Apr 2? 2009 3:45 APR-27-2889 @OIS? AGENCY HEALTH CARE ADMIN 856 921 4158 P.@8 : STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. - Case No. 2008009652 H, C, HEALTHCARE, INC., d/b/a TRINITY COMMUNITY HOSPITAL, 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 H. C. HEALTHCARE, INC., d/b/a TRINITY COMMUNITY HOSPITAL (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to Revoke the license of H. C. HEALTHCARE, INC., d/b/a TRINITY COMMUNITY HOSPITAL, pursuant to Section 395.003, Florida Statutes. JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to Section 395, Part 1, Florida Statutes. 2. Venue lies pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207, Florida Administrative Code, Apr 2? 2009 3:45 APR-27-2889 @9'58 AGENCY HEALTH CARE ADMIN 856 921 4158 P.@9 PARTIES 3. The Agency is the regulatory authority with regard to hospital licensing and regulation pursuant to Chapter 395, Part I, Florida Statutes, and Rule 59A-3, Florida Administrative Code, respectively. 4, Respondent is a hospital located at 506 NW 4” Street, Jasper, Florida 32052, and is licensed under Chapter 395, Part I, Florida Statutes and Chapter 59A-3, Florida Administrative Code, license number 3924. 5. Respondent was at all times maternal hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT! 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7, That pursuant to 59A4-3.273(1), Florida Administrative Code, each hospital is under the direction of a.chief executive officer appointed by the governing body, who 13 responsible for the operation of the hospital in a manner commensurate with the authority conferred by the governing body. 8. That on August 12, 2008, the Agency performed a survey of Respondent’s facility. 9. Upon review of the record and after interview with staff the Agency was made aware that the facility failed to appoint a Chief Executive Officer. 10. That the Agency cited the Respondent facility for the above referenced deficiency. Apr 2? 2009 3:45 APR-27-2889 @9'58 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1a COUNT 1]. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. That pursuant to 39A-3,2085(5) 35, Florida Administrative Code, eachhospital shall employ a registered nurse on a full time basis who shall have the authority and responsibility for managing nursing services and taking all reasonable steps to assure that a uniformly optimal level of nursing care is provided throughout the hospital. 13. That pursuant to 59A-3.2085(5) 5 (b), Florida Administrative Code, the registered nurse shall be responsible for ensuring that a review and evaluation of the quality and appropnateness of nursing care is accomplished. The review and evaluation shall be based on written criteria, shall be performed at least quarterly, and shall examine the provision of nursing care and its effect on patients. 14, That on or about August 12, 2008, the Agency conducted a survey of the Respondent facility and made the following findings: At 1:37 p.m., the survey group was sitting in the conference room when the power went out. The emergency generator did not go on. A surveyor went: over to the ER area and observed a Doctor and two murses talking and standing by the door near ER #1. When asked if there was a patient in the room, one of the nurses walked toward the area which was dark and said the patient was ok. The patient in ER# 1’s Chief Complaint was nausea and vomiting. The patient was alone in the dark. The Surveyor asked the ER Nurse (Darlene) how many patients were in the ER, she stated “Three patients, one in ER# 1, one in ER# 2, and one in ER# 3. The Surveyor went to check on the patient in ER # 2 and found the patient standing by the door outside the room. When asked if the patient was ok standing, the patient responded s/he was in pain and would like to sit down. The DON then went to get a wheelchair for the patient. The patient in ER #2’s Chief Complaint was bilateral flank pain. Apr 2? 2009 3:45 APR-27-2889 @9'58 AGENCY HEALTH CARE ADMIN 856 921 4158 ‘ The Patient from ER# 3 was sitting out in the hallway with intravenous (IV) fluid to gravity flow. The IV had been running on an electric pump and the battery was discharged. Chief complaint: Elevated glucose. At 2:15 p.m. (during a power outage at the facility) a patient arrived walking into the department. She was complaining of chest pain, shortness of breath and pains radiating down her arms. She was placed, by an ER nurse, in a chair in the waiting room. No vital signs were taken, and no history was asked. 2:25 p.m. the patient remained in the waiting room crying. Staff did not return to the waiting room to obtain history or vital signs. 