STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DPR ALLY STATE OF FLORIDA, NGS AGENCY FOR HEALTH ) 4. Q S T 4 CARE ADMINISTRATION, Petitioner, vs. Case No. 2008012857 SUSAN AMBROSE, 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 Susan Ambrose (hereinafter Respondent), pursuant to Section 120.569 and 120.57, Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of one thousand dollars ($1000.00) based upon one (1) cited State Class I deficiency pursuant to §429.71(1)(a), Fla. Stat. (2008). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, Florida Statutes (2008) and Chapters 408, Part II, and 429, Part II, Florida Statutes (2008). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. ’ PARTIES 3. The Agency is the regulatory authority responsible for licensure of adult family care homes and enforcement of all applicable state statutes and rules governing adult family care homes pursuant to the Chapters. 408, Part II, 429, Part II, Florida Statutes (2008), and Chapter 58A-14 Florida Administrative Code. 4. Respondent operates a four (4)-bed adult family care home located at 8108 N. Elmer Street, Tampa, Florida 33614, and is licensed as an adult family care home, license number 6905802. 5. Respondent was at all times material hereto a licensed facility 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. That pursuant to Florida law, an adult family care home provider shall, be at least twenty- one (21) years of age, live in the home, be able to read, write and complete written materials involved in applying for an AFCH license and maintaining and AFCH, and complete required training as required under Rule S8A-14.008 2)(a)(1-4), Florida Administrative Code. Adult family care homes “provide housing and personal care for disabled adults and frail elders who choose to live with an individual or family in a private home. The adult family-care home provider must live in the home. The purpose of this part is to provide for the health, safety, and welfare of residents of adult family-care homes in the state.” § 429.63(2), Fla. Stat. (2008) (emphasis supplied). 7. That on October 24, 2008, the Agency conducted an Aborted Annual Licensure Survey of Respondent. 8. That based upon observation and interviews, Respondent failed to ensure that the provider resided in the licensed facility. 9. That Susan Ambrose is the AFCH provider and licensee of a licensed AFCH facility. 10. That on October 24, 2008, the Agency conducted an annual survey of the Respondent and the Respondent’s facility. 11. That based upon the observation and interview, Respondent did not reside in the AFCH facility, the same being contrary to law. 12. That on September 16, 2008 between 10:45 to 11:20 a.m., Petitioner’s representative toured the licensed adult family care home and observed no separate bed or other sleeping quarters in which the provider, Susan Ambrose, could utilize while living within the licensed address. 13. That Petitioner’s representative observed one bedroom utilized by the current resident, and two (2) other bedrooms which were vacant, with no personal property such as clothing or personal care items which would indicate that they were occupied, such bedrooms and the empty beds therein constituting the remaining licensed bed capacity of four (4). 14. That there was no other occupied sleeping area or other indication that Ms. Susan Ambrose was a resident of and lived in the licensed address. 15. That Petitioner’s representative interviewed Respondent’s caregiver on site at 11:25 a.m. on October 24, 2008 who indicated as follows: a. “[Susan Ambrose] does not live at the home. She [Susan Ambrose] lives at another address in the Tampa area.” b. That the caregiver resides in a small building or cottage on the real property which is not a part of the licensed premises. 16. That the failure of the licensed provider to reside in the licensed home is contrary to the mandates of law. 17, That an AFCH provider must reside and live in an AFCH facility in order to properly care for the residents. 18. That among the duties and responsibilities created by Chapter 429, Florida Statutes, and Chapter 58A-~-14, Florida Administrative Code, an AFCH provider must ensure that: a. The residents are appropriate for placement and continued residency in the home as provided under Rule 58A-14.0061; b. The personal care and services provided to the residents (including assistance with activities of daily living and assistance with medication or the supervision of self administration of medication) is in accordance with Rule 58A-14.007(1); c. The residents are properly supervised, which includes being aware of their general whereabouts and well-being while the residents are on the premises of the AFCH in order to ensure the residents’ safety and security, and reminding the residents of any important tasks or activities, including appointments, as needed by them, as provided under Rule 58A-14.007(2). Under no circumstances shall a resident be left unattended for more than 2 hours under this rule; d. The observation, recording and reporting of any significant changes in a resident’s normal appearance, behavior or state of health to the resident’s health care provider and representative or case manager as provided under Rule 58A- 14.007(3); and e. ,_ The operation and maintenance of the AFCH facility under the Florida Statutes and Florida Administrative Code as provided under Rule 58A-14.008(2)(b)1. 19. That by failing to reside and live in the licensed facility, the Respondent failed to properly care for the residents and created a condition or practice that directly threatened the physical or emotional health, safety, or welfare of the residents. 