see tle ta ey casas STATE OF FLORIDA AGENCY: FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . Case No.: 2012005201 vs. : 2012005202 ANDRADA SUNSHINE CORPORATION d/b/a GOOD SAMARTTAN RETIREMENT HOME, Respondent, / ee ADMINISTRATIVE COMPLAINT ERE TE LOMPLAINT COMES NOW the Agency For Health Care Administration (the . . “Agency”) and files this administrative complaint against Andrada Sunshine Corporation d/b/a Good Samaritan Retirement Home, (“Respondent” or “Respondent Facility”), pursuant to SS 120.569, and 120.57, Fla, Stat., and alleges: | NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of twenty thousand dollars ($20,000.00) and for such other relief as this tribunal may determine, including a survey fee, pursuant to Chapters 408, Part II, and 429, part I, Fla. Stat, . JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and 429.07, and Chapters 408, Part TI, and 429, Page 1 of 28 ini i ings d At st 23, 2012 9:11 AM Division of Administrative Hearing: File ugu: , : ne ey Part I, Florida Statutes, . 2. Venue lies Pursuant to Fla. Admin. Code R. 28-106. 207, PARTIES 3. The Agency licenses all assisted living facilities and enforces all applicable Florida statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes, and: Chapter S8A-5, Florida Administrative Code. 4. Respondent operates a 65-bed assisted living facility located at 507 S.E. 1st Avenue, Williston, Florida 32696, and is licensed as an assisted living facility, license number 25, 5, At all times material to this complaint, Respondent was licensed by the Agency and was required to comply with all applicable rules and statutes, COUNT I Al0 6. The Agency re-alleges and incorporates Paragraphs 1 through 5, as if fully set forth in this count. 7. Rule 58A-5.0181, Florida Administrative Code, requires; 1. If the individual needs assistance with self- administration the facility must inform the resident Page 2 of 28 of the professional qualifications of facility staff who will be providing this assistance, and if unlicensed staff will be providing such assistance, obtain the resident's or the resident's surrogate, guardian, or attorney-in-fact’s written informed consent to provide such assistance as required under Section 429.256, F.s, 2. The facility may accept a resident who requires the administration of medication, if the facility has a nurse to provide this service, or the resident or the -tesident’s legal representative, désignee, surrogate, guardian, or attorney in fact contracts with a licensed third party to provide this service to the resident. (f) Any special dietary needs can be met by the facility. . (k) Not require any of the following nursing services: 1. Oral, nasopharyngeal, or tracheotomy suctioning; 2. Assistance with tube feeding; 3. Monitoring of blood gases; 4. Intermittent positive pressure breathing therapy; or 5. Treatment of surgical incisions or wounds, unless the surgical incision or wound and the condition which Caused it have been stabilized and a plan of care developed, . (1) Not require 24-hour nursing supervision, (n) Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator shall base the decision on: 1. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429.26, F.S., and subsection (2) of this rule; 2. The facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and (2) HEALTH ASSESSMENT, As part of the admission criteria, an individual must undergo a face-to-face medical examination completed by a licensed health care provider, as specified in either paragraph (a) or (6) of this subsection. (a) A medical examination completed within 60 calendar days prior to the individual’s admission to a facility Page 3 of 28 pursuant to Section 429.26(4); Fig, The examination must address the following: - 1. The physical and mental status of the resident, including the identification of any health-related problems and functional limitations; 2. An evaluation of whether the individual will require supervision or assistance with the activities of daily living; . . 3. Any nursing or therapy services required by the individual; : 7. A statement: on the day of the examination that, in the opinion of the examining licensed health care provider, the individual's needs can be met in an assisted living facility; and 8. The date of the examination, and the name, signature, address, phone number, and license number of the examining licensed health care provider. The medical examination may be conducted by a currently licensed health care provider from another state, (b) A medical examination completed after the ' resident’s admission to the facility within 30 Calendar days of the admission date, The examination must be recorded. on AHCA Form 1823, Resident Health Assessment for Assisted Living Facilities, October 2010. The form is hereby incorporated by reference. A faxed copy of the completed form is acceptable. A copy of AHCA Form 1823 May be obtained from the Agency Central Office or its website at Age feche: State. £1.us/MCHQ/Long Term Care/ assisted _living/pdt/AHCA_Form 18238 pdf. The form must be completed as follows: 1. The resident's licensed health care provider must complete all of the required information in Sections 1, Health Assessment, and 2, Self-Care and General Oversight Assessment, a. Items on the form that may: have been omitted by the Page 4 of 28 either verbally or in writing from the licensed health care provider. ; , c, Omitted information received verbally must be documented in. the resident's record, including the "name of the licensed health care provider, the name of the facility staff recording the information and the date the information was provided. . 