| re a STATE OF FLORIDA . AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, . ; Case No. 2012002106 HOSPICE OF FLORIDA KEYS, INC. d/b/a VISITING NURSE ASSOCIATION OF THE FLORIDA KEYS, Respondent, / ADMINISTRATIVE COMPLAINT. COMES NOW the Petitioner, State of Florida, Agency For Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, HOSPICE OF FLORIDA KEYS, INC. d/b/a VISITING NURSE ASSOCIATION OF THE FLORIDA KEYS (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and alleges as follows: NATURE OF THE ACTION This is an action to impose an administrative fine against a home health agency in the amount of ONE THOUSAND FIVE HUNDRED DOLLARS ($1,500.00) pursuant to Sections 400.474 and 400.484(2)(c), Florida Statutes (2011), based upon one (1) uncorrected Class III deficiency. JURISDICTION AND VENUE 1, This Court has jurisdiction over the subject matter pursuant to Sections 120,569 and 120.57, Florida Statutes (2011). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and Filed September 5, 2012 1:45 PM Division of Administrative Hearings 120.60, Florida Statutes (2011); Chapters 408, Part II, and 400, Part III, Florida Statutes (2011), and Chapter 59A-8, Florida Administrative Code. 3. Venue lies pursuant to Rute 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees home health agencies in Florida and is responsible for the enforcement of the applicable state regulations, statutes and rules governing home health agencies pursuant to Chapter 408, Part II, and Chapter 400, Part ill, Florida Statutes (2011), and Chapter 59A-8, Florida Administrative Code. The Agency may deny, revoke, or suspend a license, or impose an administrative fine, for violations as provided for by Sections 400.474 and 400,484, Florida Statutes (2011), and Rules 59A-8,003 and 59A-8.0086, Florida Administrative Code. 8. The Respondent was issued a license by the Agency (License No. 21245096) to operate a home health agency located at 1319 William Street, Key West, Florida 33040, and was at all material times required to comply with the applicable federal and state statutes, regulations . and rules for home health agencies. . COUNT I The Respondent Failed To Establish A Medication List Format That Provided The Required Data To Be Included On The Medication Record That Would Accompany A Priority Patient To A Special Needs Shelter Should The Patient Be Evacuated For Special Needs Care During An Emergency In Violation Of Rule 59A-8.027(16-17), Florida Administrative Code 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, the patient record for each person registered as a special needs patient shall include information as listed in Section 400.492(1), Florida Statutes (2011). The home health agency is required to maintain in the home of the special needs patient a list of patient-specific medications, supplies and equipment required for continuing care and service should the patient be evacuated. The list must include the names of all medications, their dose, frequency, route, time of day and any special considerations for administration. The list must also include any allergies; the name of the patient’s physician and the physician’s phone number(s); the name, phone number and address of the patient’s pharmacy. If the patient permits, the list can also include the patient’s diagnosis. Rule 59A-8.027(16-17), Florida Administrative Code. 8. On or about November 28, 2011 through December 1, 2011, the Agency conducted a Relicensure Survey of the Respondent’s Facility. 9, Based on record review and administrative interview, it was determined that the home health agency had not established a medication list format that provided the required data to be included on the medication sheet that would accompany a Category 1 or Category 2 priority patient to a special needs shelter should any of the patients be evacuated with special needs care during an emergency for four (4) of four (4) priority patient record reviewed, specifically Patient number five (5), Patient number seven (7), Patient number twelve (12), and Patient number thirteen (13), 10. In conversations with the Director of Access and Quality during the survey process, it was shared that should the home health agency have any patients that would need to be sent to a special needs shelter, the medication sheet that was both part of the clinical record and a duplicate copy maintained in the patient's home would accompany the priority special needs patient to the shelter during evacuation. 11. = During an interview with the Director of Access and Quality on December 1, 2011 at 4:30 p.m., it was confirmed the home health agency's medication profile sheet that would accompany Patient number five (5), Patient number seven (7), Patient number twelve (12), and Patient number thirteen (13) failed to include all of the required information necessary to provide continued patient care such as: (1) the physician's name and phone number; (2) the dispensing name, address and phone number; and (3) any supplies and durable medical equipment required for continuing care and services should the patient(s) be evacuated to the special needs shelter. 12. The Respondent’s act, omission or practice had an indirect, adverse effect on the health, safety, or security of a patient constituting a Class II{ deficiency. Section 400.484(2)(c), + Florida Statutes (2011). 13. The Agency cited the Respondent for a Class III violation in accordance with Section 400.484(2)(c), Florida Statutes (2011). 14. The Agency provided the Respondent with a mandatory correction date of January 1, 2012. 15, On or about January 9, 2012 through January 10, 2012, the Agency conducted a Follow-Up Survey of the Relicensure Survey of November 28, 2011 through December 1, 2011 of the Respondent’s facility. 16. Based on observation, interview, and record review, the home health agency failed to establish and maintain a medication list format that provided the required data to be included on the medication sheet that would accompany a Category 1 or Category 2 priority patient to a special needs shelter should any of the patients be evacuated with special needs care during an emergency for three (3) of three (3) patients sampled for home visits, specifically Patient number twenty (20), Patient number twenty one (21), and Patient number twenty two (22). The list must include all medications, supplies and equipment, the physician name and phone number(s), and the pharmacy’s name, address, and phone number should the patient be evacuated. 