STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, ‘ AHCA Nos. 2013011394 2014005321 SEBRING HOSPITAL MANAGEMENT ; File No. 100049 ASSOCIATES, LLC, d/b/a HIGHLANDS : License No. 4321 REGIONAL MEDICAL CENTER, Provider Type: Hospital Respondent. . ee 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, Sebring Hospital Management Associates, LLC, d/b/a Highlands Regional Medical Center (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2013), and alleges as follows: NAT THE ACTION This is an action to modify the Respondent’s hospital license to delete its Level 1 adult cardiovascular services program based upon its failure to have in effect a formalized, written transfer agreement with a hospital that has a Level II adult cardiovascular services program, including written transport protocols, to ensure the safe and efficient transfer of a patient within 60 minutes. In addition, this is an action to impose a $2,000.00 administrative fine against the Respondent based upon a deficiency related to emergency room care and services. PARTIES 1, The Agency is the licensing and regulatory authority that oversees hospitals in the @ @ ) oY state of Florida and enforces the state statutes and rules that govern such facilities. Chs. 395, Part I, 408, Part II, Fla, Stat., Ch. 59A-3, Fla. Admin. Code. The Agency may deny, revoke, and suspend any license issued to a hospital, and impose an administrative fine, for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or the applicable rules. §§ 408.813, 408.815, 408.831, 395.003, 395.1041, Fla. Stat, (2013). 2. The Respondent was issued a license by the Agency to operate a hospital Jocated at 3600 South Highlands Avenue, Sebring, Florida 33870 (“the Facility”), and was at all times material required o comply with the applicable state statutes and rules governing such facilities. As the licensee, the Respondent was a controlling interest as defined by section 408,803(7), Florida Statutes (2013). Effective June 4, 2012, the Respondent's license was modified to allow it to operate a Level I adult cardiovascular services program. Under Florida law, thete are two licensure levels for hospitals. concerning adult cardiovascular services programs. A Level I program authorizes the performance of adult percutaneous cardiac intervention without onsite cardiac surgery. A Level II program authorizes the performance of adult percutaneous cardiac intervention with onsite cardiac surgery (sometimes referred to as “open heart surgery backup”). § 408.0361(3)(a), Fla. Stat. (2013) COUNT I Emergency Services Requirements For Adult Diagnostic Cardiac Catheter Program 3. Under Florida law, each provider of diagnostic cardiac catheterization services shall comply with rules adopted by. the Agency that establish licensure standards governing the operation of adult inpatient diagnostic cardiac catheterization programs, The mules shall ensure that such programs: (a) Comply with the most recent guidelines of the American College of Cardiology and American Heart Association Guidelines for Cardiac @ | @ /) ) Catheterization and Cardiac Catheterization Laboratories. (b) Perform only adult inpatient diagnostic cardiac catheterization services and will not provide therapeutic cardiac catheterization. or any other cardiology services, (c) Maintain sufficient appropriate equipment and health care personnel to ensure quality and safety. (d) Maintain appropriate times of operation and protocols to ensure availability and appropriate referrals in the event of emergencies. (e) Demonstrate a plan to provide services to Medicaid and charity care patients, § 408.0361(1), Fla. Stat. (2013), 4. Under Florida law, each provider of adult cardiovascular services or operator of a burn unit shail comply with rules adopted by the Agency that establish licensure standards that govern the provision of adult cardiovascular services or the operation of a burn unit. Such rules shall consider, at a minimum, staffing, equipment, physical plant, operating protocols, the provision of services to Medicaid and charity care patients, accreditation, licensure period and fees, and enforcement of minimum standards. The certificate-of-need rules for adult cardio- vascular services and bur units in effect on June 30, 2004, are authorized pursuant to this subsection and shall remain in effect and shall be enforceable by the agency until the licensure tules are adopted. Existing providers and any provider with a notice of intent to grant a certificate of need or a final order of the agency granting a certificate of need for adult cardiovascular services or burn units shall be considered grandfathered and receive a license for their programs effective on the effective date of this act. The grandfathered licensure shall be for at least 3 years or until July 1, 2008, whichever is longer, but shall be required to meet licensure standards applicable to existing programs for every subsequent licensure period. § 408.0361(2), Fla, Stat. (2013). 