Nov 23 2010 12:59 11/23/2818 13:82 85892148158 Soe ~ "| STATE OF FLORIDA AGENCY FOR HEALTH CARE. ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. JEROLD MACK, SR., Respondent. ADMINISTRATIVE COMPLAINT 2010008022 2010008939 2010008953 2010008960 PAGE COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against Jerold Mack, Sr. (hereinafter Respondent), pursuant to Section 120.569 and 120.57, Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s licerise to operate an adult family care home (hereinafter also referred to as “AFCH”) pursuant to §§ 408.815 and 429.69, Florida Statutes (2010) and to impose an administrative fine in the ammount of five thousand five bundred dollars ($5,500.00) based upon two (2) cited State Class 1 deficiencies and sixteen (16) uncorrected Class III deficiencies pursuant to §429.71(1) Florida Statutes (2010). JURISDICTION AND VENUE 1. The Agency. has jurisdiction pursuant to §§ 20.42, 120,60, 429.71 and 429.73, Florida Statutes (2010). a2/57 Now 23 2010 13:00 11/23/2818 13:82 8589218158 PAGE 83/57 ”. Venue lies Pursuant to. Florida Ad we 3. The Agency is the regulatory authority responsible for licensure of adult family cate homes and enforcement of all applicable federal regulations, state statutes and rules governing adult family care homes pursuant to the Chapters 408 and 429, Part II, Florida Statutes (2010), and Chapter 58A-14 Florida Administrative Code. 4, ° Respondent is licensed as a five (5) bed adult family care home located at 7512 Oxford Garden Circle, Apollo Beach, Florida 33572, license number 6906334. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. . COUNT 1 (002) 6. The Agency te-alleges and incorporates paragraphs (1) through (5) as if fully set forth © herein. 7. That pursuant to Florida law, “Adult family-care home” means a full-time, family-type living arrangement, in a private home, under which a person who owns or rents the home provides room, board, and personal care, on a 24-hour basis, for no more than five disabled adults or frail elders who are not relatives... § 429.65(2), Fla. Stat. (2010). A person who intends to be an adult family-home care provider must own or rent the adult family-care home that is to be licensed and reside therein. § 429.67(2), Fla. Stat. (2010). Tn addition, a person who is licensed as an AFCH provider must live in the adult family care home facility. R- 5BA- 14. 008(2)(a)2), Florida Administrative Code. AFCHs “provide housing and personal care for disabled adults and frail elders who choose to live with an individual or family in a private home. The adult family-care home provider must live in the home. The purpose of ‘this part is to Now 23 2010 13:00 11/23/2616 13:82 8589218158 PAGE 84/57 provide for the health, safety, and welfare of residents of adult family-care homes in the state.” § 429.63(2), Fla. Stat. (2010) (emphasis supplied). , 8. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. | 9. That based upon observation and interview, Respondent does not reside in the licensed address, the same being contrary to law. 10. That Petitioner's representatives toured the Respondent facility.on June 29, 2010 and noted as follows: - a. The facility had three (3) bedrooms and a garage which had been turned into another bedroom; . b. Two (2) of the facility’s five (5) residents resided in one (1) of the bedrooms while the other two (2) resided in a second bedroom; -&. Inthe third bedroom, two (2) staff members, neither of which was the Respondent, resided; d. The converted garage was occupied by a staff member and the fifth resident who was a live-in companion of the referenced staff member; ce. There was no available space within the physical plant to serve as a residence or sleeping area for Respondent. 11. That Petitioner’s representative interviewed the residents and staff present on June 29, 2010, and ali confirmed that the Respondent Jerold Mack, Sr. does not reside at the facility address. . . 12. That the above reflects that Respondent does not reside in the licensed facility, a violation of licensure requirements. Now 23 2010 13:00 11/23/2818 13:82 8589218158 PAGE 5/57 13. That the Agency determined that this violation constitutes conditions or occurrences “related to the operation and maintenance of a provider or to the care of clients which indirectly ot ~ potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class HI violation in accord with law. 14.‘ That the Agency provided Respondent with a mandatory correction date of July 29, 2010, 15. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 16. That based. upon observation and interview, Respondent does not reside in the licensed address, the sare being contrary to law. 17, That Petitioner’s representatives toured the Respondent facility on June 29, 2010 and noted as follows: a. The facility had three (3) bedrooms and a garage which had been tumed into another bedroom; b. Two (2) of the facility’s five (5) residents resided in one (1) of the bedrooms, two (2) resided in a second bedroom, and the fifth resident resided in the third bedroom; ) c. The converted garage was occupied by two (2) live-in staff members, d. There was no available space within the physical plant to serve as a residence of sleeping area for Respondent. 18. That Petitioner’s representative interviewed the residents and staff present on August 17, 2010, and:alt confirmed that the Respondent Jerold Mack, Sr. does not reside at the facility address. Now 23 2010 13:00 11/23/2616 13:82 8589218158 PAGE 86/ 5? 19, That the above reflects that Respondent does pot reside in the Hieensed facility, a violation of licensure requirements. . 20. That the Agency determined that. this violation constitutes conditions or occurrences related to the operation and maintenance of a provider ot to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class TI] violation in accord with law. 1. That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1}(c), Florida Statutes (2010). COUNT TL (01 22. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. That pursuant to Florida law, the adult family-care home provider shall maintain a. separate record for each resident on the premises and available for inspection by the agency. The record shall contain ....A complete accounting of any resident funds being received or distributed by the provider as required by Section 429.85, F.8. R. 58A-14,0085(1)(a)(5), Florida Aduainistrative Code. 24. That pursuant to Florida law, a resident of an adult family-care home may not be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the State Constitution, or the Constitution of the United States solely by reason of status as a resident of the home. Each resident has the right to ... Manage the resident’s own financial affairs unless the resident or the resident's guardian authorizes the provider to provide safekeeping for funds in Now 23 2010 13:01 11/23/2616 13:82 8589218158 PAGE 87/57 accordance with procedures equivalent to those provided in s. 429.27. § 429.85(f, Florida . ‘Statutes, (2010). . . 25. Thaton Jurie 29, 2010, the Agency conducted an annual licensure and complaint survey, . CCR# 2010004903 of Respondent. 26. That based upon the review of records and interview, Respondent failed to maintain a complete accounting of resident funds for five (5) out of five (5) residents reviewed, the same being contrary to law. ‘27, That Petitioner's representative reviewed Respondent’s resident fund accounting records on June 29, 2010 and noted that all record keeping had stopped in April 2010 and that the records as presented were not accurate. 28. That Petitioner’s representative interviewed Respondent on June 29, 2010 who indicated that there was just not enough time to do-all requited record keeping. 29, That the above reflects Respondent's failure to maintain an accurate accounting of resident funds placing residents at risk of misappropriation by intent or negligence of theit funds. 30. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class IMI violation in accord with law. 31. Thatthe Agency provided Respondent with a mandatory correction date of July 29, 2010. 32, That on August 17, 2010, the Agency conducted a re-visit to. the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 33, That based upon the review of records and interview, Respondent failed to maintain a Now 23 2010 13:01 11/23/2818 13:82 8589218158 PAGE 8/57 complete accounting of resident funds for three @) out of three (3) residents reviewed, the same being contrary to law. 34. That Petitioner’s representative reviewed Respondent's resident fund accounting records for three (3) residents on August 17, 2010 and noted that all record keeping had stopped in April 2.010 and that the records as presented were not accurate. 35. That Petitioner’s representative interviewed Respondent on August 17, 2040 who indicated that he was reviewing the funds and was working on creating an accurate record. 36. ° That the above reflects Respondent's failure to maintain an accurate accounting of resident funds placing residents at risk of misappropriation by intent or negligence of their funds. 37. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class II violation in accord with law. 38, That the same constitutes an uncorrected deficiency as defined by law | WHEREFORE, the Agency intends to impose ah administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1 6), Florida Statutes (2010). COUNT BI (204) 39, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 40, That pursuant to Florida law, the adult family-care home provider shall maintain a separate record for each resident on the premises and available for inspection by the agency. The record shall contain ... A copy of the residency agreement which meets the requirements of Rule Now 23 2010 13:01 11/23/2616 13:82 8589218158 PAGE 89/57 58A-14,0062, F.A.C., including a copy.of any. notices of rate inereases sent to the resident or the .. residents representative and any addendums. R. §8A-14.0085(1(a)(2), Florida Administrative vey i Code. 41. That pursuant to Florida law, pursuant to Section 429.81, F 8., before or at the time of admission to an adult family-care home, the provider and the resident or the resident’s _ representative must sign a residency agreement, a copy of which must be given to the provider and kept on file for 5 years after the expiration of the agreement, and a copy of which must be provided to the resident or resident’s representative.. R. 58A-14.0062(1), Florida Administrative Code. An addendum shall be added to the residency agreement to reflect any additional services and charges not covered by the original agreement. Such addendum must be dated and signed by the provider and the resident or resident's representative and a copy given to the provider and the resident or the resident’s representative. R. $8A-14.0062(3), Florida Administrative Code 42, That pursuant to Florida law, each resident must be covered by a residency agreement, executed before or at the time of admission, between the provider and the resident or the ” resident’s designee or legal representative. Each party to the contract must be provided a duplicate copy or the original agreement, and the provider must keep the residency agreement on file for 5 years after expiration of the agreement. § 429.81(1), Florida Statutes, (2010). 43. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Resporident. 44. That based upon the review of records, Respondent failed to provide residency agreements for three (3) of five (5) sampled residents, the same being contrary to law. 45. That Petitioner’s representative reviewed Respondent’s records regarding residents and noted as follows: Now 23 2010 13:02 11/23/2818 13:82 8589218158 PAGE 18/57 a. Resident number one (1) — The resident’s contract, dated August 1, 2009, did nat contain the resident's name and was not signed by the resident or representative. The resident was admitted to the facility on March 10, 2010, b. Resident number two (2) — No contract between the facility and the résident was presented, The resident was admitted to the facility on October 2, 2009. ¢. Resident number four (4) — Respondent maintained no records regarding this resident, including but not limited to no contract between the resident and Respondent. 46, That the above reflects Respondent’s failure to maintain residency. contracts in accord with the minimum mandates of law, depriving residents of their protections provided by law and contract, 47. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class ITI violation in accord with law. 48. . That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 49. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 50... That based upon the review of records, Respondent failed to provide residency — agreements for two (2) of three (3) sampled residents, the same being contrary to law. 51. That Petitioner’s representative reviewed Respondent’s records regarding residents and noted as follows: Now 23 2010 13:02 11/23/2818 13:82 8589218158 PAGE 11/57 a. Resident number one (1) — The resident's contract did not contain the resident's name and was not signed by the resident or representati reflect when the resident was admitted to the facility. b. Resident number two (2) — No contract between the facility and the resident was presented. The resident was admitted to the facility on October 2, 2009, 52, That the above reflects Respondent’s faiture to maintain residency contracts in accord with the minimum mandates of law, depriving residents of their protections provided by law and contract. 53. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or secutity of clients and cited Respondent with a Class ILI violation in accord with law. 54, That the same constitutes an uncotrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). . COUNT IV (213) 54. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 56. That pursuant to Florida law ... as part of health monitoring, residents must be weighed ; monthly. R, 58A-14.007(4), Florida Administrative Code, The adult family-care horne provider shall maintain a separate record for each resident on the premises and available for inspection by the agency. The record shall contain ... the resident’s monthly weight record as required by Now 23 2010 13:02 11/23/2818 13:82 8589218158 PAGE 12/57 Rule 58A-14.007, F._A.C. R. 58A-14.0085(1)(a)(10), Florida Administrative Code. 57. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. 58. That based upon the review of records, Réspondent failed to obtain and or maintain monthly weight records for its residents as required by law for four (4) of five (5) sampled residents. 59. That Petitioner's representative reviewed Respondent’s resident records during the survey of June 29, 2010 and noted as follows: a, Resident number one (1) — The resident was admitted to the Respondent facility on March 10, 2010 and the last resident weight recorded was in April 2010. b. Resident number two (2)- The resident was admitted to the Respondent facility on October 1, 2009 and the last resident weight recorded was in June 2010. c. Resident number three (3) - The resident was admitted to the Respondent facility on July 6, 2009 and the last resident weight recorded was in April 2010, a. Resident number four (4) - There was no resident record available for review as "the same had purportedly been taken with the resident to a physician’s appointment. No weight records for the resident were presented. 60. That the above reflects Respondent’s failure to obtain or maintain monthly weight records for residents, the same presenting a risk that health care providers are not notified of sudden or unexpected weight change which may be symptomatic of other health issues. 61. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and ‘maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited iW Now 23 2010 13:02 11/23/2818 13:82 8589218158 PAGE 13/57 Respondent with a Class HT violation in acvord with law. 62. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 63. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted conyplaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 64. That based upon the review of records, Respondent failed to obtain and or maintain monthly weight records for its residents as required by law for three (3) of three (3) sampled residents. | 65. That Petitioner’s representative reviewed Respondent’s resident records during the survey of August 17, 2010 and noted as follows: a. Resident. number one (1) - The tesident was admitted to the Respondent facility on October 1, 2009 and the last resident weight recorded was in June 2010. b. Resident number two (2) - The resident’s records did not reflect the resident’s date of admission to the Respondent facility or any records of resident weights. c. Resident number three (3) — The resident was admitted to the Respondent facility on July 6, 2009 and the last weight recorded was April 2010. ) 66. That the above reflects Respondent’s failure to obtain or maintain monthly weight records for residents, the same presenting a risk that health care providers are not notified of sudden or unexpected weight change which may be symptomatic of other health issues. 67. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or . potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class II vielation in accord with law. 11/23/2818 13:82 8589218158 Nov 25 2010 15205 PAGE 14/57 . 68, That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two bundred fifty dollars ($256.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). COUNT ¥V (400 69. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 70, That pursuant to Florida law, adult family-care home providers ‘nust maintain personnel records on the premises available for Agency inspection. R. 58A-14.0085(2), Florida Administrative Code. 71. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCRH 2010004903 of Respondent. 72. That based upon the review of records and interview, Respondent failed to maintain or provide for Agency review personnel records for his staff for three (3) of four (4) sampled staff members, the same being contrary to law. 73, That Petitioner’s representative requested of Respondent the opportunity to review the personnel records for Respondent’s four (4) staff members. 74, That Respondent failed to produce any personnel records related to staff members numbered two (2), three (3), or four (4). 75, That Petitioner’s representative interviewed Respondent regarding the lack of personnel records above referenced and Respondent indicated that he could not find the referenced personnel records, 76. That the failure to maintain personnel records places residents at risk of being placed in Now 23 2010 : 11/23/2818 13:82 85892148158 ves PAGE 15/ a? the care of unqualified, untrained, or disqualified personne! and is contrary to law. , 77, That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited _ Respondent with a Class Til violation in accord with law, | 78. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 79, That on August 17,2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 201 0008103 of Respondent facility. 80. That based upon the review. of records and interview, Respondent failed to maintain or provide for Agency review personnel records for his staff for one (1) of four (4) sampled staff members, the same being contrary to law. - 81. That Petitioner’s representative requested of Respondent the opportunity to review the personnel records for Respondent’s four (4) staff members. 82. That Respondent failed to produce any personnel records related to staff member number four (4). | 83. That Petitioner’s representative interviewed Respondent regarding the lack of personnel records above referenced and Respondent indicated that he could not find the referenced ‘personnel record, 84, That the failure to maintain personnel records places residents at risk of being placed in the care of unqualified, untrained, or disqualified personnel and is contrary to law. 85. That the Agency determined that this violation constitutes conditions or occurrences related to'the operation and maintenance ofa provider or to the care of clients which indirectly or Now 23 2010 : 11/23/2818 13:82 8589218158 ves PAGE 16/ 5? potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class Ti] violation in accord with law. | 86, That the same constitutes an uncorrécted deficiency as defined by law WHEREFORE, the 1e Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). COUNT Vi (401) 87... The Agency re-alleges and incorporates paragraphs (1 through (5) as if fully set forth herein. : 88. That pursuant to Florida law, an adult family-care home provider shall, at a minimum, — maintain the following personnel records ... . For the adult family-care home provider, each relief person, each adult household member, and each staff person verification of freedom, from communicable disease as requized under Rule 58A-14.008, F.A.C. R. 58A-14.085(2)(a)()), Florida Administrative Code. The provider, all staff, each relief person, and all adult household members must submit a statement from a licensed health care provider that he or she is free from apparent signs and symptoms of communicable diseases, including tuberculosis. The statement must be based on an examination conducted within the six months prior to employment. Annually thereafter, the individual must submit documentation from a licensed health care provider that he or she is free from tuberculosis. An exception is that an individual with a positive tuberculosis test must submit a statement from a licensed health care provider that he or she does not constitute a risk of communicating tuberculosis. R. 58A-14.008(1){a), Florida Administrative Code. 29. