STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, () q- () 3 UY C AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008013059 (Fines) 2008013061 (Cond.) PARADISE PINES HEALTH CARE ASSOCIATES, LLC, d/b/a Harts Harbor Health Care Center, 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 Paradise Pines Health Care Associates, LLC, d/b/a Harts Harbor Health Care Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate a nursing home in the State of Florida pursuant to §§ 400.121(1)(a) and 400.121(3)(d), Florida Statutes (2008), impose an administrative fine of twenty thousand dollars ($20,000) based upon the citation one (1) State Class I deficiency pursuant to § 400.102(1), Florida Statutes (2008). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing November 07, 2008, and impose a survey fee in the amount of six thousand dollars ($6,000.00), based upon the Respondent being cited for one State Class I deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2008). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 180-bed nursing home, located at 11565 Harts Road, Jacksonville; Florida 32218, and is licensed as a skilled nursing facility (license number 15640961). 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I RESPONDENT’S FACILITY FAILED TO: e PROVIDE ADEQUATE AND APPROPRIATE HEALTH CARE e FOLLOW PHYSICIAN ORDERS OR TO PROPERLY RECORD THE REASON FOR DEVIATING FROM SUCH ORDERS §§ 400.022(1)(@), 400.102(1), and 400.121(1)(a), Florida Statutes (2008) and Rule 59A- 4.107(5), Florida Administrative Code. ISOLATED CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. Florida law provides the following: . ¥ a. Section 400.102(1), F.S., “In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility...” b. Section 400.022(1)(), F.S., “All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.” c. Section 400.121(1)(a), F.S., “The agency may deny an application, revoke or suspend a license, and impose an administrative fine, not to exceed $500 per violation per day for the violation of any provision of this part, part II of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest: A violation of any provision of this part, part II of chapter 408, or applicable rules.” d. Rule 59A-4.107(5), F.A.C., “All physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift.” 8. The Agency conducted a re-licensure survey starting on November 3, 2008 and ending November 7, 2008. 9. Based on observation, clinical record review, review of policies and procedures, and staff interviews the facility violated statute and rule when it failed to provide the care and treatment necessary to protect the health and well-being of 4 of 5 sampled residents (resident # 80, #241, #107, and #14) with regard to vascular access lines and when it failed to follow physician orders for 3 of 5 sampled residents (resident #14, 107, 241). The facility failed to: (1) implement necessary measures for Resident #80 after placement of a mid-line catheter for intravenous access resulting in the resident experiencing a preventable loss of blood, (2) provide appropriate care of a jugular central line which likely resulted in oxygen desaturation for Resident #241, to follow physician orders to discontinue a TLC line, and to properly record why the orders were not followed; (3) follow physician orders by providing one on one monitoring to prevent the removal of the vascular access line for Resident #107 and to properly record why the orders were not followed; and (4) follow the physician orders for the care of the vascular line for Resident #14 and to properly record why the orders were not followed. The findings include: 10. On 11/4/08 at 9:50 a.m., a surveyor entered the room for Resident #80 who was observed curled up in bed under a sheet. No staff were present in the room. A pool of blood approximately six inches in diameter was observed on the floor next to the bed. The resident was observed laying in a pool of blood approximately 18 inches by 12 inches. The resident had pulled an intravenous line from his/her arm resulting in the observed blood loss. The surveyor called for help and a nurse came to the room. The nurse stated the resident had a history of pulling out intravenous lines. 11. Resident #80 had a midline vascular access line inserted on 11/3/08 at 8:00 PM according to the record review. The work order document for IV Access, Inc. (11/3/08 at 8:00 PM) stated, “Nurse reports patient pulls out short PIV ok to insert midline, order states midline or PICC.” 12. The physician assistant (PA) came to see the resident (#80) and stated, “we knew the resident would do that, but we have to do what we have to do.” The physician was in the building and came to assess the resident at 10:10 a.m. The physician entered the room and did a brief assessment. He stated the resident ‘was fine and then stated that the resident was expected to pull the line out and he would change the order to Rocephin (antibiotic) to be administered intramuscularly via injection. He also gave an order to apply a pressure dressing to the right arm to prevent further bleeding from the site. 13. Review of the clinical record for the resident #80 revealed that the resident labs drawn on 11/3/08 documented a hemoglobin of 6.3 and a hematacrit of 19.3. On 11/5/08 the day following the observed blood loss, the labs drawn showed a decrease in the following levels; hemoglobin of 5.9 (14-18) and hematocrit of 17.3 (42-52). The clinical record stated the resident refused all blood products related to religious beliefs, Review of the physician progress notes dated 11/5/08 stated he spoke with the resident’s daughte:- concerning the recent blood loss and the critical lab levels despite support measures. 