STATE OF FLORIDA Oo? 4 iS “hy AGENCY FOR HEALTH CARE ADMINISTRATION tog 4 by ~ A of iz 4: 493 STATE OF FLORIDA, é AGENCY FOR HEALTH CARE ADMINISTRATION, 0 7 Q «| q Petitioner, vs. Case No. 2007004310 H. C. HEALTHCARE, INC., d/b/a TRINITY COMMUNITY HOSPITAL, 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 H. C. HEALTHCARE, INC., d/b/a TRINITY COMMUNITY HOSPITAL (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2006), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of eight thousand dollars ($8,000.00) pursuant to Sections 120.569, 120.57, 395.1055 and 395.1065, Florida Statutes (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Section 395, Part I, Florida Statutes (2006). 2. Venue lies pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 Florida Administrative Code. PARTIES 3. The Agency is the regulatory authority with regard to hospital licensing and regulation pursuant to Chapter 395, Part I, Florida Statutes, and Rule 59A-3, Florida Administrative Code, respectively. 4. Respondent is a hospital located at 506 NW 4" Street, Jasper, Florida 32052, and is licensed under Chapter 395, Part I, Florida Statutes and Chapter 59A-3, Florida Administrative Code, license number 3924. 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, every hospital providing emergency services shall ensure that clinical laboratory services with the capability of performing all routine studies and standard analyses of blood, urine, and other body fluids are readily available at all times to the emergency department. Rule 59A-3.255(6)(g)(1), Florida Administrative Code. 8. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 9. That based upon interviews, the Respondent failed to ensure that laboratory (hereinafter “Jab”) services needed to assure quality care for patient's that present to the hospital for care and services within its capability are readily available at all times, the same being contrary to law. 10. That the Petitioner’s representative telephonically interviewed an individual alleged as an unlicensed lab director on April 6, 2007 who indicated as follows: That he has been serving as Respondent’s lab manager, That he has six (6) years experience and a bachelors degree in clinical lab science; That he had submitted an application for supervisor's license into the Department of Health; That the lab tech at AHCA had indicated that she would "work with him” in getting his license. 11. That the Petitioner’s representative interviewed the Respondent’s administrator on April 6, 2007 who indicated as follows: a. That the Respondent does not have the lab supplies required to do a Complete Blood Count (CBC); That the quality control solution to test the accuracy of the equipment expires at midnight on April 6, 2007; That the troponin levels, or cardiac blood tests to determine heart attacks, could not be done in the hospital as the Respondent does not have the necessary supplies and though the supplies had been ordered, they are expecting delivery on Tuesday; That pending obtaining necessary supplies, the Respondent has a twenty-four (24) hour courier; That blood samples are obtained and taken to another hospital approximately twenty-five (25) miles away to have the specimen tested and then the results are faxed back to the facility That the company that provides the lab supplies had not delivered the Respondent’s orders as the supplier had not been paid and would not deliver anymore supplies. 12. That the utilization of lab services situate in excess of twenty (20) miles from the Respondent is the failure to have such services readily available to meet the needs of persons presenting within the Respondent’s service capability. 13.‘ That the failure to provide readily available lab services to patients presenting for emergency services within the Respondent’s capability is in violation of law and may dalay the necessary care and services of a presenting patient. 14.‘ That the Agency cited the Respondent facility for the above referenced deficiency. 15. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT II 16. | The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 17. That pursuant to Florida law, if the director of the dietetic department is not a registered dietitian, the hospital shall employ a registered dietitian on at least a part-time or consulting basis to supervise the nutritional aspects of patient care and assure the provision of quality nutritional care to patients. The consulting dietitian shall regularly submit reports to the chief executive officer concerning the extent of services provided. Rule 59A-3.2085(1)(b), Florida Administrative Code. 18. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 19. That based upon interview, the Respondent failed to employ a registered dietitian as required by law, the same placing at risk the patient’s nutritional needs. 20. That on April 6, 2007, the Paetitioner’s representative interviewed the Respondent’s dietary manager who indicated that the Respondent does not have in its employ a registered dietician in either a staff or consulting capacity. 