Apr 1? 2009 15:21 APR-17-2889 16:34 AGENCY HEALTH CARE ADMIN 856 921 4158 P2831 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS, . Case No. 2009000369 Life Care Centers of America, Inc. d/b/a Life Care Center of Port St. Lucie Respondent. / ADMINISTRATIVE COMPLAINT Petitioner, the Florida Agency for Health Care Administration (“4 HCA”), through undersigned counsel, files this Administrative Complaint against the above-named Respondent (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2008), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount o! Fifteen Thousand Three Hundred Two Dollars ($15,302) (the “fine amount") against Respondent, pursuant to Section 408.040, Florida Statutes, and Florida Administrative Code Rule 59C- 1,02], ‘Unless otherwise noted, all statutes and rules hereinafter cited are to the indicated year’s version of the statute or rule because this is the controlling year in question. Page | af9 Apr 1? 2009 15:22 APR-1?- 289 16:34 AGENCY HEALTH CARE ADMIN 654 921 4158 P.2i/al 2. For the calendar year 2007 (the “calendar year”), Respondent failed to comply with the Medicaid condition upon its Certificate of Need (“CON”), a copy of which is attached to this complaint as Exhibit A. JURISDICTION AND VENUE 3, This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes, and also Sections 408.031- 408.045, Florida’s “Health Facility and Services Development Act.” 4. ‘Venue is determined by Florida Administrative Code Rule 28-106.207. PARTIES 5. Pursuant to Chapter 408, Florida Statutes, and Chapter 59C-1, Florida Administrative Code, AHCA is the licensing and enforcing authority with regard to community nursing home laws and niles. 6. Respondent is a corporation authorized under the laws of Florida to do business. Respondent operates a community nursing home located at 3720 SE Jennings Road, Port _ St. Lucie Florida 34952 and is the licensee on the CON issued on May 19,1998 for a minimum of 47.00% of the 123 bed faciliry’s total annual patient days shall be provided to Medicaid patients. The CON numniber is 8975; a copy of the CON is attached to this - complamt as Exhibit A. COUNTI Respondent failed to meet its Medicaid condition Section 408.040, Florida Statutes Florida Administrative Code Rule 59C-1.021 7, AHCA re-alleges paragraphs 1-6 above. Page 2 of 9 APR-17-2889 Apr 1? 2009 15:22 16:35 AGENCY HEALTH CARE ADMIN 856 921 @158 &. Respondent failed to comply with its Medicaid condition as reported to the Agency in its Florida Nursing Home Utilization Report for the year 2007, a copy of which is attached to this complaint as Exhibit B. The facility responded to a request to provide a facility report, a copy of the report is attached to this complaint as Exhibit C. P2231 9. Respondent failed to comply with the condition set forth in iis CON, as required by Section 408.040, Florida Statutes, which provide, in part, as follows: 10. 408.040 Conditions and monitoring (1)(a) The agency may issue a certificate of need, or an exemption, predicated upon statements of intent expressed by an applicant in the application for a certificate of need. Any conditions imposed on a certificate of need or an exemption based on such statements of intent shal) be stated on the face of the certificate of need or in the exemption approval. (b) The agency may consider, in addition to the other criteria specified in s. 408.035, a statement of intent by the applicant that a specified percentage of the annual patient days at the facility will be utilized by patients eligible for care under Title XIX of the Social Security Act. Any certificate of need issued to a nursing home in reliance upon an