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, Now 23 2010 13:04 11/23/2818 13:82 8589218158 PAGE 17/57 ~ CCR# 2010004903 of Respondent. - . 90. That based upon the review of records and interview, Respondent failed to produce documentation reflecting that four (4) of four (4) sampled staff members were free from apparent signs or symptoms of tuberculosis, the same being contrary to the mandates of law. 91. That Petitioner's representative requested of Respondent the opportunity to review the personnel records for Respondent’s four (4) staff members. 92. That Respondent failed to produce any personnel records related to staff members numbered two (2), three (3), or four (4) including, but not limited to documentation reflecting that the staff members were free of signs or symptoms of tuberculosis. 93. That the personnel record of staff member number one (1) did not contain any document within the past calendar year which would reflect that the staff member had been determined free from apparent signs or symptoms of tuberculosis, the most recent documentation reflecting the same being dated April 22, 2009. 94. That Petitioner’s representative interviewed Respondent regarding the lack of personnel records above referenced and Respondent indicated that he could not find the requested records. 95. That the failure to obtain and maintain documentation reflecting that staff are free from. signs or symptoms of tuberculosis on an annual basis places residents at increased and unneeded risk of infection and is contrary to law. 96. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited. Respondent with a Class II violation in accord with law. 97. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 11/23/2818 13:82 8589218158 Now 23 2010 13:04 PAGE 18/57 98, That on August V7, 3010, the “Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 201 0004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 99. That based upon the review of records and interview, Respondent failed to produce documentation reflecting that four (4) of four (4) sampled staff members were free from apparent signs or symptoms of tuberculosis, the same being contrary to the mandates of law. 100. That Petitioner’s representative requested of Respondent the opportunity to review the personinel records for Respondent’s four (4) staff members. 101, That any persomnel records related to staff members numbered two (2), three (3), or four (4) did not include any documentation reflecting that the staff members were free of signs or symptoms of tuberculosis at any time or on an annual basis as required. 102, That the personnel record of staff member number one (1) did not contain any document within the past calendar year which would reflect that the staff member had been determined free from apparent signs of symptoms of tuberculosis, the most recent documentation reflecting the same being dated April 22, 2009. 103. That Petitioner's representative interviewed Respondent regarding the failure to ensure that all staff have been determined free of signs and symptoms of tuberculosis on an annual basis and Respondent indicated that all staff would be going for tuberculin testing the following week. 104. That the failure to obtain and maintain documentation reflecting that staff are free from signs or symptoms of tuberculosis on an annual basis places residents at increased and unneeded tisk of infection and is contrary to law. 105, That the Agency determined that this. violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or W 11/23/2818 13:82 8589218158 Now 25 2010 15304 PAGE 19/57 potentially threaten the physical or emotional health, safety, or security of clients and cited: Respondent with a Class II] violation in accord with law. | 106. That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1}(c), Florida Statutes (2010). . COUNT VII (402) 107. The Agency re-alleges and incorporates patagraphs.(1) through (5) as if fully set forth herein. . | 108. That pursuant to Florida law, an adult family-care home provider shall, ata minimum, maintain the following personnel records ... . For theadult family-care home provider, each relief person, and each staff person: a, Written documentation of all training required by Rule 58A- 14,008, F.A.C.-b. A copy of any professional license.R. 58A-14.085(2\(a)(2), Florida Administrative Code. 109. That on June 29, 2010, the Agency.conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. 110. That based upon the review of records and interview, Respondent failed to produce documentation reflecting the completion of all required training and proof of professional licensure for three (3) of four (4) sampled staff members, the same being contrary to the mandates of law. 111. That Petitioner’s representative requested of Respondent the opportunity to review the petsonnel records for Respondent’s four (4) staff members. ) 112. That Respondent failed to produce any personnel records related to staff members _ 18 11/23/2818 13:82 8589218158 Nov 25 2010 15205 PAGE 28/57 numbered two (2), three (3), or four (4) including, but not limited to documentation reflecting that the staff members had completed all required training and documentation of the staff members’ professional licensure. 113. That Petitioner’s representative interviewed Respondent regarding the Jack of documentation reflecting required staff training and licensure and Respondent indicated that he could not find the requested records, 114, That the failure to obtain and maintain documentation reflecting that staff are appropriately trained and or professionally licensed places residents at xisk that staff are unqualified to meet the residents scheduled and unscheduled service needs and is contrary to “daw, 115. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the cate of clients which indirectly ot potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class UI violation in accord with law. 116. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 117. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 9010008198 and 2010008103 of Respondent facility. 118, That based upon the review of records and interview, Respondent failed to produce documentation reflecting the.conepletion of all required training and proof of professional licensure for three (3) of four (4) sampled staff members, the game being contrary to the mandates of Jaw. 119. That Petitioner’s representative requested of Respondent the opportunity to review the ni/23/201a 13:02 esesat6156 Nov 23 2010 13:05 PAGE 21/57 personnel records for Respondent's four (4) staff members. 120. That any ny personnel records related to staff members numbered two (2), three (3), or, four. (4) did not include any documentation reflecting that the staff members had undergone required training or training in areas relevant to the staff members? assigned duties. 121. That Petitioner’s representative interviewed Respondent regarding the failure to ensure that all staff have undergone appropriate required training and the lack of documentation reflecting said training and proof of professional licensure and Respondent indicated that all staff training would be commenced the following week. 122. That the failure to ensure staff are appropriately trained or qualified and the failure to obtain and maintain documentation reflecting that staff are appropriately trained and or professionally licensed places residents at risk that staff are unqualified to meet the residents scheduled and unscheduled service needs and is contrary to law. 123. That the Agency determined that this violation constitutes conditions of occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class III violation in accord with law. 124. That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars (§250,00) against Respondent, an adult family care home in the State of - Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). COUNT VIII (403) 125, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 20 Now 23 2010 13:05 11/23/2818 13:82 8589218158 PAGE 22/57 126. That pursuant to Florida law, personnel records must include for cach staff meniber employed by the provider, a copy of the employment application which shall include the date of beginning employment. R. 58A-14,0085(2)(a)(3), Florida Administrative Code. 127. That on June 29, 2010; the Agency conducted an annual licensure and complaint survey, ‘CCR# 2010004903 of Respondent. | 128. That based upon the review of records and interview, Respondent failed to produce . employment applications including the date of hire for the staff member for three (3) of four (4) sampled staff members, the same being contrary to the mandates of law. ) 129. That Petitioner’s representative requested of Respondent the opportunity to review the personiiel records for Respondent's four (4) staff members. 130. That Respondent failed to produce any personnel records related to staff members numbered two (2), three (3), or four (4) including, but not limited to employment applications including the date of hire for the staff members. 131. That Petitioner’s representative interviewed staff member number two (2) during the survey who indicated that he had been hired on October 1, 2009. 