FILED AHCA STATE OF FLORIDA AGENCY CLERK AGENCY FOR HEALTH CARE ADMINISTRATION MOY FEB HY A 8 yy: STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2008008054, Petitioner, AHCA No.: 2008008055 © AHCA No.: 2008008057 <=: V. AHCA No.: 2008008058 DOAH No.: 08-4349 ~ RENDITION NO.: AHCA-09- DELTA HEALTH GROUP, INC. d/b/a FOUNTAINHEAD CARE CENTER, Respondent. FINAL ORDER Having reviewed the amended administrative complaint dated August 11, 2008, attached hereto and incorporated herein (Exhibit 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Settlement Agreement (Exhibit 2) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows: ORDERED: 1. The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. 2. Respondent shall pay an administrative fine in the amount of $4,000.00. The administrative fine is due and payable within thirty (30) days of the date of rendition of this Order. 3. A check should be made payable to the “Agency for Health Care } Administration.” The check, along with a reference to these case numbers, should be sent directly to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 4. Unpaid fines pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available. 5. A conditional license is imposed commencing May 15, 2008 and ending June 19, 2008. 6. Each party shall bear its own costs and attorney’s fees. 7. The above-styled cases are hereby closed. DONE and ORDERED this _/© day of boratey , 2009, in Tallahassee, Leon County, Florida. , Secretary — ealth Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED ‘TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: R. Davis Thomas, Jr. Representative Delta Health Group, Inc. 2 North Palafox Street Pensacola, Florida 32502 (U. S. Mail) Alba M. Rodriguez, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52 Terrace — Suite 103 Miami, Florida 33166 (Interoffice Mail) Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration ; 2727 Mahan Drive, Bldg #1, MS #9 Tallahassee, Florida 32308 (Interoffice Mail) Jan Mills Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS #3. Tallahassee, Florida 32308 (Interoffice Mail) Stuart M. Lerner Administrative Law Judge Division of Administrative Hearings 1230 Apalachee Parkway Tallahassee, Florida 32399 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the [fF aay of FLruwr QS al Richard J. Shoop Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308 (850) 922-5873 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2008008054 : AHCA No.: 2008008055 Petitioner, AHCA No.: 2008008057 AHCA No.: 2008008058 Vv. Return Receipt Requested: 7004 2890 0000 5525 9969 DELTA HEALTH GROUP, INC. 7004 2890 0000 5525 7507 d/b/a FOUNTAINHEAD CARE CENTER, Respondent. / AMENDED ADMINISTRATIVE COMPLAINT* COMES NOW the State of Florida, Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against Delta Health Group, Inc. d/b/a Fountainhead Care Center (hereinafter “Fountainhead Care Center”) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2007) hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $4,000.00 pursuant to Sections 400.23(8) (b), Florida Statutes, (2007), [AHCA No.: 2008008054; AHCA No.: 2008008057]. v Amended Administrative Complaint is being issued to correct scrivener's error in the name of the facility in Count I and Count II. The name should read Fountainhead Care Center. EXHIBIT 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2007), [AHCA No. 2008008055; AHCA No.: 2008008058]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes (2007), and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Miami-Dade County pursuant to- Section 120.57, Florida Statutes (2007), and Rule 28-106.207, Florida Administrative Code (2007), PARTIES 5. AHCA is the regulatory authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (2007), and Rule 59A-4, Florida Administrative Code. 6. Fountainhead Care Center operates a 146-bed skilled nursing facility located at 390 N. EH. 135 Street, North Miami, Florida 33161. Fountainhead Care Center is licensed as a skilled nursing facility under license number 1163096. Fountainhead Care Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I FOUNTAINHEAD CARE CENTER FAILED TO ENSURE PHYSICIAN ORDERS WERE FOLLOWED. RULE 59A-4.107(5), FLORIDA ADMINISTRATIVE CODE (FOLLOW PHYSICIAN ORDERS STANDARD) CLASS III 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Fountainhead Care Center was cited with two (2) Class Til deficiencies as a result of licensure surveys and life safety surveys that were conducted on April 7, 2008, April 11, 2008, May 15, 2008, and May 27, 2008. 