21. That on April 6, 2007, the Paetitioner’s representative interviewed the Respondent’s administrator who indicated that the Respondent does not have in its employ a registered dietician in either a staff or consulting capacity. 22. That the failure to have a registered dietician on staff or as a consultant is in violation of law, placing patients at risk for nutritional deficiency or error. 23. That the Agency cited the Respondent facility for the above referenced deficiency. 24. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT II 25. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. That pursuant to Florida law, all drugs shall be prepared and stored under proper conditions of sanitation, temperature, light, moisture, ventilation, security and segregation to promote patient safety and proper utilization and efficacy. Rule 59A-3.2085(2)(c), Florida Administrative Code. 27. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 28. That based upon observation and interview, the Respondent failed to ensure that all.drugs were kept in a locked storage area in violation of law. 29. That the Petitioner’s representative observed, at 4:20 PM on April 6, 2007, the following: a. That upon entering the hospital and proceeding to the hallway where the patients are housed there was no one at the nurses's station and no staff observed in the hallways; b. That a medication cart was in a small storage room with the door open and the medication cart was unlocked; c. That there were also needles and syringes easily available to public access; d. That a small child appeared in the hallway where the unsecured medication cart and medical supplies were readily available to the public; e. That at that time a nurse came out of a patient's room and, when asked if the cart being unsecured was common practice, she indicated no and that she had just left the cart; f. That she also indicated that the unsecured cart was not in the medication room just in a room closer for her to work from. 30. That the failure to ensure that all drugs are kept secure may result in patients’ and or the public having access to medications which may have an adverse drug reaction to medications the patients are currently taking or providing the opportunity for theft, misuse, or other inappropriate utilization of medications prescribed for and intended for patient use. 31. That the Agency cited the Respondent facility for the above referenced deficiency. 32. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT IV 33. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 34. That pursuant to Florida law, every hospital must provide on the premises or by contract with a laboratory licensed under Chapter 483, Part I, F.S., a clinical laboratory to provide those services commensurate with the hospital’s needs and which conforms to the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C. Rule 59A-3.2085(9), Florida Administrative Code. Provisions shall be made to carry out clinical laboratory examinations, including routine chemistry, microbiology, hematology, general immunology, and urinalysis and for assuring the availability of emergency laboratory services 24 hours a day, seven days a week, including holidays. Rule 59A-2.085(9), Florida Administrative Code. 35. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 36. That based upon interview, the Respondent failed to ensure that routine lab testing, including but not limited to complete blood count tests, could be completed in a timely manner around the clock, the same being in violation of law and the failure of which may result in delay in care. 37. That the Petitioner’s representative interviewed the Respondent’s administrator on April 6, 2007 who indicated as follows: a. That the Respondent does not have the lab supplies required to do a Complete Blood Count (CBC); That the quality control solution to test the accuracy of the equipment expires at midnight on April 6, 2007; That the troponin levels, or cardiac blood tests to determine heart attacks, could not be done in the hospital as the Respondent does not have the necessary supplies and though the supplies had been ordered, they are expecting delivery on Tuesday; That pending obtaining necessary supplies, the Respondent has a twenty-four (24) hour courier; That blood samples are obtained and taken to another hospital approximately twenty-five (25) miles away by a twenty-fur (24) hour courrier to have the specimen tested and then the results are faxed back to the facility for Troponin, a diagnostic tool relating to cardiac arrest; That the company that provides the lab supplies had not delivered the Respondent’s orders as the supplier had not been paid and would not deliver anymore supplies. 38. That the Petitioner’s representative could locate no information regarding the Respondent’s plan on how to ensure that complete blood counts would be achieved in the future though the Respondent had identified its inability to meet this diagnostic requirement other than that the supplies would be available on Tuesday. 