2:30 p.m. Surveyor intervention — the director of nursing was asked what was being done. She stated the physician told her to move the patient to a room and assess her. The power remained out and staff did not have flashlights. The DON attempted to ambulate the patient and the surveyor intervened again by getting the physician and requesting him to assess the patient. The physician was in the lobby assessing and diagnosing another patient. He accompanied the surveyor to the waiting room where the chest pain patient remained. The surveyor again instructed the nurse to take vital signs. Director of nursing was instructed to call 911 (by the surveyor) or told we would. She voiced concerns of an EMTALA violation lodged by EMS if she called them. When it was suggested perhaps an aspirin was in order for this patient (standard of care with chest pain), she stated, “oh no, she took her medications this morning”, not knowing the chest pain protocol. 2:40 p.m. EMS arrived. Vital signs were requested and DON stated “I never got them.” 2:43 p-m. EMS leaves with patient on stretcher. 2:55 p.m. Karen (DON) stated “everyone is turning in their keys- Jets all just go to Billies after work and have some drinks.” 15. The observations of the survey team and interaction. with staff, found that the facility failed to adhere to current minimal standards 16. That the Agency cited the Respondent facility for the above referenced deficiency. COUNT IN 17. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth 4 Apr 2? 2009 3:45 APR-27-2889 @Of59 AGENCY HEALTH CARE ADMIN 856 921 4158 ‘herein. 18. That pursuant to 594-3.276, Florida Administrative Code, each hospital shall develop, implement, and maintain a written preventive maintenance plan, in conjunction with the policies and procedures developed by the infection control committee, to ensure that the facility is maintained in accordance with the following: (a) The interior and exterior of buildings shall be in good repair, free of hazards, and painted as needed. P.i2 (b) All patient care equipment shall be maintained in a clean, properly calibrated, and safe — operating condition; (c) All plumbing fixtures shall be maintained in good repair to assure proper functioning, and provided with back flow prevention devices, when required, to prevent contamination from entering the water supply; (d) All mechanical and electrical equipment shall be maintained in working order, and shall be accessible for cleaning and inspection; (e) Loose, cracked, or peeling wallpaper or paint shall be promptly replaced or repaired to provide a satisfactory finish; (f) All furniture and furnishings, including mattresses, pillows, and other bedding; window coverings; including curtains, blinds, shades, and screens, and cubicle curtains or privacy screens, shall be maintained in good repair; and (g) The grounds and buildings shall be maintained in a safe and sanitary condition and kept free from refuse, litter, and vermin breeding or harborage areas. 19. On or about August 12, 2008, the Agency conducted a survey of the Respondent facility and made the following findings: Apr 2? 2009 3:45 APR-27-2889 @Of59 AGENCY HEALTH CARE ADMIN 856 921 4158 P.13 A tour of the emergency room, beginning with the primary patient care room, was conducted. This area was messy, with debris on the floor. A hand washing sink was on the wall with a pink plastic basin under the “nu” bend in the drainage pipe. Water was leaking into the basin from this pipe. At the back of the sink where the faucet and handles are, the area was heavily soiled, with pinkish/rust colored marking that could be removed when a finger was run across them. At the back of the room was what appeared to be a storage area for supplies. This floor was heavily soiled with numerous supplies and discarded containers on the floor. An over-the-bed table was in this room. On this table was a coffee pot, in use. The table also contained all the fixings for coffee. On the counter was a container of 0.9% Sodium Chloride USP that was opened, undated and among what appeared to be trash. A small plastic container, intended to have been disposed of, was on the counter with metal instruments in it. The instruments were a pair of tweezers, scalpel handle, Trachea plug, pick and bore. | The room had a faint odor of urine, and appeared messy. The sink was soiled and leaking water from the U-tube under the sink. A pink plastic basin was half full of water from the leaking sink. Behind the door was a utility hopper with yellow stains under the water line. On top of the paper dispenser by the sink, 2 scissors were observed covered in dust, The “Pediatric” ER treatment room was observed at approximately 12 p.m. Upon entering it was observed that an upright standing scale was covered in. dust and had last been checked on 11/07. A rall of toilet paper was observed on top of the top cabinet. The air condition vent over the exam table was observed with heavy dust. The pediatric ambu-bag was observed hanging in a plastic bag by a biohazard container. The plastic bag was sticky and dirty. The mouthpiece was wedged in the corner of the bag. The infant scale was heavily soiled. The cart it rested on was soiled and rusted. The walls of the room had several large areas where the paint had chipped off. The linens on the crib did not appear fresh. The exam table in this room was rusted. A drawer on the side of the table could not even be opened. The protective covering for the table was in the form of a paper. The paper was contained on a roll which was on the floor at the head of the table. In a cabinet under the sink, signs of leaking were noted. The cabinet contained additional nebulizers, an unmarked spray bottle with blue liquid, an adult 6 Apr 2? 2009 3:47 APR-27-2889 @Of59 AGENCY HEALTH CARE ADMIN 856 921 4158 P.14 ambu- bag and accessories. Behind other articles, at the back of the cabinet a torn open plastic bag of children’s videos were located. Observation of ER room revealed that the room appeared to be utilized as a storage room. It contained three stretchers. Privacy curtains could only provide coverage for two of the three stretcher areas. Just inside the door, in the corner, a hole was in the wal]. Pipes were exposed and insulation was visible and loose. Various equipment, cabinets and wheel chairs are stored in cubicle #1 inside this room. 20. That based upon mterview and observations, Respondent’s facility failed to maintain minimum standards at its facility. 21, That the Agency cited the Respondent’s facility for the above referenced deficiency. COUNT IV 22. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. That pursuant to 694-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA | 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 694-60, F.A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 24. That pursuant to Florida’s Life Safety Code, the facility shall have an electrically supervised fire alarm, which provides emergency forces notification, is available to warn occupants, and operate protective systems shall be provided. LSC 9.6. NFPA 101- 2003 LSC. Apr 2? 2009 3:47 APR-27-2889 18:68 AGENCY HEALTH CARE ADMIN 856 921 4158 P.is 25, On or about August 12, 2008, the Agency conducted a survey of the Respondent's facility and made the following findings: The Fire Alarm System has no dialer and does not report to a U.L. Central Station. There 1s a reverse polarity monitor that sends a low volt charge thru the regular phone line, and turns a light on at the Sheriff's department, who in turn surnmons the Fire Department that the Hospital fire alarm has activated, The alarm lacks visual devices to warn the hearing impaired of fire alarm activation. Patient rooms are not sprinkled and require at least single station smoke detectors because the corridor protection is inadequate. Corridors do not have enough smoke detectors (30 ft. apart). Interview Fire Alarm contractor states that they know the alarm does not even meet the existing code and understands the facility cannot be prandfathered;. however they tag the system as “functional as installed”. 26. That based upon interview and observations, Respondent’s facility failed to meet minimum requirements. 27. The Agency cited the Respondent’s facility for the above referenced deficiency. COUNT V 28, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29, That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 69A-60, F._A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 8 Apr 2? 2009 3:47 APR-27-2889 18:68 AGENCY HEALTH CARE ADMIN 856 921 4158 P.16 50. That pursuant to Florida’s Life Safety Code, depending on construction date, the facility is required to have either an automatic sprinkler systern of a standard approved type to provide complete coverage for all portions of the facility; or specified types and heights of construction require complete sprinkler protection, All high-rise buildings (over 75' high) shall be completely protected by an approved, supervised automatic sprinkler system per The Florida Fire Code, NFPA 1,7.3.2.21.2.2 by 12/13/14. 31. That pursuant to Florida’s Life Safety Code, the facility is required to have a sprinkler system that is fully supervised and electrically connected to the fire alarm system. LSC 9.7; 18.