10. A licensure survey was conducted on April 11, 2008. Based on observation, interview, and record review, it was determined that the facility failed to ensure physician orders were followed, and failed to notify physician when scheduled Insulin was withheld four days for one, Resident #4140, of 10 residents reviewed for medication regimen. The findings include the following. 11. Resident #140 was admitted to the facility 2/19/08, with 2 subsequent hospitalizations for renal failure and wound care. Resident record review revealed Resident #140 arrived from the hospital and was admitted on 2/19/08 with diagnoses of, but not limited to, abnormal lab results, severe Peripheral Vascular Disease (PVD), gangrene of the lefc foot with Cellulitis and infection, Hypertension (HTN), Diabetes Mellitus (DM) , and Coronary Artery Disease (CAD) . 12. Record review revealed a physician order for Novulin N 100u/ml (units per milliliter) 20U subcutaneously (SQ) daily (qd). Review of the Accucheck Blood Sugars done on: 4/7/08 Blood Sugars - 88; 4/8/08 - Blood Sugars -85; 4/9/08 - Blood Sugars - 83; ‘and 4/10/08 - Blood Sugars -79. Review of the Medication Administration Record revealed that the Novulin N 100u/ml was not given on 4/7/08, 4/8/08, 4/9/08, and 4/10/08. 13. Review of the Physician Orders revealed no order to hold the insulin for any parameters. . 14. During an interview with the Director of Nursing on 4/10/08 at 8:15 a.m., she stated that the nurse called the doctor, on 4/9/08 regarding the blood sugar. She agreed there is no note about the return call from the physician. She agreed there were no orders to hold the insulin. This was not seen by the consulting pharmacist, the review for April had not beeen completed to date and are done monthly. (1s. During an interview with the staff nurse on 4/10/08 at 10:05 a.m., she stated that the physician was informed of the low blood sugars this morning and he ordered the Novulin Insulin to be decreased. Review of the Physican's Order on 4/10/08 revealed an order to decrease insulin to 10 units subcutaneously (SQ) daily. i¢. The mandated date of correction was designated as May i7. A licensure revisit survey was conducted on May 27, 2008. Based on observation, interview, and record review, it was determined that the facility failed to ensure physician orders were followed as evidenced by failure to administer Glucagon as ordered and failure to notify physician when accucheck results were below ordered parameters for one, Resident #15, of nine sampled residents scheduled for accuchecks of sixteen total sampled residents. The findings include the following. 18. Record review for Resident #15 revealed diagnosis to include, but not limited to, Diabetes Mellitus, Cognitive Disorder, Right Leg Weakness, Anemia, Hypertension, Mood Disorder, Glaucoma, Cataracts, Seizure Disorder, Hyperlipidemia, and Depression. 19. Review of the May 2008 Physician's Order Sheet revealed orders for Novolin R 100/ml Insulin sliding scale sub-0 150-199=1u, 200-249=3u, 250-299=5u, 300-349=7u, greater than (>) 349=8u. Accuchecks with sliding scale coverage: Accuchecks 2x daily. Glucose below (<) 70, give Glucagon img intramuscular (IM), ordered 1/31/08. Call Medical Doctor (MD) if blood sugar greater than (>) 350 or below (<) 70, ordered 5/7/08. wn 20. Review of Resident #15's Care Plan, initiated on 1/31/08, and updated on 5/1/08, revealed Diagnosis of Diabetes Mellitus and at risk for hypo/hyperglycemic reaction. Care Plan Approach included administering Glucagon as ordered. 21. Review of May 2008 Medication Administration Record (MAR) for Resident #15 revealed Accucheck result on 5/18/08 at 4:30 p.m., recorded at 68 and initialed by nursing staff. The Medication Administration Record reflected no’ evidence that the Glucagon was administered as ordered and no evidence that the Medical Director was notified per ordered parameters for blood sugar below (<) 70 as evidenced by absence of staff initials on the Medication Administration Record. 22. Record review revealed no entry in the licensed nurse's note section of the medical record and no entry on the 24 hour report dated 5/18/08. 23. Interview on 5/27/08, at 2:30 p.m., with the facility Director of Nursing Services (DONS) revealed a telephone conversation with the Licensed Practical Nurse (LPN) who had been scheduled 5/18/08, who stated that the Glucagon had been administered. The Director of Nursing Services stated that the facility had no policy or procedures in place for monitoring and/or documenting blood sugar or resident's condition following the administration of Glucagon. 