2. The facility administrator, or designee, must complete Section 3 of the form, Services Offered or Arranged by the Facility, or may use electronic documentation, which at a minimum includes the elements in Section 3. This requirement does not apply for residents receiving: : a. Extended congregate care (ECC) services in facilities holding an ECC license; b. Services under community living support plans in facilities holding limited mental health licenses; Cc. Medicaid assistive care services; and d. Medicaid waiver services, , ; (c) Any information required by paragraph (a) that is not contained in the medical examination report conducted prior to the individual's admission to the facility must be obtained by the administrator within 30 days after admission using AHCA Form 1823. (f) Any orders for medications, nursing, - therapeutic diets, or other services to be provided or supervised by the facility issued. by the licensed health care ‘provider conducting the medical examination may be attached to the health assessment, A licensed health Care provider may attach a do-not-resuscitate order for residents who do not wish cardiopulmonary resuscitation to be administered in the case of cardiac or respiratory arrest. (4) CONTINUED RESIDENCY. Except as follows in Paragraphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility shall be the same as the criteria for admission. As part of the continued residency criteria, a resident must have a face-to-face medical examination by a licensed health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change is defined in Rule 58A-5.0131, F.A.C, The results of the examination must be recorded on AHCA Form 1823, which is incorporated by reference Page 5 of 28 ce eee in. paragraph (2) (b) of this rule. The form must be completed in accordance with that paragraph. After the effective date of this rule, providers shall have up to 12 months to comply with this requirement. (d) The administrator is responsible for monitoring the continued appropriateness of placement of a _vesident in the facility. (5) DISCHARGE. If the resident no longer meets the criteria for continued residency, or the facility is unable to meet the resident's needs, as determined by the facility administrator or licensed health care provider, the resident shall be. discharged in accordance with Section 429,28 (1), F.S. 8. Rule 58A-5.030, Florida Administrative Code, requires: (5) ADMISSION AND CONTINUED RESIDENCY. . (a) An individual must meet the following minimum criteria in order to be admitted to an extended congregate care program. 1, Be at least 18 years of age. 2. Be free from signs and symptoms of a communicable disease which is likely to be transmitted to other residents or staff; however, a person who has human immunodeficiency virus (HIV) infection may be admitted to a facility, provided that he would otherwise be eligible for admission according to this rule. _3. Be able to transfer, with assistance if necessary. The assistance of more than one person is permitted. 4, Not be a danger to self or others as determined by . a health care provider, or mental health practitioner licensed under Chapters 490 or 491, F,S, 5. Not be bedridden. - Not have any stage 3 or 4 pressure sores. Not require any of the following nursing services: » Oral or nasopharyngeal suctioning; Nasogastric tube feeding; Monitoring of blood gases; Intermittent positive pressure breathing therapy; €. Skilled rehabilitative services as described in Rule 59G-4.290, F.A.C.; or £. Treatment of a surgical incision, unless the surgical incision and the condition which caused it have been stabilized and a plan of care developed. 8. Not require 24-hour nursing supervision. BAT aH Page 6 of 28 9. Have been determined to be appropriate for admission to the facility by the facility administrator. The administrator shall base his/her decision on: : a. An assessment of the strengths, needs, and preferences of the individual, the health assessment required by subsection (6) of this rule, and the preliminary service plan developed under subsection (1) , b. The facility’s residency criteria, and services offered or arranged for by the facility to meet resident needs; and c. The ability of the.facility to meet the uniform fire safety standards for assisted living facilities established under Section 429.41, F.S., and Rule Chapter 69A-40, F.A.c, (b) Criteria for continued residency in an ECC program shall be the same as the criteria for admission, except as follows: 1. A resident