agency conducted a Complaint Survey (#2006006582) of the Respondent facility. 9. That based upon the review of records, the Respondent failed to maintain the minimum required direct resident care staff hours per week based on its current census of thirteen (13) persons. 10. ‘That the Petitioner’s representative reviewed the Respondent’s posted staff schedule for the week of August 6, 2006 on August 11, 2006 and noted that a total of one hundred sixty-eight (168) total staff hours were scheduled for the week by staff providing direct resident care. 11. That the Respondent’s resident census was thirteen (13) during the week if August 6, 2006. 12. That the minimum required hours for an assisted living facility with a census of thirteen (13) is two hundred twelve (212) hours per week. 13.‘ That the failure to provide minimum hours of direct care staff places the residents at risk and potentially results in insufficient care and services, the same being in violation of law. 14.‘ That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility, or to the personal care of Facility residents, and directly threatened. the physical or emotional health, safety, or security of the Facility residents. 15. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2006). 16. ‘That the Agency provided a mandated correction date of September 11, 2006. 17.‘ That during a re-visit survey conducted September 14, 2006 the Agency determined that the Respondent had corrected the deficiency. 18. That on December 18, 2006, the Agency conducted a Biennial State Licensing Survey of the Respondent facility. 19. That based upon the review of records, the Respondent failed to maintain the minimum required direct resident care staff hours per week based on its current census of thirteen (13) persons. 20. +‘ That the Petitioner’s representative reviewed the Respondent’s posted staff schedule for the week of December 3, 2006 on December 18, 2006 and noted that a total of two hundred nine (209) total staff hours were scheduled for the week by staff providing direct resident care. 21. ‘That the Respondent’s resident census was thirteen (13) during the week if December 3, 2006. 22. That the minimum required hours for an assisted living facility with a census of thirteen (13) is two hundred twelve (212) hours per week. 23. That the Petitioner’s representative interviewed the Respondent’s manger on December 18, 2006 who confirmed that the posted staff schedule above discussed accurately reflected direct care staff provided by Respondent during the week. 24. ‘That the failure to provide minimum hours of direct care staff places the residents at risk and potentially results in insufficient care and services, the same being in violation of law. 25. That the Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of Facility residents, 26. That the Agency cited the Respondent for a repeat Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2006). 27. That the Agency provided a mandated correction date of January 18, 2007. 28. That this constitutes a repeat violation as provided by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). Respectfully submitted this e/ day of February, 2007. T J. Walsh I a. Bar. No. 566365 Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727-552-1525 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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. CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has been a by U.S. Certified Mail, Return Receipt No. 7004 1350 0004 2776 0437 on February ©/ _, 2007 to Brenda Roegele, Registered Agent/Administrator, 3586 — 53 Avenue, North, St. Petersburg, FL 33714. Sertior ttorney Copies furnished to: Brenda Roegele Kathleen Varga Thomas J. Walsh II, Esq. Reg. Agent/Administrator | Facility Evaluator Supervisor Agency for Health Care Admin. 3586 — 53" Avenue, North | 525 Mirror Lake Drive, 4" Floor | 525 Mirror Lake Drive, 330G St. Petersburg, FL 33714 | St. Petersburg, Florida 33701 St. Petersburg, Florida 33701 (U.S. Certified Mail) (nteroffice) (Interoffice) pom Se SENDER: COMPLE THIS SECTION & Complete items 1,2, and 3. Also complete item 4 If Restricted Delivery Is desired. @ Print your name and address on the reverse so that we can return the card to you. Attach this card to the back of the mailplece, = or on the front if space permits. 4. Article Addressed to: Reena. Roegele, hes Oat dinichator 45% Coed Buremac, Moats Sf. Rfersheue, cl, 2. Article Number {Transfer from PS Form 3811, February 2004 S37! 7004 2350 0004 27?b O43? ‘Domestic Return Receipt A. Slonefure | B, Received by ( Printed Name) A ‘Addressee_+: = — C| © Be ¢ of Delivery. Ac | if D. {s delivery address different from ttem 1 ffH-ve If YES, enter delivery address below: ONo mulce- Type. (O Certified Mall) C1 Express Mail \ CT Registered Retum Receipt for Merchandise) \ C.0.D. i (1 Insured Mal! 4. Restricted Dellvary? (Extra Fee) Cl Yes 4 OO TOOL k T t 402595-02-M-1540

Docket for Case No: 07-001684