STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vs. AHCA No. 2013004805 License No. 8941 SW FLORIDA REGIONAL MEDICAL File No. 9467 CENTER, INC., Provider Type: Health Care Clinic Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, SW Florida Regional Medical Center, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate a health care clinic and to impose an administrative fine of $15,300.00. PARTIES 1. The Agency is the regulatory authority responsible for the licensure of health care clinics and the enforcement of all applicable statutes and rules governing health care clinics in Florida. Chs. 408, Part II, and 400, Part X, Florida Statutes; Ch. 59A-33, Fla. Admin. Code. 2. The Respondent was issued a license to operate a health care clinic located at 5580 19" Court SW, Unit #2, Naples, Florida 34116, and was at all times material required to comply with the applicable statutes and rules governing such licensure. COUNT I Notice of Insurance Fraud Display 3. Section 400.9935(9) Florida Statutes, states in pertinent part: 400.9935 Clinic responsibilities. — kok * (9) In addition to the requirements of part II of chapter 408, the clinic shall display a sign in a conspicuous location within the clinic readily visible to all patients indicating that, pursuant to s. 626.9892, the Department of Financial Services may pay rewards of up to $25,000 to persons providing information leading to the arrest and conviction of persons committing crimes investigated by the Division of Insurance Fraud arising from violations of s. 440.105, s. 624.15, s. 626.9541, s. 626.989, or s. 817.234. An authorized employee of the Division of Insurance Fraud may make unannounced inspections of a clinic licensed under this part as necessary to determine whether the clinic is in compliance with this subsection. A licensed clinic shall allow full and complete access to the premises to such authorized employee of the division who makes an inspection to determine compliance with this subsection. 4, On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. 5. Based on observation and confirmed by facility staff, the Respondent failed to sas este, display the itive of insurance fraud nojice in a public area within the clinic. 6. During a tour of the facility on 02/21/2013 at 10:20 a.m., the clinic had co sigh indicating Department of Financial Services may pay rewards of up to $25,000 to persons providing information leading to the arrest and conviction of persons committing crimes investigated by the Division of Insurance Fraud arising from violations. 7. During an interview with office staff on 02/21/2013 at 10:20 am., it was confirmed that there was no notice required by Section 400.9935(9), Florida Statutes. 8. Instead, the office manager showed the surveyor a posting that stated the medical director had no malpractice insurance. 9. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part If of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $100.00 against the Respondent. COUNT I Patient’s Right to Report Complaints, Abuse 10. Section 408.810(5)(a)(b), Florida Statutes, states in pertinent part: 408.810 Minimum licensure requirements. —- In addition to the licensure requirements specified in this part, authorizing statutes, and applicable rules, each applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. (5)(a) On or before the first day services are provided to a client, a licensee must inform the client and his or her immediate family or representative, if appropriate, of the right to report: 1. Complaints. The statewide toll-free telephone number for reporting complaints to the agency must be provided to clients in a manner that is clearly legible and must include the words: “To report a complaint regarding the services you receive, please call toll-free (phone number).” 2, Abusive, neglectful, or exploitative practices. The statewide toll-free telephone number for the central abuse hotline must be provided to clients in a manner that is clearly legible and must include the words: “To report abuse, neglect, or exploitation, please call toll-free (phone number).” 3. Medicaid fraud. An agency-written description of Medicaid fraud and the statewide toll-free telephone number for the central Medicaid fraud hotline must be provided to clients in a manner that is clearly legible and must include the words: “To report suspected Medicaid fraud, please call toll-free (phone number).” The agency shall publish a minimum of a 90-day advance notice of a change in the toll-free telephone numbers. (b) Each licensee shall establish appropriate policies and procedures for providing such notice to clients. 11. On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. seve _ sed on the interview, the Respondent did not oe to inform i es 7 “The tour of the facility on 02/21/2013 at 10:15 a.m. reveal — information about the right to report complaint, abusive, neglectful, or vote wanes ; 14. During an interview with the office staff on 02/21/2013 at 11:00 am., it was confirmed that the Respondent had no documentation that each client was provided with information of the right to report complaints, and/or abuse, neglect and exploitative practices to the statewide toll-free telephone number. 15. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part IT of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for Violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $100.00 against the Respondent. COUNF Ht ~~ Clinic Responsibilities € Sign Identify. Medical Director ae 16. Section 400.9935(1)(a) Florida Statutes states in pertinent part: 400.9935 Clinic responsibilities. — () Fach clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: (a) Have signs identifying the medical director or clinic director posted in a conspicuous location within the clinic readily visible to all patients. 17, On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. 18. Based on observation during the tour of the facility and interview with the facility staff, the Respondent failed tos ir Brepicuow lobation within the clinic readily visible to all patients a sign identifying the medical director. 19. During a tour of the lobby area, there Ce a ei the medical director of the Respondent’s facility. 20, During an interview with the office manager on 2/21/13 at 11:00 am., it was on, revealed that Ske was told by Joint Commission to move the posting of the medical director out ee a ei of the lobby. 