OF eal | | FIL ER AGENCY FOR HEALTH CARE ADMINISTRATION 2099 oer 2} STATE OF FLORIDA, AGENCY FOR Api! 1M SOM OF HEALTH CARE ADMINISTRATION, HE AS i ATI g ‘Gg t Petitioner, vs. , ' - Case No. 2007004953 OCEAN HOME HEALTH CARE, INC, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against. Ocean Home Health Care, Inc (hereinafter Respondent), pursuant to Section 400.932(3), Florida Statutes, (2006) and Section 408.815(1)(e), Florida Statutes (2006) , and alleges: NATURE OF THE ACTION . This is an action to revoke the Respondent’s licensure as a home health agency. JURISDICTION AND VENUE “1. The Agency has jurisdiction pursuant to Section 120.569 and 120.57, Fla. Stat. (2006) and Chapter 59A-25, Florida Administrative Code. 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES “3, The Agency is the regulatory authority responsible for licensure of home health agencies pursuant to Chapters 400, Part VII, and 408, Part I, Florida Statutes (2006), and Chapter 59A-25, Florida Administrative Code. ry 4. Respondent is a facility located at 1671 West 38 Place, #1408, Suite B, Hialeah, Florida 33012, and was at all times material hereto a home health agency under Chapter 400, Part Vil, Florida Statutes (2006) and Chapter 59A-25, Florida Administrative Code, having been issued license number 299991761. ‘ 5. Respondent was at all times material hereto licensed under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. The Center for Medicare and Medicaid Services (“CMS”) is the unit of the United States Government that is responsible at the federal level for regulation of participation in the Medicaid and Medicare programs. 8. CMS has terminated the Respondent’s Medicare Provider Agreement and participation in the Medicare program. See Exhibit “A,” attached hereto and incorporated herein as if fully recited herein. The termination is a final decision of CMS not subject to ° further appeal by Respondent. 9. . Florida law provides in relevant part: “License or application denial; revocation. (1) In addition to the grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and — revoking a license or change of ownership application include any of the following actions by a controlling interest: ... (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the State Medical Program, the Medicaid Program of any other state, or the Medicare Program.” Section 408.815, Florida Statutes (2006). 10. Florida law also provides in relevant part: “(3) The agency may deny or revoke the license of any applicant that:... ; (c) Has been or is currently excluded, suspended, or terminated from, or has voluntarily withdrawn from participation in Florida’s Medicaid program or any other state’s Medicaid program, or participation in the Medicare program or any other governmental or private. ~ health care or health insurance program.” Section 400.932(3)(c), Florida Statutes (2006). 11: .. That the Respondent’s termination from participation in the Medicare program constitutes grounds for the revocation of the Respondent’s license as a home health , agency. WHEREFORE, the Agency intends to revoke Respondent’s license as a home health agency provider pursuant to Sections 400.953(3)(c) and 408.815(1), Florida Statutes (2006) Respectfully submitted this 30 day of May , 2007. Grant P. Dearborn, Chief Facilities Counsel - Fla. Bar. No. 0939961 See - -Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. oy RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST: A . HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 4875.0n... ame , 2007, to 1671 West 38 Place, #1408, Suite B, Hialeah; Florida 33012. Grant P. Dearborn, Chief Facilities Counsel ° Copies furnished to: Anne Mermard, Unit Manager Licensed Home Health Programs Unit Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth St, Suite. 4T20 Atlanta, Georgia 30303-8909 CENTERS for MEDICARE & MEDICAID SERVICES eo, Apple HLH. Services, 10-8197 Final Tenn Itr. - April 2, 2007 - e is Mr. J orge Pelaez, Administrator ‘Apple Home Health Services, Inc. He \ 3 ey SB = Cw Q as=z A = om th : ' Gaa po r 671 West 38" Place 1408 Suite A Bas — rl ‘Hialeah, FL 33012 aan SS fe , ero U CMS Certification Number: 10-8197 <= ee “oe Dear Mr. Pelaez: > «o:" Ahome health agency must mee “the Social Securi The Florida Agency for Health Care Administration (AHCA) conducted a recertification survey at your facility on January 2, 2007. At that time, your facility was found not to be in compliance with : the following Conditions of Participation: ; 484.18 Acceptance o ’ f Patients, Plan of Care, and Medical Supervision 484.48 Clinical Records Following submission of an acc: eptable plan of correction, the State Agency conducted revisits at your facility on February 1, 2007, and March 5, 2007. At both revisits, compliance with the following Conditi » your facility was found not to be in ons of Participation: . . 484.18 Acceptance of Patients, Plan of | Care, and Me ‘dical Supervision 484.48 Clinical Records rrect the noncompliance your provider agreement and 42 CFR 489,53). The Medicare Program will not make payment for home he plans of treatment-are established after April 2, 2007. established before Ap termination. alth services furnished to patients whose For patients whose plans of treatment are rit 2, 2007, payment may be made for up to 30 days after the date of RWywrpeitr A JUN-13-2007 WED 10:43 AM FAX NO, 3058224703 P, 08 | ‘A listing of the names and heplth insurance claim munbers of beneficiaries served by your home health agency on April 2, 200/, should be forwarded to your fiscal intermediary. By copy of this letter, we are notifying the State Medicaid Agency of this tennination action, Pursuant to Federal regulationg at 42 CFR 488,456, we are required to notify the public of