- & 19.3.5 (exception); NFPA 72. 32. That pursuant to Florida’s Life Safety Code, the main contol valve of the fire sprinkler system shall be electrically supervised with at least a local alarm activation upon closing. LSC 9.7; 18.- & 19.3.5 (exception); NFPA 72 33. That pursuant to Florida’s Life Safety Code, sprinkler systems are to be maintained, inspected, and tested periodically. LSC 18.- & 19.3.5; 4.6.1.2; 9.7; NFPA 13; NFPA 25. 34. That pursuant to Florida’s Life Safety Code, sprinkler systems shall have a continuous, reliable water supply, with continuous pressure to meet systern design. LSC 4.6.1.2; 9.7.1.1: NFPA 13; NFPA 25. 35, On or about August 12, 2008, the Agency conducted a survey of the Respondent’s facility and made the following findings: The Building Construction is NFPA 220 Type II (000) which requires a compliant Fire Sprinkler System. The sprinkler systems require quarterly testing that was not current. The fire sprinklers do not adequately protect the facility. Apr 2? 2009 3:48 APR-27-2889 18:68 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1? The sprinkler heads were supplied with water and plumbing shared from the domestic water system. This is only permitted for six or less heads, and would require dedicated plumbing. The sprinkler contractor states that they are fully aware that the system. is non compliant with the requirements for any spnnkler system Standard, Residential, or Domestic. The contractor stated that during high water use times there isn’t enough water or pressure to serve the sprinklers they do have. All water for the whole Hospital is fed by one 2 4% inch pipe. 36. That based upon interview and observations, Respondent's facility failed to meet state requirements. ‘ 37. The Agency cited the Respondent’s facility for the above referenced deficiency. COUNT VI 38. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 39. That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Flonda specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 69A-60, F.A.C,, entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 40. That pursuant to Florida’s Life Safety Code, cormdor doors shall be 1 3/4 inch solid bonded wood core doors or they shall have a 20 minute fire resistive rating. If the building or smoke compartment is fully sprinklered, the door shall only resist the passage of smoke. There 10 Apr 2? 2009 3:48 APR-27-2889 18:81 AGENCY HEALTH CARE ADMIN 856 921 @158 P.i8 * shall be no impediment to the closing of the door, and latching devices shall be provided which keep the door tightly closed in the frame. LSC 18.3.6.3, 19.3.6.3 41. On or about August 12, 2008, the Agency conducted a survey of the Respondent’s facility and made the following findings Patient Rooms in this Facility have Roller Latches. Roller Latches were prohibited on 3/13/03. A three year waiver period was issued which expired on 3/13/06. This requirement is also a CMS mandate. 42. That based upon observations, Respondent’s facility failed to meet state requirements. 43, The Agency cited the Respondent's facility for the above referenced deficiency. COUNT VII 44. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 45, That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by starute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 69A-60, F.A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 46. That pursuant to Florida’s Life Safety Code, hazardous areas shall be enclosed with one hour fire rated construction or be sprinkler protected. Doors assemblies shall be 45 minute fire rated without vision panels. In new occupancies, repair and paint shops, large storage rooms with ll Apr 2? 2009 3:48 APR-27-2889 18:81 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1i9 ‘ quantities of combustibles, trash rooms, bulk laundries, soiled linen rooms, and severe hazard labs shall be one hour fire separated and sprinklered. Sprinkler protection of isolated hazardous areas may be supplied by domestic water. LSC 18.- & 19.3.2.1 47, On or about August 12, 2008, the Agency conducted a survey of the Respondent’s facility and made the following findings: The Ante room located between the two Isolation rooms was being utilized as collection and storage site for Bio-hazardous waste. 48. That based upon observations, Respondent’s facility was using this area as a hazardous storage area that would require compliance to meet state requirements for hazardous storage. 49. The Agency cited the Respondent's facility for the above referenced deficiency. COUNT VIII 50. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set fomh herein. 