5. Under Florida law, in establishing rules for adult cardiovascular services, the Agency shal! include provisions that allow for: @ @ } 7.) (a) Establishment of two hospital program licensure levels: a Level I program authorizing the performance of adult percutancous cardiac intervention without onsite cardiac surgery and a Level I] program authorizing the performance of percutaneous cardiac intervention with onsite cardiac surgery. (b) For a hospital seeking a Level I program, demonstration that, for the most recent 12-month period as reported to the agency, it has provided a minimum of 300 aduit inpatient and outpatient diagnostic cardiac catheterizations or, for the most recent 12-month period, has discharged or transferred at least 300 inpatients with the principal diagnosis of ischemic heart disease and that it has a formalized, written transfer agreement with a hospital that has a Level Ii program, including written transport protocols to ensure safe and efficient transfer of a patient within 60 minutes. However, a hospital located more than 100 road miles from the closest-Level II adult cardiovascular services program does not need to meet the 60-minute transfer time protocol if the hospital demonstrates that it has a formalized, written transfer agreement with a hospital that has a Level II program. The agreement must include written transport protocols to ensure the safe and efficient transfer of a patient, taking into consideration the patient’s clinical and- physical characteristics, road and - weather conditions, and viability of ground and air ambulance service to transfer the patient. (c) For a hospital seeking a Level II program; demonstration that, for the most recent 12-month period as reported to the agency, it has performed a minimum of 1,100 adult inpatient and outpatient cardiac catheterizations, of which at least 400 must be therapeutic catheterizations, or, for the most recent 12-month period, has discharged at least 800 patients with the principal diagnosis of ischemic heart disease, (d) Compliance with the most recent guidelines of the American College of Cardiology and American Heart Association guidelines for staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety. (e) Establishment of appropriate hours of operation and protocols to ensure availability and timely referral in the event of emergencies, (f) Demonstration of a plan to provide services to Medicaid and charity care patients. § 408.0361(3)(b), Fla. Stat. (2013) (emphasis added). 6. Under Florida law: (h) Emergency Services. 1, All providers of adult diagnostic cardiac catheterization program services in a hospital not licensed as a Level II adult cardiovascular services provider shall have written transfer agreements developed specifically for diagnostic’ cardiac catheterization patients with one or more hospitals that operate a Level II adult cardiovascular services program. Written agreements must be in place to ensure safe and efficient emergency transfer of a patient within 60 minutes. Transfer time is defined as the number of minutes between the recognition of an emergency as noted in the hospital’s internal log and the patient's arrival at the receiving hospital. Transfer and transport agreements must be reviewed and tested at least every 3 months, with appropriate documentation maintained, including the hospital’s internal log or emergency medical services data. 2. Patients at high risk for diagnostic catheterization complications shall be referred for diagnostic catheterization services to hospitals licensed as a Level II adult cardiovascular services provider. Hospitals not licensed as a Level Il adult cardiovascular services provider must have documented patient selection and exclusion criteria’ and provision for identification of emergency situations requiring transfer to a hospital with a Level II adult cardiovascular services program. Documentation indicating the manner in which this requirement will be met shall be available for the Agency’s review. Fla. Admin, Code R. 59A-3.2085(13)(h)(1-2) (emphasis added), 7. On July 30, 2013, the Agency conducted a survey of the Respondent. 8. Based upon staff interviews and document review, the Respondent did not have in place a written transfer agreement developed specifically for diagnostic cardiac catheterization patients with one or more hospitals that operate a Level II adult cardiovascular services program to ensure the safe and efficient emergency transfer of patients within 60 minutes. 9, The Respondent is a hospital located less than 100 road miles from the closest Level I] adult cardiovascular services program and thus is required to meet the 60-minute transfer time protocol by demonstrating that it has a formalized, written transfer agreement with a hospital that has a Level I program. 10. During the survey, the Respondent presented a signed transfer agreement in place with another facility that has Level I cardiovascular service program (“the receiving facility”). 11. The receiving facility is located in another county, approximately 69 miles from Respondent’s Facility. 