14. Resident #80 had the following psychiatric diagnosis: dementia with behaviors, schizophrenia, and psychosis. The care plan for behaviors dated 10/24/07, and updated most recently on 10/10/08, had no interventions in place to direct staff on how to minimize the risks of the resident pulling out intravenous lines. Review of all of the current care plans revealed no interventions on any of the care plans to address the behaviors that put the resident at risk of blood loss related to pulling out the intravenous lines. During an interview with the care plan person on 11/6/08 at 11:00 a.m., she stated she was aware the resident was suffering from advanced dementia and "picked at things repeatedly", and she was not surprised the resident would pull out the intravenous lines. She further stated she had not care planned for that specific behavior. 15. During tour of the facility on 11/3/08 at 9:00 a.m., Resident #241 was observed in the room, in bed, with a dressing on the right side of the neck with no date or time noted on the dressing. The dressing was dirty and the tape securing the dressing to the upper part of the neck. was pulled away. The resident spoke and answered questions. On 11/3/08 at 11:45 a.m. Resident #241 was observed with the dressing pulled back from the neck with air bubbles observed in all three lines of the Triple Lumen Catheter (TLC). 16. Interview with the ADON (assistant director of nursing) at that time revealed that an RN (registered nurse) is responsible for changing the dressing but that she had not personally changed the dressing. She stated that the physician ordered the TLC line to be discontinued on Friday, 10/31/08 and was unaware as to why it was not discontinued as ordered. The DON (Director of Nursing) stated that they had a policy and procedure for intravenous lines and that only registered nurses who had special intravenous (IV) training could remove the TLC line. The ADON stated that she was not aware if there was an RN on staff over the weekend to discontinue the TLC line. 17. Interview with the Staffing Coordinator on 11/3/08 at 12:30 p.m. revealed that there was no RN on Saturday 11/1/08 as the RN (registered nurse) who usually works 7-3 and 3-11 every weekend was absent due to an emergency. 18. On 11/3/08, the ADON removed the TLC line at 12:50 p.m. and documented the procedure she used. 19. The facility policy for Catheter Removal (Section 6.8) reads as follows: “10. Following the same air embolisim precautions, apply ointment or Vaseline Gauze at the insertion site and cover with sterile gauze: 11. Apply an air occlusive dressing over the gauze. Leave the air occlusive dressing in place for a minimum of 48 hours or per prescriber’s order. (It will take some time for the tract from the skin into the vein to seal completely, the risk of air embolism remains after the catheter has been removed if this tract opens up and there is no ointment and dressing at the site).” 20. The facility policy was not followed in the removal of the TLC for Resident #241. Observation following the removal of the TLC line (triple lumen catheter) revealed a 4 inch by 4 inch gauze dressing folded into 4 and taped to the neck. No air occlusive dressing was observed on the resident's neck. The resident was observed to be unresponsive and the oxygen saturation reading taken by the physician was first 72% and then dropped down to 68%. 21. An oxygen tank was brought to ‘he room, The nursing staff was unable to activate the oxygen tank and the top of the mechanism fell on the floor. An oxygen concentrator was brought to the room and the resident was connected via nasal cannula to the concentrator. The resident's oxygen saturation came up to 96% on oxygen. 22. Rescue was called. The resident continued to be unresponsive to verbal stimuli with some tremors on the right side. The EMT (emergency medical technician) stated that the resident had gurgling in the left lung. The Staff Development nurse and the physician were present at the time, answered questions about the history of the resident, and confirmed that the resident was a “full code” in the event of cardiac arrest. 23. Observation of Resident #107 on 11/3/08 at 4:00 p.m. revealed the resident had a midline vascular access to the upper right arm. The physician had written an order on 10/24/08 for the resident to have one on one care to prevent the resident from pulling out the access line. During an interview with the unit manager on 11/3/08, she stated rather than provide a one on one . caregiver, the nurse decided to wrap the resident's arm with gauze. The reason for deviating from the physician’s order was not recorded in the resident’s medical record. 