pe STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATIONUL 26 py \ fi ; i STATE OF FLORIDA, A ori! SiON op AGENCY FOR HEALTH CARE HEA [RAT yg ADMINISTRATION, Rings "5 Petitioner, D | : ay 7Y v. Case Nos. 2007006982 PCM HEALTH CARE OF PINELLAS COUNTY, INC. d/b/a SHADY GLEN I, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration, (hereinafter “the Agency”), by and through the undersigned counsel, and files this administrative complaint against the Respondent, PCM Health Care of Pinellas County, Inc. d/b/a Shady Glen I, (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) based upon one class I deficiency. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to sections 120.569 and 120.57, Florida Statutes (2006). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2006). 3. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable federal and state regulations, statutes and rules governing such facilities. Ch. 408, Part II, and Ch. 429, Part I, Fla. Stat. (2006); Ch. 58A-5, Fla. Admin. Code. The Agency may deny, revoke, or suspend any license issued to an assisted living facility, or impose an administrative fine in the manner provided in Chapter 120, Florida Statutes. §§ 408.813, 408.815, 429.14, Fla. Stat. (2006). In addition to any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility to verify the correction of violations. § 429.19(10), Fla. Stat. (2006). 5. The Respondent was issued a license by the Agency (License Number 4160) to operate a 16-bed assisted living facility located at 451 East Orange Street, Tarpon Springs, Florida 34689, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules governing assisted living facilities. COUNTI The Respondent Failed To Provide Care And Services Appropriate To The Needs Of Its Residents Accepted For Admission To The Facility In Violation Of F.A.C. 58A-5.0182 And Failed To Provide Personal Supervision As Appropriate For Each Resident, Including The Daily Observation Of The Residents, And A General Awareness Of The Resident’s Whereabouts In Violation Of F.A.C. 58A-5.0182(1)(b)-(c) 6. The Agency re-alleges and incorporates paragraphs 1 through 5. 7. Under Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Fla. Admin. Code R. 58A-5.0182. Under Florida law, assisted living facilities shall offer personal supervision, as appropriate for each resident, including but not limited to, the daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual, and the general awareness of the resident’s whereabouts. Fla. Admin. Code R. 58A-5.0182(1)(b)-(c). 8. On or about June 6, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR #2007006180). 9. Based on record review and interview, the Respondent failed to provide care and services appropriate to the needs of residents accepted for admission to the facility and failed to provide personal supervision, as appropriate for each resident, including the daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual, and the general awareness of the residents whereabouts for 1 of 15 sampled residents (Resident #1). 10. Based upon a records review, the Resident was 83 years old. 11. The records further revealed that the Resident #1 was sitting at the Facility dining room table drinking coffee in the late afternoon of June 4, 2007. 12. When dinner was served at approximately 5:00 p.m. on that date, the Facility could not locate the Resident. 13. The Facility Administrator notified the police about the elopement and a search was begun by the police department and allegedly by the Facility staff. 14. The Facility failed to discover the Resident. 15. The Resident was not located until June 6, 2007, when his or her body was found by the local police department in a neighboring yard located a few doors away from the Facility on the same street. 16. _An interview of the Resident’s spouse on June 18, 2007, at approximately 1:20 p.m., revealed that the Resident had wandered away from their home frequently prior to the Resident’s admission to the Facility. 17. _ The spouse claimed that the Resident was often found in his or her neighborhood after eloping and falling down. 18. The health assessment for Resident #1, dated November 1, 2006, confirmed that the Resident needed daily oversight and supervision. 19, A record review for Resident #1 found no documentation in the Facility records to support daily oversight and supervision. 20. | Arecord review for Resident #1 found no documentation in the Facility records to support a proper search effort of the Facility after the Resident had eloped from the Facility. 21. | The Respondent’s deficient practice constituted a class I violation in that it was related to the operation and maintenance of a facility or to the personal care of residents, which presented an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefrom. § 429.19(2)(a), Fla. Stat. (2006). 