39. That the failure to ensure that diagnostic testing, including but not limited to complete blood counts and troponin, is in violation of law and places patients at risk for delay or failure to obtain necessary or desired diagnostic testing. 40. That the Agency cited the Respondent facility for the above referenced deficiency. 41. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2){a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT V 42. | The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 43. That pursuant to Florida law, each Class I and Class II hospital shall provide on the premises, and each Class III hospital shall provide on the premises or by contract, diagnostic imaging facilities according to the needs of the hospital and conform to Chapter 404, F.S., Chapter 64E-5, F.A.C., Part IV, Chapter 468, F.S., Chapter 64E-3, F.A.C. Rule 59A-3.2085(10), Florida Administrative Code. 44. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 45. That based upon interview, the Respondent failed to ensure that a licensed radiologist was available to provide radiological diagnostic services for patients that presented to the hospital for care, the same being contrary to law. 46. That the Petitioner’s representative interviewed the Respondent’s administrator on April 6, 2007 who indicated as follows: a. That the Respondent had a contract with the radiologist but could not provide the contract as the FBI had confiscated all of the contracts; b. That a radiologist had been reading the films but it had come to her attention yesterday that he had returned films and refused to read the x-rays; c. That the subject radiologist had not been paid for services as provided by the contract. 47. That the Petitioner’s representative telephonically interviewed the above described contract radiologist on April 6, 2007 who indicated as follows: a. That he had declined to read the x-rays as he had a contract that he was to be paid a month in advance and he had not received any paycheck for the past three (3) weeks; b. That this was not the first time his paycheck had been late; c. That he had received the x-rays back again tonight and he would read the films. 48. That the failure to provide a licensed radiologist, to read X-rays, may result in fractures or other health deficiencies from promptly being detected by persons seeking medical care from Respondent and is in violation of law. 49. That the Agency cited the Respondent facility for the above referenced deficiency. 50. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT VI 51. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 52. That pursuant to Florida law, the licensee shall have a governing body responsible for the conduct of the hospital as a functioning institution. Rule 59A-3.272(1), Florida Administrative Code. 53. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 54. That based upon interview and the review of records, the Respondent’s governing body failed to be diligent in their duties as written in the Respondent’s Bylaws for the operation and management of the hospital to maintain and provide quality care, as a functioning institution, the same being contrary to law. 55. That the Petitioner’s representative discovered during the review of Respondent on April 6, 2007 that a contract radiologist, physicians, lab supply companies, the biohazardous company, and other service or product providers had not been paid as agreed by the Respondent through its management and governing body. 56. That the Respondent hospital management had agreed on March 9, 2007, with the Agency for Health Care Administration (AHCA) that a water heater would be purchased and 11 installed within two weeks time, yet as of April 6, 2007, there was no information provided that would indicate that the described water heater had been ordered and the same had not been installed. 57. That the Petitioner’s representatives interviewed the respondent’s admission staff on April 6, 2007 who indicated that the employees’ paychecks from Respondent would not be available until April 6, 20007 after 6:00 PM. and that "The community bank is not open on the weekends and the stores that know the hospital's history of bouncing checks’ will not cash the checks and sometimes the new owners of the little stores will cash their paychecks because they don't know yet.” 58. That the Petitioner’s representative telephonically interviewed the Respondent’s contract radiologist on April 6, 2007 who indicated as follows: a. That he had not been paid for the past three weeks for reading x-rays; b. That he had been in touch with the administrator to no avail; c. . That therefore he had not read the last set of x-rays sent to him; d. That this had not been his first issues with payment. 