O, id STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2012001850 License No. HCC9329 REALITY CARE SERVICES, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Reality Care Services, Inc., (“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 revoke the Respondent’s license to operate a health care clinic. PARTIES 1. The Agency is the governing body responsible for the licensure and regulation of health care clinics in Florida under Chapters 400, Part X, and 408, Part II, Florida Statutes, and Chapter 59A-33, Florida Administrative Code. 2. The Respondent was issued a license by the Agency to operate a health care clinic located at 7500 NW 25" Street, Suite 112, Miami, Florida 33122, and was at all times material required to comply with the statutes and rules governing such facilities. COUNT I Exclusion from the Medicare or Medicaid Program 3. Under Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following: ... (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. § 408.815(1)¢e), Fla. Stat. (2011). 4, On December 27, 2010, First Coast Service Options, Inc., a Medicare administrative services contractor to the Centers for Medicare and Medicaid Services, notified Respondent by letter that Respondent’s Medicare billig number and billing privileges were revoked and terminated effective September 21, 2010. The letter is attached hereto and incorporated herein by reference as Exhibit A. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends-to revoke the Respondent’s license to operate a health care clinic. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. Respectfully submitted on this (F day of July, 2012. , Senior Attorney 754536 the-General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: (850) 412-3630 Facsimile: (850) 921-0158 2 NOTICE The Respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, and to be represented by its own counsel or qualified representative. Specific options for the administrative action are set out in the attached Election of Rights form. The Respondent is further notified that if the Election of Rights form is not received by the Agency Clerk’ Office 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 delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3; Tallahassee, FL 32308- 5407; 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 were served to Salvador Villegas, Owner and Registered Agent, 7500 NW 25" Street, Suite 112, Miami, Florida 33134 by U.S. Certified Mail, Return Receipt No. 7011 1570.0000.3003 9595;.Salvador Villegas,.Owner and Registered Agent, 1514 Aqueduct Lane, Key Largo, Florida 33037 by U.S. Certified Mail, Return Receipt No. 7011 1570 0000 3003 9601; Salvador Villegas, Owner and Registered Agent, via electronic mail to salvadorvilgs@gmail.com ; and Juan Manuel Flores, MD, Medical Director, 14455 SW 12" Lane, Miami, Florida 33184 by U.S. Certified Mail, Return Receipt No. 7011 1570 0000 3003 9618 this 14 day of July, 2012. Le Warren J. Bird Warren J. Bird, Esquire Assistant General Counsel Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 (Interoffice) Roger Bell, Unit Manager Licensure Unit Agency for Health Care Administration (Electronic Mail) PAN ai vie CATS, FIRST COAST , (CONTONS kr MRCACARY 9 MOORND Services SERVICE OPTIONS, INC. WHEN EXPERIENCE COUNTS & QUALITY MATTERS : MEDICARE ACMS-Contracted Medicare Administrative Contractor December 27, 2010 Reality Care Services, Inc. TO NW 25" Street Suite 243 Miami, Florida 33122-1720 Provider Transaction Access Number (PTAN)/Provider Identification Number (PIN): 686807 NPI; Dear Really Care Services, ine: We've recently been made aware of information that shows you are not in compliance with the regulations and standards for retaining your Medicare billing privileges, Therefore, your Medicare billing number and billing privileges are being revoked effective September 21, 2010 and you are not eligible to reapply for enrollment in the Medicare program for a period of two years, Your Medicare billing number is being revoked based on the following reason(s): Per Title 42 Code of Federal Regulations Section §424.535(a} Reasons for revocation, CMS may revoke a currently enrolled provider or supplier's Medicare billing privileges and any . corresponding provider agreement or supplier agreement for the following reasons: _—.____—_(5)-On-site-review--GMS-determines, upon: on-site review, thal-the-provider-or-supplier-is-no longer operational to furnish Medicare covered tems or services, or Is not meeting Medicare enrollment requirements under statute or regulation to supervise treatment of, or to provider Medicare: covered Items or services for, Medicare patients. Upon on-site review, CMS determines that - : () A Medicare part A Provider is no jonger operational to furnish Medicare covered items or services, or the provider fails to satisfy any of the Medicare enrollment requirements. Specifically; On May 26, 2010 at 4:35 pm and September 21, 2010 at 9:05 am, First Coast Service Options conducted an unannounced site verification at 7500 NW 25" Street, Suite 243, Miarni, Florida 33422-1720 and found that Reality Care Services, Inc. was not operational at this location. The Suite is now occupied by Dade County Rehab, First Coast Service Options was unable to locate an application to change or update the address. IF YOU DISAGREE WITH OUR DETERMINATION, PLEASE READ THE FOLLOWING: ie) A If you believe that you are able to correct the deficiencies and establish your eligibility to , participate in the Medicare program, you may submit a corrective action plan (CAP) within 30 calendar days after the postmark date of this letter. The CAP should provide evidence that you gre in compliance with Medicare requirements. The reconsideration request must be signed and dated by the Authorized or Delegated Official within the entity. CAP requests should be sent to: 4 . Centers for Medicare & Medicaid Services Division of Provider & Supplier Enrollment 7600 Security Blvd. ; Mailstop: C3-02-16 Baltimore, MD 21244-1850 if you believe that this determination Is not correct, you may request a reconsideration before a contractor hearing officer. The reconsideration is an independent review and will be conducted by a person who was not involved in the initial determination. You must request the reconsideration In writing, to this office within 60 calendar days of the postmark date of this letter. The request forreconsideration. must state the lssues, oF the findings of fact with which you disagree and the reasons for disagreement. You may submit additional inforrration with the reconsideration request that you believe may have a bearing on the decision. The reconsideration request must be signed and dated by the authorized or delegated official within the entity. Failure to timely request a raconsideration is deamed a waiver of all rights to further » administrative review. The request for reconsideration should be sent to: Centers for Medicare & Medicaid Services Division of Provider & Supplier Enrollment 7500 Security Blvd, _ Mallstop: C3-02-16 Baltimore, MD 21244-1850 Vou may-contact our Customer Service-Ares'al-}-866-454-0007 for general questions concerning the appeals process. Sincerely, Marian Love Manager, Provider Enrollment CC: Department of Health and Human Services Sam Nunn Atlanta Federal Center CMS, Region IV Division of Survey and Certification 61 Forsyth Street, SW Suite 4720 Ailanta, Georgia 30303-8909 Attn: Sandra M Pace

Docket for Case No: 13-000791