24. The occlusive dressing was completely covered with flexible gauze. There was no date or initial on the dressing. When the nurse removed the gauze dressing at 4:15 p.m., she pulled the tape off with such force that the resident’s skin came off with the dressing, leaving the resident with an open wound approximately 1 % inches by 4 inch. 25. Resident #14 was admitted on 5/21/03 and re-admitted to the facility on 11/1/08. The resident retumed to the facility on 11/1/08 at 2:50 p.m. with IV (intravenous) Metronidazole IV BID (twice daily) until 11/8/08 and Vancomycin 1 Gm IV BID until 11/8/08. 26, The 11/3/08 physician order for resident #14 documented to: 1) flush double lumen PICC with 10 cc NS before each IV dose and 10 cc NS followed by 5 cc Heparin flush after each dose, and 2) Change PICC dressing Q (every) 3 days. 27. IV medications were ordered by the physician on admission to be given at 8 a.m., 12 p.m., 6 p.m., and 8 p.m. One dose of flush was recorded on 11/2/08. On 11/3/08 the same times were documented for medications given IV with only one flush documented on 11/3/08. On 11/4/08 the medication times were the same with only one flush documented on 11-7 shift. The MAR was noted to have the order discontinued 11/4/08. The MAR documented PICC dressing changes documented on 11/3/08 with a notation to discontinue the order on 11/4/08. 28. Review of section 6.2 of the facility policy, Infusion Therapy Procedures, revealed that pre-use and post use for midline, midclavicular, PICC, subclavian or Jugular CVC was to flush with 10 ml pre use and 10 ml of saline post use. The minimum intervals for flushing for these lines is every 8 hours and PRN and the flush was to be 10ml normal saline. 29. The Respondent had a legal duty to provide adequate and appropriate health care, pursuant to § 400.022(1)(), F.S., specifically with regard to administration and maintenance of vascular access lines. According to standard nursing practice for the situation, adequate and appropriate health care for care of intravenous lines for residents with a known history of temoving lines (such as Residents #80 and #107) involves implementing precautionary measures to ensure that the resident does not remove the line. For Resident #107, adequate and appropriate health care related to the administration of access lines was dictated by physician order and involved implementing a specific precautionary method, one on one care. 30. The Respondent intentionally or negligently failed to fulfill its legal duty to provide adequate and appropriate health care when it failed to address residents removing and interfering with access lines. Specifically, with regards to Resident #80, the facility staff was aware of and expected the resident to pull the line out but failed to put any precautionary monitoring measures in place, which is against standard of nursing practice for such a situation. The Respondent’s intentional or negligent act materially affected the health of Resident #80 by causing significant blood loss and by causing the resident’s hemoglobin and hematocrit levels to drop significantly below normal levels. Specifically, with regards to Resident #107, the Respondent failed to provide adequate and appropriate health care when it ignored the physician’s orders that the tesident be given one on one care to prevent the resident from pulling out the access line. Instead, the facility merely wrapped the Resident’s arm in gauze; the facility’s actions did not constitute adequate and appropriate health care for Resident #107. As a result of the Respondent’s intentional or negligent acts involving Resident #107, the resident had the potential to suffered blood loss and damage to the blood vessel if the resident pulled the line out. The Respondent intentionally or negligently failed to provide adequate and appropriate health care to Resident #80 and Resident #107 in violation of § 400.022(1)(), F.S., and the Respondent’s intentional or negligent act materially affected the residents’ health. Therefore, the Agency has authority pursuant to § 400.102(1), F.S., to take action against the Respondent. 31. The Respondent had a legal duty to provide adequate and appropriate health care, pursuant to § 400.022(1)(1), F.S., specifically with regard to the administration and care of catheters, such as for Resident #241 and Resident #107. Based on standard nursing practice for the situation, adequate and appropriate care for catheters includes noting the date and time and initials of the staff member who administered the dressings, as well as securing the edges of the dressings, and ensuring that the resident has a clean dressing. Also, based on standard nursing practices, an air occlusive dressing was necessary after the removal of a resident’s catheter. Finally, standard nursing practices dictate that removal of a dressing should be done so as to eliminate or reduce the harm to the resident and that the catheter should be removed as soon as . possible after the physician orders that the catheter be removed. 