59. That the Petitioner’s representative interviewed the Respondent’s physician on staff and emergency room physicians on April 6, 2007 who indicated the that payment for professional services had not been provided by Respondent in the past three weeks and that this is not the first time this has happened. 60. That the Petitioner’s representative reviewed the Respondent’s invoices from its contracted biohazardous waste removal company on April 6, 2007 and noted that the statement reflected that invoices had not been paid for the past several months. 61. That the Petitioner’s representative telephonically interviewed a representative of the Respondent’s contracted biohazardous waste removal company on April 9, 2007 and was informed that there would be no further pick up of biohazardous waste until the Respondent’s outstanding balance is paid. 62. That the governing body has failed to monitor management and to actively resolve issues that physicians, vendors and the AHCA surveyors have brought to their attention. 63. That this failure of the governing body to effectively assure the operation of the facility, including the practice of not paying bills, results in lack of supplies and lack of required staff and service to be able to operate the hospital efficiently effectively and to meet patient needs. 64. That the failure to conduct a hospital as a functioning institution may result in harm to patients seeking medical services, and is contrary to law. 65. That the Agency cited the Respondent facility for the above referenced deficiency. 66. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT VIL 67. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 68. That pursuant to Florida law, the chief executive officer shall take all reasonable steps to provide for: (a) Compliance with applicable laws and regulations; and (b) The review of and prompt action on reports and recommendations of authorized planning, regulatory, and inspecting agencies. Rule 59A-3.273(2)(a)-(b), Florida Administrative Code. 69. That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility. 70. That based upon interviews, the review of records, and observation, the Respondent’s chief executive officer did not respond to previous deficient practice as agreed with the Agency ‘on March 9, 2007, when the lack of hot water issue was investigated by the Agency for Health Care Administration (AHCA). . 71. That the Petitioner’s representative noted that the Respondent’s water heater had not been repaired or replaced by April 6, 2007 as the Respondent had indicated to the Agency would be accomplished during the Petitioners survey of March 9, 2007. 72. That the Petitioner’s representative interviewed the Respondent’s certified nursing assistant on April 6, 2007 who indicated that there was no hot water in the patient's rooms, that in the utility room across from the nurse's station was the only sink that had warm water, and after letting it run it would get hotter. 73. That the Petitioner’s representative turned on the hot water in room number twenty-six (26) on April 6, 2007 at 4:15 PM and that after three to four minutes the water remained cold. 74. That Respondent’s maintenance director was not in the facility at the time of arrival but did appear 30 minutes later. 75. That the Petitioner’s representative interviewed the Respondent’s mmaintenance director on April 6, 2007 at 4:45 Pm who indicated as follows: a. That "the hot water heater has been ordered and the company has not called to let me know it had gotten in yet. The company was told that a check would be cut for them when the heater was delivered and then another check would be cut for labor after it was installed;" That in order to have somewhat hot water in the patient rooms, he had been turning on the hot water in the hopper at the far end of the hospital and let it run, until the patient rooms had heated water; That this was done every three (3) hours that there is a written log with the water temperatures recorded; d. That the "aides on the night shift help him out by turning on the hopper, to let the water run.” 76. That the Petitioner’s representative toured the Respondent’s eemergency department on April 6, 2007 at 4:40 PM and noted as follows: a. b. In examination room A, the water temperature was 110 degrees Fahrenheit In examination room B, the water temperature was 95 degrees; In examination room C, the water temperature was 105 degrees; In patient room 29, the water temperature was 105 degrees; In patient room 32, the water temperature was 110 degrees; That it was noted the water in the hopper room at the end of the hall had been running which had elevated the water temperatures in the patient rooms; That the maintenance director indicated that he had turned the water on upon his arrival to the facility. 77. That the Petitioner’s representative reviewed the Respondent’s water temperature log provided and noted a lack of consistency with the dates or times or evidence of it being checked every three (3) hours as alleged by the maintenance director. 