51. That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Cade 2006 edition, as adopted within Rule Chapter 69A-60, F.A.C., entitled the «007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 52. That pursuant to Florida’s Life Safety Code, the design, installation, and use of commercial cooking equipment is in accordance with NFPA 96, LSC 9.2.3, 18.3.2.6, 18.3.2.6 12 Apr 2? 2009 3:49 APR-27-2889 18:81 AGENCY HEALTH CARE ADMIN 856 921 4158 P.28 53. That pursuant to the National Fire Protection Association, an exhaust system 18 to be cleaned semi-annually. NFPA 96, 11.3. 34. On or about August 12, 2008, the Agency conducted a survey of the Respondent’s facility and made the following findings: The Kitchen Fire suppression System was out of date for mandatory semi- annual testing. There was no current documentation that the exhaust hood was semi-annually depreased and cleaned. 55. That based upon observations, Respondent’s facility was not in compliance. 56. The Agency cited the Respondent’s facility for the above referenced deficiency. COUNT IX 57, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 58. That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 69A-60, F.A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 59. That pursuant to Florida’s Life Safety Code, non-flammable medical gas systems and equipment shall comply with NFPA 99, chapter 8. (Respiratory Therapy). LSC 18- & 19.3.2.4 60. On or about August 12, 2008, the Agency conducted a survey of the Respondent’s 13 APR-27-2889 Apr 2? 2009 3:49 14: @2 AGENCY HEALTH CARE ADMIN 856 921 4158 facility and made the following findings: 61. That based upon interviews and observations, Respondent’s facility was not in Patient room 25 had a leak in the oxygen outlet. Surveyor requested that the nearest isolation valve be turned off. Staff tured off valve and it started to leak. We proceeded to the next isolation valve and shut it off which also began to leak. The staff assessed patients on oxygen and switched to e-tank cylinders. The main valve to the facility could not be shut off because no one knew how. In addition, the system is in a locked up fence. When asked who had the key, the Maintenance Assistant stated that the Maintenance Director had it. The surveyor asked, “Where is the Maintenance Director?” “He got laid off Monday,” the Maintenance Assistant replied. The staff contacted the Med Gas contractor who came out and shut it down. There was no documentation of any kind demonstrating periodic testing and/or maintenance of the Piped in Medical Gas System. compliance. 62. The Agency cited the Respondent’s facility for the above referenced deficiency 63. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 64. That pursuant 19 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 694-60, F.A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of COUNT X 14 P.2i Apr 2? 2009 3:49 APR-27-2889 18:82 AGENCY HEALTH CARE ADMIN 856 921 4158 P22 " subsection (1) of Section 633.022, Florida Statutes. 65. That pursuant to Florida’s Life Safety Code, a smoke barrier shall be provided on every floor used or usable for patients and on.non-patient floors with an occupant load of 50 or more. (Existing requires smoke barriers on sleeping floors with more than 30 patients). LSC 18- & 19.3.7.1., 18. & 19.3.7.2, 83 66. On or about August 12, 2008, the Agency conducted a survey of the Respondent's facility and made the following findings: Four of six fire/smoke doors failed to close latch or seal appropriately, This was based both on manual testing and activation of the fire alarm system. Removing lay-in ceiling tiles revealed that there are a multitude of penetrations by pipe, wire, plumbing, and just empty holes in the barriers, vertical and horizontal, that were left unprotected. 67, That based upon observations, Respondent’s facility was not in compliance. 58. The Agency cited the Respondent’s facility for the above referenced deficiency. COUNT XI 69. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 70. That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NEPA. 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Unifoum Fire Code 2006 edition, as adopted within Rule Chapter 694-60, F.A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference and are applicable to those buildings and structures specified in paragraphs (a) and (b) of 13 Apr 2? 2009 3:49 APR-27-2889 18:82 AGENCY HEALTH CARE ADMIN 856 921 4158 P.23 * subsection (1) of Section 633.022, Florida Statutes. 