STATE OF FLORIDA 0 Lp AGENCY FOR HEALTH CARE ADMINISTRATION ~~ af) . 9 by i 2 . 4 . STATE OF FLORIDA, OX VI U > INS Te Y Oe 42 AGENCY FOR HEALTH CARE CARS UNE Aly, ADMINISTRATION, co Petitioner, vs. Case No. 2007013976 VANDERBILT BEACH ASSISTED LIVING HOME, LLC d/b/a VANDERBILT BEACH ASSISTED LIVING HOME, 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, VANDERBILT BEACH ASSISTED LIVING HOME, .LLC d/b/a VANDERBILT BEACH ASSISTED LIVING HOME (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of FOUR THOUSAND DOLLARS ($4,000.00) and to assess a survey fee in the amount of FIVE HUNDRED DOLLARS ($500.00) based upon eight (8) uncorrected Class If deficiencies. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2007). 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 assisted living facilities. Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes (2007); Chapter 58A-5, Florida Administrative 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. Sections 408.813, 408.815, 429.14, Florida Statutes (2007). 5. The Respondent was issued a license by the Agency (License Number 5582) to operate a 13-bed assisted living facility located at 517 100° Avenue N., Naples, Florida 34108, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules governing assisted living facilities. COUNT I The Respondent Failed To Provide An Admission Package With Required Components In Violation Of Rule 58A-5.024(1)(i), and Rule 58A-5.0181(3)(a), Florida Administrative Code (2007) 6. The Agency realleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, facility records shall include the admission ‘package presented to new or prospective residents (less the resident’s contract) described in Rule 58A- 5.0182, Florida Administrative Code. Rule 58A-5.024(1)(i), Florida Administrative Code. Pursuant to Florida law, the facility shall make available to potential residents a written statement(s) which includes the following information. A copy of the facility resident contract or facility brochure containing all the required information shall meet this requirement: The facility’s residency criteria; The daily, weekly or monthly charge to reside in the facility and the services, supplies, and accommodations provide by the facility for that rate; Personal care services that the facility is prepared to provide to residents and additional costs to the resident, if any; Nursing services that the facility is prepared to provide to residents and additional costs to the resident, if any; Food service and the ability of the facility to accommodate special diets; The availability of transportation and additional costs to the resident, if any; Any other special services that are provided by the facility and additional cost if any; Social and leisure activities generally offered by the facility; Any services that the facility does not provide but will arrange for the resident and additional cost, if any; A statement of facility rules and regulations that residents must follow as described in Rule 58A-5.0182, Florida Administrative Code; A statement of the facility policy concerning Do Not Resuscitate Orders pursuant to Section 429.255, Florida Statutes, and Advance Directives pursuant to Chapter 765, Florida Statutes; If the facility also has an extended congregate care program, the ECC program’s residency criteria; and a description of the additional personal, supportive, and nursing services provided by the program; additional costs; and any limitations, if any, on where ECC residents must reside based on the policies and procedures described in Rule 58A-5.030, Florida Administrative Code; If the facility advertises that it provides special care for persons with Alzheimer’s disease and related disorders, a written description of those special services as required under Section 429.177, Florida Statutes; and a copy of the facility’s resident elopement response policies and procedures. Rule 58A-5.0181(3)(a), Florida Administrative Code (2007). | 8. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 9. Based on interview and record review, the facility does not have an. admission package with required components. 10. | On October 8, 2007, the facility manager provided a one page marketing tri-folder and an advertising postcard announcing "50% off the Ist Month's Rent." 11. — The facility administrator stated the facility is in the process of creating a revised admission package. There was no admission package available for review on October 8, 2007. 12. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 13. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. 14. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 15. Based on observation and interview, the facility does not have an admission package, with required components. 16. An inspection of the Admission Package on November 19, 2007, revealed the package does not include a list of room rental rates; accommodations which the facility can make, if any, for residents with special dietary needs, and the Resident Bill of Rights. 17. During an interview with the facility owner/administrator at 2:10 p.m. on November 19, 2007, the owner/administrator stated, "We didn’t put the room rate in because the room rate will depend upon the care the resident needs." 18. An observation of the package at the time of the interview revealed no charge amounts noted besides the listing of personal services offered by the facility. 