21. She stated it was hung in the billing office wall. ee ee 22. The license of the medical director was ot readily visible to all vaina> ~ __ enone 23. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $100.00 against the Respondent. COUNT IV Clinic Responsibilities — Licensed Staff 24. — Section 400.9935(1)(b)(d), Florida Statutes, states in pertinent part: 400.9935 Clinic responsibilities. — (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the foliowing activities on behalf of the clinic. The medical director or the clinic director shall: (b) Ensure that all practitioners providing health care services or supplies to patients maintain a current active and unencumbered’Florida license. (d) Ensure that all health care practitioners at the clinic have active appropriate certification or licensure for the level of care being provided, 25. Rule 59A-33.012(5)@), Florida Administrative Code, states in pertinent part: 59A-33.012 Survey Requirements and Process. (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: (i) Copies of professional licenses issued by the respective boards and the Department of Health under the several practice acts. 26. On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. 27. Based on review of the patient records and confirmed by staff interview, the Respondent’s medical director failed to ensure that an x-ray Py 28. Areview of Patient’ #1 and #4 records had an x-ray that was taken at the facility. ' 29. A review of the list of employees with their title and license did not include an X- ray technician. . 30. During an interview with the office manager on 2/21/13 at 1:00 p.m., it was revealed a new X-ray service started during the month and that a technician took X-rays of Patients #1 and #4 on 2/11/13. 31. The office manager § staiédsthat had worked one day and then did not come back. - 32. The office manager confirmed that she did not have a personnel folder with this employee's license. 33. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNTV Clinic Responsibilities Systematic ans 34, — Section 400.9935(1)(g), Florida Statutés;states-in-pertifient part: 400.9935 Clinic responsibilities. — (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: (g) Conduct systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful. Upon discovery of an unlawful charge, the medical director or clinic director shall take immediate corrective action. If the clinic performs only the technical component of magnetic resonance imaging, static radiographs, computed tomography, or positron emission tomography, and provides the professional interpretation of such services, in a fixed facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the Accreditation Association for Ambulatory Health Care, and the American College of Radiology; and if, in the preceding quarter, the percentage of scans performed by that clinic which was billed to all personal injury protection insurance carriers was less than 15 percent, the chief financial officer of the clinic may, in a written acknowledgment provided to the agency, assume the responsibility for the conduct of the systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful. 35. Florida Administrative Code Rule 59A-33.012(5)(m) states in pertinent part: 59A-33.012 Survey Requirements and Process. (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: (m) Description of means by which the health care clinic conducts a systematic review of billings that ensures billings are not fraudulent or unlawful. A sample must be reviewed by the medical director or clinic director at least once every 30 days and a record maintained by the health care clinic for at least three years identifying the records reviewed and when and what action was taken to correct fraudulent or unlawful billings. A log of systematic reviews shall be kept and maintained in a discrete file at the health care clinic for review on request of the Agency during the retention period. (b) Ensure that all practitioners providing health care services or supplies to patients maintain a current active and unencumbered Florida license. (c) Review any patient referral contracts or agreements executed by the clinic. (d) Ensure that all health care practitioners at the clinic have active appropriate certification or licensure for the level of care being provided. (e) Serve as the clinic records owner as defined in s. 456,057, (f) Ensure compliance with the recordkeeping, office surgery, and adverse incident reporting requirements of chapter 456, the respective practice acts, and rules adopted under this part and part II of chapter 408. (g) Conduct systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful. Upon discovery of an unlawful charge, the medical director or clinic director shall take immediate corrective action. If the clinic performs only the technical component of magnetic resonance imaging, static radiographs, computed tomography, or positron emission tomography, and provides the professional interpretation of such services, in a fixed facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the Accreditation Association for Ambulatory Health Care, and the American College of Radiology; and if, in the preceding quarter, the percentage of scans performed by that clinic which was billed to ali personal injury protection insurance carriers was less than 15 percent, the chief financial officer of the clinic may, in a written acknowledgment provided to the agency, assume the responsibility for the conduct of the systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful. 43. Rule 59A-33.012(5)(q), Florida Administrative Code, states in pertinent part: 59A-33.012 Survey Requirements and Process. (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: (q) An all-inclusive and up to date listing of original signatures and initials of all persons entering information on billing and patient records, the printed name and medical designation, if any, such as PA, RN, MD, etc. The log shall be kept and concurrently maintained at the health care clinic. Information required by this rule shall be stored and maintained by the health care clinic for a period of 5 years. 44. On 02/21/2013, the Agency conducted a license renewal survey of the Respondent’s facility. 