78. That the Petitioner’s representative interviewed the Respondent’s administrator on April 15 6, 2007 who indicated that the administrator had not received any money from Respondent’s administration to pay for the water heater as of April 6, 2007. 79. That the failure to obtain a water heater to meet the facility’s needs is contrary to the requirement that the Respondent’s chief executive officer act promptly to take actions recommended by regulatory agencies as agreed on March 9, 2007. 80. That the Agency cited the Respondent facility for the above referenced deficiency. 81. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). COUNT VII 82. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. . 83. . That pursuant to Rule 59A-3.276(1)(a)-(g), Florida Administrative Code, each hospital shall develop, implement, and maintain a written preventive maintenance plan, in conjunction with the policies and procedures developed by the infection control committee, to ensure that the facility is maintained in accordance with the following: a) The interior and exterior of buildings shall be in good repair, free of hazards, and painted as needed. b) All patient care equipment shall be maintained in a clean, properly calibrated, and safe operating condition; 16 c) All plumbing fixtures shall be maintained in good repair to assure proper functioning, and provided with back flow prevention devices, when required, to prevent contamination from entering the water supply; d) All mechanical and electrical equipment shall be maintained in working order, and shall be accessible for cleaning and inspection; e) Loose, cracked, or peeling wallpaper or paint shall be promptly replaced or repaired to provide a satisfactory finish; f) All furniture and furnishings, including mattresses, pillows, and other bedding; window coverings; including curtains, blinds, shades, and screens; and cubicle curtains or privacy screens, shall be maintained in good repair; and g) The grounds and buildings shall be maintained in a safe and sanitary condition and kept free from refuse, litter, and vermin breeding or harborage areas. 84, That on April 6, 2007, the Petitioner Agency completed a complaint survey, complaint number 2007003855, of the Respondent facility 85. That the Petitioner re-alleges and incorporates paragraphs (69) through (76) as if fully set forth herein. . 86. That based upon interview and inspection, the Respondent failed to purchase and have installed a water heater, or to otherwise ensure that extant facility equipment be repaired or maintained to ensure proper water temperatures for staff and patient use as the Respondent had agreed to implement in its previous plan of correction dated March 22, 2007. 87. That review of the facility's survey history revealed that on March 9, 2007, the Respondent facility was cited for failure to have a functioning water heater based upon patients’ rooms not having hot water. 88. That the failure to ensure that the Respondent’s equipment is maintained in a manner to provide proper services, i.e. hot water provision to the facility taps for patient, staff, and public use is a failure to maintain the premises and it plumbing and equipment in good repair and is in violation of law. 89. That the Agency cited the Respondent facility for the above referenced deficiency. 90. That the above cited deficiency subjects the Respondent facility to the imposition of an administrative penalty in a sum not to exceed one thousand dollars ($1,000.00) per violation per day. § 395.1065 (2)(a) Florida Statutes (2006). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, a hospital in the State of Florida, pursuant to § 395.1065 (2)(a) Florida Statutes (2006). Respectfully submitted this <. day of May, 2007. ar. No. 566365 sel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7004 1350 0004 2776 0659 on May , 2007 to Foye B. Walker, Esq., 506 N.W. Fourth St., Jasper, Florida 32052. alsh II, Esquire Copies furnished to: Foye B. Walker, Esquire Kriste Mennella Counsel for Respondent 14101 NW Hwy 441 506 N.W. Fourth Street , Suite #800 Jasper, Florida 32052 Alachua, FL 32615 (U.S. Certified Mail) (U.S. Mail) Thomas J. Walsh, II, Esquire Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) a 19 SENDER: COMPLETE gigliS SECTION COMPLETE THIS SECTIO gma DELIVERY He ®@ Complete items 1, 2, and 3. Also complete A. Signature item 4 if Restricted Delivery is desired. x Co Agent lm Print your name and address on the reverse AY J eee dressee_! -$o that we can return the card to you. B, Received by (Printed Name) C. Date of Delive "iw Attach this card to the back of the mailpiece, % 5 ota or on the front if space permits. RUG MAA : D. Is delivery address different from item 1 EhYes— 1 Cou, Addressed to: ind If YES, enter delivery address below: [1 No foe 6. walker Caguirg | 506 WW. “Fourth Shred — / Cours. Hesp- t Jasper, Flovdle S| Ss Oo insured Mal Oco.. & A CSA 4. Restricted d Delivery? Extra Fee) Yes a (Transfer from PS Form 381 1, February 2004 Domestic Return Receipt 102595-02-M-1540 :

Docket for Case No: 07-003819