La 9/27/2887 13:29 ° 9547760904 . GOGE «8B a 4 SEP-27-2807 11:15 AGENCY HEALTH CARE ADMIN abu S21 e158“ Pyg2 o . Fat oN ” STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION - STATE OF FLORIDA, ' AGENCY FOR HEALTH CARE . ADMINISTRATION, 7 y Ky | - Petidoner, O 5 VS . . ; AHCA No.: 2007005018 ARLINGTON HOUSE ACLF, , ff - Respondent. ap te aS T) Cc LAIN: COMES NOW the Petitioner, State of Florida, Agency For Health Care Administration (hereinafter “the Agency"), by and through its ‘widorsigned counsel, and files this Administrative Complaint against the Reapondent, Arlington House ACLF (hereinafter “the Respondent"), putsuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges as follows: NATURE OF THE ACTION . I. - This is an action to impose an administrative fine against an assisted living facility in the amount of one thousand dotlars (31,000), pursuant to section 429,19(2)(b), Florida Statutes (2006), based upon one (1) Class Il deficiency, . JURISDICTIO VE 2. This Court has jurisdiction over the subject matter pursuant to Seetions 120.569 and 120,57, Florida Statutes (2006). . 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 49, Part © Florida Statutes (2006), Chapter 584-5, Florida Administrative Code (2006) and Ch. 408, Part II, Florida Statutes (2006). . 89/27/2887 13:29 9547768984 PAGE 43 SEP-27-2887 11:15 ; AGENCY HEALTH CARE ADMIN 850 921 4158 PLB " "4. >. Venue’ lies in Putnam County pursuant to Rule 28-106.207, Florida Administrative Code (2006), . BP. ES 5. The Agency is the regulatory authority responsible for the licensure of assisted : living facilities and the enforcement of all applicable federal and state regulations, atatutes and rules, governing assisted living facilities pursuant to Chapter 429, Part J, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code * (2006). 6. ‘The Respondent is a Florida licensed assisted living facility (License Number 7349), operates a one hundred and fifty (150) bed assisted living facility located at -203 S. Moody Road, Palatka, FL 32177, and was at ail times material required to comply with all applicable state regulations, statutes and rules for assisted living facilities. COUNT! THE RESPONDENT FAILED TO FILE A ONE DAY ADVERSE INCIDENT REPORT TO THE AGENCY FOR HEALTH CARE ADMINISTRATION, EVEN THOUGH THEY WERE FULLY AWARE OF THE REGULATIONS AS THEY HAVE BEEN CITED FOR THIS EXACT ISSUE IN THE RECENT PAST IN VIOLATION OF CHAPTER 429,23(3) Fla, Stat, (2006) 7. The Agency re-alleges paragraphs 1 through 6. 8. On or about Mach 12, 2007, the Agency made an unannounced compisint investigation of the Respondent. 9. At that time, the Respondent did not comply with the above provisions of ‘the Florida Statutes, 9/27/2807 13:29 9547768984 PAGE 44 SEP-27-2887 11:15 AGENCY HEALTH CARE ADMIN ry 858 921 @158 P.a4 os “10, Based on record review and interview the facility failed to file a one day adverse incident report to the Agency for Health Care Adrninistration, even though they - were fully aware of the regulations as they have been cited for this exact issue in the recent past. The findings include: , \ Review of the facility's history revealed the facility was cited for failing to file 2 one day . adverse incident report during their October 30-31, 2006 Change of Ownership survey. Further review of the facility's history revealed the facility has an uncorrected class IT deficiency regarding it's failure to submit a one day adverse incident report, during the follow up to the Change of Ownership follow up survey conducted on 12/1/06. During review of facility records, it was discovered that an adverse incident had occurred on 2/28/2007, where it was necessary to transport the resident to the hospital. This resident later expired as a result of the injuries sustained during the incident. Review of the facility's recorda revealed that the Administrator did not submit the required Tnitial ' Adverse Incident Report to the Agency until 3/2/2007. Interview with the Human Relations Manager on 3/12/2007 at 2:00 PM revealed that he/she was not aware of the delay in reporting the Adverse Incident by the Administrator. 11, AHCA gave a correction date of 4/12/2007. 12. The Agency seeks to imposes an administrative fine in the amount of one thousand dollars ($1000.00), against the Respondent pursuant to scotion 429,28(2)(b), Florida Statutes (2006). ) , an CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests that the Court order the following relief against Respondent: (A). Make findings of fact and conolusionis of law in favor of the Agency as set forth above. - (B) Recommend an administrative fine in the amount of one thousand dollars ($1,000) pursuant to Section 396.1065(2)(a), Florida Statutes (2006); and (C) Grant all other general and equitable relief allowed by law. 99/27/2807 13:29, 9547768984 PAGE 85 SEP-27-2007 14:15 AGENCY HEALTH CARE ADMIN 85@ 921 0158 P.8S Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120,569, Fiprida Statutes, Specific options for administrative action ara set out in the attachod Election of Rights form. All requests for hearing shell be made to the stiention of Richard Shoo, Agency Clerk, Agency for Health Care Administration, 2727 Mahiatt Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the tight to be represented by an attorney in this matter. 