19. This remains an uncorrected deficiency. 20. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 21. The Respondent’s deficiency constituted an uncorrected Class III violation. 22. The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 23. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT I The Respondent Failed To Ensure In-Service Training To Staff Who Provide Direct Care To Residents In Violation Of Rule 58A-5.0191(2)(d), And Rule 58A-5.0191(11)(a), Florida Administrative Code (2007) 24. The Agency re-alleges and incorporates by reference paragraphs one (1) through ‘five (5). 25. Pursuant to Florida law, staff who provide direct care to residents, other than nurses, certified nursing assistants, or home héalth aides trained in accordance with Rule 59A- 8.0095, Florida Administrative Code, must receive three (3) hours of in-service training within thirty (30) days of employment that covers the following subjects; Resident behavior and needs and providing assistance with the activities of daily living. Rule 58A-5.0191(2)(d), Florida Administrative Code. Pursuant to Florida law, except as otherwise noted, certificates of any training required by this rule shall be documented in the facility’s personnel files which documentation shall include the subject matter of the training program, the trainee’s name, the date of attendance, the training provider’s name, signature and credentials, professional license number if applicable, and the number of hours of training. Rule 58A-5.0191(11)(a), Florida Administrative Code. 26. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 27. Based on record review, the facility failed to ensure two (2), employee number one (1) and employee number four (4), of four (4) direct care employees sampled received a required class on emergencies, major incidents, and adverse incidents. 28. Employee number one (1) was hired on August 5, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function ina direct care giver role. 29. A review of the employee's personnel file on October 8, 2007, does not locate evidence of completion of training in emergencies, major incidents, and adverse incidents. 30. | Employee number four (4) was hired on August 3, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 31. A review of the employee's personnel file on October 8, 2007, does not locate evidence of completion of training in emergencies, major incidents, and adverse incidents. 32. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 33. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. 34. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 35. Based on record review, the facility failed to ensure one (1), employee number one (1), of one (1) direct care employee sampled received a required class on emergencies, major incidents, and adverse incidents. 36. | Employee number one (1) was hired on August 5, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 37. Areview of the employee's personnel file on November 19, 2007, does not locate evidence of completion of training in emergencies, major incidents, and adverse incidents. 38. | This remains an uncorrected deficiency. 39. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 40. The Respondent’s deficiency constituted an uncorrected Class III violation. 41. The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 42. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT It ; The Respondent Failed To Provide In-Service Training To Staff Regarding Resident Elopement Response Policies And Procedures Within Thirty (30) Days Of Employment In Violation Of Rule 58A-5.0191(2)(c), and Rule 58A-5.0191(11)(a) Florida Administrative Code (2007) 43. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 44. Pursuant to Florida law, staff who provides direct care to residents, who have not taken the core training program, shall receive a minimum of one (1) hour in-service training within thirty (30) days of employment that covers the following subjects: Resident rights in an assisted living facility. Recognizing and reporting resident abuse, neglect, and exploitation. Rule 58A-5.0191(2)(c), Florida Administrative Code. Pursuant to Florida law, except as otherwise noted, certificates of any training required by this rule shall be documented in the facility’s personnel files which documentation shall include the subject matter of the training program, the trainee’s name, the date of attendance, the training provider’s name, signature and credentials, professional license number if applicable, and the number of hours of training. Rule 58A-5.0191(11)(a), Florida Administrative Code. 45. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 46. Based on record review, the facility failed to ensure one (1), employee number one (1), of four (4) direct care employees sampled is trained on abuse/neglect/rights within thirty (30) days of hire. 47. Employee number one (1) was hired on August 5, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 48. A review of the employee's personnel file on October 8, 2007, does not locate evidence of completion of training in abuse/neglect/rights. 49. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 50. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. 51. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 52. Based on record review, the facility failed to ensure one (1), employee number one (1), of one (1) direct care employee sampled is trained on abuse/neglect/rights within thirty (30) days of hire. 53. Employee number one (1) was hired on August 5, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 54. A review of the employee's personnel file on November 19, 2007, does not locate evidence of completion of training in abuse/neglect/rights. 55. This remains an uncorrected deficiency. 56. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 57. The Respondent’s deficiency constituted an uncorrected Class IIT violation. 58. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 59. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT IV The Respondent Failed To Ensure An Employee Had Received Training In Elopement Response Policies And Procedures Within Thirty (30) Days Of Hire In Violation Of Rule 58A-5.0191(2)(f), Florida Administrative Code (2007) 60. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 61. Pursuant to Florida law, all facility staff shall receive in-service training regarding the facility’s resident elopement response policies and procedures within thirty (30) days of employment. All facility staff shall be provided with a copy of the facility’s resident elopement response policies and procedures. All facility staff shall demonstrate an understanding and competency in the implementation of the elopement response policies and procedures. Rule 58A- 5.0191(2)(f), Florida Administrative Code. 62. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 63. Based on record review, the facility failed to ensure two (2), employee number one (1) and employee number (4), of four (4) direct care employees sampled received training in elopement response and policies/procedures within thirty (30) days of hire. 64. Employee number one (1) was hired on August 5, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 65. A review of the employee's personnel file on October 8, 2007, does not locate evidence of completion of training in elopement response and policies/procedures within thirty (30) days of hire. 66. Employee number four (4) was hired on August 3, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 67. A review of the employee's personnel file on October 8, 2007, does not locate evidence of completion of training in an elopement response and policies/procedures within thirty (30) days of hire. 68. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 69. The Respondent was given a mandatory correction date of November 9, 2007 for this deficient practice. 70. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 71. Based on record review and interview, the facility failed to ensure one (1), employee number one (1), of one (1) direct care employee sampled received training in elopement response and policies/procedures within thirty (30) days of hire. 72. Employee number one (1) was hired on August 5, 2007. The employee is a Certified Nursing Assistant who is hired by the facility to function in a direct care giver role. 73. A review of the employee's personnel file on November 19, 2007, does not locate evidence of completion of training in elopement response and policies/procedures within thirty (30) days of hire. 74. On November 19, 2007 at 1:30 p.m., during an inspection of the attendance signatures for the elopement policy and procedures, The Business Office Manager stated, "The employee did not attend the class we had on October 12th.” 75. This remains an uncorrected deficiency. 76. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 771. The Respondent’s deficiency constituted an uncorrected Class III violation. 78. The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 79. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). | COUNT V ; The Respondent Failed To Ensure An Employee Had A Health Care Provider Statement Indicating Freedom From Communicable Disease, Including Tuberculosis, In Violation Of Rule 58A-5.024(2)(a)1, Florida Administrative Code (2007) - 80. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 81. Pursuant to Florida law, personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition, records shall contain the following, as applicable, documentation of compliance with all staff training required by Rule 58A-5.0191, Florida Administrative Code. Rule 58A-5.024(2)(a)1, Florida Administrative Code. 82. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 83. Based on record review, the facility failed to ensure two (2), employee number one (1) and employee number four (4), out of four (4) employees sampled have a health care provider statement indicating freedom from communicable disease, including Tuberculosis. 84. | Employee number one’s (1) personnel file review completed on October 8, 2007, and confirmed by the facility manager, fails to locate a document signed by a health care provider indicating freedom from communicable disease, including Tuberculosis. 85. | Employee number four’s (4) personnel file review completed on October 8, 2007, and confirmed by the facility manager, fails to locate a document signed by a health care provider indicating freedom from communicable disease, including Tuberculosis. 86. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429. 19(2)(C), Florida Statutes (2007). 87. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. 88. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 89. Based on record review, the facility failed to ensure one (1), employee number one (1), out of one (1) employee sampled have a health care provider statement indicating freedom from communicable disease, including Tuberculosis. 90. | Employee number one’s (1) personnel file review completed on November 19, 2007, and confirmed by the Business Office Manager at 1:30 p.m., fails to locate a document signed by a health care provider indicating freedom from communicable disease, including Tuberculosis. 91. This remains an uncorrected deficiency. 92. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 93. The Respondent’s deficiency constituted an uncorrected Class III violation. 94. The Agency shall impose an administrative fine for a cited Class Hl violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 95. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT VI . The Respondent Failed To Ensure That Staff Had Documentation Of Medication Assistance Training In Violation Of Section 429.256(b), Florida Statutes (2007) And Rule 58A-5.0191(5)(c), And Rule 58A-5.024(2)(a)1, Florida Administrative Code (2007) 96. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 97. Pursuant to Florida law, "unlicensed person" means an individual not currently licensed to practice nursing or medicine who is employed by or under contract to an assisted living facility and who has received training with respect to assisting with the self-administration of medication in an assisted living facility as provided under s. 429.52 prior to providing such assistance as described in this section. Section 429.256(b), Florida Statutes (2007). Pursuant to Florida law, unlicensed persons who will be providing assistance with self-administered medications as described in Rule 58A-5.0185, Florida Administrative Code, must receive a minimum of four (4) hours of training prior to assuming this responsibility. Courses provided in fulfillment of this requirement must meet the following criteria: Unlicensed persons, as defined in Section 429.256(1)(b), Florida Statutes, who provide assistance with self- administered medications and have successfully completed the initial four (4) hour training, must obtain, annually, a minimum of two (2) hours of continuing education training on providing assistance with self-administered medications and safe medication practices in an assisted living facility. The two (2) hours of continuing education training shall only be provided by a licensed registered nurse, or a licensed pharmacist. Rule 58A-5.0191(5)(c), Florida Administrative Code. Pursuant to Florida law, personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition, records shall contain the following, as applicable, documentation of compliance with all staff training required by Rule 58A-5.0191, Florida Administrative Code. Rule 58A-5.024(2)(a)1, Florida Administrative Code. 98. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 99. ° Based on record review, the facility failed to ensure two (2), employee number one (1) and employee number four (4), out of four (4) employees sampled has received Medication Assist Update training on an annual basis. 100. A review of residents indicates there are residents in the facility who are assessed as having to receive assistance with self-medication from unlicensed staff. There are no licensed nurses working in the facility, with the exception of the Hospice nurse who communicates with the staff for one resident. 101. Arrecord review of Employee number one’s (1) personnel file on October 8, 2007, indicates the employee date of hire as August 5, 2007. The file documents the employee had received Medication Assistance Training on March 31, 2004. There is no documentation of annual Medication Assist Update classes from that date to present. 102. A record review of Employee number four’s (4) personnel file on October 8, 2007, indicates the employee date of hire as August 3, 2007. The file documents the employee had received Medication Assistance Training in April 2006. There is no documentation of annual Medication Assist Update classes from that date to present. 103. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class II deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 104. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. 105. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 106. Based on record review and interview, the facility failed to ensure one (1), employee number five (5), of one (1) newly hired employees sampled has documentation of medication assistance training. 107. Employee number five (5) was hired on November 7, 2007 as a direct care Certified Nursing Assistant. 108. A review of the employee's personnel training file revealed no certificate for having completed a four (4)-hour Medication Assist class. 109. During an inspection of the Excel employee training spreadsheet with the Business Office Manager on November 19, 2007 at 12:00 p.m., the manager stated, "This person is a Med Tech." There was no evidence of completion of a Med Tech class in the employee's file. 110. At the time of the interview on November 19, 2007 at 12:00 p.m., the Business Office Manager indicated that the term "Med Tech" class on the computer spreadsheet actually meant "Completion of a 4-hour Medication Assistance class." When questioned if the employee was giving assistance with medications to the facility residents, the manager answered, "Yes." 111. This remains an uncorrected deficiency. 112. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 113. The Respondent’s deficiency constituted an uncorrected Class ITI violation. 114, The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 115. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT VIT Respondent Failed To Ensure That Sampled Employees Who Provide Services Which Require Licensure Or Certification Had Documentation Of That Licensure Or Certification In Violation Of Section 429.275(2), Florida Statutes (2007), And Rule 58A- §.024(2)(a)2, Florida Administrative Code 116. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 117. Pursuant to Florida law, the administrator or owner of a facility shall maintain personnel records for each staff member which contain, at a minimum, documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, and a copy of all licenses or certification held by each staff who performs services for which licensure or certification is required under this part or rule. Section 429.275(2), Florida Statutes (2007). Pursuant to Florida law, Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition, records shall contain the following, as applicable: Copies of all licenses or certifications for all staff providing services which require licensing or certification. Rule 58A-5.024(2)(a)2, Florida Administrative Code. 118. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 119. Based on interview and record review, the facility fails to ensure one (1), employee number two (2), of five (5) employees providing services which require licensure or certification has documentation of that licensure or certification. 120. A review of employee number two’s (2) personnel file on October 8, 2007, indicates the employee was hired on September 28, 2007, as a newly graduated nursing assistant. There is documentation of her course work in her file. There is no documentation in her file of certification. 121. An interview with the facility manager and the administrator at 6:30 p.m. on October 8, 2007, confirms she has completed her required training and has applied to the State for her certification, but neither could provide proof of her application to become certified. 122. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Il deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 123. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent's ; facility. 125. Based on interview and record review, the facility failed to ensure two (2), employee number two (2) and employee number five (5), of two (2) employees providing services which require licensure or certification has documentation of that licensure or certification. 126. A review of employee number two’s (2) personnel file on November 19, 2007, indicates the employee was hired on September 28, 2007, as a newly graduated nursing assistant. There is documentation of her course work in her file. There is no documentation in her file of a Certified Nursing Assistant certification. 127. An interview with the Business Office Manager and the owner/administrator at 2:30 p.m. on November 19, 2007, confirms the employee has completed the required training and has applied to the State for her certification, but proof of the employee's application to become certified is located in the employee's personnel file. The owner/administrator stated, "I even helped the employee to fill out the application, talked to the school the employee went to and got an admission number for the employee.” "We do not have anything from the employee saying when the employee is scheduled for the test.” | 128. A review of employee number five’s (5) personnel file on November 19, 2007, indicates the employee was hired on November 7, 2007 as a direct care Certified Nursing Assistant. 129. This remains an uncorrected deficiency. 130. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 131. The Respondent’s deficiency constituted an uncorrected Class III violation. 132. The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars 20 ($1,000.00) for each violation. 133. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT VOT Respondent Failed To Ensure Elopement Drill Participation For Sampled Employees In Violation Of Rule 58A-5.024(2)(a)5, Florida Administrative Code 134. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 135. Pursuant to Florida law, Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. In addition, records shall contain the following, as applicable: Documentation of facility direct care staff and administrator participation in resident elopement drills pursuant to paragraph 58A-5.0182(8)(c), Florida Administrative Code. Rule 58A-5.024(2)(a)5, Florida Administrative Code. 136. On or about October 8, 2007 the Agency conducted a Biennial Survey of the Respondent and its facility. 137. Based on record review and interview, the facility failed to ensure elopement drill participation for three (3), employee number one (1), employee number two (2), and employee number three (3), out of five (5) employees sampled. 138. A review on October 8, 2007 of the elopement drills log indicates five (5) drills were held, including ones on September 22, 2005, March 10, 2006, September 6, 2006, April 10, 2007, and September 6, 2007. 