45. Based upon interview with the Respondent’s office manager, it was revealed that the Respondent did not have an all ifclusive list of original signatures and initials of all persons entering information on billing and patitnt records since the clinic opshed ee een 36. On 02/21/2013, the Agency conducted a license renewal survey of the Respondent's facility. 37. Based upon interview, the Respondent’s office manager failed to provide a log of a systematic review of clinic billings completed by the medical director to ensure that the billings are not fraudulent or unlawful. 38. During an interview with the office manager on 02/21/2013 at 1:00 p.m., it was revealed eee she was unaware of any system of how the medical director conduct) reviews of billings to verify ; rots thunaewe in aneeareity atte Ahern nnRent tay appropriate charges. Ot ae a nmap netienee 39. The office manager stated this is the third medical director since the facility was opened. 40. She stated she has been working on the job since August 2012 and was unaware of any system whereby the medical director or anyone else would review the insurance billings to ensure they are not fraudulent or unlawful. 41. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT VI Clinic Responsibilities ~ Record Sign Off 42. — Section 400.9935(1)(a)-(g) Florida Statutes, states: 400.9935 Clinic responsibilities. — (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: (a) Have signs identifying the medical director or clinic director posted in a conspicuous location within the clinic readily visible to all patients, 46. During an interview with the office manager on 02/21/2013 at 1:45 p.m., it was further revealed that she had no log or list of original signatures and initials of all persons entering information on billing and patient records. 47. The office manager further stated that she had started in 08/2012 and that the prior manager did not leave behind any log of original signatures and initials of all persons who documented in patient records and on billings. 48. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT Vil License Revocation 49. The Agency re-alleges and incorporates by reference Counts I through VI as set forth above. 50. Pursuant to Section 408.815(1)(c)-(d), Florida Statutes, 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 actions by a controlling interest: .... (c) A violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. 51. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations 10 of the requirements of this part or rules of the Agency. 52. The Respondent’s actions or inactions constituted a violation of this part, authorizing statutes, or applicable rules. 53. The Respondent’s actions constituted a demonstrated pattern of deficient performance. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to revoke the Respondent’s license to operate this facility. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: lL. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. Respectfully submitted on this / day of June, 2013. Deborah Leoci, Senior Attortey Florida Bar No. 814423 Office of the General Counsel Agency for Health Care Administration 2295 Victoria Avenue, Third Floor Ft. Myers, Florida 33901 Telephone: (239) 335-1251 Facsimile: (239) 338-2699 11 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 THEREBY CERTIFY that a true and correct copy of the foregoing has been served to the below named persons or entities on this the y, day of June, 2013. hah Moe Deb Leoci, Senior Attorney Florida Bar No, 814423 Office of the General Counsel Agency for Health Care Administration 2295 Victoria Avenue, Third Floor Ft. Myers, Florida 33901 Telephone: (239) 335-1251 Facsimile: (239) 338-2699 t Rafael Madan, Sr. Thomas Jones, Unit Manager President/Registered Agent Health Care Clinic Unit SW Florida Regional Medical Center, Inc. Agency for Health Care Administration 5580 19" St. SW, Unit 2 (Electronic Mail) Naples, Florida 34116 (Certified Mail (7011 1570 0002 1694 8726) -I -- pate ' DEFICIENCY) LC9467 AME. OF PROVIDER: OR SUPPLIER 02/24/2043 SW FLORIDA REGIONAL MEDICAL CENTER Ih U 160] Continued From page 2 U 160 to clients, Based on interview, the facility did not have a system to inform clients of the right to report complaints, abusive, neglectful, or exploitation practices, This Statute or Rule is not met as evidenced by: | The findings include: The tour of the facility on 2/21/13 at 10:15 am. : fevealed no posting of information about the right to raport complaint, abusive, neglectful, or ; ©xploitation practices, “ Interview with the office staff on 2/21/13 at 11:00 @.m. confirmed the facility had no documentation that each client was provided with information of the right to report complaints, abuse, neglect and j exploitation to the statewide toll-free telephone. | U 306, 400,9935(1)(a), F.S. Clinic Responsibiliies-Sign | U306 {U306} | 3/5/13 | Identify Med Dir Refer to response on 400.9935(1)(a), F.S. The medical director or the clinic director shall have signs identifying the medical director or | clinic director posted in a conspicuous tocation \ within the clinic readily visible to all patients. | AHCA Form 3020-0007 STATE FORM anne page 4, 4OLN11 Meontinuation sheet 3 of 8 FROM ® MAR 5S 2013 13:5675T.13:53/No. FSSe561915 p é ” PRINTED: 03/0 if Agency for Health Care,Ad STATEMENT OF DEFICIENCIES - AND PLAN OF CORRECTION inistration 4X4) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: {X2) MULTIPLE GONSTRUCTION A. BUILDING: (%3) DATE SURVEY COMPLETED . | B WING STREET ADDRESS, CITY, STATE, ZIP CODE 5580 19TH CT SW UNIT #2 ; neon NAPLES, FL 34916 : no 7 we LC9467 02/21/2013 NAME.OF PROVIDER OR SUPPLIER — SW FLORIDA REGIONAL MEDICAL CENTER Ih (X4}10 | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S-PLAN OF CORRECTION {X5) PREFIX (EACK DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE . } COMPLETE } TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG | CROSS-REFERENCEO TO THE APPROPRIATE tol DATE DEFICIENCY) } U 335: Continued From page 5 ! by the Joint Commission on Accreditation of Healthcare Organizations or the Accreditation (U835 continuation) ~ 3/5/2013 Association for Ambulatory Health Care, and the : : ; . American College of Radiology; and if, in the Our Medical Records has - “| praceding quarter; the percentage of scans vote ‘| performed by that-clinic which was billed to all oom Implemented a Bi-Morithiy personal injury protection insurance carriers was less than 15 percent, the chief financial Officer of Systematic billing review i the clinic may, in a written