24. Interview via telephone on 5/27/08 az 3:35 p.m. with the Licensed Practical Nurse confirmed that he/she had worked on 5/18/08. Licensed Practical Nurse stated that she recalled doing the accucheck for Resident #15 on 5/18/08, and administering the Glucagon due to low blood sugar results. The Licensed Practical Nurse stated that the facility protocol following administration of Glucagon is to recheck the resident's blood sugar and monitor condition. The Licensed Practical Nurse stated that she checked “’e blood sugar which was "normal". The Licensed Practical Nurse scated that as a nurse he/she would normally document the resident's condition following administration of Glucagon. The Licensed Practical Nurse was unable to recall recording the results of the repeat accucheck or documenting Resident 15's condition in the clinical record. 25. Record review revealed that last entry in the licensed nurse's notes was dated 5/12/08. The Licensed Practical Nurse stated that the doctor had not been contacted to report the blood sugar results, because it was Sunday and Resident #15 had eaten 100% of his/her dinner. This is an uncorrected deficiency from the survey of April 11, 2008. 26. Based on the foregoing facts, Fountainhead Care Center violated Rule 59A-4.107(5), Florida Administrative Code, herein classified as an isolated uncorrected Class III violation pursuant to Section 400.23(8), Florida Statutes (2007), which carries an assessed fine of $1,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b) 4 Florida Statutes (2007). ‘COUNT II FOUNTAINHEAD CARE CENTER FAILED TO ENSURE THE ACCURACY OF THE ANNUAL FIRE ALARM CERTIFICATION. RULE 59A-4.107(5), FLORIDA ADMINISTRATIVE CODE (LIFE SAFETY CODE STANDARD) CLASS III 27. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 28. A Fire Life Safety recertification survey was conducted on April 7, 2008: Based on a review of documentation and interview, it was determined that the facility did not ensure the accuracy of the annual fire alarm certification. The fire alarm company documentation failed to indicate that all of the fire alarm devices were inspected and tested; and the fire alarm company failed to provide completed documentation relating to the annual certification. The findings include the following. 29. During the Life Safety survey conducted on April 7, 2008, while reviewing the two most recent certifications, Inspection and Test Report, of the fire alarm systems with the Administrator between 9:30 a.m. and 12:30 p.m. the following were revealed: 30. There was a discrepancy in the number of smoke detectors recorded in each report. The semi-annual Inspection and Test Report dated December 27, 2006 listed 55 Ton smoke detectors in the fire alarm system, The annual certification's Inspection and Test Report, dated June 26, 2007, listed 52 Ion smoke detectors in the fire alarm system. 31. When -questioned, neither the Administrator nor Maintenance Director could offer an explanation. A telephone call was placed to the fire alarm company's service supervisor at 10:30 a.m. He was not immediately available, and never returned the call. 32. The Fire Alarm Log Book was. not being kept up to date. There were no entries between November 11, 2007 and March 4, 2008. The Log Book is a permanent record of ail inspections, testing and maintenance by fire alarm technicians. Information required includes the date, name of the technician, what was done and the results. When a fire alarm technician comes to the facility, this information must be recorded in the Log Book. 33. Documentation regarding testing the fire alarm panel's batteries was incomplete. Because the facility does not have an emergency generator for use in the event of an electrical power failure, an additional test of the fire alarm panel's secondary 9 power supply, back-up batteries, is required. According to NFPA 72, the National Fire Alarm Code, the back-up batteries must have sufficient capacity to operate the fire alarm system for 24 hours. At the end of the 24-hour period, the batteries must be capable of operating all alarm notification devices for 5 minutes. In addition, the back-up batteries must be capable of supplying power for emergency voice/alarm during a fire or other evacuation emergency at maximum connected load for 15 minutes. - . The documentation left at the facility by the fire alarm company indicated that the batteries test took place on March 4, 2008; however, the document did not explain what the "battery load test" entailed. 