12. The estimated drive time between the Respondent’s Facility and the receiving facility is approximately 1 hour and 20 minutes. 13. A review of an agreement with a local air medical transport company revealed the medical transport has agreed to provide transport services for the Respondent. 14. On July 29, 2013, at approximately 10:00 a.m., the Respondent's Chief Executive Officer (CEO) was interviewed. The CEO stated that in the event an air transport could not be accomplished, the patient would be transferred by ground to the receiving facility. 15. The CEO further stated he was aware that ground transport time would be greater than 60 minutes. . 16, _ The Respondent’s CEO provided a test run of the arrangement via air transport that was performed on May 3, 2013. 17. According to the run report, the report was created at 8:36, there was launch page at 9:22 and the patient arrived at the receiving facility at 10:23. The time from the launch page to the time the patient arrived at the receiving facility was 61 minutes per the test run. 18. The test run did not log the patient’s “transfer time” to the receiving facility, which is “defined as the number of minutes between the recognition of an emergency as noted in the hospital’s internal log and the patient’s arrival at the receiving hospital.” 19. The test was dated May 3, 2013. No other test run was available for review. 20. The CEO confirmed there had been no test of transport time via ground. -21. The CEO did not provide any evidence there was a back-up plan in place that would ensure patients could be transferred by ground to a Level II cardiovascular service facility @ , e ) j within 60 minutes should air transport be unavailable. 22, The Agency provided the Respondent written notice of this deficiency and the opportunity to correct the deficiency. 23. On October 16, 2013, the Agency conducted a revisit of the July 30, 2013, survey. 24, During the October visit, it was determined that the Respondent still did not have in place a written transfer agreement developed specifically for diagnostic cardiac catheterization patients with one of more hospitals that operate a Level fi adult cardiovascular services program to ensure the safe and efficient emergency transfer of patients within 60 minutes. 25. A review of the Respondent's transfer agreement in place for the Level II cardiovascular air transport revealed that the receiving facility was located in another county, approximately 69 miles from the Respondent’s location. 26. The Respondent’s Risk Manager provided documentation of a test run by air transportation of transport time performed on August 15, 2013. 27. —_ According to the run report, the report was created at 9:31, there was launch page at 9:33 and the patient arrived at the receiving facility at 10:32. The time from the launch page to the time that the patient arrived at the receiving facility was 59 minutes per the test run. 28, The test run did not log the patient’s “transfer time” to the receiving facility, which is “defined as the number of minutes between the recognition of an emergency as noted in the hospital’s internal log and the patient’s arrival at the receiving hospital.” 29, The Respondent did not provide documentation demonstrating that should ground transport be required due to inclement weather or other problems, there was a plan in place to ensure the transport of the patient within 60 minutes. 30. The CEO, however, provided documentation that he had attempted to secure a @ @ ) -) transfer agreement for ground transport to another facility with a Level IT program, but had not been successful. 31. The last ground transport test that had been performed was in March 2013, when the Respondent had a transport agreement in place with another facility at that time. This previous ground transport agreement is no longer in effect, and there is no other ground transport agreement in place with another level II facility that could receive the patient with 60 minutes. - 32. The August 2013 air transport test measured only time from when the transport team was called by the Respondent to the time of the patient's arrival at the receiving hospital. The time from when the decision was made to transport the patient until the arrival of the patient at the receiving facility was not measured, 33. There was no evidence at either the July 30, 2013 or October 16, 2013, surveys that the Respondent had a transfer agreement in place for ground transport within the 60 minute requirement from the decision to transport to the arrival at the receiving facility. If air transport is not possible in a particular situation, a patient could not be transferred by ground to a level II facility with a ground transport agreement with Respondent within the 60 minute window. 34, The Agency provided the Respondent written notice of this deficiency and the opportunity to correct the deficiency. 