acknowledgment : provided to the agency, assume the responsibility i for the conduct of the systematic reviews of clinic ! billings to ensure that the billings are not That is documented by | i fraudulent or unlawful, Our Medical record and i 59A-33,012(5)(m), FAG. Kept in our billing review The health care clinic shall have a description of , . . { | Means by which the health care clinic conducts a Log. Our policies and | i systematic review of billings that ensures billings | @re not fraudulent or unlawful. A sample must be Procedures were updated : | reviewed by the medical director oF clinic director i at least once every 30 days and a record For compliance and we do maintained by the health care clinic for at least three years identifying the records reviewed and when and what action was taken to correct | fraudulent or unlawful billings. A log of systematic at our facitit reviews shall be kept and maintained in a ty. ! discrete file at the health care clinic for review on request of the Agency during the retention period. Not provide MRI services Our Medical Director is reviewing ten patient i | ; billing charts per month on our systematic billing teview form which provides ia. . , itiple of record : | This Statute or Rule is not met as evidenced by: TPUMlple areas of F ; Based on interview , the facility office manager ! . " review, including billin i failed to provide a log of a systematic review of evlew, Including billing i AFCA Form 3050-0001 review for five patient STATE FORM enee 1OLN11 vontinualion sheet 6 of 8 charts at once. The information collected FROM Agency for Health Care Administration STATEMENT OF DEFICIENCIES Oa) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION “fee SADENTIFIGATION. NUMBER: LC9467 STREET NAME OF PROVIDER OR SUPPLIER SW FLORIDA REGIONAL MEDICAL CENTER !h A BUILDING: "ADORESS, CITY, STATE, ZIP CODE 8680 19TH CT SW UNIT #2 NAPLES, FL 34146 trons voiapinima men CTUE)MAR SS 2O1S 18:56/ST. 13:53/No. TSasss1s1s5 p 10 PRINTED: 03/05/201 FORM APPROVE! "| (K8) CATE. SURVEY (X2) MULTIPLE CONSTRUCTION E :. COMPLETED B.WING 02/21/2013 U cxayio | SUMMARY STATEMENT Of DEFICIENCIES w PROVIDER'S PLAN OF CORRECTION ) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL > PREFIX (BACH CORRECTIVE ACTION’ SHOULD BE ST COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) Tao! CROSS-REFERENCED TO THE APPROPRIATE ~:~ | DATE ' DEFICIENCY) U335| Continued From page 6 335 ‘on our systematic ; | clinic billings completed by the medical director to billing review forms ensure that the billings are not fraudulent or ve bitte yeey ~ untawful. will be kept in our Billing The findings include: Review log'and all forms Interview.with.the office. manager. on.2/21/13 at are-signed by our Medical 4:00.p.m. revealed she was unaware of any system of how the medical director conducts Director along with any reviews of billings to verify appropriate charges. . noted recommendations The office manager stated this is the third medical director since the facility was opened. (if any noted) and kept : She stated she has been doing the job since : i August 2012 and is unaware of any system in our Administrators office. whereby the medical director or any one else : ; reviews the insurance billings to ensure they are 13/5/2013 not fraudulent or unlawiul. (¥340) 1 3/5/ i i 1 Pi - 340] 59A-33.012(5)(q), F.A.C. Clinic u 340 er S9A-33.012(5)(Q) esponsibilities-R i Responsibilities-Record Sign Off We have established a 59A-33.012(5)(q), F.A.C. a : The health care clinic shall have an all-inclusive Responsibilities sign-off j | and up to date listing of original signatures and \ initials of all persons entering information on for records. Ail original : | billing and patient records, the printed name and 1 medical designation, if any, such as PA, RN, MD, Signatures, and initials | etc. The log shall be kept and concurrently ‘ j | maintained at the health care clinic. Information | required by this rule shall be stored and | maintained by the health care clinic for a period of 5 years. And titles of all persons 1 entering information on. Our policies and procedures Have been updated for i | This Statute or Rule is not met as evidenced by: AHCA Form 3020-0001 STATE FORM compliance. e500 YOLN11 Wf continuation shast 7 6 PRINTED: 03/05/2043 FORM APPROVED From d. I x % B I UeUS 8 PSSUMNOSH ele UiiG} OOS) Ul DAG SompaoOIT IV =z re 7 Rlsose fedipsui BU} Ul UudsIad Saunpeso:d peresipuy ueRSAUG *¢ | NNSA WNINTA VNINTA WNINTA Zs & INSEL¥e | ENGL ; ~ MBAS ONIT IE SNES ___ Gt Z30NVNNSS B vier pOLOSUG WoIdsK | e422 CL PIP fy ‘BVEA/HINOW | “ON "MSLNZO TVOIGSN TWNOIDSN vaRio 4 aS MSIASY SNITHE DILVNALSAS 4 ay 4) PLO A REGIONAL GY) MEDICAL CENTER T, 239,304.2471 F, _ dh, | 9 [AG 5580.19" CT SW UNIT 2, NAPLES, FL. 34216 FAX COVER SHEET TO: MARILYN STEINER DATE: 02/28/2013 FROM: AYLEEN time: A £OOAAA » # OF PAGES (included cover sheet) FAX NUMBER SENDING TO: 239-338-2372 Re: o Please: __ Review attached and call “oer your request ___For your information Comments: Confidentiality: If you have received this fax in error, please call the number above. This fax was intended for the person (s) named above and all information (including any attachments) is strictly confidential and not to be read, talked about, or passed on to anyone except the intended recipient. i men si s Pe Salata! ne Mant Ga PURSUANT TO s. 626.9892, Florida Statutes, the Department of | Financial Services may pay rewards of up to $25,000 to persons providing information leading to the arrest and conviction of persons committing crimes investigated by the Division of Insurance Fraud arising from violations of s. 624.15, s. 626.9541, 8. 