35. The fire alarm company did not test or verify the activation of the facility's fire sprinkler system devices during either certification. Since these devices are connected to and activate the fire alarm, it is required that when certifying the fire alarm system the fire alarm company test or at least verify that ...when a tamper switch is tripped, the activation is indicated ag a "trouble" or "supervisory" signal on the fire alarm panel; and ...when ‘a water flow device’ (Inspectors Test Valve) is activated (by being opened to simulate the flow of water from a single sprinkler head), the water flow initiates the fire alarm throughout the facility; and within 90 seconds or less, as required. 10 36. It is required that all devices in the fire alarm system must be inspected, tested and certified as fully operational annually. The fire alarm company cannot certify that a fire alarm system is 100 per cent functional when not all devices are inspected and tested as required. 37. The mandated date of correction was designated as May 11, 2008. | 38. A revisit Life Safety survey was conducted on May 15, 2008. Based on a review of documentation and interview, it was determined that the facility did not ensure the accuracy of the annual fire alarm certification. The fire alarm company documentation failed to indicate that all of the fire alarm devices were inspected and tested; and the fire alarm company failed to provide completed documentation relating to the annual certification. The findings include the following. 39. During the Life Safety revisit survey conducted on May 15, 2008, the facility was unable to produce documents that the fire alarm company had explained discrepancy in the number of smoke detectors recorded in each report, nor the other discrepancies noted in the Life Safety survey on 04/07/08. 40. The Director of Maintenance stated the facility was changing alarm companies; unsure when the inspection and testing of the fire alarm system would be completed. 41. There was a discrepancy in the number of smoke cetectors recorded in each report. The semi-annual Inspection and Test Report dated December 27, 2006 listed 55 ION smoke detectors in the fire alarm system. The ‘annual certification's Inspection and Test Report, dated June 26, 2007, listed 52 ION smoke detectors in the fire alarm system. 42. The Fire Alarm Log Book was not being kept up to date. There were no entries between November 11, 2007 and March 4, 2008. The Log Book is a permanent record of all inspections, testing and maintenance by fire alarm technicians. Information required includes the. date, name of the technician, what. was done and the results. When a fire alarm technician comes to the facility, this information must be recorded in the Log Book. 43. Documentation regarding testing the fire alarm panel's batteries was incomplete. Because the facility does not have an emergency generator for use in the event of an electrical power failure, an additional test of the fire alarm panel's secondary power supply, back-up batteries, is required. According to NFPA 72, the National Fire Alarm Code, the back-up batteries must have sufficient capacity to operate the fire alarm system for 24 hours. 44. The fire alarm company did not test or verify the activation of the facility's fire sprinkler system devices during either certification. Since these devices are connected 12 to and activate the fire alarm, it is required that when certifying the fire alarm system the fire alarm company test or at least verify that ...when a tamper switch is tripped, the activation is indicated as a "trouble" or "supervisory" signal on the fire alarm panel; and ...when a water flow device (Inspectors Test Valve) is activated (by being opened to simulate the flow of water from a single sprinkler head), the water flow initiates the fire alarm throughout the facility; and within 90 seconds or less, as required. 45. It is required that all devices in the fire alarm system must be inspected, tested and certified as fully operational annually. The fire alarm company cannot certify that a fire alarm system is 100 per cent functional when not all devices are inspected and tested as required. This is an uncorrected deficiency from the survey of April 7, 2008. 