71. That pursuant to Florida’s Life Safety Code, air conditioning and ventilation has been installed and maintained to all manufacturers specifications, in accordance with NFPA 90A. LSC 18.5.2, 19.5.2, 9.2 72. On or about August 12, 2008, the Agency conducted a survey of the Respondent's facility and made the following findings: Although no measurements were actually taken, the entire indoors of the building was observed to be very damp, or highly humid. Some areas had strong musty odors indicating mildew. This was compared to the outdoors which revealed that the humidity indoors was significantly higher than outdoors. This may be from design, or the ratio of fresh air to re-circulated air, failure of the air condition units to evaporate moisture from the air, inability to evaporate moisture, Jncorrect unit replacement or a combination of any or all of these issues. 73. That based upon observations, Respondent's facility was not in compliance. 74. The Agency cited the Respondent’s facility for the above referenced deficiency. COUNT XII 75. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 76. That pursuant to 69A-3.012, Florida Administrative Code, except as specifically modified by statute or by the State Fire Marshal’s rules, the Florida specific edition of NFPA 101, the Life Safety Code, 2006 edition and the Florida specific edition of NFPA 1, the Uniform Fire Code 2006 edition, as adopted within Rule Chapter 69A-60, F.A.C., entitled the “2007 edition of the Florida Fire Prevention Code,” are hereby adopted and incorporated by reference 16 APR-27-2889 Apr 2? 2009 3:50 18:82 AGENCY HEALTH CARE ADMIN 856 921 @158 P24 ‘and are applicable to those buildings and structures specified in paragraphs (a) and (b) of subsection (1) of Section 633.022, Florida Statutes. 77, That pursuant to Florida’s Life Safety Code, buildings which normally use life support equipment have electrical systems designed to the standards of NFPA 99 (2002). LSC 18.5.1.3 (exception), NFPA 99- 4.3 & 13-3.4 78, On or about August 12, 2008, the Agency conducted a survey of the Respondent facility and made the following findings: The facility experienced a county wide interruption in electric service in the afternoon on 8/13/08, The generator failed to restore power to the facility in 10 seconds as required. An assessment was immediately performed to ensure that no patients were medically dependent upon electricity. Inspection of the generator revealed that there was no activity with the generator at all. The Administrative Assistant contacted the former Maintenance Director and the Generator Contractor. When the Generator Service Technician arrived he jump started the generator and got it running. The transfer switch had to be wansferred manually, it would not auto transfer. Power was restored. When questioned on the amount of fuel in the generator storage tank, the former Maintenance Director stated that, “It ought to be fine, ] had it filled just after Hurricane Charlie”. ‘ There was no documentation of battery test (specific gravity). The Maintenance Assistant stated that they don’t do that. There was no documentation of actual weekly inspection. The Maintenance Assistant stated that they don’t do that. There was no documentation of fuel testing. The Maintenance Assistant stated that they don’t have that done. There was no documentation of monthly load tests. The Maintenance Assistant stated that they don’t do that. There was no documentation of preventative maintenance by the Generator Company. ; 79. Thal based upon interview and observations, Respondent’s facility was not in 17 Apr 2? 2009 3:50 APR-27-2889 18:83 AGENCY HEALTH CARE ADMIN 856 921 4158 P.25 “compliance. 80. The Agency cited the Respondent facility for the above referenced deficiency. COUNT XIT 81. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 82. That pursuant to 59A-3.276, Florida Administrative Code, each hospita] shal] develop, implement, and maintain a written preventive maintenance plan, in conjunction with the policies and procedures developed by the infection control committee, io ensure that the facility is maintained in accordance with the following: (a) The interior and exterior of buildings shall be in good repair, free of hazards, and painted as needed. . (b) All patient care equipment shall be maintained in a clean, properly calibrated, and safe operating condition; (c) All plumbing fixtures shall be maintained in good repair to assure proper functioning, and provided with back flow prevention devices, when required, to prevent contamination from entering the water supply; (d) All mechanical and electrical equipment shall be maintained in working order, and shall be accessible for cleaning and inspection; (c) Loose, cracked, or peeling wallpaper or paint shall be promptly replaced or repaired to provide a satisfactory finish; (f) All furniture and furnishings, including mattresses, pillows, and other bedding; window coverings; including curtains, blinds, shades, and screens: and cubicle 18 APR-27-2889 83. On or about August 12, 2008, the Agency conducted a survey of the Respondent facility Apr 2? 