626.989, or s. 817.234, Florida Statutes, 8. Medical Director , MEDICAL OR.CLINIC DIRECTOR ee tee ee Re oe ee : ee oe [7] Medical Director Name (as it appears on the Florida Dept. of Health license) | Fi. Dept. of Health License # Effective Begin Date as Director [-] Ctinic Director Homes Address (Street, Cily, State, Zp Code) — Home Telephone (include area code) Business Address (Street, City, State, Zip) Business Telephone (include area code) Does the Medical or Clinic Director also provide health care services at the clinics? Hours & Days Present at Clinic: Status: . Employee yes (1 nog (1 Contracted LIST OF LICENSED HEALTH CARE CLINICS AEDICAL/CLINIC DIRECTOR (attach additional sheets if necessary) cba , é LER CaeaE Hat Pee oe Name of Clinic Ys ip) HCC License # Ay devioriad MOM CByfes. Kes jealuth Borie, heslials Pe 330/0| 6690 MeEbiebsEeiices Cente = lontia | 2¢10 laut Pjpy fer sulld BO! ash C | PBZ, ZAYED ecs, (MéiMopeling “WO pAwants. ) 77$o W'TOS? seule 208 feat Ba0K8 WMEDICAT CENTER. Vf ght my ~~ 3 Op Fotlad Mee glintiel Mtiltthl| SE8O sw GOP wmf 2 Center | fez 4 As the Medical or Clinic Director | agree, in writing, to accept legal responsibility for the activities on behalf of the clinic, as specified in Section 400.9935, F. S. - Clinic Responsibilities. £98 Date Signature of Medical or Clini A copy of the Medical Director's contract or agreement with the Clinic, including the Director's effective date of service, must be included with the application NOTE: The clinic must notify AHCA, in writing, within 21 days of change/termination of medical or clinic director oe Nees momanmncemaiitcntnnaert ro ttn nema rnin cement chim ets eenentenn lteter ceeree AHCA Recommended Form 31 10-0013, July 2012 Section 59A-35.060(1), Florida Administrative Code Page 10 of 13 Form available at: hito://ahca.myflorida. com/Publications/Forms/HOA. shtml 66/21/2813 83:56 2397936998 LAWOFF ICEOF JOSELLAGO PAGE 94/a6 - REGIONAL MEDICAL, CENTER, INC: S580 19" COURT Sw UNITH2 NAPLES, FLORIDA 34116 BILLING REVIEW (e be done aie per mont) MONTH: hall od A a CE trey re Perel ee ra ’ - ’ : 1 2. - . * 1B A B® a A . . . 3. oo eae al ant - en neem een ee Lc “, "me, f? 4. . A ce oe a ; ae oe. RB, Le ne . ea ine NN A AO nt A NA rer tetera at tien, of, 4. a / Qe Co ue t “Le =e A ett nti reehes, Teonducl fed a cdaspitensiic review of clings billing to ensure that the billings axe not fraudulent or wnlawfal: AND _Thave nat discovered any unlawfal changes; OR iL have discovered and wetewtul charge and took the following immediate corrective action: wm Bt Ciinic director aame (prin OOV TISSOL 0391.5 4OMe 7 GEE9EBZ6EZ = BG ZZ ETZ/AZ/9B ~G3AIZOAY 06/21/2613 @3:56 2397936998 LAWOFF ICEOF JOSELLAGO PAGE @5/96 . _ SW ELORIDA REGIONAL MEDICAL CENTER, INC... cosh “5580 19" COURT SW UNITH2 : NAPLES, FLORIDA 34116 ACTION TAKEN (TO BE DONE ONE PER MONTH) AR ve EO ore v x wamaalll Cscsbesee gig ECO oof a 4 Leen 8 we] 2. 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DAI heslthnare practitionnry at the chic torre aviive appropetete ovrtifiention or Ueewsure for the level of care boleg provided. . Mave conducted rystomatic reviews of cate Ratings ty vonere that bitisps are not fraadnlont or uolewiet Or Rave wpon discovery of wabnwtel change, taba livatndhete corrsetive netdett FE. Baye vaviewsd ite are: To compttanct with renire aicd aubvernn incident reparig rqutntaensy, rrpastne Pranan hea od le nore tea " @, Randomly reviewed tilling pation shart cheeltis to soaure thee pravistow of adequeto if aud Sei aii atch mene ie utr ret aor WL Randomly roviinnsd cHsicad deenmnterivtion sock ag lukial evalustion, (roetment play reviews, Aid broprats notes to ssore conipliance, BP Beco ak CTode Dyontor Nieme (Printed) Nake Date oSsvTss0P 40491 440M01 QBBSE6LGEZ © 8G'2% E107/87/98 aATIOBY 5/21/2013 83:56 2397936998 LAWOFF LCEOF JOSELLAGO PAGE @1/a6 SW FLORIDA REGIONAL MEDICAL CENTER; INC, © 5580 19™ COURT SW UNITH2 NAPLES, FLORIDA 34116 BILLING REVIEW (Ho be done nov per month) MONTR: Atlant. . nn . Terral Brows L, pee We \~ 1% al 2. _ ; Meyer 5: . ; . 1 ; Ment = \ Se hayes -- bye bey ee (Cpe 2 et z systematic review of clinic billing to ensure that the 28 are Rot fraudulent or oolawfuk AND YX have not ditcovered any unlawful charges; OR Lhave discovered and unlawful charge and took the following immediate corrective agtion: chavi c, vite “a re viewed commants; "te Oov TSSOP 403591 4JOMV] QBESEGL6EZ 8g'2% ETeZ/ez/9a AaALZOga 5/21/2013 63:56 2397936398 LAWOFF ICEOF JOSELLAGU PAGE 2/@b SW FLORIDA REGIONAL MEDIGAS CENTER INC... 5580 19"* COURT SW UNITW2 NAPLES, FLORIDA 34116 ACTION TAKEN (TO BE DONE ONE PER MONTH) De ME te OL fond OV <¢ ~- SL per apt Med. Vilere, (fle. ORL EN en ffm fF} to Slinke director nente (printed) ” Clinic Gov MSSOP S051 340M0 BbE9CE46EZ BS:2% CTH2/O%/90 CTAALIOAY Wib/21/2813 43; ob 23979369968 LAWUFF LGEUF JUSELLAGU CALE SW FLORTDA REGIONAL MEDICAL CENTER, INC. 5880 19 COURT SW ONITH2 -NAPLES, FLORIDA 3411 CLINICAL/MEDICAL DIRECTOR OVERSIGHT LOG. (40 BE DONE ONE PRR MONTH) Mates (at Sole . Rempoacebitities A. Fina the meittal dineetor oF atinte dinechor posted in x obimapteaows ticntfow within the etinte xendily o all patients. B. AT health cone practitioners wf sinin Robe a conrent active sued puedet camcbeyed Ploxide Morase C. Have woviiired oll clings patient comtrecty/agroonsecte sud determalmed (he complionde with carrent Mw. DD. AS degatincare practisipayns at the oftaae re active approtibete ony einen tion or Heomsmre for tire loved oR taire hela provided, Have cnaducted npstenantic rettrint af exrady Aitthees to nesetnie thet btitheps dive wnt fretcrtulent of nikewiit ockate upon dieavery of emiqwinl change, tale bandrodinte terrective action, F, Mavereviewed if} Forreetly tn eomphance wf rover hace ta diverse Enehtent. reportieg rojulrenioats tempeive Keptetiye Praciies Ants amd rules aopted théry abet & Randoatly reviewed charts tot poticrt hare chet fo steare ths proriian of eqwnte: ted Meceeamry prrelbotherapy omrriots att teepreting ctiebral dopuattenetion. . 3S Reatonily reviewed etal dotam notation sci wx (niztal evaloation, trewimant piae reviews, aual progress mites to avsare cémplanee, Com montis Section. gE #8 8 8 8 8 DOoco 8b OF Q OSV TISOr s0FO140Me BEESCbLEEZ 86:22 €102/02/90 MS3AIS0RY [he fF Beta 03/86 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, , vs, AHCA No. 2013004805 License No, 8941 SW FLORIDA REGIONAL MEDICAL, ; File No, 9467 CENTER, INC., Provider Type: Health Care Clinic Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency” , by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, SW Florida Regional Medical Center, Ihe. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: | NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate a health care clinic and to ‘impose an administrative fine of $15,300.00. PARTIES 1. The Agency is the regulatory authority responsible for the licensure of health care clinics and the enforcement of all applicable statutes and rules governing health care clinics in Florida, Chs, 408, Part II, and 400, Part X, Florida Statutes; Ch. 59A-33, Fla. Admin. Code, 2. The Respondent was issued a license to operate a health cate clinic located at 5580 19" Court SW, Unit #2, Naples, Florida 34116, and was at all times material required to comply with the applicable statutes and rules governing such licensure. wemensaae tid COUNTI Notice of Insurance Fraud Display 3, Section 400.9935(9) Florida Statutes, states.in pertinent part; 400.9935 Clinic responsibilities. — ke * (9) In addition to the requirements of part Il of chapter 408, the clinic shall © display a sign in a conspicuous location within the clinic readily visible to all patients indicating that, pursuant to s. 626.9892, the Department of Financial Services may pay rewards of up to $25,000 to persons providing information leading to the arrest and conviction of persons committing crimes investigated by the Division of Insurance Fraud arising from violations of s. 440.105, s. 624.15, s. 626.9541, s. 626.989, or s. 817.234. An authorized employee of the Division of Insurance Fraud may make unannounced inspections of a clinic licensed under this part as necessary to determine whether the clinic is in compliance with this subsection. A licensed clinic shall allow full and complete access to the premises to such authorized employee of the division who makes an inspection to determine compliance with this subsection. 4, On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. 5, Based on observation and conte by facility staff, the “Respondent failed to display the notice of insurance fraud notice in a public area within the clinic. 6. During a tour of the facility on 02/21/2013 at 10:20 am. the clinic had no sign indicating Department of Financial Services may pay rewards of up to $25,000 to persons providing information leading ‘to the arrest and conviction of persons committing crimes investigated by the Division of Insurance Fraud arising from violations. 7, During an interview with office staff on 02/21/2013 at 10:20 am., it was confirmed that there was no notice required by Section 400.9935(9), Florida Statutes. 8. Instead, the office manager showed the surveyor a posting that stated the medical director had no > malpractice insurance. ) . 9 Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part I of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administeative fines of up to $5,000 per violation for violations SB pO ly ves of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $100.00 against the Respondent. COUNT Patient’s Right to Report Complaints, Abuse 4 , 10, Section 408.810(5)(a)(b), Florida Statutes, states in pertinent part: q _ 408.810 Minimum licensure requirements. —- In addition to the licensure i requitements specified in this part, authorizing statutes, and applicable rules, each , applicant and licensee must comply with the requirements of this section in order to obtain and maintain a license. : * OR (5)(a) On or before the first day services are provided to a client, a licensee must inform the client and his or her immediate family or representative, if appropriate, of the right to réport: ; 1. Complaints. The statewide toll-free telephone number for reporting complaints to the agency must be provided to clients in a manner that is clearly legible and must include the words: “To report a complaint regarding the services you receive, please call toll-free (phone number).” 2, Abusive, neglectful, or exploitative practices. The statewide toll-free telephone J number for the central abuse hotline must be provided to clients in a manner that i is clearly legible and must include the words: “To report abuse, neglect, or exploitation, please call toll-free (phone number).” | 3. Medicaid fraud. An agency-written description of Medicaid fraud and the 1 statewide toll-free telephone number for the central Medicaid fraud hotline must be provided to clients in a manner that is clearly legible and must include the words: “To report suspected Medicaid fraud, please call toll-free (phone number).” The agency shall publish a minimum of a 90-day advance notice of a change in the toll-free telephone numbers. . i (b) Each licensee shall establish appropriate policies and procedures for ; providing such notice to clients. a Il. On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. re reas ae an CE a ee TS 12. Based on the interview, the Respondent did not have a system to inform clients of the right to report comiplaints, or abusive, neglectful or exploitative practices. 13, The tour of the facility on. 02/21/2013 at 10:15 am. tévealéd ‘no posting’ of information about the right to report complaint, abusive, neglectful, or exploitation practices. 14. During an interview with the office staff on 02/21/2013 at 11:00 am., it was confirmed that the Respondent had no documentation that each client was provided with information of the right to report complaints, and/or abuse, neglect and exploitative practices to ‘the statewide toll-free telephone number. 15. Pursuant to Section 400.995(1), Florida Statutes, in addition io the requirements of Part Il of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $100.00 against the Respondent. COUNT It Clinic Responsibilities — Sign Identify Medical Director 16. Section 400,9935(1)(a) Florida Statutes states in pertinent part: 400.9935 Clinic responsibilities, — (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: _ (a) Have signs identifying the medical director or clinic director posted in a conspicuous location within the clinic readily visible to all patients. 17. On 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. 18. Based on observation during the tour of the facility and interview with the facility poten Staats ect delete ae tue staff, the Respondent failed.to post in a conspicuous location within the clinic readily visible to all patients a sign identifying the medical director. 19. During a tour of the lobby area, there was no posting identifying the medicals.) 0-5 director of the Respondent's facility. 20. During an interview with the office managet on 9/21/13 at 11:00 am., it was revealed that she was told by Joint Commission to move. the posting of the medical director out . of ‘the lobby. 