may be bedridden for up to 14. consecutive days. 2. A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: a. The resident qualifies for, is admitted to, and consents to the services of a licensed hospice which coordinates and ensures the provision of any additional care and services that may be needed; b. Continued residency is agreeable to the resident and the facility; c. An interdisciplinary care plan is developed and implemented by a licensed hospice in consultation with the facility. Facility staff may provide any nursing service within the scope of their license including 24-hour nursing supervision, and total help with the activities of daily living; and d. Documentation of the requirements of this subparagraph is maintained in the resident's file. (6) HEALTH ASSESSMENT. Prior to admission to an ECC program, all persons. including residents transferring within the same facility to that portion of the facility licensed to provide extended congregate care services, must be examined by a physician or advanced registered nurse practitioner pursuant to Rule 58A- 5.0181, F.A.C. A health assessment conducted within 60 days prior to admission to the ECC program shall meet Page 7 of 28 SOUR WNHE this requirement. Once admitted, a new health assessment must be obtained at least annually. (7) SERVICE PLANS. (a) Prior to admission the extended congregate care ‘ supervisor shall develop a preliminary service plan which includes an assessment of whether the resident meets the facility’s residency criteria, an appraisal of the resident’s unique physical and psycho social needs and preferences, and an evaluation of the facility’s ability to meet the resident's needs. (bo) Within 14 days of admission the congregate care supervisor shall coordinate the development of a written service plan which takes into account the resident’s health assessment obtained pursuant to subsection (6); the resident's unique physical and psycho social needs and preferences; and how the facility will meet the resident’s needs including the following if required: Health monitoring; ; Assistance with personal care services; _ Nursing services; : Supervision; . Special diets; Ancillary services; The provision of other services such as transportation and supportive services; and 8. The manner of service provision, and identification of service providers, including family and friends, in. keeping with resident preferences. (c) Pursuant to the definitions of “shared responsibility” and “managed risk” as provided in Section 429.02, F.S., the service plan shall be developed and agreed upon by the resident or the resident's representative or designee, surrogate, guardian, or attorney-in-fact, the facility designee, and shall reflect the responsibility and right of the resident to consider options and assume risks when making choices pertaining to the resident’s. service needs and preferences. (d) The service plan shall be reviewed and updated quarterly to reflect any changes in the manner of service provision, accommodate any changes in the resident’s physical or mental status, or pursuant to recommendations for modifications in the resident's care as documented in the nursing assessment. 9, Rule 58A-5,0131(33), Florida Administrative Code, Page 8 of 28 bo cee mt defines: (33) “Significant change” means a sudden or major shift in behavior or mood, or a deterioration in health status such as unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure sore. Ordinary day-to~day fluctuations in functioning and behavior, a short-term illness such as a cold, or the gradual deterioration in the ability to carry out the activities of daily living that accompanies the aging process are not considered significant changes. 10. The Agency conducted a revisit to the Agency's February 3, 2012, survey of the Respondent's assisted living facility on March 26, 2012. 11. Based on the Agency’s surveyors’ review of Respondent’ s records, observations and interviews, the Agency concluded that the Respondent facility retained two residents, Residents #1 and #2, who did not meet the criteria for continued - residency. 12. On March 26, 2012, at 12:10 PM, the Agency’s surveyor ‘observed Resident #1 in Room B-9, In the room were an oxygen concentrator and eight (8) unsecured oxygen tanks standing in various locations in the room. The Agency’s surveyor observed a note on the wall of the room, reading: "When Ms, Dorothy is in the wheelchair using portable oxygen please put the 'CF2" on the dial. When returning to room, out of wheelchair please turn dial to 'Off' to save oxygen. Thank you management." 13. On 3/26/12 at 12:15 PM, the Agency’s surveyor observed Resident #2 in Room B-16. ‘The Agency’s surveyor saw an oxygen Page 9 of 28 eee concentrator with un-bagged nasal cannula hanging on the wall. The Agency’s surveyor observed a note on the wall of the room reading: "When Ms. Edna is in wheelchair using portable oxygen please put the number 2 on the dial. When not in use please turn’ dial to '0' (zero) to save oxygen. Thank you management." 