the termination date, Accordingly, p legal ad ran in the Miami Herald on March 24, 2007. Termination scheduled for April 2, 2007. If you have any questions, Please contact Elizabeth Jacobson at (404) 562-7428 or Colleen Sandmann at (404) 562-7458. : Sincerely, Sandra M. Pace Associate Regional Administrator | Division of Survey and Certification | ce: Florida Agency for Health Care Administration (AHCA) Florida Medicaid Agency Enclosures JUN- 13-2007 WED 10:42 Al FAX NO, 3058224703 P, 06 AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA . - ] L E RE: Ocean Home Health Care, jnc CASE NO: 20070043007 2} Py nllVisig , , ELECTION OF RIGHTS AOHINTS Treg i FARINGS YE ‘ 1 This Election of Rights form is attached lo a proposed action by the Agency for Health Care Administration (AEICA). The litle may be Notice of Intent to Impose a Late Fee, Notice of Intent to {mpose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the da receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Cormplaint. t . Tf your Election of Rights with your selected option is not received by ANCA 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 atlomey or your representative prefer to reply according to Chapter120, Florida Statutes (2004) 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) ___ I adwit to the allepations 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 o object and to have a hearing, 1 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)_ af ady it 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 suhmit testimony and written evidence to the Agency to show that the proposed administrative actioniis 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 roust file a written petition in order to obtain a formal hearing before the Division of Administrative Hens under Section 120.57(1), Florida Statutes. It must be JUN-13-2007 WED 10:43 AN FAX NO. 3058224703 P, O7 teceived by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing musi 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 receiyed notice of the Agency's proposed action. 4. A staternent of all disputed isspes 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: A (ALF? nursing home? medical equipment? Other type?) Licensee Name: (heenm Lowe. Hoa th. ( (x? Ene, License number: eM, 99 g Gy /6/ Contact person: Serre. || ow AD CHC CPC Name Title adress: 2323 Prmkel(Ave., Ste AT, Miaw? Al. 33/99 : Street and number City Zip Code Telephone No. 305°25 8° 4S00Pax No. 305~398"5//3 Email(optional) ( Peerce| (2) utrle heat lows . Cot Thereby certify that am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care — (he licensee referred to above, et £ oO om Print Name: Of GE / ECA E 2 Title: Ves. Late fee/fine/AC Section Page 1 of 1 [Code of Federal Regulations] [Title 42, Volume 3] FUL ED [Revised as of October 1, 2006] From the U.S. Government Printing Office via GPO Access [CITE: 42CPR424.545] 2008 OCT 2} P y 02 [Page 494) HV ISIOR TITLE 42--PUBLIC HEALTH ADWINis Th oF HEARINGS VE CHAPTER IV--CENTERS FOR MEDICARE nner’ & MEDICAID SERVICES, a8 DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 424 CONDITIONS FOR MEDICARE PAYMENT--Table of Contents Subpart P_Requirements for Establishing and Maintaining Medicare Billing Privileges Sec. 424.545 Provider and supplier appeal rights. (a) A provider or supplier that is denied enrollment in the Medicare program or whose Medicare enrollment has been revoked may appeal CMs! decision in accordance with part 405, subpart H, for suppliers, or part 498, subpart A for providers, of this chapter, which set forth the appeals process for providers and suppliers. When revocation of billing privileges also results in the termination of a corresponding provider agreement, the provider may appeal CMS' decision in accordance with part 498 of this chapter with the final decision of the appeal applying to both the billing privileges and the provider agreement. Payment is not made during the appeals process. If the provider or supplier is successful in overturning a denial or revocation, unpaid claims for services furnished during the overturned period may be resubmitted. (b) A provider or supplier whose billing privileges are deactivated may file a rebuttal in accordance with Sec. 405.374 of this chapter. (c) The provider or supplier must be able to demonstrate that it meets the enrollment requirements and it must be able to make available any documents and records that support the provisions of this regulation and the Medicare enrollment application if requested by CMS or its agents. Section Page 1 of 3 [Code of Federal Regulations] {Title 42, Volume 3] [Revised as of October 1, 2006] FIL ED From the U.S. Government Printing Office via GPO Access {CITE: 42CFR424.535] 2008 9 [Page 492-493) 2] p sa 02 TITLE .42--PUBLIC HEALTH ADMIN SON OF CHAPTER IV--CENTERS FOR MEDICARE HEARINGS . & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 424 CONDITIONS FOR MEDICARE PAYMENT-~-Table of Contents Subpart P_Requirements for Establishing and Maintaining Medicare Billing . Privileges Sec. 424.535 Revocation of enrollment and billing privileges in the Medicare progr (a) Reasons for revocation. CMS may revoke a currently enrolled provider or supplier's Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons: (1) Noncompliance. The provider or supplier is determined not to be in compliance with the enrollment requirements described in this section or in the enrollment application applicable for its provider or supplier type and has not submitted a plan of corrective action as outlined in part 484 of this chapter. All providers and suppliers are granted an opportunity to correct the deficient compliance requirement prior to a final determination to revoke billing privileges. (i) CMS may request