applicant's statements that a specified percentage of annual patient days will be utilized by residents eligible for care under Title XIX of the Social Security Act must include a statement that such certification is a condition of issuance of the certificate of need. The certificate-of-need program shall notify the Medicaid program office and the Department of Elderly Affairs when it imposes conditions as authorized in this paragraph in an area ip which a community diversion pilot project is implemented. (c) A certificate holder or an exemption holder may apply to the agency for a modification of conditions imposed under paragraph (a) or paragraph (b). If the holder of a certificate of need or an exemption demonstrates good cause why the certificate or exemption should be modified, the agency shall reissue the certificate of need or exemption with such modifications as may be appropriate. The agency shall by mile define the factors constituting good cause for modification. (a) If the holder of a certificate of need or an exemption fails to comply with a condition upon which the issuance of the certificate or exemption was predicated, the agency may assess an administrative fine against the certificate holder in an amount not to exceed $1,000 per failure per day. Failure to annually report compliance with any condition upon which the issuance of the certificate or exernption was predicated constitutes noncompliance. In assessing the penalty, the agency shalJ take into account as mitigation the. degree of noncompliance. Proceeds of such penalties shal] be deposited in the Public Medicaid Assistance Trust Fund, ed The foregoing violation warrants imposition of the above-mentioned fine amount pursuant to Florida Administrative Code Rule 59C-1.021, which provides, in part: 59C-1.021 Penalties. (1) General Provisions. The agency shall initiate administrative proceedings for revocation of a certificate of need for violation of paragraphs 408.040(2)(a) and (b), F.S., or the assessment of administrative fines for failure to comply with conditions placed om a certificate of need as specified under Rule $9C-1,013, F.A.C Page 3 of 9 Apr 1? 2009 15:22 APR-17-2889 16:35 AGENCY HEALTH CARE ADMIN 856 921 @158 P2331 (3) Penalties for Failure to Comply with Certificate of Need Conditions. The agency shall review the annual compliance report submitted by the health care providers who are licensed and operate the facilities or services and other pertinent data to assess compliance with cestificate of need conditions. Providers who are not in compliance with certificate of need conditions shall be fined. For community nursing homes or hospital-based skilled nursing units certified as such by Medicare, the first compliance report on tbe slats of conditions must be submited 30 calendar days following the eighteenth month of operation or the first month where an 85 percent occupancy is achieved, whichever comes first. The schedule of fines is as follows: (a) Facilities failing to comply with any conditions set forth on the Certificate of Need will be assessed a fine, not to excecd $1,000 per failure per day. In assessing the penalty the agency shall take into account the degree of noncompliance. (b) The assessed fine shall be paid to the agency within 45 calendar days after written notification of assessment by certified mail or within 30 calendar days after final agency action if an administrative hearing has been requested. If a health care provider desires it may remit payment according to a payment schedule accepted by the agency. The health care provider must submit the schedule of payments to the agency within 30 calendar days after the date of receipt of the notification of assessment or 21 calendar days after final agency action. The final balance will be due no later than 6 months after the health care provider has been notified in writing by the agency of the amount of the assessed fine or 6 months after final agency action. 