STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Petitioner, )

)

vs. )

) BETHEL HEALTH CARE CORP., d/b/a ) GOOD HOPE MANOR, )

)

Respondent. )

Case No. 12-1167MPI

)

RECOMMENDED ORDER

A hearing was conducted in this case pursuant to sections

120.569 and 120.57(1), Florida Statutes 1/ before Administrative Law Judge Jessica Varn of the Division of Administrative Hearings (DOAH). The hearing was held on January 23, 2013, by video teleconference at sites in Lauderdale Lakes and Tallahassee, Florida.

APPEARANCES

For Petitioner: Daniel Lake, Esquire

Agency for Health Care Administration Fort Knox Building 3, Mail Station 3 2727 Mahan Drive

Tallahassee, Florida 32308

For Respondent: Annie Mathew, pro se

Good Hope Manor

2251 Northwest 29th Court Oakland Park, Florida 33311

STATEMENT OF THE ISSUE

Whether Respondent violated section 409.913, Florida Statutes, by failing to retain required Medicaid records, thereby incurring a $10,000 fine according to Florida Administrative Code Rule 59G-9.070(7)(e).

PRELIMINARY STATEMENT

On December 7, 2011, the Agency for Health Care Administration (Agency) conducted an unannounced compliance inspection of Respondent Bethel Health Care Corporation, doing business as Good Hope Manor (Respondent). On February 10, 2012, the Agency issued a sanction letter advising Respondent of its intent to apply sanctions for failure to maintain required Medicaid recipient records. The letter directed Respondent to pay a $10,000 fine for the alleged violations.

Respondent requested a hearing on the Agency's imposition of the sanction. The matter was referred to DOAH on March 30, 2012, for the assignment of an administrative law judge to conduct a formal hearing and to submit a recommended order to the Agency.

Pursuant to notice, the final hearing in this case was scheduled for June 28, 2012. On April 12, 2012, Respondent filed a Motion for Leave to Amend Petition for Administrative Hearing, which was granted on April 20, 2012. On May 24, 2012, an unopposed Motion for Continuance was filed by Respondent. The

hearing was rescheduled for August 2, 2012. On July 27, 2012, Respondent's attorney sought to withdraw as counsel.

On August 2, 2012, the undersigned granted the Motion to Withdraw, and the hearing was rescheduled for August 15, 2012.

On August 9, 2012, a Joint Motion to Continue was filed.

The hearing was rescheduled for October 15, 2012. On October 4, 2012, another Joint Motion to Continue was filed. The hearing was rescheduled for December 6, 2012. Finally, on October 10, 2012, a Joint Motion for Continuance was filed. The hearing was rescheduled for January 23, 2013.

At the hearing, the Agency presented the testimony of Jesus Rosello, an Agency Administrator; Abdel Cedeno, an Agency Inspector Specialist; and Judy Hollis-Stancil, a consulting nurse. Agency Exhibits A-G and N were offered and received into evidence. Agency Exhibits H, I, J, L, and M were officially recognized. Respondent presented the testimony of Annie Mathew, and offered no exhibits into evidence.

The Transcript of the proceedings was filed with DOAH on February 11, 2013. The parties timely filed Proposed Findings of Fact and Conclusions of Law, which have been considered in the preparation of this Recommended Order.

FINDINGS OF FACT

1. Respondent is a Medicaid Provider of Assistive Care Services in Oakland Park, Florida. Annie Mathew is a registered nurse who manages Respondent's facility.

2. Respondent was obligated, pursuant to the Medicaid Provider Agreement executed in June 2008, to comply with applicable Medicaid laws, administrative rules, and Medicaid handbooks.

3. The Agency is the state agency charged with the administration of the Medicaid program in Florida. Within the Agency, the Inspector General ensures the integrity of the Medicaid program by conducting investigations of providers to ensure compliance with all Medicaid rules.

4. On December 7, 2011, the Agency conducted an unannounced on-site inspection of the medical records retained by Respondent. Mr. Cedeno and Ms. Hollis-Stancil conducted the investigation, reviewing ten recipient files.

5. The investigators found that nine of the recipient files did not contain a proper service plan; one recipient did not contain a service plan at all, and had an outdated health assessment.

6. Respondent did not use the Medicaid form found in the Medicaid Assistive Care Services Coverage and Limitations Handbook for service plans; instead, Respondent used a form

   
   

   created by Respondent, which contained some, but not all, of the components addressed in the Medicaid form.