22. Pursuant to section 429.19(2)(a), Florida Statutes (2006), the Agency shall impose an administrative fine for a class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. An administrative fine may be levied notwithstanding the correction of the violation. 23. Based upon the extreme danger in that the resident was exposed to the hot Florida weather and the busy streets of Tarpon Springs, Florida, and based the actual injury and death of the Resident, the Agency is justified in seeking the maximum fine of $10,000.00. 24. The Respondent was given a mandatory correction date of June 28, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of ten thousand dollars ($10,000.00). COUNT HI ; (Assessment of Survey Fee) 25. The Agency re-alleges and incorporates by reference paragraphs 1 through 5 and the allegations in Count I. 26. The Agency received a complaint about the Respondent (CCR# 2007006180). 27. In response to the complaint, the Agency conducted a complaint survey of the Respondent and its Facility on or about June 7, 2007. 28. As a result of the Agency’s complaint survey, the Respondent was cited for a deficiency. 29. The basis for the deficiency alleged in this Administrative Complaint relates to the complaint made against the Respondent and its Facility. 30. Pursuant to Section 429.19(10), Florida Statutes (2006), the Agency is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 429.28(3)(c), Florida Statutes (2006), to verify the correction of the violations. 31. In this case, the Agency is authorized to seek a survey fee of $134.00. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration respectfully requests the Court to assess a survey fee against the Respondent in the amount of one hundred thirty four dollars ($134.00). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the total amount of ten thousand dollars ($10,000.00). 3. Assess a survey fee against the Respondent in the amount of one hundred thirty four dollars ($134.00). 4. Enter any other relief that this Court deems just Respectfully submitted this 28th day of June, 2007. Florida Bar No. 709311 Agency for Health Care Administration Office of the General Counsel The Sebring Building, Suite 330L 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election or Right form have been served to: Paula Comer, Registered Agent, PCM Health Care of Pinellas County, Inc., 1917 Brookstone Way, Clearwater, Florida 33760, by U.S. Certified Mail, Return Receipt No. 7099 3400 0002 2451 1535, and Lealy/J. Harroyo, Administrator, Shady Glen I, 451 East Orange Street, Tarpon Springs, Floridg j .S. Certified Mail, Thomas M. Hoeler, SenjorAttorney Florida Bar No. 709311 Agency for Health Care Administration Office of the General Counsel The Sebring Building, Suite 330L 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 Copies furnished to: Paula Comer, Registered Agent Thomas M. Hoeler, Senior Attorney PCM Health Care of Pinellas County, Inc. Agency for Health Care Administration 1917 Brookstone Way Office of the General Counsel Clearwater, Florida 33760 525 Mirror Lake Drive North, Suite 330 (U.S. Certified Mail) St. Petersburg, FL 33701 ; (Interoffice) Leah J. Harroyo, Administrator Kathleen Varga Shady Glen I Facilities Evaluator Supervisor 451 East Orange Street Agency for Health Care Administration Tarpon Springs, Florida 34689 525 Mirror Lake Drive North, Fourth Floor (U.S. Certified Mail) St. Petersburg, FL 33701 (Interoffice) ee eaten eect tree inlets aE ne ame renee mena Re Ene tte at Rican papas SENDER: COMPLETA JHIS SECTION COMPLETE THIS SECTION ON DELIVERY ™ Complete items 1), und 3, Also complete oF ‘ i item 4 if Restricted Delivery is desired. x a Ip Sroert @ Print your name and address on the reverse Addressee * so that we can return the card to you. Name) ® Attach this card to the back of wae or on the front if space permits. D. Is delivery address different from item 2%, 1 Article Tener, to: [7 + If YES, enter delivery address below: se , ay = 4 tau (a mer, ge e pom Health a Cave 6 “a Co. 1917 Brookstone Wad Cs a ae 3. Service Type Tae — C learwater, FL 33760 CO Certified Mail 1 Express Mai? wy ~ I Registered C1 Retum Receipt fayMerchandise } Cl insured Mail C.0.0. é 4. Restricted Delivery? (Extra Fee) O Yes 2. Article Number 7 O 3400 0002 2, 1$35- He_200T DOK i {Transfer from service label) OLo i PS Form m 3811, February 2004 ia i Domestic He Return Recelpt 02 M1540“ = Complete items 1, Bud 3. Also complete item 4 if Restricted Delivery is desired. 1 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 mailpiece, or on the front if space permits. 4. Article Addressed to: tea h a | Harr og? D. —damny wares diferent rom fern 1 O Yes if YES, enter delivery address below: 1 No cera Se i Ta Atticle Number 5049 “3 00 (iranster irorts 3urice latos> ‘ veceewote eh PS Form 3811, February 2004 - Domestic Return Receipt BOL 24ST 750

Docket for Case No: 07-003474