additional documentation from the provider or supplier to determine compliance if adverse information is received or otherwise found concerning the provider or supplier. (i1) Requested additional documentation must be submitted within 60 calendar days of request. (2) Provider or supplier conduct. The provider or supplier, or any owner, managing employee, authorized or delegated official, medical director, supervising physician, or other health care personnel of the provider or supplier is-- (i) Excluded from the Medicare, Medicaid, and any other Federal health care program, as defined in Sec. 1001.2 of this chapter, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of the Act. ; (ii) Is debarred, suspended, or otherwise excluded from : participating in any other Federal procurement or nonprocurement program or activity in accordance with the FASA implementing regulations -and the Department of Health and Human Services nonprocurement common rule at 45 CFR part 76. (3) Felonies. The provider, supplier, or any owner of the provider or supplier, within the 10 years preceding enrollment or revalidation of enrollment, was convicted of a Federal or State felony offense that CMS has determined to be detrimental to the best interests of the program and its beneficiaries. (i) Offenses include-- (A) Felony crimes against persons, such as murder, rape, assault, and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. Section Page 2 of 3 (B) Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. {C) Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct. (D) Any felonies that would result in mandatory exclusion under section 1128(a) of the Act. (ii) Denials based on felony convictions are for a period to be determined by the Secretary, but not less than 10 years from the date of conviction if the individual has been convicted on one previous occasion for one or more offenses. (4) False or misleading information. The provider or supplier certified as ‘“true'' misleading or false information on the enrollment application to be enrolled or maintain enrollment in the Medicare program. (Offenders may be subject to either fines or imprisonment, or both, in accordance with current law and regulations.) (5) On-site review. CMS determines, upon on-site review, that the provider or supplier is no longer operational to furnish Medicare covered items or services, or is not meeting Medicare enrollment requirements under statute or regulation to supervise treatment of, or to provide Medicare covered items or services for, Medicare patients. [{Page 493]] Upon on-site review, CMS determines that-- (i) A Medicare Part A provider is no longer operational to furnish Medicare covered items or services, or the provider fails to satisfy any of the Medicare enrollment requirements. (ii) A Medicare Part B supplier is no longer operational to furnish Medicare covered items or services, or the supplier has failed to satisfy any or all of the Medicare enrollment requirements, or has failed to furnish Medicare covered items or services as required by the statute or regulations. (6) Inadequate reverification information. The provider or supplier fails to furnish complete and accurate information and all supporting documentation within 60 calendar days of the provider or supplier's notification from CMS to submit an enrollment application and supporting documentation, or resubmit and certify to the accuracy of its enrollment information. (7) Misuse of billing number. The provider or supplier knowingly sells to or allows another individual or entity to use its billing number. This does not include those providers or suppliers who enter into a valid reassignment of benefits as specified in Sec, 424.80 or a change of ownership as outlined in Sec. 489.18 of this chapter. (b) Effect of revocation on provider agreements. When a provider's or supplier's billing privilege is revoked, any provider agreement in effect at the time of revocation is terminated effective with the date of revocation. {c) Re-enrollment after revocation. If a provider or supplier seeks to re-establish enrollment in the Medicare program after notification that its billing privileges is revoked (either after the appeals process is exhausted or in place of the appeals process), the following conditions apply: ce (1) The provider or supplier must re-enroll in the Medicare program through the completion and submission of a new applicable enroliment application and applicable documentation, as a new provider or supplier, for validation by CMS. (2) Providers must be resurveyed and recertified by the State survey Section Page 3 of 3 agency as a new provider and must establish a new provider agreement with CMS's Regional Office. (d) Reversal of revocation. If the revocation was due to adverse activity (sanction, exclusion, or felony) against an owner, managing employee, or an authorized or delegated official; or a medical director, supervising physician, or other personnel of the provider or supplier furnishing Medicare reimbursable services, the revocation may be reversed if the provider or supplier terminates and submits proof that it has terminated its business relationship with that individual within 30 days of the revocation notification. (e) Additional review. When a provider or supplier is revoked from the Medicare program, CMS automatically reviews all other related Medicare enrollment files that the revoked provider or supplier has an association with (for example, as an owner or managing employee) to determine if the revocation warrants an adverse action of the associated Medicare provider or supplier. (f) Effective date of revocation. Revocation becomes effective within 30 days of the initial revocation notification.

Docket for Case No: 08-005326