46. Based on the foregoing facts, Fountainhead Care Center violated: Rule 59A-4.107(5), Florida Administrative Code, herein classified as a widespread, uncorrected Class III violation pursuant to Section 400.23(8), Florida Statutes (2007), which Carries an assessed fine of $3,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b) Florida Statutes (2007). THIS PAGE LEFT BLANK DELIBERATELY 14 DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes (2007), Fountain head Care Center shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A” EXHIBIT “A” Conditional License License # SNF1163096; Certificate No.: Effective date: 05/15/2008 Expiration date: 04/30/2010 Standard License License # SNF1163096; Certificate No.: Effective date: 07/02/2008 Expiration date: 04/30/2010 15305 15306 PRAYER FOR RELIEP 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 Counts I and II. 2. Assess against Fountainhead Care Center an administrative fine of $4,000.00 for the violations cited above. 3. Assess against Fountainhead Care Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess costs related to the investigation and “prosecution of this matter, if applicable. 5. 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 Sections 120.569 and 120.57, Florida Statutes (2007). 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 the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED TEAT FAILURE TO RECEIVE A REQUEST A EEARING WITHIN TWENTY-ONE (21) COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, DAYS OF RECEIPT OF THIS WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, REPRESENTED BY AN ATTORNEY IN THIS MATTER YOU HAVE THE RIGHT TO BE fo Alba M. Fla. Bar No.: a) IY. Relea Rodriduer toast ‘| 47 t 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: R. Steve Emling Field Office Manager Agency for Health Care Administration 8355 N. W. 53%° Street Miami, Florida 33166 (U.S. Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tailahassee, Florida 32308 (Interoffice Mail) ‘CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished “by U.S. Certified Mail, Return Receipt Requested to Carmen Telot, Administrator, Fountainhead Care Center, 390 N. E. 135 Street, North Miami, Florida 33161; Kimberly A. Seith, Registered Agent, 2 North Palafox Street, Pensacola, Florida 32502 on this jprr day of August, 2008. oN, ; . a . Calpe FT). Aadis Baa Alba M. Rodrifguez’ Esq.(. va STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Delta Health Group, Inc. d/b/a AHCA No.: 2008008054/AHCA No.: 2008008055 Fountainhead Care Center AHCA No.: 2008008057/AHCA No.: 2008008058 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day vou receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-922-5873 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) J admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2)____—Ss—s«s admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced, OPTION THREE (3) ___I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 davs of your 1..eipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A-statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: : Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: . Date: . Print Name: ; Title: Late fee/fine/AC STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2008008054 Petitioner, AHCA No.: 2008008055 AHCA No.: 2008008057 Vv. AHCA No.: 2008008058 DOAH No.: 08-4349 DELTA HEALTH GROUP, INC. d/b/a FOUNTAINHEAD CARE CENTER, Respondent. SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”}, through its undersigned representatives, and Respondent, Delta Health Group, Inc. d/b/a Fountainhead Care Center (hereinafter “Respondent”), pursuant to Section 120.57(4), Florida Statutes, each individually, a “party,” collectively as “parties,” hereby enter into this Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Respondent is a nursing home licensed pursuant to Chapters 400, Part II, and 408 Part II, Florida Statutes (2007), Section 20.42, Florida Statutes (2007), and Chapter 59A-4, Florida Administrative Code; and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authorit over. Respondent, pursuant to EXHIBIT AB Chapter 400, Part II, Florid ); and WHEREAS, the Agency served Respondent with an amended administrative complaint on or about August 14, 2008, notifying the Respondent of its intent to impose administrative fines in the amount of $4,000.00 and assign a conditional licensure status commencing May 15, 2008 and ending July 1, 2008; and WHEREAS , Respondent requested a formal administrative proceeding by selecting Option Three (3) on the Election of Rights form; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals herein are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, Respondent agrees to waive any and all appeals and proceedings to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), Florida Statutes, a formal proceeding under Subsection 120.57(1), Florida Statutes, appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court of competent jurisdiction; and Page 2 of 6 agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled, provided, however, that no agreement herein shall be deemed a waiver by either party of its right to judicial enforcement of this Agreement. 