14. The Agency’s sSurveyor’s review of Respondent’s records for, Resident #1 found a Health Assessment, Agency form 1823, dated 12/26/11 which specifies that Resident #1 "Needs Medication Administration." Page 5 of the health assessment form; in column 1, for "Needs identified from sections 1 & 2," line 5 states "medication" and in column 4 "Service Provider Name" it states "Med tech [medication technician] ." 15, Review of the Medication Observation Record (MOR) revealed that the facility uses a Medication Technician to distribute medications to the residents. 16. The Agency’s surveyor’s review of Respondent’s records for Resident #2 found a Health Assessment, Agency form 1823, dated 10/31/2011, indicating Resident #2's diagnoses of Dementia, Chronic Kidney Disease, Hyperthyroidism; Cognitive | status of "confused" on Hospice. The 1823 also specifies that Resident #2 "Needs Total Assistance with Administration of Meds." Review of page 5 of this health assessment revealed in line 2 that Column 1 states "medication" and column 5 states that the service will be provided by a "med tech." Page 10 of 28 seers eee bee 17. When interviewed by the Agency’s surveyor on 3/26/12 at 1:35 PM, Resident #1 stated that the Respondent's staff turn her oxygen on and off for her, When asked if she could turn it on and off by herself she responded, "No," that nobody ever showed her how to do it. 18. When interviewed by the Agency’s surveyor on 3/26/12 at 1:55 PM, Resident #2 was not able to answer the surveyor’s questions regarding how she was doing today nor if her lunch was good. Resident #2 is not inter-viewable. A portable oxygen. tank was observed on Resident #2's wheelchair. 19. A Review of the Respondent’ s records by the Agency's Surveyor found that Resident #1 is receiving Home Health Agency services, and Resident #2 is under Hospice Care, 20. The Agency’ s surveyor interviewed an employee of the "Home Health Agency being utilized by Resident #1 on 04/05/12 at 9:39 AM. Resident #1's registered nurse (“RN”) from the Home Health Agency stated that the resident is receiving wound care services and physical therapy. When asked if the Home Health Agency is providing medications administration or if they are managing the resident's oxygen, the RN stated that they were not. Further interview indicated that when a member of the staff of the Home Health Agency goes to see Resident #1 they will obtain an oxygen saturation for the resident, and if they think she needs -her oxygen, they will put it on, but they do not Page 11 of 28 routinely manage her oxygen, as it is not part of the service plan for her. 21. On 04/05/12 at 9:45 AM, the Agency’s surveyor interviewed the Hospice nurse caring for Resident #2. The Hospice nurse stated that Hospice is not providing the resident with medication administration .or oxygen administration, as they are not at the facility 24 hours a day, 7 days a week. 22. The Agency determined that the Respondent’s retaining as residents two people who require nursing services that are not being provided for by a third-party nurse is a violation of law and describes conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determines to be a class II violation for the purposes of sections 408.813, 408.815, 429,14 and 429,19, Florida Statutes. WHEREFORE, the Agericy intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violations, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. . COUNT II A052 Page 12 of 28 23. The Agency re-alleges and incorporates paragraphs 1 through 5, as if fully set forth in this count. 24. Section 429,256, Florida Statutes, requires: (2) Residents who are capable of self-administering their own medications without assistance shall be encouraged and allowed to do so. However, an. unlicensed person may, consistent with a dispensed prescription’s label or the package directions of an over-the-counter medication, assist a resident whose condition is medically stable with the self~administration of routine, regularly scheduled medications that are intended to be self-administered. Assistance with self- medication by an unlicensed person may occur only upon a documented request by, and the written informed consent of, a resident or the resident’s surrogate, guardian, or attorney in fact. For the purposes of this section, self~administered medications include both legend and over-the-counter oral dosage forms, topical dosage forms and topical ophthalmic,, otic, and nasal dosage forms including solutions, suspensions, sprays, and inhalers. . (3) Assistance with self-administration of medication includes: : . (a) Taking the medication, in its previously dispensed, properly labeled container, from where it is stored, and bringing it to the resident. . (b) In the presence of the resident, reading the label, opening the container, removing a prescribed amount of medication from the container, and closing the container. (c) Placing an oral dosage in the resident's hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth. (d) Applying topical medications. (e) Returning the medication container to proper storage, (£) Keeping