21. She stated it was hung in the billing office wall. 22, . The license of the medical director was not readily visible to all patients 23. Pursuant to Section 400,995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this patt or rules of the Agency. | WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $100.00 against the Respondent. COUNTIV Clinic Responsibilities — Licensed Staff 24, — Section 400.9935(1)(b)(d), Florida Statutes, states in pertinent part: 400.9935. Clinic responsibilities. — ; (1) Each clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: (b) Ensure that all practitioners providing health care services or supplies to patients maintain a current active and unencumbered Florida license. (d) Ensure that all health care practitioners at the clinic have active appropriate: certification or licensure for the level of care being provided, 25. Rule 59A-33.012(5)(j), Florida Administrative Code, states in pertinent part: 59A-33.012 Survey Requirements and Process. (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: G)' Copies of professional licenses issued by the respective boards and ‘the Department of Health under the several practice acts. 26. On: 02/21/2013, the Agency conducted a licensure renewal survey of the Respondent’s facility. | 27. Based on.teview of thé patient records and confirmed by. staff interview, the Respondent's medical director failed to ensure that an x-1ay technician providing service had a current Florida license on file. . 28, Areview of Patient's #1 and #4 records had an x-ray that was taken at the facility. 29. A review of the list of employees with their title and license did not include an X- ray technician. 30. During an interview with the office manager on 2/21/13 at 1:00 p.m., it was revealed a new X-ray service started during the month and that a technician took X-rays of Patients #1 and #4 on 2/11/13. 31. ° The office manager stated that he had worked one day and then did not come back, 32. The office manager confirmed that she did not have a personnel folder with this employee's license. 33. Pursuant to Section 400,995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations cof the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNTY ; Clinic Responsibilities — Systematic Bill Review 34, Section 400.9935(1)(g), Florida Statutes, states in pertinent part: 400.9935 Clinic responsibilities. — (1) Each clinic shall appoint a medical director or clinic director who shall agree 1 in writing to accept legal responsibility for the following activities on behalf of ] the clinic. The medical director or the clinic director shall: ue | (g) Conduct systematic reviews of clinic billings to ensure that the billings are not fraudulent ot unlawful. Upon discovery of an unlawful charge, the medical | director or clinic director shall take immediate corrective action. If the clinic | performs only the technical component of magnetic resonance imaging, static radiographs, ‘computed tomography, or positron emission tomography, and provides the professional interpretation of such services, in a fixed facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the Acoreditation Association for Ambulatory Health Care, and the American - College of Radiology; and if, in the preceding quarter, the percentage of scans | performed by that clinic which was billed to all personal injury protection ; insurance carriers was less than 15 percent, the chief financial officer of the clinic may, in. a written acknowledgment provided to the agency, assume the responsibility for the conduct of the systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful. te cet 35, Florida Administrative Code Rule 59A-33.012(5)(m) states in pertinent part: 59A-33.012 Survey Requirements and Process. 3 (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: (m) Description of means by which the health care clinic conducts a systematic review of billings that ensures billings are not fraudulent or unlawful. A sample must be reviewed by the medical director or clinic director at least once every 30 days and a record maintained by the health care clinic for at least three years identifying the records teviewed and when and what action was taken to correct fraudulent or unlawful billings. A log of systematic reviews shall be kept and maintained in a discrete file at the health care clinic for review on request of the Agency during the retention period. seats diet athe (b) Ensure that all practitioners providing health care services or supplies to patients maintain a current active and unencumbered Florida license. (c) Review any patient referral contracts or agreements executed by the clinic. (d) Ensure that all health care practitioners at the clinic have active appropriate certification or licensure for the level of care being provided. _ (e) Serve as the clinic records owner as defined in s, 456.057. (f) Ensure compliance with the recordkeeping, office surgery, and adverse incident reporting requirements of chapter 456, the respective practice acts, and tules adopted under this part and part II of chapter 408. (g) Conduct systematic reviews of clinic billings to ensure that the billings are not fraudulent or unlawful, Upon discovery of an unlawful charge, the medical director or clinic director shall take immediate corrective action. . If the clinic performs only the technical component of magnetic resonance imaging, static tadiographs, computed tomography, or positron emission tomography, and provides the professional interpretation of such services, in a fixed facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the Accreditation Association for Ambulatory Health Care, and the American College of Radiology; and if, in the preceding quarter, the percentage of scans performed by that clinic which was billed to all personal injury protection insurance carriers was less than 15 percent, the chief financial officer of the clinic may, in.a written acknowledgment provided to the agency, assume the tesponsibility for the conduct of the systematic reviews of clinic billings to ensure r ; that the billings are not fraudulent or unlawful. 4 ; 43. Rule 59A-33.012(5)(q), Florida Administrative Code, states in pertinent part: 59A-33.012 Survey Requirements and Process. (5) To facilitate a licensure survey, the health care clinic shall have the following materials readily available for review at the time of the survey: (q) An all-inclusive and up to date listing of original signatures and initials of all persons entering information on billing and patient records, the printed name and : medical designation, if any, such as PA, RN, MD, etc. The log shall be kept and “} concurrently maintained at the health care clinic. Information required by this rule - shall be stored and maintained by the health care clinic for a period of 5 years, 44. On 02/21/2013, the Agency conducted a license renewal survey of the Respondent’s facility. 