7. The investigators noticed that the facility was clean and in good condition.

8. At the hearing, Respondent admitted to not using the Medicaid form for service plans, and agreed that not all of the components addressed in the Medicaid form were addressed in the form created by Respondent.

9. Specifically, the service plan must contain the expected outcome for the resident, and identify who is going to provide specific services to the resident. Respondent's forms did not reflect this information.

10. As to one recipient, recipient S.V., the file did not contain a current health assessment. The health assessment found in the file had expired in September 2011, three months prior to the inspection in December 2011.

11. All ten counts against Respondent are supported by the

    
    

    evidence.

    
    

    CONCLUSIONS OF LAW

    
    

12. DOAH has jurisdiction over the subject matter of this proceeding and of the parties hereto pursuant to chapter 120, Florida Statutes.

13. AHCA is statutorily charged with the responsibility of operating a program to oversee the activities of Florida Medicaid

    
    

    recipients, and providers and their representatives, to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible, and to recover overpayments and impose sanctions as appropriate under section 409.913.

14. Section 409.913(9), requires Medicaid providers to retain medical, professional, financial, and business records pertaining to services and goods furnished to a Medicaid recipient and billed to Medicaid.

15. Florida Administrative Code Rule 59G-9.070(7)(e) provides that the Agency may sanction a provider with a $1,000 fine per claim found to be in violation of the Medicaid rules, if it is a first offense. It may do so, however, only if the violation is proven by clear and convincing evidence. See Dep't of Banking & Fin., Div. of Sec. & Inv. Prot. v. Osborne Stern and

    Co., 670 So. 2d 932, 935 (Fla. 1996).

    
    

16. As to the service plans, the Assistive Care Services Coverage and Limitations Handbook (Handbook), at 2-8, requires that each recipient must have a service plan completed, and Form 036 shall be used for each recipient. It further states that the Medicaid form must be included in the recipient's case file at the facility. This requirement is also reflected in sections 2- 6, 2-9, and 2-10 of the Handbook.

17. The required components of the Service Plan are listed in the Handbook at 2-9, as follows:

    
    

    Identifying information (facility name, resident's name, Medicaid Identification number, and date);

    
    

    Services that address all needs identified in the health assessment;

    A list of the Assistive Care Services that will be provided on a daily basis;

    
    

    Assistance with at least one ADL by the provider if the health assessment indicates a need for ADL assistance;

    
    

    Level of functioning and assistance needed; Service provider;

    Expected outcome of service;

    
    

    A signature and date by facility representative and resident guardian or designated representative; and

    
    

    Updates to the plan when conditions change.

    
    

    All needed ACS components must be specified in the recipient's Resident Service Plan for Assistive Care Services, AHCA-Med Serv Form 036.

    
    

18. Respondent did not use the required form, and the form that Respondent created did not include all the components required; specifically, Respondent's forms did not identify the expected outcome of service and did not identify the service provider. Nine recipient files did not contain proper service plans.

19. As to health assessments, the Handbook, at section 2-7, requires that recipients have a complete health assessment at least annually by a physician or other licensed practitioner, or

    
    

    sooner if a significant change in the recipients condition occurs.

20. In one recipient file, the health assessment had expired approximately three months prior to the date of the inspection.

21. All ten counts against Respondent were proven by clear and convincing evidence.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that pursuant to rule 59G-9.070(7)(e), the Agency for Healthcare Administration fine Respondent $10,000 for ten first offense counts of failure to comply with the Medicaid rules.

DONE AND ENTERED this 19th day of March, 2013, in Tallahassee, Leon County, Florida.

S

JESSICA E. VARN

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 19th day of March, 2013.

ENDNOTE

1/ Unless otherwise noted, all references to the Florida Statutes are to the 2012 codification.

COPIES FURNISHED:

Daniel Lake, Esquire

Agency for Health Care Administration Fort Knox Building 3, Mail Station 3 Suite 3431 2727 Mahan Drive

Tallahassee, Florida 32308

Annie Mathew Good Hope Manor

2251 Northwest 29th Court Oakland Park, Florida 33311

Elizabeth Dudek, Secretary

Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

Stuart Williams, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

Richard J. Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3

Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.

Docket for Case No: 12-001167MPI

Orders for Case No: 12-001167MPI