a record of when-a resident receives : assistance with self-administration under this section, (4) Assistance, with self-administration does not include: . (a) Mixing, compounding, converting, or calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed. . Page 13 of 28 (b) The preparation of syringes for injection or the administration of medications by any injectable route. (c) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. (e) Administration of parenteral preparations. (f) Irrigations or debriding agents used in the treatment of a skin condition, (g) Rectal, urethral, or vaginal preparations. (h) Medications ordered by the physician or health care professional with prescriptive authority to be given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and at the request of a competent resident. (1) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person, 25. Rule 58A-5.0185, Florida Administrative Code, requires: (3) ASSISTANCE WITH SELF-ADMINISTRATION. (a) For facilities which provide assistance with self- administered medication, either: a nurse; or an unlicensed staff member, who is at least 18 years old, trained to assist with self-administered medication in accordance with Rule 58A-5.0191, F.A.C., and able to demonstrate to the administrator the ability to accurately read and interpret a prescription label, must be available to assist residents with self- administered medications in accordance with procédures described in Section 429.256, F.S, (b) Assistance with self-administration of medication includes verbally prompting a resident to take medications as prescribed, retrieving and opening a properly labeled medication container, and providing assistance as specified in Section 429.256(3), F.S. in order to facilitate assistance with self- administration, staff may prepare and make available Such items as water, juice, cups, and spoons. Staff may also return unused doses to the medication container. Medication, which appears to have been contaminated, shall not be returned to the container. Page 14 of 28 eet (c) Staff shall observe the resident take the medication. Any concerns about the resident’s reaction to the medication shall be reported to the resident's health care provider and documented in the resident's record, . (d) When a resident who receives assistance with medication is away from the facility and from facility staff, the following options are available to enable the resident to take medication as prescribed: 1. The health care provider may prescribe a medication schedule which coincides with the resident’s presence in the facility;: ; 2. The medication container may be given to the resident or a friend or family member upon leaving the facility, with this fact noted in the resident's medication record; 3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection: (2), and given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record; or 4. Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose ‘packaging; (e) Pursuant to Section 429.256(4) (h), F.S., the term “competent resident” means that the resident is _ cognizant of when a medication is required and understands the purpose for taking the medication, (f£) Pursuant to Section 429.256(4) (i), F.S., the terms “judgment” and “discretion” mean interpreting vital signs and evaluating or assessing a resident's condition, (5) MEDICATION RECORDS, (a) : : (o) The facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care Provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the Medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the Page 15 of 28 a medication is offered or administered. (7) MEDICATION LABELING AND ORDERS. (c) If the directions for use are “as needed” or “as directed,” the health care provider shall be contacted and requested to provide revised instructions. For an “as needed” prescription, the circumstances under which it would be appropriate for the resident to request the medication and any limitations shall be specified; for example, “as needed for pain, not to exceed 4 tablets per day.” The revised instructions, including the date they were obtained from the health care provider and the signature of the staff who obtained them, shall be noted in the medication record, or a revised labe shall be obtained from the pharmacist. (d) Any change in directions for use of a medication for which the facility is providing assistance with self-administration or administering medication must be accompanied by a written medication order issued and signed by the resident’s health care provider, or a faxed copy of such order. The new directions shall promptly be recorded in the resident's medication observation record. The facility may then place an “alert” label on the medication container which directs staff to examine the revised directions for use in the MOR, or obtain a revised label from the pharmacist. (e) A nurse may take a medication order by telephone. Such order must be promptly documented in the resident's, medication observation record. The facility Must obtain a written medication order from the health care provider within 10 working days. A faxed copy of a signed. order is acceptable. ; 26. Rule 58A-5.024, Florida Administrative Code, requires: (3)-RESIDENT RECORDS. Resident records shall be maintained on the premises and include: (h) For facilities which manage a pill organizer, ‘assist with self-administration of medications or administer medications for a resident, the required medication records maintained pursuant to Rule 58A- 5.0185, F.A.C. ; 27. On February 3, 2012, an unannounced monitoring survey Page 16 of 28 chee eee eee eee we tee was conducted of the Respondent. 