132. That Petitioner’s representative interviewed Respondent regarding the lack of employment applications including the date of hire for the staff members and Respondent indicated that he could not find the requested records, 133. That the failure to obtain and maintain employment applications including the date of hire for staff members is contrary to law. 134. That the Agency determined that this violation constitutes conditions or occurrences rclated to the operation and maintenance ofa provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Pal Now 23 201 : 11/23/2818 13:82 8589218158 p fees PAGE 23/57 “ ; hat a Respondent with a Class 135. That the Agency provided Re onident ham ii . 136. That on August 17, 2010, the Agency conducted are-visit to the annual licensure and- complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s . 2010008198 and 2010008103 of Respondent facility. 137. That based upon the review of records and interview, Respondent failed to produce employment applications including the date of hire for the staff member for one (1) of four (4) sampled staff members, the same being contrary to the mandates of law. 138. That Petitioner’s representative requested of Respondent the opportunity to review the personnel records for Respondent’s four (4) staff members. 139. That no personnel record was produced for staff member number four (4) including no application and the designation of the date of hire, otherwise identified as tow (2) weeks prior thereto. 140, That Petitioner's representative interviewed Respondent regarding the lack of an application and date of hire for staff membet number four (4} and Respondent indicated that he could not locate the records. - 14]. That the failure to obtain and maintain employment applications including the date of hire for staff members is contrary to law. 142. That the Agency determined that this violation constitutes conditions or occurrences related to the operation. and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class III violation in accord with law. 143. . That the same constitutes an uncorrected deficiency as defined by Jaw 22 11/23/2818 13:82 8589218158 Now 23 2010 13:06 PAGE WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars (8250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1){c), Florida Statutes (2010). COUNT IX (602) 144. The Agency re-alleges and incorporates paragrapbs (1) through (5) as if fully set forth herein. 145. That pursuant to Florida law, the adult family-care home provider shall annually obtain 3 hours of continuing education in topics related to the care and treatment of frail elders or disabled adults, or the management and administration of an adult family-care home. R, 58A- 14.008(4)(b), Florida Administrative Code. Except as otherwise noted, certificates of any training required by this rule shall be documented in the facility’s personnel files. R. 58A- 14.008(4)(e), Florida Administrative Code. 146, That on June 29, 2010, the Agency conducted an antival licensure and complaint survey, CCR# 2010004903 of Respondent. 147, That based upon the review of records and interview, Respondent failed undergo or to produce documentation reflecting that he had completed annually three (3) hours of continuing education in topics related to the care and treatment of frail elders or disabled adults, or the management and administration of an adult family-care home, the same being contrary to the mandates of law. 148. That Petitioner’s represenitative reviewed the personnel record of Respondent and could locate no documentation reflecting that he had undergone mandatory annual continuing education related to the care and treatment of frail elders or disabled adults, or the management and administration of an adult family-care home. 24/57 11/23/2818 13:82 8589218158 Nov 25 2010 15206 PAGE 25/57 149, That Petitioner’s representative interviewed Respondent during the survey and Respondent acknowledged that he had not completed the required three (3) hours annually of continuing education as above referenced. 150, That the failure to complete required continuing education places residents at risk that their provider is ill equipped or otherwise untrained to respond to the residents’ scheduled or unscheduled service needs. 151. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class III violation in accord with law. 152. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 153. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2910004903, and conducted complaint surveys for CCR #s 9010008198 and 2010008103 of Respondent facility. 154, That baséd upon the review of records and interview, Respondent failed undergo or to produce documentation reflecting that he had completed annually three (3) hours of continuing education in topi¢s related to the care and treatment of frail elders or disabled-adults, or the management and administration of an adult family-care home, the same being contrary to the . mandates of law. 155, That Petitioner’s representative reviewed the personnel record of Respondent and could locate no documentation reflecting that he had undergone mandatory annual continuing education related to the care and treatment of frail elders or disabled adults, or the management and administration of an adult family-care home. 24 11/23/2818 13:82 8589218158 Nov 25 2010 13:00 PAGE 156. . That Petitioner’s representative interviewed Respondent during the survey and Respondent acknowledged that he had not completed the required three (3) hours annually of continuing education as above referenced. 157. That the failure to complete required continuing education places residents at risk that their provider is ill equipped or otherwise untrained to respond to the residents’ scheduled or unscheduled service needs. 158. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance ofa provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class Til violation in accord with law. | 159, Thatthe same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the atiount of _ two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)), Florida Statutes (2010). - COUNT X (603) 160, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 161. That pursuant to Florida law, the adult family-care home provider must designate one or more relief persons to assume responsibility for the care of residents if the provider is not available to perform that duty. The relief person must be:1. At least 21 years of age; and 2. Knowledgeable about and able to provide for all care needs of the residents. The provider must notify the agency in writing within 30 days of a change in relief persons and ensure that the relief person is appropriately background screened and trained as described in this rule, R. 58A- 25 26/57 Now 23 2010 13:07 11/23/2818 13:82 8589218158 PAGE 27/57 14.008(3), Florida Administrative Code. 162. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. . 163. That based upon the review of records and interview, Respondent failed to designate in writing a relief person if the provider was not present, the same being contrary to the mandates of law. . 164. That Petitioner’s representative entered the Respondent facility on me 29, 2010 at approximately 9:00 AM and Respondent was not at the facility. 165. That a Allen Courtney self identified as the “program manager” of the Respondent facility. 166. That the relief persons of record with the Agency for Health Care Administration as designated by Respondent are Theisha Mack or Chris Quesada. 167. That the failure to designate a qualified relief person places residents at risk that persons left in their care will not be competent to or qualified to care meet resident needs. 168. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class ILI violation in accord with law. ) 169. That the Agency provided ‘Respondent with a mandatory correction date of July 29, 2010. 170. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2016004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 171. That based upon the review of records and interview, Respondent failed to designate in 26 11/23/2818 13:82 8589218158 Now 23 2010 13:07 PAGE 28/57 writing a relief person if the provider was not present, the same being contrary to the mandates of jaw. 172. ‘That Petitioner’ s representative entered the Respondent facility on August 17, 2010 at approximately 7-00 AM and Respondent was not at the facility. 173. That a Travis self identified as a staff member of the Respondent facility and that he was the only one in the facility at night. 174, ‘That the relief persons of record with the Agency for Iealth Care Administration as designated by Respondent are Theisha Mack or Chris Quesada, 175. That the failure to designate a qualified relief person places residents at risk that persons left in their care will not be competent to or qualified to care meet resident needs. 176. Thatthe Agency determined that this violation constitutes conditions OF OCCUITENCES related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with, a Class TI violation in-accord with law. 177... That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care Florida, pursuant to §429.71(1Xe), Florida Statutes (2010). COUNT XI (606) home in the State of 178. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 179. That pursuant to Florida law, prior to assuming responsibility for the care of residents or within 30 days of employment, the AFCH provider shall ensure that each relief person and all 27 11/23/2818 13:82 asa921a158 Nov 23 2010 13:07 PAGE 29/57 thi. person s job duties, including emergency e food safety, reporting abuse and neglect, and Except as otherwise noted, certificates of any training required by this mle shall be documented in the facility’s personnel files. R. 58A-14.008(4)(e), Florida Administrative Code. 180, That on June 29, 2010, the Agency conducted an annual licensure and complaint survey. CCR# 2010004903 of Respondent. ° 181. That based upon the review of records and interview, Respondent failed to assure that staff received and or that Respondent maintained documentation reflecting that staff personnel records contained documentation of training related to the staff member’s job duties, the same being contrary to law. 182. That Petitioner’s representative reviewed two (2) available health assessments of the resident’s of the Respondent facility and noted that the residents required assistance with medications, assistance with the activities of daily living, and one (1) of the residents was positive for HIV/AIDS. 183, That Petitioner's representative requested of Respondent the opportunity to review the personnel records for Respondent’s four (4) staff members. 