32, The Respondent intentionally or negligently failed to fulfill its legal duty to provide adequate and appropriate health care to Resident #241 when it failed to: 1) note the time, date, and initials of the staff member who administered the dressing, 2) change the dressing when .dressing was dirty, 3) properly seal the edges of the dressing, and 4) timely remove the resident’s triple lumen catheter. As a result of the Respondent’s intentional or negligent acts, particularly the failure to properly seal the edges of the dressing, air bubbles entered all three lines of his/her catheter. Second, the facility failed to remove the catheter until approximately three days after the physician ordered that the catheter be removed. Finally, when the facility did remove the resident’s catheter, they failed to follow standard nursing practice by providing the resident with an air occlusive dressing on the resident’s neck. Resident #241 suffered a severe clinical decline, , including tremors and verbal unresponsiveness, as result of oxygen desaturation due to the Respondent’s failure to follow standard nursing practice and facility policy for the removal of the resident’s Triple Lumen catheter. The Respondent intentionally or negligently failed to fulfill its legal duty to provide adequate and appropriate health care, to Resident #107 when it failed to note the time, date, and initials of the staff member who administered it as well as injuring the resident when the staff member removed the dressing. As a result of the Respondent’s intentional or negligent act of incorrectly removing the dressing, the resident suffered a wound approximately 1 4 inches by % inch. The Respondent intentionally or negligently failed to provide adequate and appropriate health care to Residents #241 and #107 in violation of § 400.022(1)(), F.S., and the Respondent’s intentional or negligent act materially affected the residents’ health. Therefore, the Agency has authority pursuant to § 400.102(1), F.S., to take action against the Respondent. 33. The Respondent had a legal duty: to provide adequate and appropriate health care, pursuant to § 400.022(1)(1), F.S., specifically with regard to the proper administration of intravenous medication. Standard nursing practice dictates that IV lines should be “flushed” or cleaned before and after each dose of medicine is administered in order to ensure that the lines are free from any contaminants or blockage so that the medicine reaches the resident without intereference. . 34. The Respondent intentionally or negligently failed to fulfill its legal duty to provide adequate and appropriate health care to Resident #14 when it failed to flush the resident’s IV before and after each dose of medication on November 3 and 4, 2008. As a result of the Respondent’s intentional or negligent failure to flush the IV lines, the resident’s line could have developed a clot, prevented the resident from receiving the antiobotics necessary to treat his/her infection and resulting in complications from the infection. The Respondent intentionally or negligently failed to provide adequate and appropriate health care to Residents #14 in violation of § 400.022(1)(), F.S., and the Respondent’s intentional or negligent act materially affected the residents’ health. Therefore, the Agency has authority pursuant to § 400.102(1), F.S., to take action against the Respondent. 35. Pursuant to Rule S9A-4.107(5), F.A.C., the Respondent had a legal duty to follow physician orders or, during the same shift, to note in the resident’s medical records the reason that the orders were not followed. Based on the legal duty in Rule 59A-4.107(5), F.A.C., the Respondent had the legal duty to follow physician orders for: 1) to discontinuce Resident #241’s Triple Lumen Catheter on October 31, 2008, 2) to provide one on one care to Resident #107 starting on October 24, 2008 to prevent the resident from pulling out his/her access line, and 3) starting November 3, 2008, to flush Resident #14’s double lumen PICC before and after each of four doses of IV medication given on November 3 and November 4, 2008. In any three instances that the Respondent did not follow these orders, the Respondent had the legal duty to record the reason for not following the ordér in the résident’s record during the medical shift that the decision was made. 36. The Respondent intentionally or negligently failed to fulfill its legal duty to follow physician orders or, in the alternative, to its record the reason for the decision during the medical shift during which the decision was made for any of the three physician orders listed in this paragraph. Specifically, the Respondent failed to follow the October 31, 2008, physician order to discontinue Resident #241’s catheter until November 3, 2008. Secondly, the Respondent failed to follow the October 24, 2008, physician order to provide Resident #107 with one on one care to prevent the resident from pulling out his/her access line when the Respondent did not provide one on one care on any day that the physician’s order was in effect. Finally, the Respondent failed to follow the November 3, 2008, physician’s order to flush Resident #14’s PICC line before and after each of four doses of medication daily when it only flushed the resident’s PICC line once on November 3, 2008, instead of eight times on November 3, 2008 and eight times on November 4, 2008. The Respondent never recorded, in any instance related to the above mentioned orders, the reason it deviated from the physician’s orders. Therefore, the Respondent violated Rule 59-4.107(5), F.A.C., and pursuant to § 400.121(1)(a), Florida Statutes, the Agency may take action against the Respondent’s license, including fines and revocation, for violations of applicable rules, which includes the rule cited herein. Thus, the Agency has authority to take this action against the Respondent. Furthermore, even if the Respondent properly noted the reason that a physician order was not followed, the Respondent still had a legal duty pursuant to § 400.022(1)(1), F.S., to provide adequate health care when the Respondent varied from the physician orders. However, in each instance that the Respondent deviated from the physician orders, it also failed to provide adequate and appropriate health care, as alleged in paragraphs 29 through 34. 