28. Based on the Agency’s surveyor'’s review of Respondent’ s records and interviews, the Agency determined that the Respondent failed to ensure proper orders for medications for 5 residents ~ Residents #2, #3, #4, #5 and #6 -- of 39 residents whose care was reviewed. The Respondent also failed to follow physician’s-orders for medication for 1 resident, . Resident #7. 29. When the Agency’s surveyor reviewed the Medication Observation Record (“MOR”) for Resident #2, the MOR indicated that the resident has an “as-needed” (“PRN”) order for Hydroxyzine HCL 10 mg Tablet: “Take 1 Tablet by mouth twice a day as needed, Dx. Anxiety.” There were no orders Clarifying the appropriate “as-needed” circumstances: for the resident to take the medication. 30. When the Agency's surveyor reviewed the MOR for Resident #3, the MOR indicated a PRN order for Tussinl00 mg/5 ml liquid, Generic for Iophen NR Liq PT Anbr/Raspby: “Take 5 ml by mouth every 4 hours as needed.” There was no diagnosis listed, or why to take the medication, nor were the parameters of ‘as- needed” clarified. 31. Both Residents $2 and #3 reside in the secure unit for Alzheimer’s patients. 32. The Agency's surveyor’s review of the Medication Page 17 of 28 ee Seen Observation Records (“MOR”) -for Resident #4 revealed that the . resident has diagnosis of DM, Alzheimer's, PUD, Urinary Incontinence and has PRN orders for APAP Arthritis Pain 650 Ext- Release Tablet: “Take 1 tablet by mouth every 4 hours. as needed.” No diagnosis listed or reason for taking the medication, nor were the parameters of “as-néeded” clarified. 33. The Agency’s surveyor’s review of the Medication Observation Records (MOR) for Resident #5 revealed that the. resident has diagnosis of Advanced Dementia, Depression, HTN, Hx of Psychosis. Resident #5 has PRN orders for the following medications - APAP 650 mg Suppo 12 CLA, use 1 suppository per rectum every 4 hours.as needed for mild pain or fever - APAP Arthritis Pain 650 mg Ext-Release Tablet, Take 1 tablet by mouth , every 4 hours as needed for pain - Lorazepain 1 mg Tablet (Generic for Ativan 1 mg tablets), Take 1 tablet by mouth or crushed under tongue every 4 hours as needed for restlessness. However, Respondent’s records did not contain a clarifying orders for these medications such as the maximum number of pills to be taken within 24 hours. 34. The Agency’s surveyor’s review of the Medication Observation Records (MOR) for Resident #6 revealed that the resident has diagnosis of Dementia and Chronic Kidney Disease, Resident #6 has PRN orders for Albuterol Sulfate 0.083 ml solution (Generic for Proventil 0.083 ml solution), 1 vial 3 Page 18 of 28 wk times a day via nebulizer as needed for Dysnéa. However, Respondent’s records do not contain a clarifying order for any of these medications such as the maximum daily dosage. 35. The Agency’s surveyor’s review of the Medication Observation Records (MOR) for Resident #7 revealed that the resident has diagnosis of Pancreatitis, DM, Atrial Fibrilation, COPD, HTN and CRF, Resident #7 has medication orders for Cyanocobalamin 1000 (Generic for Cobal 1000 mcg/ml injection), Inject 1 ml intra-muscular every month [to be administered by SHC (a home health agency)] - the record indicates that the medication has been given.- However, the initials on the MOR are those of employee #4, an unlicensed person. . 36. On 2/3/12 at 12:50 PM, the Agency’s surveyor interviewed Respondent's employee #1, who confirmed PRN (as needed) medications listed for residents having Dementia, Alzheimer's diagnosis as well as the MOR indicating the additional dosages of medication given to Resident #7. 37. The Agency determined that Respondent’s medication administration violations identified during the Agency's February 3, 2012, survey are conditions or occurrences related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threaten the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II Page 19 of 28 violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violations observed. on February 3, 2012, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT III AQ53 38. The Agency re-alleges through 5 and Paragraphs 10 thro this count. 