184, That Respondent failed to produce any personnel records related to staff members numbered two (2), three (3), or four (4) inchiding, but not limited to any verification that the staff members had received training in medication assistance, assistance with the activities of daily living, or training related to HIV/AIDS. 185. That Petitioner's representative reviewed the personnel file of staff member number one (1) and noted documentation that the staff member had been trained in HIV/AIDS, but no 28 11/23/2616 13:82 8589218158 Now 25 2010 15308 PAGE 38/57 documentation reflected any training related to activities of daily living and assistance with medications, . 186. That Petitioner’s representative interviewed Respondent regarding the lack of personnel files and training records and Respondent indicated that he could not find the requested records. 187. That the failure to ensure that staff are trained in their job duties or to retain verification thereof places residents at risk of being placed in the care of unqualified or untrained personnel and is contrary to law. 188. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class TH violation in accord with law. 189, That the Agency provided Respondent with a mandatory cotrection date of July 29, 2010. 190. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2910004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 191, That based upon the review of records and interview, Respondent failed to assure that staff received and or that Respondent maintained documentation reflecting that staff personnel records contained documentation of training related to the staff member's job duties; the same being contrary to law. 192. That Petitioner’s representative reviewed two (2) available health assessments of the resident’s of the Respondent facility and noted that the residents required assistance with medications, assistance with the activities of daily living, and one (1) of the residents was positive for HIV/AIDS. 29 Now 23 2010 : 1lf/2a/2818 13:82 8589218158 rene PAGE é 31/57 193. That Petitioner’s representative requested of Respondent the opportunity to review the personnel records for Respondents four (4) staff members. 194, That Petitioner's representative reviewed the personnel file of staff members numbered one (1), two (2), and three (3) and noted documentation that the staff members had been trained in HIV/AIDS, but no documentation reflected any training related to activities of daily living and ‘assistance with medications. 195. That no personnel record was produced for staff member number four (4) including no verification that the staff member had received training in medication assistance, assistance with. the activities of daily living, or training related to HIV/AIDS. 196. That Petitioner’s representative interviewed Respondent regarding the lack of training records and Respondent indicated that he would schedule required training commencing the next week. | , 197. That the failure to ensure that staff are tramed in their job duties or to retain verification thereof places residents at risk of being placed in the care of unqualified or untrained personnel and is contrary to law. 198, That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class II violation in accord with law. 199, That the same constitutes an uncorrected deficiency as defined by Jaw WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(¢), Florida Statutes (2010). 30 Now 23 2010 13:08 11/23/2818 13:82 8589218158 PAGE 32/57 COUNT. XT (609) 200. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 201. That pursuant to Florida law, the provider, all staff, each relief person, and all adult houschold members must meet Level | background screening requirements established in Section 435.03, F.S., or have been exempted from disqualification as provided in Section 435.07 . BR. 58A-14,008(1)(b), Florida Administrative Code. Upon receipt of a completed license application or license renewal, and the fee, the agency shall initiate a level 1 background screening as provided under chapter 435 on the adult family-care home provider, the designated relief person, all adult household members, and all staff members. Section 429.67(4), Florida Statutes (2009). 202. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. 203. That based upon the review of records and interview, Respondent failed to assure that three (3) of four (4) staff members had undergone level 1 criminal background screening as required by law. 304. That Petitioner’s representative requested of Respondent the opportunity to review the personnel records for Respondent’s four (4) staff members, . 205. That Respondent failed to produce any personnel records related to staff members numbered two (2), three (3), or four (4) including, but not limnited to any verification that the staff members had undergone level 1 criminal background screenings. 206. ‘That Petitioner's representative interviewed Respondent regarding the lack of documentation reflecting that the staff members had undergone criminal background sereening 31 11/23/2818 13:82 8589218158 Now 29 2010 15208 PAGE 33/57 "histories places residents at increased risk of abuse, neglect; of exploitation and is contrary to law. 208. That the Agency determined that this violation constitutes conditions or occurrences yelated to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class III violation in accord with law. 209, ‘That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 210. That on August 17, 201 0, the Agency conducted a re-visit to the annual: licensure and complaint survey, CCR# 9010004903, and conducted complaint surveys for CCR #s 2010008198 and 201 0008 103 of Respondent facility. 211, That based upon the review of records and interview, Respondent failed to assure that three (3) of four (4) staff members had undergone level | criminal background screening as required by law. 212. That Petitioner’s representative reviewed personnel records presented by Respondent and "noted that no record reflected that staff members numbered two 0), three (3) and four (4) had undergone required level 1 criminal background screening. 213, That Petitioner’s representative interviewed Respondent regarding the Jack of criminal background screening for the staff members and Respondent indicated that he would submit criminal background screening information for processing that week, 214. That the failure to ensure that staff are appropriately screened for disqualifying criminal histories places residents at increased risk of abuse, neglect, or exploitation and is contrary to 32 __an/23/2e1a 13:02 asaa71 A188 Now 23 2010 13:09 PAGE 34/57 law. 215, That the Agency determined that this violation constitutes conditions or occurrences related to the operation and rhaintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class II violation in accord with law. 216. That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to 9429.71(1\0), Florida Statutes (2010). COUNT X11 (704) 217. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. | 218. That pursuant to Florida law, the adult family-care home provider shall ensure the provision of the following in accordance with Part II of Chapter 429, F.S., this rule chapter, and the residency agreement ... A list of currently prescribed medications shall be maintained for all residents who self-administer or who sequire supervision or assistance with medications which includes the name of each medication prescribed, its strength and directions for use, and common side effects. R, 584-14.007(1)(b)(4), Florida Administrative Code. 219, That on June 29, 2010, the Agency conducted an anrwal licensure and complaint survey, CCR# 2010004903 of Respondent. 220. That based upon the review of records and interview, Respondent failed to maintain 4 current list of resident medication for four (4) of five (5) sampled residents, the same being contrary to law- 33 11/23/2818 13:82 85892148158 Nov 29 2010 15410 PAGE 35/57 a. Resident number one (1) ~ Respondent had no current list of the resident’s medications; b. Resident number two (2) — Respondent had no current list of the resident’s medications; c. Resident number four (4) — Respondent maintained a list of medications for the resident, however the list was not current containing listed medications which the- resident was not taking and omitting medications which the resident was taking; d. Resident number five (5) — Respondent maintained a list of medications for the resident, however the list was not current containing listed medications which the resident was not taking and omitting medications which the resident was taking. 222. That Petitioner’s representative interviewed Respondent regarding the absent ot inaccurate resident medications lists and the provider indicated that he was trying to update the medication lists. 323. . That the failure to maintain accurate medication lists places residents at risk of medication exror and deprives health care providers of accurate information in emergent situations. 224. That the Agency. determined that this violation constitutes a condition or occurrence telated to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients and cited Respondent with a Class I violation in accord with law. 205, That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 34 11/23/2m1a 13:82 asaszi0158 Nov 25 2010 15:10 PAGE 36/57 296, That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 3010008198 and 2010008103 of Respondent facility. 227, That based upon the review of records and interview, Respondent failed to maintain a current list of resident medication for two (2) of three (3) sampled residents, the same being contrary to law. 228. That Petitioner’s representative reviewed Respondent’s records related to the facility residents and noted as follows: a. . Resident number one (1) — Respondent maintained a list of medications for the resident, however the list was not current containing listed medications which the resident was not taking and omitting medications which the resident was taking; b. Resident number two (2) — Respondent had no current list of the resident’s medications. 229, That Petitioner’ s representative interviewed Respondent regarding the absent or inaccurate resident medications lists and the provider indicated that he was trying to update the medication lists. . 