20. That the Agency determined that the above constitution grounds for the imposition of a Class I deficiency in that it presents an imminent danger to the residents or quests of the facility or a substantial probability that death or serious physical or emotional harm would result therefore and cited the Respondent for a State Class I deficiency. 21. That the Agency provided Respondent with a mandatory correction date of November 24, 2008. 22. That the same constitutes a Class I offense as defined in Section 429.71(1)(a), Florida Statutes (2008). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1000.00 against Respondent, an adult family care home in the State of Florida, pursuant to § 429.71(1)(a), Fla. Stat. (2008). COUNT II 23. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 24, That pursuant to Florida law, the Agency may deny, suspend, or revoke the license of an AFHC operator for any violation of Chapter 429, Part II, Florida Statutes (2008), or any rule adopted by the Agency under this chapter, which results in conditions or practices that directly threaten the physical or emotional health, safety, or welfare of the residents. § 429.69(5), Fla. Stat. (2008). 25. That under Florida law, the Agency may deny or revoke the license of an AFCH operator based upon the facility’s (a) intentional or negligent act materially affecting the health or safety of a resident of the facility or (b) a violation of the facility’s authorizing statutes or applicable rules, in this particular instance, Chapter 429, Part II, Florida Statutes (2008), and Chapter 58A- 14, Florida Administrative Code, respectively, or (c) a violation of this part, authorizing statutes, or applicable rules. § 429.815 Florida Statutes (2008). 26. That pursuant to Florida law, a person who is licensed as an AFCH provider must own or rent the adult family care home facility and must reside in the AFCH facility. § 429.67(2), Fla. Stat. (2008). In addition, a person who is licensed as an AFCH provider must live in the adult family care home facility. R. 58A-14.008(2)(a)2, Florida Administrative Code. AFCHs “provide housing and personal care for disabled adults and frail elders who choose to live with an individual or family in a private home. The adult family-care home provider must live in the home. The purpose of this part is to provide for the health, safety, and welfare of residents of adult family-care homes in the state.” § 429.63(2), Fla. Stat. (2008) (emphasis supplied). 27. That pursuant to Florida law, an authorized officer or employee of the agency may make or cause to be made any inspection or investigation deemed necessary by the agency to determine the state of compliance with this part, authorizing statutes, and applicable rules. The right of inspection extends to any business that the agency has reason to believe is being operated as a provider without a license, but inspection of any business suspected of being operated without the appropriate license may not be made without the permission of the owner or person in charge unless a warrant is first obtained from a circuit court. Any application for a license issued under this part, authorizing statutes, or applicable rules constitutes permission for an appropriate inspection to verify the information submitted on or in connection with the application. (a) All inspections shall be unannounced, except as specified in s. 408.806; (b) Inspections for relicensure shall be conducted biennially unless otherwise specified by authorizing statutes or applicable rules. (2) Inspections conducted in conjunction with certification may be accepted in lieu of a complete licensure inspection. However, a licensure inspection may also be conducted to review any licensure requirements that are not also requirements for certification. (3) The agency shall have access to and the licensee shall provide copies of all provider records required during an inspection at no cost to the agency. § 408.811(1)-(3), Fla. Stat. (2008) 28. That based upon observation and interviews, Respondent failed to ensure that the provider resided in the licensed facility, the same being contrary to law. 29. That Susan Ambrose is the AFCH provider and licensee of a licensed AFCH facility. 30. That on October 24, 2008, the Agency conducted an annual survey of the Respondent and the Respondent’s facility. 31. That on September 16, 2008 between 10:45 to 11:20 a.m., Petitioner’s representative toured the licensed adult family care home and observed no separate bed or other sleeping quarters in which the provider, Susan Ambrose, could utilize while living within the licensed address. 32. That Petitioner’s representative observed one bedroom utilized by the current resident, and two (2) other bedrooms which were vacant, with no personal property such as clothing or personal care items which would indicate that they were occupied, such bedrooms and empty beds therein constituting the remaining licensed bed capacity of four (4). 33. That there was no other occupied sleeping area or other indication that Ms. Susan Ambrose was a resident of and lived in the licensed address. 34. That Petitioner’s representative interviewed Respondent’s caregiver on site at 11:25 a.m. on October 24, 2008 who indicated as follows: a. “[Susan Ambrose] does not live at the home. She [Susan Ambrose] lives at another address in the Tampa area.” 35. That the caregiver resides in a small building or cottage on the real property which is not a part of the licensed premises. 36. That Petitioner’s representative requested the opportunity to review numerous documents and records which Respondent’s caregiver could not locate. 37. That the provider, Susan Ambrose was not on site to produce required documentation. 