35. On March 20, 2014, the Agency conducted a complaint survey of the Respondent. During the March 2014 visit, it was determined that the Respondent was still not in compliance with the previously cited deficiency, 36. Based upon document review and staff interview, it was determined the Respondent still did not have a written agreement in place to ensure that patients requiring an emergent transfer to a Level II cardiovascular facility could be transported within the required 60-minute timeframe. 37, _ A review of the current air transfer agreement in place for the transfer of patients to a Level II cardiovascular (open heart) facility is with:a hospital located approximately 69 miles away from the Respondent. 38. The Respondent produced to the Agency an air transport run reported dated December 20, 2013: 39. According to the run repott, the report was created at 9:40, there was launch page at 9:41 and the patient arrived at the receiving facility at 10:35. The time from the launch page to the time that the patient arrived at the receiving facility was 54 minutes per the test run. 40, The test run did not log the patient’s “transfer time” to the receiving facility, which is “defined as the number of minutes between the recognition of an emergency as noted in the hospital’s internal log and the patient's arrival at the receiving hospital.” 41, During an interview with the Director of Quality/Risk Management on March 20, 2014, at approximately 2:30 p.m., it was revealed that if air transport was not available due to inclement weather or other conditions, the Respondent would transfer the patient to the receiving facility via ground transportation. 42. The Director confirmed that the Respondent does not have a transfer agreement with a Level II cardiovascular acute care facility for ground transportation transfer. 43. She further confirmed that the Respondent has not performed a mock drill using ground transportation. 44. The Respondent did not demonstrate that an emergent patient could be transferred . to a Level II cardiovascular facility within 60 minutes when air transport could not be utilized. 45. The Agency provided the Respondent written notice of this deficiency and the opportunity to correct the deficiency. Sanction. 46. Under Florid law, in addition to the requirements of part II of chapter 408, whenever the Agency finds that there has been a substantial failure to comply with the requirements established under this part or in rules, the agency is authorized to deny, modify, suspend, and revoke: (a) A license; (b) That part of a license which is limited to a separate premises, as designated on the license; or (c) Licensure approval limited to a facility, building, or portion thereof, or a service, within a given premises. § 395.003(7), Fla. Stat. (2013). 47. 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 actions by a controlling interest: (c) A violation of this part, authorizing statutes, or applicable rules. § 408.815(1)(c), Fla. Stat. (2013). " WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to modify the Respondent’s hospital license to delete its Level I adult cardiovascular services program. Emergency Services Personnel 48. Under Florida law, “emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted ‘by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility. § 395,002(9), Fla. Stat. (2013). 49. Under Florida law, every hospital offering emergency services and care shall 10 provide emergency care available 24 hours a day within the hospital to patients presenting to the _ hospital. At a minimum, emergency services personnel shall be available to ensure that emergency services and care are provided in accordance with Section 395,002(9), Florida Statutes (2013). Fla. Admin. Code R. 59A-3.255(6)(a)1. 50. Based upon record review and staff interview, the Respondent failed to ensure through screening, triage and assessment, that an emergency medical condition existed and failed to provide care in a timely manner to two of eleven patients reviewed (Patient #2 and #5) 51. On March 20, 2014, the Agency conducted a complaint survey of the Respondent. During the survey, the Agency found the following deficiencies. Patient #5 ‘52. ‘Patient #5 arrived at the Respondent’s Emergency Department (ED) on December 28, 2013, at 6:09 p.m., with a chief complaint of chest pain. 53. Documentation revealed an ED clerk checked in Patient #5, 54. _ A review of the Facility’s record revealed that at 6:43 p.m., Patient #5 left the Facility, 55. The Facility’s nursing documentation stated "patient stated they were leaving due to unknown reasons." 56. A review of the Facility’s nursing documentation revealed no evidence the nurse attempted to assess the Patient's condition or explain the risk of leaving without being seen to determine if an emergency medical condition existed. 57, During an interview with the Director of Quality/Risk Management on March 20, 2014, at approximately 3:00 p.m., the above findings were confirmed. 