2009 3:50 16:3 AGENCY HEALTH CARE ADMIN 856 921 4158 curtains or privacy screens, shall be maintained in good repair; and (g) The grounds and buildings shall be maintained in a safe and sanitary condition and kept free from refuse, litter, and vermin breeding or harborage areas. and made the following findings: 84. That based upon interview and observations, Respondent's facility was not in There were multiple leaks from the roof pervasive through the facility, many wet ceiling tiles were observed, and buckets were placed throughout to catch water. The Attomey General's Office Representative was with the team during the survey and informed the team that the facility was given a Medicaid Government Grant for a Rural Hospital to have the entire roof replaced by the roofing contractor. The grant was for approximately $80,000 based on the estimates that the faciliry provided. Inspection of-the roof with the Maintenance Assistant and the Former Maintenance Director revealed that one section of the roof was replaced by a Roofing Contractor (approximately 1/3 of the area). The former Maintenance Director and the Assistant stated that they got a bunch of rolled roofing supplies and 5 gallon buckets of roof tar and the two of them tried to fix the leaks in the roof. They stated that they spent 6 or 7 thousand dollars. No roof project was submitted to the AHCA Office of Plans and Construction, the last project submitted to AHCA was 1998. compliance. 85. The Agency cited the Respondent facility for the above referenced deficiency. 86. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 87. That pursuant to 59A-3,2085(10)(a)-(i), Florida Administrative Code, provides that each Class I and Class Il hospital shall provide on the premises, and each Class III hospital shall COUNT XIV 19 P.26 APR-27-2889 Apr 2? 2009 3:51 16:3 AGENCY HEALTH CARE ADMIN 856 921 4158 ‘provide on the premises or by contract, diagnostic imaging facilities according 10 the needs of the hospital and conform to Chapter 404, F.S., Chapter 64E-5, F.A.C., Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C. (a) The radiology department or other similarly titled part shall be maintained free of hazards for patients and personnel. (b) Each hospital shall have a radiologist either full time or part time on a consulting basis to discharge professional radiology services. (c) Each hospital shall have certified radiologic technologists or basic x-ray machine operator in hospitals of 150 beds or less, and shall be on duty or on call at all times, pursuant to Part IV, Chapter 468, F.S.; and Chapter 64E-3, F.A.C. (d) The use of all diagnostic imaging apparatus shall be limited to personnel designated as specified in Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C. (e) The credentials of each person providing diagnostic and therapeutic radiation, imaging and nuclear medicine services, including formal training, on-the-job experience, and certification or licensure where applicable, shall be maintained on file at all times. (f) Each hospital shall maintain and enforce policies and procedures for the provision of all diagnostic and therapeutic radiation, imaging, and nuclear medicine services, and ensure compliance with the requirements of Chapter 64E-5, F.A.C. Such policies and procedures shall be written, reviewed annually, and revised as necessary in conformance with Chapter 645-5, F.A.C., and shall be dated as to time of last review. (g) Each hospital shall require that all diagnostic and therapeutic radiology, imaging or nuclear medicine services be performed only upon written order of a licensed physician. The request and all results must be recorded in the patient's medical record; (h) Each hospital shall ensure documentation, and reporting to the Bureau of Radiation Control of the Department of Health of all misadministration of radioactive materials, as those terms are defined by Chapter 64E-5, F.A.C. (i) Each hospital shall maintain and document in writing a quality control program designed to minimize the unnecessary duplication of radiographic studies, to minimize exposure time of patients and personnel, and to maximize the quality of diagnostic information and therapy provided. 88. On or about August 12, 2008, the Agency conducted a survey of the Respondent facility and made the following findings: P.2? APR-27-2889 89, That based upon interview and observations, Respondent’s facility was not in Apr 2? 