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. a“ a ), Respectfully submitted on ag day of August, 2007. Cf) . Agency for Health Care Administration teqzy, 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 ., (850) 922-5873 CERTIBNIGATE OF SERVICE, ~ I HEREBY CERTIFY that the Administrative Complaint and Election of Rights form have been served to: Administrator, Andy Subachan, Arlington House ACLF, 203 S. Moody Road, Palatka, Florida 32177, by U.S. Certified Mail, Return Receipt Requested (7004 2890 0000 5527 1190), to Owner A & J of Palatka, Inc, 11606 Hibbs Grove Drive, Cooper City, Florida 33330, by U.S. Certified Mail, Return Receipt Requested (7004 2890 0000 5527 1183), and Registered Agent, Judy Subachan, 11606 Hibbs Grove Drive, Cooper City, Florida aCe by U.S. Certified Mail, Return Receipt Requested (7004 2890 00000 5527 1176) on this —n 69/27/2887 13:29 9547768984 PAGE 4&6 SEP-27-207 14:16 AGENCY HEALTH CARE ADMIN ta 85@ 921 0158 P.65 ; ries day of August, 2007. Copy furnished to: Kris Mennella, FOM. TOTAL P.@5 Q@1/16/20a7 10:46 9547768984 PAGE 82° . Division of Administrative He’ - STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRAT! ' 2727 Mahan Drive, MS#30 Tallahassee, FL 32308 g \ . = oF ~\ a a IN RE: THE REQUEST FOR HEARING CONCERNING | ae 2M - FRAES NO, 2006010879 S45 ¢ pf - . ARLINGTON HOUSE ACLF, . 239 2 oT 203 South Moody Road ~ 9 > ~ = | Palatka, FL 32177 O 7-0 U OCz= 2 To (386) 328-0657 s Oo.” wo ; AMENDED REQUEST FOR FORMAL HEARING Cames now, ARLINGTON HOUSE ACLF, by and through its undersigned counsel, and file this its AMENDED REQUEST FOR FORMAL HEARING and alleges: 1. Undersigned counsel represents Arlington House with regards to the AHCA'S Notice of Intent to Deny dated December 413, 2006 wherein the CHOW application for an assisted living facility license was denied. 2. Arlington House received the Notice of Intent to Deny on December 18, 2006 by certified mail. . 3. If the CHOW license | is denied, such denial will substantially affect the facility by forcing it to close after a substantial’ expenditure of funds to purchase the business and substantial efforts to continue to house and care for long term residents, 4. If the CHOW license is denied, such denial will substantially affect the facility by compelling it to relocate long term residents who will be traumatically displaced fram ‘the only home they've known for years, 5. AHCA conducted an unannounced CHOW survey at the facility.on October 31,- 2006, citing the facility with nineteen alleged Class II] deficiencies, 6.AHCA conducted a follow up survey on December 1, 2006, citing the facility with seventeen Class II! remaining alleged deficiencies. 7. The facility was and is in substantial compliance with Chapter 429, Part 1, F.S. and Chapter 58A-5.029, FAC. : 8. All issues of material fact are in dispute as: A). The facility maintained up to date A&D logs containing the names and dates of admission and discharge for those residents receiving LMH services. B). The facility annually updated compliant proper community living. support plans. . C) For residents for whom the facility acts as representative payee, the facility maintained proper documentation verifying that the residents were given quarterly financial statements as required, thus keeping the _Tesidents fully informed regarding their financial status, D) As representative payee for residents, the facility the facility provided each resident with statements detailing the amount and type of funds credited to the resident for whom the funds are held. The residents were not at risk for not being fully informed regarding their financial status. E). For residents for whom the facility acts as representative payee, the facility properly notified residents in writing of the manner in which it holds residents’ funds, providing the residents with the name and address of the depository holding the funds and the type of funds credited, The residents were not at risk for not being fully informed regarding their financial status. F) Asa representative payee, the facility held more than sufficient bond for funds it holds equal to twice the average monthly aggregate income or personal funds due to residents or expendable for their account. For OSS residents, the facility holds sufficient bond equal to twice the SSI or SSD.income plus OSS payments including the personal needs allowance. The residents were not at risk for not having their income safeguarded should the facility suffer financial difficulty. G). The facility had documentation that it was in the process of obtaining satisfactory annual fire safety inspections conducted by the local fire marshal or authority having jurisdiction. H).The facility maintained proper up to date records of adverse incidents occurring within the last 2 years. 