11. AHCA, in determining the penalty imposed, considered the degree of noncompliance. WHEREFORE, AHCA demands the following relief: (1) enter factual and legal findings as sct forth in this Count; (2) impose the above-mentioned fine amount for the violation; and (3) impose such other relief as this tribunal may find appropriate. NOTICE RESPONDENT is hereby 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 (one page) and explained in the attached Explanation of Rights (one page). 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 Dr., Bldg. 3, MS #3, Tallahassee, Florida, 32308; Attention: Agency Clerk, RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE. ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF: THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Page 4 of 9 APR-17-2089 16:36 AGENCY HEALTH CARE ADMIN Apr 1? 2009 15:23 856 921 4158 P.24/31 Submitted as of the date indicated on the below Certificate of Service. Agency for Health Care Administration n f c yd asl lS Richard Joseph Saliba, Esquire Senior Attorey Fla. Bar No. 0240389 Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3, MS #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-9313 CERTIFICATE OF SERVICE IT HEREBY CERTIFY that a copy of the original Administrative Complaint, Explanation of Rights form, and Election of Rights form have been sent by U.S. Certified Mail, Return Receipt Requested (receipt # 7004 2890 000 5527 2432) to Respondent, Attention: Administrator, at 3720 SE Jennings Road, Port St. Lucie Florida 34952 on thige.WS day of February 2009. Agency for Health Care Administration af we pie 1 \ yt . ine ‘ Richard/Joseph Saliba, Esquire Senior Attorney Fla. Bar No, 0240389 Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3, MS #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-9313 Page 5 of 9 Apr 1? 2009 15:23 APR-17-2889 16:36 AGENCY HEALTH CARE ADMIN 856 921 @158 P2531 EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES (To be used with the attached Election of Rights form) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA” or “Agency”), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date you receive the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION i. If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Complaint. You will be provided a copy of the final order. OPTION 2. If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the matenal facts alleged in the Complaint.), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. if the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under .' Section 120,57(1), F.8., Respondent’s request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. IF YOU SELECT OPT. 3, CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent’s Election of Rights in this matter must be RECEIVED by AHCA within 21 days from the date Respondent receives the Administrative Complaint. If the election form with Respondent’s selected option is not received by AHCA within 21 days from the date of Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. Page 6 of 9 Apr 1? 2009 15:24 APR-17-2889 16:36 AGENCY HEALTH CARE ADMIN 856 921 @158 P2631 EXHIBITS (AHCA vy. Life Care Center of Port St. Lucie Case No.2009000369) EXHIBIT “A” — Respondent's CON # 8975, requiring a minimum of 47.00% of the 123 bed facility’s total annual patient days shall be provided to Medicaid patients. EXHIBIT “B” — Florida Nursing Home Utilization Report for Year 2007, page 118. EXHIBIT “C” —Respondent’s facility report for calendar year 2007, (All are copies) Page 9 of 9 Apr 1? 