2009 3:51 16: a4 AGENCY HEALTH CARE ADMIN 856 921 4158 A portable X-Ray machine was sitting in the hall outside the X-ray room. Equipment in this room appeared was old and yellowed. A plastic protective coating over the keyboard for the operation of the equipment was cracked, peeling and in some instances missing. A room behind the control room contained the developer. Beneath the developer were several layers of blankets/sheets. When a staff member was asked about these linens, it was stated that they were there because the developer leaked (chemicals). A review of policy and procedure for this department revealed all films are sent out for a radiologist to review and interpret. This process could take 12 to 24 hours. A policy also states “Diagnostic Imaging services will be provided 24 hours a day, seven days a week. Imaging services will be provided under the direction and supervision of a qualified Radiologist, by trained state-certified technologist or Basic Machine Operator.” An interview with staff indicates a Radiologist is not on the premises most days. “He is only here when an invasive procedure is being done.” It was further stated that the technologist is not under the direct supervision of a Radiologist as indicated by the above mentioned policy (019.005). compliance. 90. The Agency cited the Respondent facility for the above referenced deficiency. WHEREFORE, the Petitioner finds that there has been a substantial failure to comply with the requirements of Florida Law, and therefore seeks to REVOKE the license of Trinity Community Hospital, pursuant to Section 395.003, Florida Statutes. Respectfully submitted this ath, of September, 8. =~ yi SAL! S Shaddrick A. Haston Fla. Bar. No. 30197 Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 850.487.9845 (office) $50,921,0158 (fax) 21 P.28 Apr 2? 2009 3:51 APR-27-2889 18:84 AGENCY HEALTH CARE ADMIN 856 921 4158 P.29 ‘Respondent is notified that it has aright 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, FL 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 1 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 4233 to William B. Watson, HI, Watson & Watson, 4131 NW 2R Lane, Gainesville, Florida 32606; and by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 4264 to Robert Krasnow, President, H.C. Healthcare, Inc. d/b/a Trinity Community Hospital, 9517 Southwest 34" Lane, Gainesville, Florida 32608 this gy day of September, 2008. Shaddrick A. Haston, Esq. U.S. Postal Service, U.S. Postal Service, Cop Kris ™ CERTIFIED MAIL. RECEIPT wa CERTIFIED MAIL, RECEIPT Beg: (Domestic Mail Only; No insurance Coverage ey) Re ee ee roca surance Coverage Provited) 5 _For-delivery.information visit our Si Gor delivery inormanon visit our website at w ie r f ur Website BL WWWUSDS- orm — r we WWW. LISP S.cory, fl OFFICIAL USE § CL_OFFICIAL USE m Pind eyo mel Reve a Cortified Fas A Cc oOo Cartifiad Fee ij - Endarsenrant eee Postman S ccpasmanon Regie) re Dl GiPfbiciod Dothan Fen qa Restricted Delivery Fee a iorsement win 4 (Endorsement "Byer Krasnow, President { 7, Tit Posty illiam B. Watson, IIT taaPost, H.C, Healtheare, Inc. d/b/a Trinity | ays qyetson & Watson a 775 Community Hospital re 131 NW 28" Dane hessarape 9517 Southwest 34" Lane or FO Box Nc Gainesville, Florida 32608 Gainesville, Florida 32606 Apr 2? 2009 3:52 856 921 4158 P.38 APR-27-2889 18:85 AGENCY HEALTH CARE ADMIN COMPI CTE THE APCTION ON DEIVERY A,_Flecalved by (Please Print Clearly) |B, Date of Dallvary’ Ets Me Wawd (O/d¥ G, Signature xjarior (ailad Feet D1 Addressee D. Is delivery address diferent trom hem 17 C0 Yes (f YES, enter delivery address balow: © No AR: COMPLETE THIS SECTION Complete items 1, 2, and 3, Also complete item 4 If Restrictad Dalivary 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. 1. Article Addressed to: William B. Watson, IT Watson & Watson 2 4131 NW 28 . Lane 3. Sepice Type Gainesville, Florida 32606 Gertlfied Mali (C1 Express Mall O Registered (1 Return Recelpt for Merchandise insured Mail ==) G.0.0. 4, Flestricted Delivery? (Extra Fea) TD Yes 2, = Number (Copy from service label) 7004 LibD OO03 3739 4233 PS Form 9811, July 1999 Domastle Return Recalpt 102508-00-M-0862 Postage & Fa: uspe! eS. aid Parmit No, G-10 UNITED Staves PostaL SERvicE | | | | | . First-Class Mai . ; ; Sender: Please print your name, address, and ZIP+4 in this box « Lisa Jensen Agency for Health Care Administration 2727 Mahan Drive, MS#3 Tallahassee, Florida 32308 POOL AOD F6O3BL id sitilaabecd barstocalaslalbons tRHoli ow . laddali dade TOTAL PF. 38

Docket for Case No: 09-002263

Orders for Case No: 09-002263