139. Areview of a current listing of facility employees on October 8, 2007, indicates 21 only two (2) employees on the list, employee number three (3) and employee number five (5), received elopement drill training. Attendance for the September 22, 2005 drill included employee number three’s (3) name and attendance for employee number five’s (5) name appeared on the September 6, 2007 drill list. 140. An interview with the facility manager and the administrator on October 8, 2007 at 6:00 p.m., indicates no signature sign-ins can be produced for the remaining elopement drills to verify attendance of current personnel drill attendance. 141. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class Ill deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 142. The Respondent was given a mandatory correction date of November 8, 2007 for this deficient practice. 143. On or about November 19, 2007 through November 20, 2007 the Agency conducted a Follow-Up Survey of the Biennial Survey of October 8, 2007 to the Respondent’s facility. 144. Based on record review and interview, the facility failed to ensure elopement drill participation for three (3), employee number one (1), employee number two (2), and employee number three (3), out of three (3) employees sampled. 145. On November 19, 2007, a review of the attendance signatures for an elopement drill held on November 12, 2007 reveals that employee number one (1), employee number two (2), and employee number three’s (3) names are not listed as attending. 146. An interview with the Business Office Manager and the owner/administrator of the facility on November 19, 2007 at 2:30 p.m., confirms that these three employees did not 22 attend the most recently scheduled elopement drill. When asked if the facility held any other drills after that date, the owner/administrator stated "No." 147. This remains an uncorrected deficiency. 148. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which indirectly or potentially threatens the physical or emotional health, safety, or security of the facility residents and constituted a Class III deficiency as provided for in Section 429.19(2)(c), Florida Statutes (2007). 149. The Respondent’s deficiency constituted an uncorrected Class IH violation. 150. The Agency shall impose an administrative fine for a cited Class III violation in an amount not less than five hundred dollars ($500.00) and not exceeding one thousand dollars ($1,000.00) for each violation. 151. The Respondent was given a mandatory correction date of December 19, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). COUNT IX Assessment of Survey Fee 1. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and the allegations in Counts I, II, III, IV, V, VI, VI, and VIII. 2. Pursuant to Florida law, “in addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $500.00, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 400.428(3)(c) to verify the correction of the violations.” Section 429.19(7), 23 Florida Statutes (2007). 3. In this particular instance, the Agency is entitled to assess a survey fee against the Respondent in the amount of five-hundred dollars ($500.00). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assess a survey fee against the Respondent in the amount of five hundred dollars ($500.00). 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 and assess a survey fee against the Respondent in the total amount of FOUR THOUSAND FIVE HUNDRED DOLLARS ($4,500.00). 3. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this_loat*_day of __V0 Geel, , 2008. Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 24 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 Rights form have been served to: Rudolph Yeager, Administrator, Vanderbilt Beach Assisted Living Home, LLC d/b/a Vanderbilt Beach Assisted Living Home, 517 100" Avenue N., Naples, Florida 34108, by U.S. Certified Mail, Return Receipt No. 7006 2760 0003 1536 6909, and to: Fowler White Boggs Banker, P.A., Registered Agent for Vanderbilt Beach Assisted Living Home, LLC d/b/a Vanderbilt Beach Assisted Living Home, 5811 Pelican Bay Boulevard, Suite 600, Naples, Florida 34108, by U. S. Certified Mail, Return Receipt No. 7006 2760 0003 1536 6916 onthis_ Yat dayof__(N\orwe , 2008. Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 25 Copies furnished to: Rudolph Yeager, Administrator Vanderbilt Beach Assisted Living Home, LLC d/b/a Vanderbilt Beach Assisted Living Home 517 100 Avenue N. Naples, Florida 34108 (US. Certified Mail) Andrea M. Lang, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice Mail) Fowler White Boggs Banker, P.A. Registered Agent for Vanderbilt Beach Assisted Living Home, LLC d/b/a Vanderbilt Beach Assisted Living Home 5811 Pelican Bay Boulevard, Suite 600 Naples, Florida 34108 (U.S. Certified Mail) Kriste J. Mennella Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) 26 COMPLETE THIS SECTION ON DELIVERY SENDER: COMPLETE THIS SECTION "1 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 mailpiece, or on the front if space aca oa Article Addressed to: to: 200 70 Dl Agent C1] Addressee Dz ig delivery address different from iter 17 O Yes if YES, enter delivery address below: [1] No 3. Service Type D0 Certified Mail. Express Mail 0 Registered © Return Receipt for Merchandise O insured Mail 11C.0.D. 4. Restricted Delivery? (Extra Fee) 2. Article Number | a | Ace Nunbet a 7006 2760 0003 1536 6909 __[ransfer from service fabel) ane PS Form 3811, February 2004 Domestic Return Receipt ; 102595-02-M-1540 ;

Docket for Case No: 08-001743