STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case Nos.: 2010007815 2010007729 SERENITY VILLAGE, INC, d/b/a SERENITY VILLAGE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Petitioner” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against SERENITY VILLAGE, INC., d/b/a SERENITY VILLAGE (hereinafter “Respondent”), pursuant to Section § 120.569 and Section § 120.57, Fla. Stat. (2010), 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) State Class II deficiency pursuant to Section § 429.19(2)(b), Fla. Stat. (2010); one thousand, five hundred ($1500.00) based upon three (3) uncorrected cited State Class III deficiencies pursuant to Section § 429.19(2)(c), Fla. Stat, (2010) and the imposition of a survey fee of five hundred dollars ($500.00) pursuant to the provisions of Section § 429.19(7), Fla. Stat. (2010) for a total assessment of three thousand dollars ($3000.00). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Section § 20.42, Section § 120.60 and Chapters Filed September 22, 2010 4:51 PM Division of Administrative Hearings. 408, Part II, and 429, Part I, Fla. Stat. (2010). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part 1, Florida Statutes, and Chapter 58A-5, Florida Administrative Cade. 4, Respondent operates a eight (8) bed assisted living facility (hereafter “ALF”) located at 11277 Freedom Court, Seminole, Florida 33772, and is licensed as an ALF, license number 7021. 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. COUNTI-Tag A806 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. Pursuant to Florida law, specifically 58A-5.019(1)(b), Florida Administrative Code, Administrators in assisting living facilities may supervise a maximum of cither three facilities or a combination of housing and health care facilities or agencies on a single campus. However, administrators who supervise more than one facility shall appoint in writing a separate “manager” for each facility who must: e Beat least 21 years old; and « Complete the core training requirement pursuant to Rule 58A-5.0191, F.A.C. 8, On May 24 2010, the Agency conducted an Assisted Living Facility (ALF) Limited Page 2 of 10 Nursing Services (LNS) Licensure survey and complaint investigation and found the facility out of compliance with this rule. 9. During an interview with an assistant manager and as a result of records reviewed at approximately 11:15 AM, it was revealed there was no documentation in writing assigning a manager for the facility. At the time, the Administrator was supervising more than one facility, including Serenity Village II which has since converted to a group home. 10. | The Agency determined this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency violation. 11. The Agency provided Respondent with a mandatory correction date of June 24, 2010. 12, On July 13, 2010, the Agency conducted a follow-up to the May 24, 2010 Assisted Living Facility (ALF) Limited Nursing Services (LNS) Licensure survey and complaint investigation of the Respondent facility. 13. Based on records review and interviews with personnel, the facility failed to assure in writing an assigned manager for the facility with core training. At 10 AM, the surveyor’s findings included that: © the facility did not have documentation of a manager assigned to the facility; e the only staff member on duty was not able to find any documents and assist with the plan of correction; and « the administrator and the manager were not present or available. 14. | The Agency determined this [uncorrected] deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency violation. 15. The failure to correct the cited deficiency within the time period specified is a violation of law and constitutes grounds for a fine. See § 408.813(2)(c). Page 3 of 10 WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an ALF in the State of Florida, pursuant to Section § 429.19(2)(c), Fla. Stat. (2010). COUNT I - Tag N300 16. The Agency re-alleges and incorporates paragraphs one (1) through fifteen (15) as if fully set forth herein. . 17. Assisted living facilities licensed to provide Limited Nursing Services (LNS) must employ or contract with a nurse who shall be available to provide such services as needed by residents. 58A-031(2)(d), F.A.C. 18. On May 24 2010, when the Agency conducted the ALF Limited Nursing Services (LNS) Licensure survey and complaint investigation, the facility was found to be out of compliance with this rule. 19. During the 11:15 AM interview with the assistant manager, it was revealed that the administrator was unavailable and the assistant manager was unable to obtain the documents requested regarding Limited Nursing Services. 20. Based on an interview with the Assistant Manager, the facility failed to provide documentation of a contract with a nurse or agency for limited nursing services. Findings included: The Assistant Manager was interviewed 5/24/10 at approximately 11:00 AM. During the interview it was revealed that the facility did not have a contracted or employed nurse available to provide nursing services as needed by the residents. If a health care provider were to write an order for LNS services, no nurse would be readily available. While the facility’s contract states that such services “are available if needed,” [at that time] there were no residents on LNS. Page 4 of 10 21. The Agency determined this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class Il deficiency violation. 