39, Section 429.256, Flori (2) Residents who are capab and incorporates paragraphs 1 ugh 21, as if fully set forth in da Statutes, requires: le of self-administering their own medications without assistance shall be encouraged and allowed to di person may, consistent with label or the package direct medication, assist a reside medically stable with the gs routine, regularly schedule intended to be self-adminis medication by an unlicensed &@ documented request by, an consent of, a resident or t guardian, or attorney in fa section, self-administered legend and over-the-counter dosage forms and topical op dosage forms including solu and inhalers, (3) Assistance with self-adi includes; (a) Taking the medication, © so. However, an unlicensed a dispensed prescription’s ions of an over-the-counter nt whose condition is elf-administration of ad medications that are tered. Assistance with self- person may occur only upon d the written .informed he resident’s surrogate, ct. For the purposes of this medications include both oral dosage forms, topical hthalmic, otic, and nasal tions, suspensions, sprays, ministration of medication in its previously dispensed, Page 20 of 28 properly labeled container, from where it is stored, arid bringing it to the resident. (b) In the presence of the resident, reading the label, opening the container, removing a prescribed amount of ‘ medication from the container, and closing the container. . (c) Placing an oral dosage in the resident’s hand or placing the dosage in another container and helping the resident by lifting the container to his or her mouth. (d) Applying topical medications. (e) Returning the medication container to proper storage. (£) Keeping a record of when a resident receives assistance with self-administration under this section. (4) Assistance with self-administration does not include: (a) Mixing, compounding, converting, or calculating medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or crushing a tablet as prescribed, (b) The preparation of syringes for injection or the administration of medications by any injectable route, - (c) Administration of medications through intermittent positive pressure breathing machines or a nebulizer. (d) Administration of medications by way of a tube inserted in a cavity of the body. (e) Administration of parenteral preparations. (£) Irrigations or debriding agents used in the treatment of a skin condition. (g) Rectal, urethral, or vaginal preparations. _ (h) Medications ordered by the physician or health care professional with prescriptive authority to be given ‘as needed,” unless the order is written with specific Parameters that preclude independent judgment on the : part of the unlicensed person, and at the request of a competent resident. (1).Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person. 40. Rule 58a-5.0182, Florida Administrative Code, provides: (5) NURSING SERVICES. Page 21 of 28 (a) Pursuant to Section 429,255, F.S., the facility may employ or contract with a nurse to: 1. Take or supervise the taking of vital signs; 2. Manage pill-organizers and administer medications as described under Rule 58A-5.0185, F.A.C.; 3. Give prepackaged enemas pursuant to a physician’s order; and 4. Maintain nursing progress notes. (b) Pursuant to Section 464.022, F.8., the nursing services listed in paragraph (a) may also be delivered ‘in the facility by family members or friends of the resident provided the family member or friend does not receive compensation for such services, - :41. Rule 58A-5.0185, Florida Administrative Code, requires: (4) MEDICATION ADMINISTRATION. (a) For facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider's order or prescription label, (b) Unusual reactions or a significant change in the resident’s health or behavior shall be documented in the resident’s record and reported immediately to the resident’s health care provider. The contact with the health care provider shall also be documented in the resident’s record. (c) Medication administration includes the conducting ‘ of any examination or testing such as blood glucose testing or other procedure necessary for the proper administration of medication that the resident cannot conduct himself and that can be performed by licensed staff, 42. On September 22 and 23, 2011, the Agency conducted a complaint investigation survey of the Respondent. 43. Based on the Agency’s surveyor’s observations, reviews of Respondent's records, and interviews, the Agency determined that the Réspondent failed to have licensed personnel provide administration of injectable medications for 2 of 16 residents, Page 22 of 28 Residents. #4 and #14. 44. On 9/22/2011 at 12:00 PM, at 1:00 PM and at 1:30 PM, the Agency’s surveyor observed that Respondent’s unlicensed medication technicians were preparing to administer insulin to residents who were incapable of self-administering the injections. 45. The Agency’s surveyor’s review of the medical records’ for Residents #4 and #14, showed a failure to document. administration of insulin, including dates and times of insulin injections for the two residents. 