230. That the failure to maintain accurate medication lists places residents at risk of medication error and deprives health care providers of accurate information in emergent situations. 231, That the Agency determined that this violation constitutes conditions or occurrences telated to the operation and maintenance of a provider or to the care ‘of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited . Respondent with a Class IY violation in accord with law. 35 Nov 23 2010 13:10 11/23/2818 13:82 8589218158 PAGE 37/57 232. | That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). COUNT XIV (800 233. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 234. That pursuant to Florida law, the adult family-care home provider shall ensure the provision of the following in accordance with Part II of Chapter 429, F.S., this rule chapter, and the residency agreement ... Assistance with or supervision of the activities of daily living as required by the resident. For a diabetic resident or a resident who has documented circulatory problems, cutting toenails shall only be permitted with written approval of the health care provider... Assistance with or supervision of the. self-administration of medication, or medication administration ... Residents who are capable of self-administering their medications shall be encouraged and allowed to do so. 2. For residents who require supervision or assistance with self-administration, the provider or staff shall, as needed: a. Remind residents when to take medications; b. Prepare and make available such items as water, juice, cups, spoons, Or other items necessary for administering the medication; o. Obtain the medication and provide it to the resident; d, Observe the resident take the medication and verify that the resident is taking the dosage as prescribed; and ¢. Provide any other assistance at the express direction of the resident or the.resident’s representative, except for administering the medication as defined in Section 465.003, F.S. R. 58A-14.007(1(a and b), Florida Administrative Code. 235, That pursuant to Florida Jaw, each resident has a right to have access to adequate and 36 11/23/2818 13:82 8589218158 Now 23 2010 13:11 PAGE appropriate bealth care. Section 429,85(1)), Florida Statutes (2010). 236. That on August 17, 201 0, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. 237. ‘That based upon the review of records, observation, and interview, Respondent failed 10 provide personal services, including but not limited to assistance with medications, for one (1) of five (5) sampled residents, the same being contrary to law. 238. That Petitioner’s representative reviewed Respondent’s records related to resident number four (4) during the survey and noted as follows: a. The resident had discharge orders from a hospital dated August 13, 2010 at 4:57 PM; b. The discharge orders reflected that the resident was discharged after hospitalization for the implantation of a pacemaker, c, The discharge orders included a list of medications for the resident to take after discharge from hospitalization which included the following: Divalproex Sodium (Depakote) 500 mg to be taken every eight (8) hours and Levetiracetam (Keppta) 750 mg to be taken. twice daily; ““d. These medication are most commonly used for seizure disorders; e, . The discharge orders also provided “Depakote Jevel on Monday 8/16/10 results to patient’s primary care MD and neurologist,” which was highlighted in yellow; f. ‘The resident’s health assessment dated August 13,2010 signed by the physician documented séizure disorder as one of the resident’s diagnoses; g. A prescription from the hospital dated August 13, 2010 prescribed three (3) 37 ae/57 11/23/2616 13:82 8589218158 Now 23 2010 13:11 PAGE medications: Depakote 500 img by mouth every eight (8) hours, Keppra 750 mz by mouth every twelve (12) hours, and Risperdal 4mg by mouth at bed time. 239, That Respondent’s staff member produced a box in which Respondent facility stores resident medications and Petitioner's representative reviewed the same for the medications of resident number four (4) on. August 17, 2010 at 9:45 Am, noting as follows: a. The resident’s medications were stored in a plastic bag which also contained a weekly pill organizer; b. No medication bottle was labeled as containing either the prescribed Depakote or Keppra; c. Another common medication utilized for seizure disorders, Dilantin, was noted, however no prescription for this medication was located. . 240. That Petitioner's staff member confirmed that no other medications for resident mumber four (4) other than those produced were maintained by the facility. 241. That Petitioner’s representative interviewed Respondent regarding the medication services provided for resident number four (4) on August 17, 2010 and Respondent indicated as follows: a. He acknowledged the prescription for the Depakote and Keppra had not been filled stating “It’s only been a day” b. In explanation, Respondent alleged that the resident had returned from the hospital on August 15, 2010 and in support thereof directed attention to the discharge orders which were clearly dated August 13, 2019; c. Respondent could produce no verification that the resident had returned to the facility on August 15 a3 opposed to August 13, 2010 as annotated on the hospital a8 39/57 Now 23 2010 : 11/23/2818 13:82 8589218158 mn PAGE 4a/ Bf? discharge orders; 4. Respondent acknowledged that the resident's health care provider had not been notified that the resident was not receiving the prescribed medications; e. Respondent claimed to be unaware of the highlighted provision of the discharge order which required that the resident’s Depakote level be checked on August 16, 2010. 242. That the above reflects that the resident was not provided anti-seizure medications as prescribed and that prescribed medical testing was not arranged for the resident, the same being necessary personal services for the resident. 243. “Thal the above reflects Respondent’s failure to provide personal services, including medication practices, supervision of activities of daily living, and the failure to ensure the right of resident number four (4) to access to health care where Respondent, inter alia: a. Failed to fill a prescription for seizure medications; b. Failed to ensure that prescribed medications are provided for a resident, c. Failed to notify the resident’s health care provider of the failure to provide prescribed medications for the resident; d. Failed to ensure a prescribed medical test was timely administered. - 244. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom and cited Respondent for a Class I deficient practice. . WHEREFORE, the Agency intends to impose an administrative fine in the amount of 39. Now 23 2010 13:11 11/23/2818 13:82 8589218158 PAGE 41/57 sida, pursuant to $429.71 (a), Florida Statutes (2019). | COUNT XV_(810) - 245. The Agency re-alleges and incorporates paragraphs () through (5) as if fully set forth herein. 246, That pursuant to Florida law, cach resident has a right to live in a safe and decent living environment, free from abuse and neglect and to be treated with consideration and respect and with due recognition of personal dignity, individuality, and privacy. Section 429,85(1\(a and b), Florida Statutes (2010). 247. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 29100081 98 and 2010008103 of Respondent facility. 348. That based upon the review of records and interview, Respondent failed to ensure that two (2) residents were ensured that their rights to live in a safe and decent living environment, free from abuse and neglect and to be treated with consideration and respect and with due recognition of personal dignity, individuality, and privacy were honored, the same being contrary to the mandates of law. 249, That Petitioner's representative reviewed Respondent’s records elated to resident number two (2) during the survey and noted as follows: a. Progress notes dated June 13, 2010 by a former staff member documented a'series of altercations between the resident and the staff member; b. Documentation included that the resident spilled coffee on self so the staff member “punished” the resident by denying the resident cigarettes, that at “app. Ad Now 23 2010 13:12 11/23/2818 13:82 8589218158 PAGE 6:00,” the resident began using foul language ‘when the staff ‘member aiterpisd to administer medications $0 the staff member “gotin the resident's face” to which, the resident responded by hitting the staff member in the face to which the staff member responded by striking the resident with an open hand; c. Progress nofes dated June 18, 2010 document another confrontation between the resident and the former staff member during which a second staff member, who remains an employee of Respondent, intervened and put the resident "back on punishment” without detailing the nature thereof. 250. That Petitioner’s representative interviewed Respondent regarding the progress notes of resident number two (2) of June 13 and 18, 2010 and responded as follows: a. He was unaware that the former staff member had documented having hit the resident; b. He purchases resident cigarettes and the denial of cigarettes is the only way to get the attention of the resident; c. ‘he resident has a history of challenging behavior. - 251, That Petitioner’s representative reviewed Respondent’s records related to resident number one (1) during the survey and noted as follows: a. The resident lived with the former staff member referenced above and had a relationship with the staff member; . b. On July 9, 2010 the two began arguing and the staff member knocked the resident from a wheel chair and slammed the resident to a bed; | c . The resident suffered scrapes to the right shoulder and thigh and an ambulance was called; 41 42/57 Now 23 2010 13:12 11/23/2616 13:82 8589218158 PAGE 43/57 + sili ws . d. Police took the staff member to an alcohol treatment center; e. The resident would not press charges as the resident loves the staff member and — knows the staff member has problems; f. The resident reports another staff member gets close to the resident's face and yells at the resident to which the resident responds by spitting at the staff member. 