38. That as approximately 11:50 a.m. on October 24, 2008, the Respondent’s caregiver on site informed Petitioner’s representative to discontinue the survey indicating that Susan Ambrose just told the care giver by phone to make sure that the survey did not proceed due to Susan Ambrose not being on site. 39, That Petitioner’s representative telephonically interviewed Respondent Susan Ambrose on October 24, 2008 at 11:50 a.m. indicating that the Petitioner had attempted in good faith to schedule the survey within the parameters the licensee had provided, which included Fridays, and that the survey must continue. 40. That Respondent Susan Ambrose indicated in response that the Respondent’s scheduling preference had changed and insisted that the Petitioner cease its survey functions. 41. That Petitioner’s representative subsequently indicated to Respondent’s caregiver on staff that the survey would continue to which the caregiver on staff indicated that Respondent had directed the caregiver on site to no longer cooperate with Petitioner’s staff and directed Petitioner’s staff to immediately leave the licensed property. 42. That the failure of an AFCH provider to reside and live within the AFCH facility is a condition or practice that directly threatens the physical or emotional health, safety, or welfare of the residents. § 429.69(5), Fla. Stat. (2008). 43. That an AFCH provider must reside and live in an AFCH facility in order to properly care for the residents. 44. That among the duties and responsibilities created by Chapter 429, Florida Statutes, and Chapter 58A-14, Florida Administrative Code, an AFCH provider must ensure that: f The residents are appropriate for placement and continued residency in the home as provided under Rule 58A-14.0061; g. The personal care and services provided to the residents (including assistance with activities of daily living and assistance with medication or the supervision of self administration of medication) is in accordance with Rule 58A-14.007(1); h. The residents are properly supervised, which includes being aware of their general whereabouts and well-being while the residents are on the premises of the AFCH in order to ensure the residents’ safety and security, and reminding the residents of any important tasks or activities, including appointments, as needed by them, as provided under Rule 58A-14.007(2). Under no circumstances shall a resident be left unattended for more than 2 hours under this rule; i. The observation, recording and reporting of any significant changes in a resident’s normal appearance, behavior or state of health to the resident’s health care provider and representative or case manager as provided under Rule 58A- 14.007(3); and j. The operation and maintenance of the AFCH facility under the Florida Statutes and Florida Administrative Code as provided under Rule 58A-14.008(2)(b)1. 45. That by failing to reside and live in the licensed facility, the Respondent failed to properly care for the residents and created a condition or practice that directly threatened the physical or emotional health, safety, or welfare of the residents. 46. That by failing to reside and live in the licensed facility, the Respondent committed an intentional or negligent act that materially affected the health or safety of a resident of the facility. 47. That by failing to reside and live in the licensed facility, the Respondent violated the facility’s authorizing statutes or applicable rules, in this particular instance Chapter 429, Part II, Florida Statutes (2008), and Chapter 58A-14, Florida Administrative Code, respectively. 48. That by failing to permit the Petitioner the right of entry to conduct its mandated inspection responsibilities, Respondent intentionally violated the provisions of Florida law authorizing said entry and inspection, Section 408.811(1) — (3), Florida Statues (2008). 49. That the failure to provide regulatory review as provided by law places residents at risk where minimum requirements of law relating to staffing, care, physical plant, and other health and safety mandates of law may not be assured. 50. The Agency provided the Respondent with a mandatory correction date of October 16, 2008. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter an order revoking the Respondent’s license to operate an adult family care home. wae Respectfully submitted this a day of January, 2009. 4 a / Thomas. Walsh Il Courtsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 727.552.1525 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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, Florida 32308. Telephone (850) 922-5873 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. 7007 0220 0001 1589 3492 on January 5 5, 2009 to: Susan Ambrose, Licensee/Administrator, Susan Ambrose (AFCH), 8208 N. Elmer Street, Tampa, Florida 33614. / # AL, , Tigh Je Walsh II, Esquire Copies furnished to: Susan Ambrose Kathleen Varga Thomas J. Walsh II Owner/Administrator Facility Evaluator Supervisor | Agency for Health Care Admin. Susan Ambrose. (AFCH) 525 Mirror Lake Dr., 4" FI. | 525 Mirror Lake Drive, 330G 8108 N. Elmer Street St. Petersburg, Florida 33701 | St. Petersburg, Florida 33701 Tampa, Florida 32812 (Interoffice) (Interoffice Mail) (U.S. Certified Mail) COMPLETE THIS SEC ON DELIVERY ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ™ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. D. IS delivery address different from item 17 {C1 Yes 1. Article Addressed to: ilf YES, enter delivery address below: ©] No Susan Ambrose Owner / Adminisirator Susaa Ambrose (AFCH) S108 N. Elmer Street Tampa, Florida 32812 3. Service Type C Certified Mall (©) Express Mall C Registered Cl Retum Recelpt for Merchandise 1 insured. Mail C1 C.0.D. 4. Restricted Delivery? (Extra Fee) 2. Article Numb ; pa umber 700? O220 OOO1 1589 3442 Tun 200 81; PS Form 3811, February 2004 Domestic: Return Recpipt: 102595-02-M-1840

Docket for Case No: 09-000579