2009 15:24 P.27/31 856 921 4158 16:37 AGENCY HEALTH CARE ADMIN STATE OF FLORIDA ye AGENCY FOR HEALTH CARE ADMINISTRATION CERTI FICATE OF NEED Under the provisions of the “Healt Facility and Services Development Act" (Sections 406,031- 45, Florida Statutes (Supp 1992), AND Chapter 59C-1, Florida Administrative Code}, the Agency for Health Care Administration certifies the need for this project. “Condition Modified (03/09/06) _ APPLICANT: re "NUMBER: 8975 Life Care Centéts of America, Inc. : EROJECT COST: $251,645 : 3570 Keith Street, N.W. . ISSUE DATE: May 19, 1998 Cleveland, Tennessee 37320-3480 - ; TERMINATION DATE: | November 18, 1999 ; a - REVISED TERMINATION DATE: COUNTY: | St Lucie _DISYRICT: 9. *) SUBDISTRICT: 5” ‘PROJECT DESCRIPTION: Add five community iursing home beds ta CON #7555 (approved fot 118 skilled nursing beds), This project | involves na new construction or renovation, . CONDITIONS: 1) A minimum of S47 percent of the 123 bed facility’ s total annual patient days shall be provided to Medicaid patients; 2) A 20 bed Alzheimer’s unit shall be provided; and 3) A 20 bed subacute u unit shall be provided. -BORM 1793, APRIL 1993 APR- 17-2849 Apr 1? 2009 15:25 P2831 856 921 @158 TH CARE ADMIN AGENCY HEAL Mame of Facifity Palm Garden of West Pali Beach Regents Park Nursing & Rehabilitation Center Rehabibtation Center of the Palm Beaches, The FPuryal Manor Savannah Cove Suatford Court of Boca Raion Sutlon Place Cate Center. Terraces of Lake Worth Rehabilitalion & Heallh Center Wate ford Health Care Center Whitehall Boca Raton Waillowbrooke Court at Bdgewaler Poinle Estates Willowbrooke Com at St, Andrews , Wood Lake Nursing avid Rehabilitation Center Abbieyean Russell Care Center Bughion Gardens by Marriot - Emerald Health Care Center Fort Prerce Health Care Laure] Pointe Health and Rehabilitation Life Care Center of Port Sain Lucie Palm Garden of Port Saint Lucie Port Sait Lucie Nursing & Restorative Care Center Tiffany Hail Nursing and Rehab Center APR-17-2889 DISTRICT 9 NURSING HOME UTILIZATION (January 2007 - December 2007 Data) TED DAYS ANNUAL TOTALS ~ QUARTERLY TOTALS OL/07-12407 JANUARY 1, 2007 - DECEMBER 31, 2007 i Licensed Beds JaAN- APR. 6MO. JUL- GCT- 6-MO. BED PATIENT TOTAL M'CéAID MICAID Tetal Comm. Shel. MAR JUN TOT, SEP DEC TOTAL} DAYS DAYS OCCUR Days occur | 476 176 o) 5840 © 160168 16192 16192 64240 «$0413 78 48% = 4G 25044 180 186 o} 16200 163804 16560 65700 = 6DLF9 EGON «28238 46.92%) 99 99 al 8910 9108 , 3613532819) OU.B2H 25032 7h.2TB4 120 120 G] 10800 11040 - 110408 43800 «= 40887 93.35% «= 261 OT.16% 30 30 Oo} 2700 2760 10950 6865 62.09% 1894 27.59% 60 60 a] 5400 5520 2190G = 18416 84.09% 6982 471% 120 120 o} 10800 11040 43800 © 30780 70.27% «= 20949 B.S 99 99 o) = 8a40 : 9108 36135 S3SE9 92.95% BBO 83.484 60 60 o| saoo sa60 RRR 5520 21900 18504 84 49% 317%) R17 154 154 0) 13860 14014 eae 1168 S620 53193 94.63% 2 an0%| 101 4061) 3600 3680 14600 4297 29.43% # 0.00% 119 79 40] PALO 7268 28835 = «:13000 45 08% aide 32.09% 120 t20 a) 10800 43800-36364 83.02% «= Bik 86 4HGE ite 9 79 o| = 7110 7268 30 30 ie} 2700 2760 120 L370 i] 10200 Lida Wi 171 o 15340 107 107 Oo} 9630 9844 Bd 123 423 a} nae 11916 11316 & 120 120 o} 10800 11040 SS 180 120 0} 16260 16560 | asH Db} 1oace 11040 ao 21805 9297 41575 $4831 33068 39936 41991 52829 4744 1S 62% 84.90% 94 92% 7.8554 84 67% 38.99% 95 87% 80.41% 93 02% Jeet. BG: Z35¢ . 4q7aied 26312 Ta 71% 36 58%. $6 75% 6.27% 7.55%) 2.45% Apr 1? 