252. . That the above reflects Respondent's failure to ensure that his residents are living ina safe and decent environment, free from abuse, and treated with personal dignity. 253. That the Agency determined that this violation constitutes conditions or occurrences , related to the operation and maintenance of a provider or to the care of clients which present am imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom and cited Respondent for a Class i deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(a), Florida Statutes (2010). CQUNT XVI (1100) 254. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 955, That pursuant to Florida law, the adult family-care home shall be located, designed, equipped, and maintained to ensure a home-like environment, and to provide safe care and supervision for all residents. Residents shall be allowed free use of all space within the home except when such use interferes with the safety, privacy, and personal possessions of household ~ members and other residents,. R. 58A-14.009(1)(a), Florida Administrative Code. 42 Now 23 2010 13:12 11/23/2818 13:82 8589218158 PAGE 44/57 256. That on June 29, 201 0, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. . . . 257. . That based upon observation, Respondent failed to maintain a facility which is located, designed, equipped, and maintained to ensure a home-like environment, and to provide safe care and supervision for all residents, the same being contrary to law. 258, That Petitioner’s representative observed the facility during the survey and noted as follows: a. There were no grab bars in either bathroom to assist disabled residents; b. There were no light bulbs in the over-the-bed light fixture in bedroom number two (2); c. The dresser in bedroom number two (2) blocked one side of the closet and one of the beds was blocking the other side of the closet, d. Two vials of insulin were found unsecured in the refrigerator and could be accessed by any staff, resident, or visitor, e. Door jams throughout the facility were dirty and smudged; f Plaster was missing from the corner of the walls going into the hallway between bedrooms one (1) and two (2); g. There was a hole in the main bathroom door. 259, That the above reflects the failure of Respondent to maintain the physical plant as a home like environment for the safe care and supervision of residents, 260, That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited 43 Now 23 2010 13:13 11/23/2818 13:82 8589218158 PAGE Respondent with a Class Il violation in accord with law. 261, “That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 962. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 3010008198 and 2010008103 of Respondent facility. 263. That based upon observation, Respondent failed to maintain a facility which is located, designed, equipped, and maintained to ensure a home-like environment, and to provide safe care and supervision for all residents, the same being contrary to law. 264, That Petitioner’s representative observed the facility during the survey and noted as follows: a. There were no grab bars in either bathroom to assist disabled residents; b.. There were no light bulbs in the over-the-bed light fixture in bedroom number two (2); c¢. The dresser in bedroom number two (2) blocked one side of the closet and one of the beds was blocking the other side of the closet, 4. Two vials of insulin were found unsecured in the refrigerator and could be accessed by any staff, resident, or visitor, e. Door jams throughout the facility were dirty and smudged; £ Plaster was missing from the comer of the walls going into the hallway between bedrooms one (1) and two (2); g. There was a hole in the main bathroom door. 365, That the above reflects the failure of Respondent to maintain the physical plant as a home like environment for the safe care and supervision of residents. 44 45/57 Now 23 2010 13:13 11/23/2818 13:82 8589218158 PAGE 46/57 266.. That the ‘Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which h indirecily or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class III violation in accord with law, 267, That the samme constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the arpount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). COUNT XVILQ117) 268, The Agency te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 269. That pursuant to Florida law, bathrooms used by physically handicapped residents shall jhave grab bars for toilets, tubs, and showers. Hot water temperature shall be supervised for persons unable to self-regulate water temperature. R. 58A-14.009(4)(d), Florida Administrative Code. 270. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. 271. That based upon observation, Respondent failed to ensure that bathrooms utilized by , handicapped residents have grab bars for toilets therein, the same being contrary to law. 272. That Petitioner’s representative toured the Respondent facility on June 29, 2010 and noted that there were no grab bars available for use by the toilets in either of the two (2) bathrooms. 273, That handicapped persons are residents of the Respondent facility. 45 Now 23 2010 13:13 11/23/2818 13:82 8589218158 PAGE 47/57 “274. That the Agency determis related to the operation and maintenan of prov ler o potentially threaten the physical or emotional nealth, safety, or security of clients and cited Respondent with a Class II] violation in accord with law. ; 278. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 276. That on August 17, 2010, the Agency conducted a re-visit to the annual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 2010608103 of Respondent facility. 277. That'based upon observation, Respondent failed to ensure that bathrooms utilized by handicapped residents have grab bars for toilets therein, the same being contrary to law. 278. That Petitioner’s representative toured the Respondent facility on August 17,2010 and noted that there were no grab bars available for use by the toilets in either of the two (2) bathrooms. 279, That handicapped persons are residents of the Respondent facility. 280. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class If violation in accord with law. 281. That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429.71(1)(c), Florida Statutes (2010). 46 Nov 23 2010 13:14 11/23/2818 13:82 8589218158 PAGE 48/57 COUNT XVII (12025 282. The Agency re-alleges and incorporates paragraphs a) through (5) as if fully set forth ws . herein. a | 283. That pursuant to Florida law, the provider shall at all times maintain first aid and emergency supplies including a 3-day supply of non-perishable food based on the number of residents and household members currently residing in the home, and 2 gallons of drinking water per current resident and household member. R. 58A-14.0091(2\(b), Florida Administrative Code. , 284. That on June 29, 2010, the Agency conducted an annual licensure and complaint survey, CCR# 2010004903 of Respondent. 285, . That based upon observation, Respondent failed to ensure that he maintained a sufficient emergency water supply for all residents and houschold members, the same being contrary to law, 286, That Petitioner’s representative reviewed the Respondent facility on June 29, 2010 and noted that Respondent’s three (3) day emergency supplies inchided only one (1) five (5) gallon bottle of water. 287. That the Respondent facility housed five (5) residents and three (3) staff members for a total of eight (8) persons. | 288. That based upon the legal requirements for emergency supplies, forty-eight (48) gallons of water would be required to be maintained in Respondent's emergency supplies. 289, That Petitioner’s representative interviewed Respondent’s caregiver during the survey who indicated that the five (5) gallon bottle was the only emergency water supply retained. 290. That the Agency determined that this violation constitutes conditions or occurrences 47 Now 23 2010 : 11/23/2818 13:82 8589218158 aan PAGE é 4g/57 “ yelated to the operation and maintenance of a provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class IN violation in accord with law. 291. That the Agency provided Respondent with a mandatory correction date of July 29, 2010. 292, That on August 17, 2010, the Agency conducted a re-visit to the arinual licensure and complaint survey, CCR# 2010004903, and conducted complaint surveys for CCR #s 2010008198 and 2010008103 of Respondent facility. | 293. That based upon observation, Respondent failed to ensure that he maintained a sufficient emergency water supply for all residents and household members, the same being contrary to — . 294, That Petitioner's representative reviewed the Respondent facility on August 17, 2010 and noted that Respondent’s three (3) day emergency supplies included only one (1) five (5) gallon bottle of water, 295. That the Respondent facility housed five (5) residents and two (2) staff members fora total of seven (7) persons. | 296. That based upon the legal requirements for emergency supplies, forty-two (42) gallons of water would be required to be maintained in Respondent’s emergency supplies. 397. That the Agency determined that this violation constitutes conditions or occurrences related to the operation and maintenance of a provider orto the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients and cited Respondent with a Class Ii violation in accord with law. 298. That the same constitutes an uncorrected deficiency as defined by law WHEREFORE, the Agency intends to impose an administrative fine in the amount of 48 Nov 23 2010 13:14 11/23/2818 13:82 8589218158 PAGE 58/57 two hundred fifty dollars ($250.00) against Respondent, an adult family care home in the State of Florida, pursuant to §429,71(1)(¢), Florida Statutes (2010). COUNT xIX (Revoke) 299. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and the remaining counts of this complaint as if fully set forth herein, 300, - That pursuant to Florida law, the Agency may deny, suspend, ot revoke the license of an AFHC operator for the failure to comply with the background screening standards of this part, s. 408.809 (1), or chapter 435. § 429,69, Fla. Stat. (2010). Respondent has failed to comply with these requirements. 