22. The Agency provided Respondent with a mandatory correction date of June 24, 2010. 23. On July 13, 2010, the Agency conducted a follow-up to the May 24, 2010 Assisted Living Facility (ALF) Limited Nursing Services (LNS) Licensure survey and complaint investigation of the Respondent facility. 24. At the July 13, 2010 revisit, despite the facility’s stated intentions in its plan of correction, the facility failed to provide a signed contract for nursing services and was still unable to provide nursing services as needed to the residents. Findings included: That, at 9:30 AM, the only employee on duty was not able to locate the policy and procedures or the required contract with a licensed nurse for review. A current license was posted on a bulletin board for a Nurse Practitioner with an expiration date of 7/31/10. The resident aide on duty stated “I do not know what limited nursing services are or where the book is kept.” Neither the administrator nor _ assistant administrator were available. 25. The Agency determined this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency violation. 26. The failure to correct the cited deficiency within the time period specified is a violation of law and constitutes grounds for a fine. See § 408.813(2)(c). WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an ALF in the State of Florida, pursuant to Section § 429.19(2)(c), Fla. Stat. (2010). Page 5 of 10 COUNT Ill — Tag N301 27. The Agency re-alleges and incorporates paragraphs one (1) through twenty-seven (27) as if fully set forth herein. 28, Assisted living facilities shall maintain documentation of the qualifications of nurses providing limited nursing services in the facility’s personnel file. See 58A-031(2)(d), F.A.C. 29. On May 24 2010, when the Agency conducted the ALF Limited Nursing Services (LNS) Licensure survey and complaint investigation, the facility was found to be out of compliance with this rule. 30. Based on records reviewed and interview with the Assistant Administrator, the facility failed to provide documentation of the qualifications of nurse(s) providing limited nursing services, Findings included: During records review of personnel files on 5/24/10 at approximately 11:00 AM with the Assistant Administrator, it was revealed that the facility did not have any contract with a licensed nurse nor any documentation of the qualifications of a nurse or nurses who could provide limited nursing services. 31. The Agency determined this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency violation. 32. The Agency provided Respondent with a mandatory correction date of June 24, 2010. 33. On July 13, 2010, the Agency conducted a follow-up to the May 24, 2010 Assisted . Living Facility (ALF) Limited Nursing Services (LNS) Licensure survey and complaint investigation of the Respondent facility. 34. At the July 13, 2010 revisit, despite the facility’s stated intentions in its plan of correction, the facility failed to provide documentation of qualifications of nurse(s) providing limited nursing services. Findings included: Page 6 of 10 That, during the revisit of 7/13/10 at approximately 9:30 AM, the facility did not have any documentation regarding the qualifications of a nurse or nurses that would be available to provide limited nursing services as needed. In fact, there was no contract with such a nurse in the files. 35. The Agency determined this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents and cited Respondent for a State Class III deficiency violation. 36. The failure to correct the cited deficiency within the time period specified is a violation of law and constitutes grounds for a fine. See § 408.813(2)(c). WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00), against Respondent, an ALF in the State of Florida, pursuant to Section § 429.19(2)(c), Fla. Stat. (2010). COUNT IV — Tag A509 37. The Agency re-alleges and incorporates paragraphs one (1) through thirty-six (36) as if fully set forth herein. 38. Section 429.174(2), Florida Statutes (2010), addresses background screening for employees of assisted living facilities and states: The person required to be screened has been continuously employed in the same type of occupation for which the person is seeking employment without a breach in service which exceeds 180 days, and proof of compliance with the level 1 screening requirement which is no more than 2 years old is provided. Proof of compliance shall be provided directly from one employer or contractor to another, and not from the person screened. Upon request, a copy of screening results shal! be provided by the employer retaining documentation of the screening to the " person screened. 