45. Based upon interview with the Respondent's office manager, it was revealed that the Respondent did not have-an all inclusive list of original signatures and initials of all persons entering information on billing and patient records since the clinic opened. a ee eens 36. On 02/21/2013, the Agency conducted a license renewal survey of the Respondent’s facility. 37. Based upon interview, the Respondent's office managet failed to provide a log of a systematic review of clinic billings completed by the medical director to ensure that the billings are not fraudulent or unlawful. ” 38. During an interview with the office manager on 02/21/2013 at 1:00 p.m., it was revealed , she was unaware of any system of how the medical director conducts reviews of billings to verify appropriate charges, 39, The office manager stated this is the third medical director since the facility was opened. 40. She stated she has been working on the job since August 2012 and was unaware of any system whereby the medical director or anyone else would review the insurance billings to ensure they are not fraudulent or unlawful. 41. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part Il of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT VI . Clinic Responsibilities - Record Sign Off 42, Section 400.9935(1)(a)-(g) Florida Statutes, states: 400.9935 Clinic responsibilities. —- (1) Bach clinic shall appoint a medical director or clinic director who shall agree in writing to accept legal responsibility for the following activities on behalf of the clinic. The medical director or the clinic director shall: (a) Have signs identifying the medical director or clinic director posted in a conspicuois location within the clinic readily visible to all patients. eatin nt talenninieed mainstem 46. During an interview with the office. manager on 02/21/2013 at 1:45 p.m., it was further revealed that she had no log or list of original signatures and initials of all persons entering information on billing and patient records, | _ 47, The office manager further stated that she had started in 08/2012 and that the prior manager did not leave behind any log of original signatures and initials of all persons who documented in patient records and on billings, 48, Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part II of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations of the requirements of this part or rules of the Agency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT VII License Revocation ; 49. The Agency re-alleges and incorporates by reference Counts I through VI as set forth above. ) 50. Pursuant to Section 408.815(1)(c)-(d), Florida Statutes, 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 actions by a controlling interest: .... (c) A violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. . 51. Pursuant to Section 400.995(1), Florida Statutes, in addition to the requirements of Part Ii of Chapter 408, the Agency may deny the application for a license renewal, revoke and suspend the license, and impose administrative fines of up to $5,000 per violation for violations sotte Sloe STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: SW Florida Regional Medical Center, Inc. AHCA No, 2013004805 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached proposed agency -action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you ‘will have waived your right to contest the proposed, agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your répresentative prefer to reply according to Chapter 120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF VES) 2 OE SIND LEASE SELECT ONLY 1 OF THESE 3 OPTIONS ‘OPTION ONE (1) 1 admit to the allegations of facts and law contained in the Notice of Intent to Impose a. Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order ‘will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that ‘the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. fepeppom ao tee i ee eee PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing, You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this -proposed agency action, ‘The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: - 1. The name, address, telephone number, and facsimile number (if any) of the Respondent, 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. . 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. : 4. A statement of when the respondent received-notice of the administrative complaint. 5, A statement including the file namber to the administrative complaint. © Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency , agrees. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (Optional) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. ; Signed: Date: Print Name: Title: 14 Re ee arc SS EEL DED i rar Deanne sie ices ese eh det che L

Docket for Case No: 13-002449

Issue Date	Proceedings
Dec. 02, 2013	Settlement Agreement filed.
Dec. 02, 2013	Agency Final Order filed.
Oct. 02, 2013	Order Closing File and Relinquishing Jurisdiction. CASE CLOSED.
Oct. 02, 2013	Motion to Relinquish Jurisdiction to the Agency filed.
Sep. 04, 2013	Notice of Unavailability filed.
Aug. 13, 2013	Order Granting Continuance and Re-scheduling Hearing (hearing set for October 16 and 17, 2013; 9:00 a.m.; Naples, FL).
Aug. 09, 2013	Motion for Continuance filed.
Jul. 12, 2013	Notice of Hearing (hearing set for August 27 and 28, 2013; 9:00 a.m.; Naples, FL).
Jul. 12, 2013	Notice of Filing Respondent's Response to Petitioner's First Set of Request for Admissions filed.
Jul. 12, 2013	Notice of Filing Respondent's Response to Petitioner's First Set of Interrogatories filed.
Jul. 11, 2013	Order of Pre-hearing Instructions.
Jul. 10, 2013	Joint Response to Initial Order filed.
Jul. 03, 2013	Notice of Service of Petitioner's First set of Request for Admissions, First Set of Interrogatories and Request for Production of Documents filed.
Jul. 03, 2013	Initial Order.
Jul. 02, 2013	Administrative Complaint filed.
Jul. 02, 2013	Respondent's Petition for a Formal Administrative Hearing Pursuant to Section 120.57(1), Florida Statutes filed.
Jul. 02, 2013	Election of Rights filed.
Jul. 02, 2013	Notice (of Agency referral) filed.

Orders for Case No: 13-002449

Issue Date	Document	Summary
Nov. 27, 2013	Agency Final Order