301. That under Florida law, the Agency may deny or revoke the license of an AFCH operator based upon the facility’s (a) intentional or negligent act materially affecting the health or safety of a resident of the facility or (b) a violation of the facility’s authorizing statutes or applicable rules, in this particular instance, Chapter 429, Part 11, Florida Statutes (2010), and Chapter 58A- 14, Florida Administrative Code, respectively, or (c) a violation of this part, authorizing statutes, or applicable rules. § 429.815 Florida Statutes (2010). 302. That pursuant to Florida law, a person who js licensed as an AFCH provider must own or rent the adult family care home facility and must reside in the AFCH facility. § 429.67(2), Fla. Stat. (2010). In addition, a person who is licensed as an AFCH provider must live in the adult family care home facility. R. 584-14.008(2)(@)@), Florida Administrative Code. AFCHs “provide housing and personal care for disabled adults and frail elders who choose to live with . an individual or family in a private home. The adult ‘Jamily-care home provider must live in the home. The purpose of this part is'to provide for the health, safety, and welfare of residents of adult family-care homes in the state.” § 429.63(2), Fla. Stat. (2010) (emphasis supplied). 49 Nov 23 2010 13:15 11/23/2818 13:82 8589218158 PAGE 51/57 bee 303. That based upon observation and interviews, Respondent failed to ensure that the provider resided in the licensed facility. 304. That Jerold Mack Sr. is the adult family-care home provider and licensee of a licensed adult family-cate home facility. . 305, That Agency surveys of the Respondent and the Respondent’s facility clearly reflect that Respondent does not reside in the licensed facility. 306. That the failure of an AFCH provider to reside and live within the AFCH facility is intentional or negligent act materially affecting the health or safety of a resident of the facility, a violation of the facility’s authorizing statutes or applicable rules, in this particular instance, Chapter 429, Part II, Florida Statutes (2019), and Chapter 58A-14, Florida Administrative Code, respectively, or a violation of this part, authorizing statutes, or applicable miles. § 429.815 Florida Statutes (2010). | 307, That an AFCH provider must reside and live in an AFCH facility in order to properly care for the residents. | 308. That among the duties and responsibilities created by Chapter 429, Florida Statutes, and Chapter 5BA-14, Florida Administrative Code, an AFCH provider must ensure that: a. The residents are appropriate for placement and continued residency in the home as provided under Rule 584-14.0061, b. The personal care and services provided to the residents (including assistance with activities of daily living and assistance with medication or the supervision of self administration of medication) is in accordance with Rule 584-14.007(1), - c. The residents are properly supervised, which includes being aware of their general whereabouts.and well-being while the residents are on the premises of the AFCH 50 Nov 23 2010 13:15 11/23/2818 13:82 85892148158 PAGE 52/57 in order to ensure the residents’ safety and security, and reminding the residents of any important tasks or activities, including appointments, as needed by them, te as provided under Rule 58A-14.007(2). Unde no circumstances shall a resident be left unattended for more than 2 hours under this rule; d. The observation, recording and reporting of any significant changes in a resident’s normal appearance, behavior or state of health to the resident’s health care provider and representative or case manager as provided -under, Rule S8A- 14.007(3); and e. The operation and maintenance of the AFCH facility under the Florida Statutes and Florida Administrative Code as provided under Rule S8A-14.008(2)(b)(1). 309. That by failing to reside and live in the APCH facility, the Respondent failed to properly care for the residents and created a condition or practice that directly threatened the physical or emotional health, safety, or welfare of the residents. 310. That by failing to reside and live in the AFCH facility, the Respondent conamitted an ' intentional or negligent act that materially affected the health or safety of a resident of the facility. 311. That by failing to reside and live in the AFCH facility, the Respondent violated the . facility's authorizing statutes or applicable rules, in this particular instance Chapter 429, Part Il, Florida Statutes (2010), and Chapter 58A-14, Florida Administrative Code, respectively. 312. That the Agency may revoke any license issued under Part II of Chapter 429 of the Florida Statutes for an intentional or negligent act materially affecting the health, safety, or welfare of the adult family care home residents and or the a violation of Part {I of Chapter 429, Florida Statutes or adopted rules of Chapter 58A-14, Florida Administrative Code, which results 3t Nov 23 2010 13:15 11/23/2818 13:82 8589218158 PAGE 53/57 “ina condition ox pract 1e physical of emotional health, safety, or welfare of residents, or a demonstrated pattern of deficient performance. Section 429.69, Florida Statutes (2010) and Section 408.815, Florida Statutes (2010). 313, That the Respondent has been cited with two (2) State Class I deficiencies and sixteen (16) uncorrected Class III deficiencies on Agency surveys of August 17, 2010. 314, That these violations constitute a violation of the facility’s authorizing statutes or applicable males, in this particular instance, Chapter 429, Part TI, Florida Statutes (2010), and Chapter 584-14, Florida Administrative Code, respectively, constitute a violation of Chapter 408, Part 11, Florida Statutes or Chapter 429, Part Il, Florida Statutes (2010), and Chapter 58A- 14, Florida Administrative Code, and constitute a demonstrated pattern of deficient performance. 315. That these violations are of a repeat and ongoing nature and constitutes an intentional or negligent act that materially affects the health, safety, or welfare of the adult family care home residents or is a violation of Part II of Chapter 429, Florida Statutes or adopted tules of Chapter 58A-14, Florida Administrative Code, results in a condition or practice that directly threaten the physical or emotional health, safety, or welfare of residents, or constitutes a demonstrated pattem of deficient performance, thereby meriting the revocation of the Respondents licensure. 316. That Respondent has violated the minimum requirements of Jaw and his license is therefore subject to revocation under the Legislative licensing scheme for adult family-care homes. See, §§ 408.815 and 429.69, Florida Statutes (2010). WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815 and 429.69, Florida Statutes (2010). S2 Nov 23 2010 13:15 11/23/2818 13:82 8589218158 PAGE 54/57 Respectfully submitted this “.-_ day of October, 2010. a“ ve, ie ff oe A Thomés J. Walsh, 0 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701. 727.552.1947 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to rétain, 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 inade to the Agency for Health Care Administration and delivered to: Agency Clerk, Apency for Health Care Administration, 2727 Mahan Drive, Bidg #3, MS #3, Tallahassee, Florida 32308. Telephone (850) 922-3873 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 bee: 1 served by U.S. Certified Mail, Return Receipt No. 7004 2890'0000 5526 7063 on October ~ , 2010 to: - Jerald Mack, Owner/Licensee, 7512 Oxford Garden Circle, Apollo Beach, Florida 33372, SA . Thais J Walsh Il, Esquire of oo& Copies furnished to: Jerald Mack Thomas J, Walsh, II Kathleen Varga Owner/Licensee Senior Attorney Facility Evaluator Supervisor 7512 Oxford Garden Circle Agency for Health Care Admin, | 525 Mirror Lake Dr., 4” Fl. Apollo Beach, Florida 33572, | 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (U.S. Certified Mail) St. Petersburg, Florida 33701 (Interoffice) (nteroftice Mail) 53 Now 23 2010 13:16 11/23/2818 13:82 8589218158 PAGE 55/57 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Jerold Mack, 5r. CASE NO. 2610008022 2010008939 2010008953 2010008966 soot ELECTION OF RIGHTS , This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint, If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency's proposed action and a final order will be issued, (Please use this form unless you, your attomey or your representative prefer to reply according to Chapter} 20, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone! 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1). { admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and 1 waive my right to object and to have a hearing. I understand that by giving up my tight to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) 1 admit to the allegations of tacts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where 1 may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)____—s-A dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and [ request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before Now 23 2010 13:16 11/23/2818 13:82 8589218158 PAGE 56/57 the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone nuinber, and the name, address, and telephone number of your representative or lawyer, if any. 2> The file number of the proposed action. “8 3. -A statement of when you received notice of the Agency’ $ proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none, Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency _ agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name; ; License number: Contact person: Name Title Address: Street and mumber City ; Zip Code Telephone No. Fax No. Email(optional) thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC Nov 23 2010 13:16 11/23/2818 13:42 85892148158 PAGE 57/57 q AA, Fii © Complete tems 'S. and 3. Also complete item 4 If Restricted Delivery fa desired. " @ Print your narne and address on the reverse 80 that we can retum the card to you. l Attach this card fo the back of the malipleca, - or on the front if space permits. - 1. Artitie Addressed 10: DB iy alteny ecarecs lero hon fern 1? OVea IVES, enter delivery address below: © EI No ; Jerold Mack “en : Owner/Licensee - 7512 Oxford Garden Circle Apollo Beach, Florida 33572 3. eexe eNO 4 . a Raglstered oF C1 insured Mait o C.0.0, 4, Regtricted Delivery? (Extre Fee) 4 2, Article Number! 2004 ZASO OOOO 5526 703 000 ¥O2 Tra far 9008 Eo | re) PS Fort 3811, February 2004 Domestic Return Receipt 402505-02-M4i

Docket for Case No: 10-010369PL