STATE OF FLORIDA oft Ps AGENCY FOR HEALTH CARE ADMINISTRATION oe ope , OSSEP 23 PHY AGENCY FOR HEALTH CARE [oe / /¢ vA ADMINISTRATION, a : r ADI ATIVE Petitioner, AHCA No.: 2008006528) = ARHVa5 Vv. Return Receipt Requested: 7008 0500 0002 0764 5246 BAYVIEW HOLDINGS, INC., d/b/a BAYVIEW RETIREMENT HOME, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Bayview Holdings, Inc. d/b/a Bayview Retirement Home (hereinafter “Bayview Retirement Home”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes, (2007), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,000.00 pursuant to Section 429.19, Florida Statutes (2007), for the protection of the public health, safety and welfare pursuant to Section 429.19(2) (c), Florida Statutes (2007). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Broward County, pursuant to Section 120.57, Florida Statutes and Rule 28-106.207, Florida Administrative Code. 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 I, Florida Statutes (2007), and Chapter 58A-5, Florida Administrative Code. 5. Bayview Retirement Home operates a 12-bed assisted living facility located at 2625 N.E. 13° Court, Fort Lauderdale, Florida 33304. Bayview Retirement Home is licensed as an assisted living facility license number AL10479, with an expiration date of July 12, 2008. Bayview Retirement Home 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 BAYVIEW RETIREMENT HOME FAILED TO PROVIDE VERIFICATION OF FREEDOM FROM TUBERCULOSIS FOR SOME EMPLOYEES Section 429.275(4), Florida Statutes, and/or Rule 58A-5.024(2) (a), Florida Administrative Code (STAFF RECORDS STANDARDS) REPEATED AND UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the survey conducted on 6/08/06 and based on record review and interview, it was determined that the facility failed to ensure that 1 out of 4 staff members reviewed is free from communicable disease (employee 4). 8. During the Staff Records Standards portion of the survey conducted on 06/08/2006 at approximately 12 PM, it was noted that an employee record did not contain documentation to verify that the staff member is free from communicable disease. The employee has been employed at the facility for more than 30 days. The Administrator was interviewed on 06/08/2006 at approximately 4 PM and after investigation, confirmed . the finding. 9. During the full biennial re-licensure survey conducted on 02/25/08 and based on record review and interview, it was determined that the facility failed to provide verification of freedom from communicable disease including tuberculosis for 4 out of 5 applicable sampled employees (Employees #2, #3, #4, and #5). 10. During the Staff Records Standards portion of the survey, conducted on 02/25/2008 at approximately 12:00 PM, it was noted that the records for Employees #2, #3, #4, and #5 lacked documentation of a verification of freedom from communicable disease including tuberculosis, as required. Employee hire dates are as follows: Employee #2: 04/23/2007 Employee #3: 11/12/2007 Employee #4: 02/06/2008 Employee #5: 02/21/2008 2 3 10. During an interview, conducted with the facility Administrator during the review, it was confirmed that the documentation was never obtained from the employees upon hire, as required. No further documentation was provided by the conclusion of the survey. This is a repeat deficiency from the survey of 6/08/06. ll. During an Exit Conference, conducted with the facility Administrator and the Office Manager on 02/25/2008 at approximately 3:00 PM, the findings were acknowledged. 12. During the first review survey conducted on 4/16/08 and Based on record review and interview, it was determined that the facility continues to fail to provide verification of freedom from communicable disease including tuberculosis for 3 out of 4 applicable sampled employees (Employees #2, #3, and #4). 13. During the Staff Records Standards portion of the survey, conducted on 04/16/2008 at approximately 2:00 PM, it was noted that the records for Employees #2, #3, and #4 still lack documentation of a verification of freedom from communicable disease including tuberculosis, as required. Employee hire dates are as follows: Employee #2: 11/12/2007 Employee #3: 03/01/2008 Employee #4: 05/14/2007 14. During an interview, conducted with the facility Administrator during the review, it was confirmed that the documentation was not in the employee files at the time of the survey, and that no further documentation could be provided at that time. 15. During an Exit Conference, conducted with the facility Administrator and the Office Manager on 04/16/2008 at approximately 4:00 PM, the findings were acknowledged. This is a repeat deficiency from the 6/08/06 survey and uncorrected from the survey of 2/25/08. 16. Based on the foregoing, Bayview Retirement Home violated Section 429.275(4), Florida Statutes, and/or Rule 58A- 5.024(2) (a), Plorida Administrative Code, a repeated and an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $1,000.00. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $1,000.00 against Bayview Retirement Home on Count I pursuant to Section 429.19(2) (ec), Florida Statutes. Cc. Grant such other relief as this 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 Form. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FAC ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY T AGENC) Tria Lawton-Russel Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52°? Terrace Suite 103 Miami, Florida 33166 Copies furnished to: Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Finance and Accounting Revenue and Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and foregoing has been furnished by U.S. Receipt Requested to Alice Rothman, Agent, Bayview Retirement H Lauderdale, Florida 33304 on Certified Mail, E. 13°" correct copy of the Return Administrator and Registered Court, Fort , 2008. Tria Lawtg iS. Postal Services CERTIFIED MAILe: RECEIPT (Domestic Malt Only; No Insurarice ‘Coverage \ivery, ‘informatl Retum eelot Fee (Endorsement Required) eometaronc aslo ® “Total Postage & Fees Baz. name nae meee oa a a w oO w a a in ggeneverse {ol franeactiony SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY lm Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. 1 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 permits. 1. Article Addressed to: Daye A. Signature yy x WA: MLE D Agent B. we eee Name) Ene D, Is delivery address different from item 1? CI Yes If YES, enter delivery address below: No | : Certified Mail ©) Express Mail 0 Registered -Retum Receipt for Merchandise Cl insured Mail (3 C.0.0. . 2. Article Number (Transfer from service labe —__ 7008 _ ‘50 a a ode a 7b 4 . 5e 46 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 08-004764

Orders for Case No: 08-004764