Certified Mail Receipt OM tat y ; (7003 1010 0000 9715 4136) WO AN mY Pay bt 32 STATE OF FLORIDA AGENCY FOR HEALTH CARE/ADMINISTRATION STATE OF FLORIDA . AGENCY FOR HEALTH CARE O«- O\O0\ - ADMINISTRATION, Petitioner, AHCA Nos.: 2007012301 VS. LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, Respondent. ee ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Lake View Nutrition Consulting Services, Inc. d/b/a Henderson House (hereinafter “Ann’s House Inc. II”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2007), alleges: NATURE OF THE ACTION 1. This is an action to impose one (1) administrative fine against Henderson House in the amount of One Thousand Dollars ($500.00), based upon one (1) uncorrected class III deficiency, pursuant to Sections 429.19(2)(c), Fla. Stat. (2007), and Rule 58A- 5.185(5)(b), Fla. Admin. Code (2007). | JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 429, Part 1 and Section 120.569 and 120.57, Fla. Stat. (2007). 3. Venue lies in Lake County, Eustis, Florida, pursuant to Section 120.57 Fla. Stat. (2007); Rule 58A-5, Fla. Admin. Code (2007) and Section 28,106,207, Fla. Stat. (2007). | 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 429, Part l, Fla. Stat. (2007) and Rule 58A-5, Fla. Admin. Code (2007). 5. Henderson House is a for-profit corporation, whose: 44-bed assisted living facility is located at 907 E. Orange Avenue, Eustis, Florida 32726. Henderson House is licensed as assisted living facility license # AL6622; certificate nuiber #24151, effective November 8, 2007 through February 7, 2008. Henderson House was at all times imatertal hereto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I HENDERSON HOUSE FAILED TO MAINTAIN STATE TAG A619-MEDICATIONS CARE STANDARDS Section 429.19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ADMINISTRATION FINES; GROUNDS Rule 58A-5.185(5)(b), Fla: Admin. Code (2007) MEDICATION PRACTICES 6. AHCA te-alleges and incorporates paragraphs (1) through (5).as if fully set forth herein. . 7. On or about September 12, 2007, AHCA conducted a follow-up survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about August 8, 2007, Henderson House failed to ensure that staff documented in the (MOR) Medication Observation Record when they assisted 11 (#1-#11) of 11 residents in the potential for medication error. b.) During a follow-up survey-on or about September 12, 2007, Henderson House failed to maintain an up to date daily medication observation record for each resident that, reflected that the residents who receive assistance with self administration of medications had received their medications as ordered. Failure to maintain up-to-date MORs may result in a resident being overdose as no one would know the resident had already taken the medications. The Findings are: Review of the facility's 09/2007 MOR revealed that the facility failed to record that resident #1 had taken his/her medication, and that resident #2 had refused to take his/her medication. Resident #1 was scheduled to receive the following medications at 8:00 AM: Aspirin 325 milligram (mg); Benztropine MES 0.5 mg; Stelazine 2 mg; and colace 100 mg. The facility had not recorded that the resident had. received his/her medications. Per the 2:45 PM, at 09/12/2007 interview the medication tech assigned to assist with medications reported that she had assisted with the medications, but failed to record them as taken, because she turned the page to fast. Resident #2 was scheduled to take 16, 8:00 AM medications, including Zoloft 50 mg; Lexapro 10 mg; Aspirin 352 mg; and Lasix 20 mg. Pre interview, conducted on 09/12/07 at 2:45 PM, ‘the med tech reported that resident #2 had refused to take his/her medication; and that she had not recorded, R, to indicate that the resident had refused. Class II Correction Date: 10/12/07 8. The regulatory provisions of the Fla. Stat. (2007), that is pertinent to this alleged violation read as follows: 429,19 Violations;-imposition of administrative fines; grounds. ~ _ (2(c) Class "III" 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 indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class 11 or class II violations. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation is required to. be corrected. If a class III violation is corrected within the time specified, no fine. may be imposed, unless it is a repeated offense. * ok * 58A-5.0185 Medication Practices. (5)(b) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for' use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each. time the medication is offered or administered. : 9. The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $500.00. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $500.00. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Henderson House an administrative fine in the amount of $500.00 for the violation cited above. 3. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2007). Specific options for administrative action 'are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). . All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL le THE AGENCY. Florida. ; Michael O. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true.and gfrrect copy of the foregoing has been served by ‘certified mail on __ (day of SMS" 2*1, 2007 to Evelyn Richardson, | Administrator, Henderson House, 907 E. Orange Avenue, Eustis, Florida 32726. Michael O. Mathis, Esq. ‘9zZzE 4 ‘SILSNA Ul £002 ‘91 JequIancN UO Wd OZ!) Je PAJeA!|ap Sem WAY JNO, Me) Pa1aaeg :snjeys 9ELP SLZ6 0000 OLOL £002 JOquINN ydisoay/jeqe] syNSey Yoreag ee Reverse for Instructions. Se WYO) gy YIeAL 2 Retum Reciept Fee (Endarsement Required) (Oomestic Mail Only; No insurance Coverage Provided) For delivery information visit our website at www.usps.co! | HB U.S. Postal Servicer CERTIFIED MAIL, RECEIPT Restricted Delivery Fee (Endorsement Required) Total Postage & Fees PS Form. 3800. 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Docket for Case No: 08-000101