37. The above findings reflect Respondent’s intentional or negligent failure to provide adequate and appropriate health care regarding catheter dressings to multiple residents, intentional or negligent failure to follow doctors orders and that such failures resulted in actual harm, including blood loss, wounds, and severe clinical decline characterized by unresponsiveness, and provided the potential for the likelihood of serious material injury or harm to the residents, thus the Respondent’s actions constituted a Class I deficiency, pursuant of § 400.023(8)(a), Florida Statutes(2008). 38. _ Pursuant to § 400.102(1), F.S., any intentional or negligent act that materially affects the health or safety of a resident is grounds for administrative action. The Respondent has been cited for multiple acts, international or negligent, that materially affected the health of its residents. The Agency has supported its citations with specific factual findings that support the alleged deficiencies. Therefore, pursuant to §§ 400.022(1)(1), 400.102(1), and 400.023(8)(a) Florida Statutes (2008) and Rule 59A-4.107(5), Florida Administrative Code, the Agency has sufficient grounds for taking this administrative action against the Respondent. 39. The Agency provided Respondent with the mandatory correction date for this deficient practice of December 7, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $20,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2008). COUNT IT 40. The Agency re-alleges and incorporates Counts I of this Complaint as if fully set forth herein. . 41. Respondent has been cited for one (1) isolated State Class I deficiency and therefore is subject-to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400,19(3), Florida Statutes (2008). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of $6,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2008). COUNT IT 42. The Agency re-alleges and incorporates Counts I and II of this Complaint as if fully set forth herein. oS 43. Based upon Respondent’s cited isolated State Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2008). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2008) commencing November 7, 2008. COUNT IV 44. The Agency re-alleges and incorporates Counts I, II and II] of this Complaint as if fully set forth herein, 45. That the Agency may revoke any license under §§ 400.121(2)(a) and 400.121(3)(d), Florida Statutes (2008), for the violation of applicable rules and for two Class I deficiencies arising from separate surveys within a 30-month period. 46. That the Respondent has been cited with one (1) Class I deficiency pursuant to §§ 400.022(1)(1), 400.102(1), 400.121(1)(a) and 400.23(8)(a), Florida Statutes (2008) and Rule 59A-4.107(5), Florida Administrative Code. 47. That based thereon, the Agency seeks the revocation of the Respondent’s license. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate a nursing home facility in the State of Florida, pursuant to §§ 400.121(1)(a) and 400.121(3)(d), Florida Statutes (2008). § 400.121(3)(d), F.S., authorizes the Agency to revoke the license of a nursing if the nursing home is cited for two Class I deficiencies arising from separate surveys or investigations within a 30-month period. Approximately six and a half months ago, or within a 30-month time period, on or about June 25, 2008, the Agency issued an Administrative Complaint (Agency Case Nos. 2008007399 and 200800400) which cited the Respondent with a Class I deficiency based on a survey separate from the survey at issue on this Administrative Complaint. Therefore, based on §§ 400.121(1)(a) and 400.121(3)(d), F-.S., the Agency has proper statutory authority to revoke the Respondent’s license because the Respondent violated applicable rules and has been cited for two Class I deficiencies arising from separate surveys within a 30-month time period. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I, II, III and IV; (B) Recommend administrative fines against Respondent in the amount of $20,000 for Count I, an isolated Class I deficiency; _(C) Recommend a six (6) month survey cycle for a period of two years and a survey fee in the amount of $6,000.00 for Count II; 1 (D) Assign a conditional licensure status commencing November 7, 2008; (E) Grant the revocation of Respondent’s license; (F) Assess attorney’s fees and costs; and (G) Grant all other general and equitable relief allowed by law. 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 form. All requests for hearing shall be made to the attention of , Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attomey) You'have the right to be represented by an attorney in this matter. 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. Respectfully submitted this December _@A, 2008. Mark Pluk Waly Fla. 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Docket for Case No: 09-000346