17. A review of records on January 10, 2012 documented Patient number twenty (20) was admitted for home care on December 15, 2011, with skilled nursing, physical therapy, and home -health aide services. At the time of the revisit survey, Patient number twenty (20) was receiving skilled nurse visits twice weekly. During home visit on January 10, 2012 at about 10:00 a.m., observation of Patient number twenty’s (20) medications revealed Glimapride 2 mg by mouth daily prescribed December 6, 2011. The home folder was found to contain a list of Patient number twenty’s (20) medications. The list did not include the pharmacy address or the Glimapride. 18. A review of records on January 10, 2012 documented Patient number twenty one (21) was admitted for home care on November 18, 2011 with skilled nursing services. At the time of the revisit survey, Patient number twenty one (21) was receiving skilled nurse visits twice weekly. During a home visit on January 10, 2012, at about 11:00 a.m. an observation of Patient number twenty one’s (21) medications revealed Terazosin 2 mg by mouth every twelve (12) hours was prescribed on November 17, 2011. The home folder was found to contain a list of Patient number twenty one’s (21) medications. The list did not include the pharmacy address, phone number, or the Terazosin. °19, A review of records on January 10, 2012 documented Patient number twenty two (22) was admitted for home care on December 17, 2011 with physical therapy services. At the time of the revisit survey, Patient number twenty two (22) was receiving physical therapy visits four (4) times weekly. 20, During a home visit on January 10, 2012 at about 11:30 a.m. an observation of Patient number twenty two’s (22) medications revealed Nitroglycerine 0.4 mg sublingual as needed for chest pain prescribed October 11, 2011. The home folder was found to contain a list of Patient number twenty two’s (22) medications. The list did not include the pharmacy name, address, phone number, or the Nitroglycerine. 21, In an interview on January 10, 2012 at about 11:30 am., the Director of Nursing confirmed there was no pharmacy information on Patient number twenty two’s (22) medication list. The Director of Nursing explained that they were waiting for a new medication form arrival from the printer. 22. The Respondent’s act, omission or practice, had an indirect, adverse effect on the health, safety, or security of a patient constituting a Class III deficiency. Section 400.484(2)(c), Florida Statutes (2011). 23. The Respondent’s deficient act, omission or practice constitutes an uncorrected Class III deficiency. Section 400.484(2)(c), Florida Statutes (2011). 24, Upon finding an uncorrected or repeated Class Ill deficiency, the agency shall impose an administrative fine not to exceed $1,000 for each occurrence and each day that the uncorrected or repeated deficiency exists pursuant to Section 400.484(2)(c), Florida Statutes (2011). 25. The Agency provided the Respondent with a mandatory correction date of February 10, 2012. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND FIVE HUNDRED DOLLARS (81,500.00) based upon three (3) occurrences of an uncorrected Class III deficiency pursuant to Sections 400.474 and 400.484(2)(c), Florida Statutes (2011). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent: 1. Make findings of fact and conclusions of law in favor of the Agency. cee nee eel 2. Impose an administrative fine against the Respondent in the amount of ONE THOUSAND FIVE HUNDRED DOLLARS ($1,500.00). 3. Enter any other relief that this court deems just and appropriate. Respectfully submitted this Jn day of AA re ol : _, 2012. ne CAR @ (wT. “A CAE Andrea M. Lang, Assistant General Cotin Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 335-1253 NOTICE THE RESPONDENT IS NOTIFIED THAT IT HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, OF THE FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT 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 FORM. THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM 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, MAIL STOP 3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form have been served to: Joan L. Gross, Administrator, Hospice of Florida Keys, Inc. d/b/a Visiting Nurse Association of the Florida Keys, 1319 William Street, Key West, Florida 33040, by United States Certified Mail, Return Receipt No. 7011 2000 0001 4884 4886, and to Gregory J. Wheeler, Registered Agent for Hospice of Florida Keys, Inc, d/b/a Visiting Nurse Association of the Florida Keys, 2211 Flagler Avenue, Key West, Florida 33040, by U.S. Certified Mail, Retum Receipt No. 7011 2000 0001 4884 4893, this Ouxc& _ day of Copies furnished to: On ha See, Wn, | CA Pomel Andrea M, Lang, Assistant General Covfiigel Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 335-1253 Joan L. Gross, Administrator Hospice of Florida Keys, Inc. d/b/a Visiting Nurse Association of the Florida Keys 1319 William Street Key West, Florida 33040 (U.S. Certified Mail) Andrea M. Lang, Assistant General Counsel Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Gregory J. Wheeler, Registered Agent for Hospice of Florida Keys, Inc. d/b/a Visiting Nurse Association Harold Williams Field Office Manager Agency for Health Care Administration of the Florida Keys 2295 Victoria Avenue, Room 340A 2211 Flagler Avenue Fort Myers, Florida 33901 Key West, Florida 33040 (Electronic Mail) (U.S. Certified Mail) | ; COMPLETE THIS SECTION QW QELIVERY | PMNS fo SENDER: COMPLETE THIS SECTION ‘ ml Complete items 1, 2, and 9, Also complete tem 4 if Restristed Delivery Is desired. i @ Pant your name and address on the reverse so that we can return the card to you. : m Attach this card to the back of tha mallplece, or on the front If space permits. . 4. Artlole Addressed to; : : Loan Z, Gross, Mbininristrafoe . Yiseteny Norse Associaton . ak tre Fforits ery® ABUT Wylleam Street Key West, Flords 32040 2. Article Number. i a (transfer hom sero label 2011 2000, ‘O001 BBY 486b Beaks thed non. PS Form 3811, February 2004 . DomestioRetum Reoelpt 2. 9/200 24 06 1O2695-02M-1640 9. Service Type O Centfied Melt ) Express Mall 1D Regtstered 1 Return Receipt for Merchandise Cl Ineured Mali 0) 0,0.0, 4. Restiloted Delivery? (Extra Fee)

Docket for Case No: 12-002907

Orders for Case No: 12-002907