2009 15:25 P.2o/a1 Life Care Centers of America Southeast Division CON Medicaid Condition Compliance 2007 co m3 ——y s 3% of Ti i i of Tradifronat % of Tradmenat es a A if eto a B A+B Medicaid Days c A+B+C plus, Hospice nm CON TOTAL DAYS con racitional _ Traditiona! | piusMedicad | Meuicare a | Maditional ACO | Medicaid plus Days %ot Menicaid Taditionat | to Total | Mecicaia | ° plus, Hospice | MCRw MCD fF. O3 Vananee ta 3: BOOKS Requirements Gow MCO Days plus [Hospice Bays to| Days with 3 Hc veniance irs] Conditions " Meuicaid Deys Hospice IMCD Hosnice Total Days Medios Co MMevicald ptys, | Coms. Days ro Conga me Days Sonked Days a Bopked insure MCRA Days wi Total Days nee MCD Colns- Bookes a5 64K 38,242 17 454 11433 30% Sad 42,113 79.59%| “313 30.00% S7.4ag 17,235 24,724 a4, 3,96 23,889 5.58% 13,506 20.00% 39,796 7.859 11,6121 29.55% 24 14443 42.05% a aral 50.00%) 38,740! 19,370 23,064 s9.5au| 2,821 25,B07 78.54% 14,096 ap 90% 39,927 +1974 14,045 35.1884 2at2 16,457] At2I% 4,878 21,036 52 65% 4,058 22 6o%f 45.ATK 40,898 18,981 6,588 18.11% yea 6,952 70 1,284 3.236 20.14% 45.00% 39,786 17,908 15,297 38.65% [eT 17,388 43.70% 1,909 19,297 48.50% =| 25.50% 14,208 9,742 W739 20 23%| zs 7abd 20.85% ar 10,991 TT Bi : a 23.05% 40,428 14,452 10,759 26.35% 698 11457 28.06% 3,942| 15,399 Beare im 53.55% 62,138 33,275 BT tad 65 3,405 30,849] 40.85% 36.479 58.22% ad 119% 39,144] 12,396 5,602 14.40% 4.495 rat 15.50% aan7 zs00%| i. 1 <8 18.54% 47,478 18,298 1,rT4 41.65% sm 20,285 42.294 22,252 46.87% A TS.00% 30,750} 23,064] 4,821 15.03% - ai 421 15.03% r,089| 23.05% ra Wi 47.00% 39,930 18,767 12,802 16% 3,020 15,622| 39.12% 17,738 44.42% > S600% 55,422 71,076; 34070 S606 2,924 11,954) 61.14%. 16,504 BS ATs; 3 34.36%] 33 MG 13,416 12,140 31.0985 14,103 612% ry S33 % 40,455 20,262) 19,284 A750 SF 24,213 59.05% L +> 54 51% 41,157 AS.97% 48.93% 38,057 87.40%. oo ry wo col mn & & a ct _ - = ~ Y. i cc. Apr 1? 2009 15:26 APR-17-2089 16:39 AGENCY HEALTH CARE ADMIN a5a 921 158 P.3a/3 UNITED STATES. Ea POSTAL SERVICEe Home | Hele | Sian.in Track & Confirm Search Results Label/Receipt Number: 7004 2890 0000 5527 2432 an TT eater Status: Dellvered Track & Confirm =“ al Enter LabelReceipt Number. Your item was delivered at 12:08 PM on February 28, 2009 in PORT ——ESESee SAINT LUCIE, FL 34952. Notification Options Track & Confirm by email Get current event Information or updates for your item sent to you or others by amail. ¢ Gio>) Big Map Gontadt Ue Forms Gov'l Bervicga dabs Privacy Polley Termng of ee Nallonal & Pramier Accounts Copyright® 1999-2007 USPS. All Rights Reserved. No FEAR Acl EEO Data = FOIA @ pote http://trkenfrm] .smi.usps.com/PTSInternet Web/InterLabellnquiry do 3/26/2009 Apr 1? 2009 15:26 APR-17-2689 16:39 AGENCY HEALTH CARE ADMIN 858 921 41538 P.31/31 SENDER: GOMPLETE THIS SECTION COMPLETE THIS SCOTION ON DELiveny ™ Complete Items 1, 2, and 3. Also complete itam 4 If Restricted Dalivery ie desired. R Print your name and address on the reverse 50 that we can retum the card to you. AR) ama ’ l# Attach this card to the back of the maliplece, ; ©, Datorof Daivery or on the front if space permits, Like Care Comer ofteek S. Olen: Gairnint Strader 2Tap SE Dennings Ra. apd St. Lancig, FLay IS D. 1s delivery address different 1. alt YES, enter delivery address below: O No 3, lee Type Certified Mall =] Express Malt Registered (2 Retum Receipt for Merchandise O1 insured Mal =O G.0.. 4, Restrictad Delivery? (Extra Fea) Ove 2. Article Number , (Tanster tom service fabs) 7004 2890 0000 5527 2432 PS Form 3811, February 2004 Domestic Retum Recalpt 102505-02-M-1é40 TOTAL FP.31

Docket for Case No: 09-002076