46. On 9/22/2011 at 2:00 PM, the Agency's surveyor observed the owner of Respondent, who is a Registered Nurse (RN). The owner did not know where the insulin administered to Respondent’s residents was stored, but Respondent's Administrator showed him where it wan, 47, The Agency’s surveyor conducted an interview with Respondent’s Administrator on 9/22/2011 at 3:00 PM. The Administrator told the Agency’s surveyor that a terminated Assistant Administrator, who.was a Certified Nursing Assistant, formerly provided the insulin injections, until 9/13/2011. The owner of the facility is a Registered Nurse (“RN”), but on September 14, 15, 16, 17, 18, 19, 20 and 21, 2011, other employees of respondent who are not licensed professionals provided the residents with their insulin shots. The Page. 23 of 28 Administrator admitted knowing the Limitations of unlicensec} staff and medications. 48. The agency determined that Respondent’s allowing unlicensed professionals to administer injectable medications to residents is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the agency determined directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes, 49. On March 26, 2012, the Agency conducted a revisit survey to the Agency’s survey of February 3, 2012. 50. Based on the Agency’s surveyor’ s review of Respondent’s records and on interviews on February 3, 2012, the Agency determined that the Respondent allowed an unlicensed Med Tech to administer medications to two (2) residents, Residents #1 and #2, of ‘sixteen (16) residents whose care was reviewed by the Agency's surveyor. 51. The Agency determined that Respondent’s failure to provide residents needing medication administration with medication administration by a licensed person is a condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the Agency determined Page 24 of 28 directly threatens the physical or emotional health, safety, or security of the residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 and 429.19, Florida Statutes. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violation identified during the March 26, 2012, Agency survey, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. COUNT IV 2827 52. The Agency re-alleges and incorporates paragraphs 1 through 5, paragraph 8 and paragraphs 10 through 21, as if fully set forth in this count. 53, On March 26, 2012, the Agency conducted a revisit survey to the Agency’s survey of February 3, 2012, of the Respondent. 54. Based on the Agency’s surveyor’s review of Respondent’s records and on interviews, the Agency determined that the Respondent provided services beyond those allowed under Respondent’s assisted living facility license with extended corigregate care designation, therefore engaging in unlicensed conduct, pursuant to §§ 408.804 and 408.812, Florida Statutes. Page 25 of 28 55. The Agency determined that Respondent’s provision of medication administration by an unlicensed person to residents . Needing medication administration isa condition or occurrence related to the operation and maintenance of a provider or to the care of residents which the Agency determined directly threatens the physical or emotional health, safety, or security of the _ residents, and which the Agency determined to be a class II violation for the purposes of sections 408.813, 408.815, 429.14 “and 429,19, Florida Statutes, WHEREFORE, the Agency intends to impose an administrative 'fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, for the above-described class II violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just, COUNT V_ SURVEY FEE 56. The Agency re-alleges and incorporates paragraphs 1 through 5 and above Count II. S7. Section 429.19(7), Florida Statutes, provides: (7) In addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 429.28(3) (c) to verify the correction of the violations. Page 26 of 28 58. The February 3, 2012, Agency survey was a monitoring survey, at which the Agency’s surveyor’s investigation resulted in the finding of one or more violations that were the subject of the monitoring visit. WHEREFORE, the Agency intends to impose a survey fee to be determined by this tribunal against Respondent, an assisted living facility in the State of Florida, for the above-described class I violation, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, or such further relief as this tribunal deems just. NOTICE 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 retain, and be represented by an attorney in this matter. Specific options for administrative’ action are set out in the attached Election of Rights. ‘ All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, FL 32308, whose telephone number is 850-412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7010 0780 0001 9836 2855, to Miskel Ortiz, Administrator, 507 S.E. 1°* Avenue, Williston, FL 32696, and by regular U.S, Page 27 of 28 Mail to Gus R. Benitez, Esq., as attorney for Andrada Sunshine Corp., 1223 East Concord Street, Orlando, FL 32803, on July fl. , 2012. Copies furnished to: Agsistant General Counsel Fla’ Bar. No. 817775 Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 727-552-1944 (office) : 727-552-1440 (facsimile) ‘Anna Lopez, HEE Supervisor, Alachua Page 28 of 28 wee eee tee iMiskel Ortiz Administrator 507 S.E. 1** Avenue IMilliston, FL 32696 0780 0001 9836

Docket for Case No: 12-002845