58. The Director stated that the Facility does not have a policy in place that addresses a protocol for staff to follow when a patient arrives to the ED with a chief complaint of chest pain. 59. The Director also stated the Facility does not have a policy in place that addresses a protocol for staff to follow for patient's that attempt to leave prior to being seen by a medical provider to determine if an emergency medical condition exists. . Patient #2 60, Patient #2 arrived at the Respondent’s ED on October 5, 2013, at 6:24 p.m., with a chief complaint of abdominal pain and a possible kidney stone. 61. A review of the record revealed that at 7:37 p.m., Patient #2 left the Facility. 62. The Facility’s nursing documentation stated "patient stated they were leaving due to wait time." 63. =A review of the Facility’s nursing documentation revealed no evidence the nurse attempted to assess the Patient's condition or explain the risk of leaving without being seen to determine if an emergency medical condition existed. 64, During an interview with the Director of Quality/Risk Management on March 20, 2014, at approximately 5:30 p.m., the above findings were confirmed. Sanction 65. Under Florida law, the Agency may impose an administrative fine, not to exceed $1,000 per violation, per day, for the violation of any provision of Chapter 395, Part I, or Chapter 408, Part tl, or the applicable rules, Each day of violation constitutes a separate violation and is subject to a separate fine. § 395.1065(2)(a), Fla. Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $2,000.00 against the Respondent. 12 CLAIM FOR RELIEF 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 fayéy of the Agency. 2. Imposes the relief sought against the Responds: Respectfully submitted on this they of J Thomas J. Walsh M, Senior Attorney Florida Bar No 566365 Office of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive, Sebring Building St, Petersburg, Florida 33701 Telephone: (727) 552-1947 Facsimile: (727) 552-1440 -and- Bradford C. Herter, Senior Attomey Florida Bar No 069060 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone (850) 412-3639 Facsimile (850) 922-6484 Tne NOTICE OF RIGHTS Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120,57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28-106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form, The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received, If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address, The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120,373, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. -CERTIFICATE OF CE ] HEREBY CERTIFY that a-true and correct copy of jt Administrative Complaint and Election of Rights form were served to: Geoffrey Sm ia electronic mail at Geoff@smithlawtlh.com on this bad day of June, 24 Thomas J. Walsh fl, Senior Attorney Florida Bar No 566365 Office of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive, Sebring Building St. Petersburg, Florida 33701 Telephone: (727) 552-1947 Facsimile: (727) 552-1440 -and- Bradford C. Herter, Senior Attorney Florida Bar No 069060 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone (850) 412-3639 Facsimile (850) 922-6484 15 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Sebring Hospital Management Associates, LLC AHCA Nos. 2013011394 d/b/a Highlands Regional Medical Center 2014005321 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 within 21 days 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 representative prefer to reply according to Chapter] 20, 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: 850-922-5873 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) TI admit to the allegations of facts and conclusions of law contained in the 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 Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where 1 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 Administrative Complaint and I request a formal hearing (pursuant to Section ] 20.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings, 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 Tepresentative 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 number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, ; License Type: (ALF? Nursing Home? Medical Equipment? Other Type?) Licensee Name: License Number: 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: 17 “) ) Hoeler, Thomas From: Hoeler, Thomas Sent: Wednesday, June 11, 2014 3:35 PM To; Geoffrey Smith Ce: Walsh Il, Thomas; Herter, Bradford Subject: Highlands Regional Medical Center Attachments: DOCO61114-06112014143832.pdf Geoff - Please find attached the Administrative Complaint that we discussed today. Tom Walsh Is lead counsel on this case, but feel free to call either he or | if you wish to discuss this matter, Thomas Hoeler - SENIOR ATTORNEY ‘ Bidg. 3, MS #3, Rm, 3407B - GENERAL COUNSEL AHCA Privacy Statement: teader of this e-mail is not the intended recipient or his or her authorized agent, the reader is hereby nolified that any dissemination, distribution or copying of this 8-mall Is prohibited, If you have recetved this In error, please reply to tha sender and delete it immediately.

Docket for Case No: 14-003248