1) The facility timely submitted proper and timely preliminary reports to AHCA of all adverse incidents after their occurrence. | , ). Each resident has been properly determined appropriate for admission to the facility by the facility administrator. Medical examination reports contained all required information to make an informed decision regarding the residents’ appropriateness for admission. The facility maintains complete and legible health assessments for’ residents. There was no inappropriate determination of admission leading to the residents not receiving the care and service required, K) Residents are timely examined by a physician, physician assistant or. advanced registered nurse practitioner who provides the owner or administrator with a medical examination report. No residents failed to receive the care and services he or she required. K). The facility maintains complete Resident Health assessments for its residents. L) The facility maintains written updated records of significant changes, any illnesses which result in medical attention, major incidents, changes in the method of medication administration and other changes which result in the provision of additional services. M) The facility's physical structure, including the interior and exterior © walls, floors, roof and ceilings were structurally sound and in good repair., The sidewalk was even. Bathrooms and door frames were sanded and painted, tiles were mate sound, N) All furniture and furnishings were clean, functional, free of odors and in good repair or replaced. Q) Residents who use’ portable bedside commodes are provided curtained privacy when in use. . ( P) The facility documented that unlicensed persons who. provide assistance with self-administered medication, successfully completed the initial 4 hour training and annually obtain a minimum of 2 hours of continuing education, training on providing assistance with self- administered medications and safe medication practices in ALFs. 9. All financial records, some of which are kept off premises, are reasonably accessible to investigators. 10. Because the facility was and is in substantial compliance with Chapter 429, Part 1, F.S. and Chapter 58A-5.029, F.A.C. by because it maintains up to date A&D logs, annually updates proper community living support plans, maintains proper documentation verifying that the residents are given quarterly financial statements, provides residents with statements detailing funds credited to the resident for whom itis a representative payee, properly notifies each resident of the manner in which it halds residents’ funds, holds sufficient bond for funds it holds, documents satisfactory annual! fire safety inspections, maintains property records of adverse incidents, timely submits . proper preliminary reports of all adverse incidents after their occurrence, property 4 determines appropriateness for residents! admission to the facility, insures that residents are timely examined by a physician, physician assistant or advanced registered nurse practitioner who provides a medical examination report, maintains complete Resident Health assessments, maintains written updated records of significant changes, ilnesses, major incidents, changes in method of medication administration and other changes which result in the provision of additional services, maintains a physical structure which is sound and good repair, maintains clean, functional odor free furniture and furnishing in good repair, provides privacy for portable bedside commode use and properly documents continuing education and initial training of unlicensed persons who provide assistance with self-administered medication, ACHA's denial of the CHOW application for an assisted living facility should be reversed. 11. The facility was in substantial compliance with the rules and statutes, 58A- 5.029(2)(a), 58A-5.029(2)(c)3,a.vii, 58A-5.021(7)(a), 429.27(4) F.S., 58A-5.014(2)(c)1, 58A-5.014(2)(c)2, 58A-5.021(6)(a)1, 429.41(1)(a)1.m. F.S., 58A-5.015(1)(a)3, 429.23(2) F.S,, 429.23(3) F.S., 58A-5.0181(1)(n)1-3, 58A-5.0181(2)(a), 429.26(4) F.S., 58A- 5.0181(2)(a)1, 58A-5.0181(2)(a)2, 5BA-5.0181(2)(a)3, 58A-5.0181(2)(a)4,. 5BA- 5.0181(2)(a)5, 58A-5,0181(2)(a)6, 58A-5,0181(2)(a)7, 58A-5,.0181(2)(a)8, 429.26(4) F.S., 429.26(5) F.S., 58A-5.0181(1)(e), .58A-6.023(1)(b), 58A-5.023(1)(b), 58A- 5.0181(5)(e), 58A-5.0191(5)(c), 58A-5.024(2)(a)1, 429.256 F.S., thus requiring reversal of AHCA's denial of CHOW license. . 12, Because the facility: was in substantial compliance with the aforecited rules ~-and statutes, five or more Class II! deficiencies (the basis of license denial pursuant to FS 429.14 (1)(e)3 did not exist. 13, Because the residents were not at risk for not being fully informed regarding their financial status, .the residents were not at risk for not having their income safeguarded should the facility suffer. financial difficulty, there was no inappropriate 5 determination of admission leading to the residents not receiving the care and. service required, the CHOW application should be granted and the license issued. WHEREFORE, undersigned counsel request that the CHOW application for assisted living facility should be granted and the license issued. , | HEREBY CERTIFY that a copy of the foregoing was faxed to 850 921 9158 and mailed by Federal Express to Agency Clerk, AHCA, 2727 Mahan Drive, MS #3, Tallahassee, FL 32308 this 16" day of January, 2007, Donna Szczebak O'Neil, Esq. Attorney for ARLINGTON HOUSE Donna Szezebak O'Neil, P.A. 301 E, Commercial Boulevard Fort Lauderdale, FL 33334 ° 954 776-0887 .

Docket for Case No: 07-004561