STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2012005056 v. Return Receipt Requested: 7009 0080 0000 0586 5747 SHIRLEY’ S PERSONAL CARE SERVICES OF OKEECHOBEE, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter ‘“AHCA”’ or the “Agency”) by. and through the undersigned counsel, and files this administrative complaint against Shirley’s Personal Care Services of Okeechobee, Inc. hereinafter (“Shirley’s Personal Care Services of Okeechobee”) pursuant to 28-106.111, Florida Administration Code (2011) and Chapter 120, Florida Statutes (2011), and alleges: NATURE OF ACTION 1. This is an action to revoke Shirley’s Personal Care Services of Okeechobee license pursuant to Section 408.815 (1) (b), Florida Statutes. JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. Filed August 23, 2012 9:15 AM Division of Administrative Hearings 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4, AHCA is the enforcing authority with regard to nurse registries pursuant to Chapter 400, Part IV, Florida Statutes and Rule 59A-18, Florida Administrative Code. 5. Shirley’s Personal Care Services of Okeechobee is a nurse registry agency located at 200 $.E. 3%° Street, Okeechobee, Florida 34974 and is licensed under number 30211249 with an expiration date of 11/20/2013. Shirley’s Personal Care Services of Okeechobee was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I SHIRLEY’S PERSONAL CARE SERVICES OF OKEECHOBEE INTENTIONALLY COMMITTED AN ACT THAT HAD THE POTENTIAL TO AFFECT THE HEALTH OR SAFETY OF ONE OF THREE SAMPLED PATIENTS Section 408.815(1), Florida Statutes 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaints investigation conducted on 4/03/2012 and 4/06/2012 and based on interview and record review, it was determined that the Nurse Registry's Owner intentionally committed an act that had the potential to affect the health or safety of 1 of 3 sampled patients of the Nurse Registry (Patient #3). 8. During record review and interview with the Nurse Registry's Administrator, conducted on 04/03/2012 beginning at approximately 1:00 PM, she stated that services for Patient #3 were suddenly discontinued, per request of the patient's adult child, on 10/31/2011 and she stated that she has no idea why this decision was made to discontinue services. 9. Continued review revealed that this patient originally started receiving Housekeeping services from the Nurse Registry and then Personal Care services in 2006; the services became 24 hours daily and 7 days per week in 2007. Further review revealed that the Owner of the Nurse Registry obtained DPOA (Durable Power of Attorney) and Health Care Surrogate Designation for Patient #3 effective 09/24/2007. 10. During telephone interview with Patient #3's adult child, conducted on 04/06/2012 beginning at approximately 10:30 AM, the adult child confirmed that the Owner of the Nurse Registry obtained a quit claim deed for Patient #3's residence property on 11/21/2008. Review of this document revealed that this residence property's ownership was transferred from Patient #3 to the Owner of this Nurse Registry and this document revealed that there was no fee/charge for the transfer of ownership. 11. Based on the foregoing, Shirley’s Personal Care Services of Okeechobee violated Sections 408.815(1), and 408.803(7), Florida Statutes, which warrants the revocation of its license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for ‘Health Care Administration requests the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Shirley’s Personal Care Services of Okeechobee on Count I. 2. Revoke the Respondent’s license pursuant to Section 408.815(1), Florida Statutes, for the violation cited above, 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2011). 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 the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. or’ E. Rodney, Esq. Fla. Bar No.: 178081 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53%¢ Street, Suite #300 Miami, Florida 33166 Copies to: Field Office Manger Agency for Health Care Administration 5150 Linton Boulevard, Room 500 Delray Beach, Florida 33484 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Melissa Johnson, Administrator, Shirley’s Personal Care Services of Okeechobee, Inc., 200 S.E. 3°% Street, ~ Okeechobee, Florida 34974, on this ly day of Uhe-7 , 2012, Nelsorn’e. Rodney, Esq. SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY

Docket for Case No: 12-002846