Apr 1? 2009 15:32 APR-17-2889 16:45 AGENCY HEALTH CARE ADMIN 858 3el B158 P2831 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2009000371 Life Care Centers of America, Inc. d/b/a Life Care Center of Ocala Respondent. / ADMINISTRATIVE COMPLAINT Petitioner, the Florida Agency for Health Care Administration (“4HCA”), through undersigned counsel, files this Administrative Complaint against the above-named’ Respondent (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Thirteen Thousand Six Hundred and Sixty Dollars ($13,660) (the “fine amount”) against Respondent, pursuant to Section 408.040, Florida Statutes, and Florida Administrative Code Rule 59C- 12021. ‘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 1 of 9 Apr 1? 2009 15:32 ; APR-1?- 2889 16:45 AGENCY HEALTH CARE ADMIN 656 921 4158 P.2i/3t 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 rules. 6. Respondent is a corporation authorized under the laws of Florida to do business. Respondent operates a community nursing home located at 2800 SW 41" Street, Ocala Florida 34474 and is the licensee on the CON issued on January 26, 1996 for a minimum of 33.00% of the 120 bed facility’s total annual patient days shall be provided to Medicaid patients. The CON number is 7923: a copy of the CON is attached to this complaint 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-1'7-2889 Apr 1? 2009 15:32 16:45 AGENCY HEALTH CARE ADMIN 856 921 4158 8. 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 ig 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. P.2e/al 9. Respondent failed to comply with the condition set forth in its CON, as required by Section 408.040, Florida Statutes, which provide, in part, as follows: 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 shall 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 in 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 rule define the factors constituting good cause for modification. (d) Uf 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 exemption was predicated constitutes noncompliance. In assessing the penalty, the agency shall take into account as mitigation the degree of noncompliance. Proceeds of such penalties shall be deposited in the Public Medicaid Assistance Trust Fund. woke 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 on a certificate of need as specified under Rule 59C-1.013, F.A.C ao Page 3 of 9 . The foregoing violation warrants imposition of the above-mentioned fine amount Apr 1? 2009 15:33 APR-17-2889 16:46 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 certificate 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 the status of conditions must be submitted 30 calendar days following the eighteenth month of operation or the first month where an &5 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 exceed $1,000 per failure per day. In assessing the penalty the agency shall take into account the degree of noncompliance. (b) The assessed fine shal] 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 ater 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 set 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-17-2889 16:46 AGENCY HEALTH CARE ADMIN Apr 1? 2009 15:33 856 921 @158 P. 24/31 Submitted as of the date indicated on the below Certificate of Service. Agency for Health Care Administration 5S Richard Jéseph Saliba, Esquire Senior Attomey 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 JHEREBY 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, ‘ Retum Receipt Requested (receipt # 7004 2890 000 5527 2425) to Respondent, Attention: Administrator, at 2800 SW 41" Street, Ocala Florida 34474 on this 1604 day of February 2009. Agency for Health Care Administration CA Richard foseph 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 fa ion Page 5 of 9 Apr 1? 2009 15:34 APR-17-2889 16:46 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 1. 1f Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION | 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 material facts alleged in the Complaint.), Respondent may ‘ request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the mformal 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 120.37(1), F.S., 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 15:34 APR-17-2889 16:47 AGENCY HEALTH CARE ADMIN 856 921 4158 P2631 EXHIBITS (AHCA y, Life Care Center of Ocala Case No.2009000371) EXHIBIT “A”-— — Respondent’s CON # 7923, requiring a minimum of 33.00% of the 120bed facility’s total annual patient days shall be provided to Medicaid patients. EXHIBIT “B” - Florida Nursing Home Utilization Report for Year 2007, page 63. EXHIBIT “C” — Respondent’s facility report for calendar year 2007. 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Track & Confirm Enter Labal/Racalpt Number. Your item was delivered at 11:20 AM on February 28, 2009 in OCALA, FL 34474, Notification Options Track & Confirm by emall Get currant event information or updates for your Item sent to you or others by email. (fa>) Sis Map Goniact Ve Forms Govil Servings APR Pavacy Polley Terma of Wee Nalional & Premier Accounte e shed be Copyright® 1999-2007 USPS. All Righté Reserved. No FEAR AcLEEO Data = FOIA @ " wi http://trkenfrm 1.smi.usps.com/PTSInternet Web/InterLabelInquiry.do 3/26/2009 1? 2009 15:37 rer 856 921 4158 P.34/31 AGENCY HEALTH CARE ADMIN APR-17-2889 16:58 Complete ttams 1, 2, and 3, Also completa item 4 If Restricted Delivery is destrad, @ Print your name and addrese on the reverse 80 that we can return the card to you. M Attach this card to the back of the meilpiece, OF on the front if Space permits, 1, Article Addressed to: Life Care Cenler of Crala Palen: Pideniniatrator kop SW Ole SH Ocala FL. a4H474 C. Date of Del 2-25-0 D. fs delivery address different from item 7? Cl Yes It YES, enter delivery address below: C1 No C1 Express Mall 3 Retum Receipt for Merchandisa Ocon. 4, Restricted Delivery? (Extra Fea) O Yes 2. Atticle Number (Tranter trom servic taba) 7004 2455 O000 5527 Cues TOTAL FP.31

Docket for Case No: 09-002077