4, Upon full execution of this Agreement, Respondent agrees to pay $4,000.00 in administrative fines to the Agency within thirty (30) days of the entry of the Final Order. Respondent accepts the assignment of conditional licensure status commencing May 15, 2008 and ending June 19, 2008. 5. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in Circuit Court in Leon County, Florida. 6. By executing this Agreement, Respondent does not admit and specifically denies, and the Agency asserts the validity of the allegations raised in the administrative complaint referenced herein. No agreement made herein shall preclude the Agency from imposing a penalty against Respondent for any deficiency/violation of statute or rule identified in a future survey of Respondent, which constitutes an “uncorrected” deficiency from surveys identified in the administrative complaint. The parties agree that in such an “uncorrected” case, the Respondent reserves the right to challenge the deficiencies from the surveys identified in the administrative complaint in an appropriate forum. Page 3 of 6 7. No agreement made herein shall preclude the Agency from using the deficiencies from the surveys identified in the administrative complaint in any decision regarding licensure of Respondent, including, but not limited to, licensure for limited mental health, limited nursing services, extended congregate care, or a demonstrated pattern of deficient performance. The Agency is not precluded from using the subject events for any purpose within the jurisdiction of the Agency. Further, Respondent acknowledges and agrees that this Agreement shall not preclude or estop any other federal, state, or local agency or office from pursuing any cause of action or taking any action, even if based on or arising from, in whole or in part, the facts raised in the administrative complaint. 8. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and closing the above~-styled case. 9. Each party shall bear its own costs and attorney’s fees. 10. This Agreement shall become effective on the date upon which it is fully executed by all the parties. ll. Respondent for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, Page 4 of 6 of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Respondent or related facilities. 12. This Agreement is binding upon all parties herein and those identified in paragraph eleven (11) of this Agreement. 13. In the event that Respondent was a Medicaid provider at the subject time of the occurrences alleged in the complaint herein, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 59G-9.070, Florida Administrative Code. 14. Respondent agrees that if any funds to be paid under this agreement to the Agency are not paid within thirty-one (31) days of entry of the Final Order in this matter, the Agency may deduct the amounts assessed against Respondent in the Final Order, or any portion thereof, owed by Respondent to the Agency from any present or future funds owed to Respondent by the Agency, and that the Agency shall hold’a lien against present and future funds owed to Respondent by the Agency for said amounts until paid. 15. The undersigned have read and understand this Agreement and have the authority to bind their respective principals to it. Page 5 of 6 16. This Agreement contains and incorporates the entire understandings and agreements of the parties. 17. This Agreement supersedes any prior oral or written agreements between the parties. 18. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. 19. All parties agree that a facsimile signature suffices for an original signature. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. athe Duden CLA) Elizabeth Dudek R. Davis Thomas, Jr. Deputy Aecretary Representative Division of Health Quality Delta Health Group, Inc. Assurance. 2 North Palafox Street Agency for Health Care Pensacola, Florida 32502 Administration 2727 Mahan Drive Tallahassee, Florida 32308 Dated: Sho [3009 Dated: ie/ialo’ la i f a“ Citas 7. Ko k Alba M. Rodriguez, Esq. Acting Generai Counsel Assistant General Counsel Agency for Health Care Agency for Health Care Administration Administration 2727 Mahan Drive 8350 N.W. 52 Terrace - #103 Tallahassee, Florida 32308 Miami, Florida 33166 Dated: 2 “o/og Dated: jaf 2 1/2 g Page 6 of 6

Docket for Case No: 08-004349