39. Rule 58A-5.019(3). F.A.C., further defines the requirements of law as follows: (a) All staff, who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S., and meet the screening standards of Section 435.03, F.S. A packet containing background screening forms and instructions may be obtained from the Agency Background Screening Unit, 2727 Mahan Drive, Tallahassee, FL 32308; telephone (850)410-3400. Within ten (10) days of an individual’s Page 7 of 10 employment, the facility shall submit the following to the Agency Background Screening Unit: 1. Acompleted Level 1 Criminal History Request, AHCA Form 3110-0002, July 2005, which is incorporated by reference and may be obtained in the screening packet referenced in paragraph (3)(a) of this rule; and 2, A check to cover the cost of screening. (b) The results of employee screening conducted by the agency shall be maintained in the -employee’s personnel file. (c) Staff with the following documentation in their personnel records shall be considered to have met the required screening requirement: 1, A copy of their current professional license, proof that a criminal history screening has been conducted, and an affidavit of current compliance with Section 435.03, F.S.; 2. Proof of continuous employment in an occupation which requires Level 1 screening without a break in employment that exceeds 180 days, and proof that a criminal history screening has been conducted within the previous two (2) years; or 3. Proof of employment with a corporation or business entity or related entity that owns, operates, or manages more than one facility or agency licensed under Chapter 400, F.S., that conducted Level 1 screening as a condition of initial or continued employment. 40. On May 24, 2010, when the Agency conducted the ALF Limited Nursing Services (LNS) Licensure survey and complaint investigation, the facility was found to be out of compliance with this statute and rule. 41. Based on employee records reviewed, the facility failed to ensure that the employee was in compliance with Level 1 background screening. Findings include: During employee records reviewed for one (#1) of one employee of the ALF on 7/13/10 at approximately 11:00 AM, it was revealed the facility did not obtain background screening with clearance from FDLE for the only employee present to perform several duties twenty four hours a day. The only employee present works as a resident aide and provides personal services including assistance with medications. According to the agency that oversees licensing for health care professionals, this employee has a recent history of unprofessional conduct including acts of negligence either by omission or commission. 42. The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents. 43. The Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2010). Page 8 of 10 WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00), against Respondent, an ALF in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2010). COUNT V 44. The Agency re-alleges and incorporates the entirety of this complaint as if fully set forth herein. 45. Pursuant to Section § 429,19(7), Fla. Stat, (2010), “[i]n addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s, 429,28(3)(c) to verify the correction of the violations.” 46. On July 13, 2010, the Agency conducted a complaint inspection CCR#201 0004624 of Respondent’s facility that resulted in violations that are the subject of the complaint to the Agency. 47. Pursuant to Section § 429,19(7), Fla. Stat. (2010), such a finding subjects the Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or five hundred dollars ($500.00). 48. Respondent is therefore subject to a complaint survey fee of five hundred dollars ($500.00), pursuant to Section § 429.19(7), Fla. Stat. (2010). WHEREFORE, the Agency intends to impose an additional survey fee of five hundred dollars ($500.00) against Respondent, an ALF in the State of Florida, pursuant to Section §429,19(7), Fla. Stat. (2010). Respondent is notified that it has a right to request an administrative hearing pursuant to Section Page 9 of 10 120.569, 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 I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7008 0500 0001 9560 9503 on August 30), 2010 to Gary T. Hartfield, Administrator/Registered Agent, Serenity Village, Inc,, 11277 Freedom Court, Seminole, Florida 33772. STATE OF FLORIDA, AGENCY FOR HEALTHCARE ADMINISTRATION 525 Mirror Lake Dr. N., Suite 330H St. Petersburg, Florida 33701 Phone: (727) 552-1945; Fax: (727) 552-1440 Copy furnished to: Kathleen Varga, FOM Page 10 of 10 SENDER: COMPLETE THIS SECTION : m@ Completeitte. and 3. Also complete tem 4 if-Restrioted Delivary Is desired. ™ Print your name and address on the reverse so that we can retum the card to you. ™ Attach this card to the back of the mallplece, or on the front If space permits, 4. Articla Addressed to: Gary T. Hartfiled Serenity Village 11277 Freedom Court Seminole, FL 33772 COMPLETE THIS SECTION ON DELIVERY it YES, enter delivery address below: TI No oes [okey (Mak = C} Express Mall a Registered ‘EI Retum Hacelpt for Olineured Mall [1 G.0.D. 4, Restricted Delivery? (Extra Fee) 2. Article Number * . Bolo (anstr trom e... ron8 o500 0001 3560 9503 OO} } PS Form 3811, February 2004 Domestic Retum Recelpt . yo2895-02-Me

Docket for Case No: 10-009254