STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2014005122 File No. 19966762 NORTH BEACH HOME HEALTH CARE, LLC, License No. 299993811 Provider Type: Home Health Agency 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, North Beach Home Health Care, LLC, (“the Respondent”), pursuant to Sections 120.569-120.57, Florida Statutes (2013), and alleges: NATURE OF THE ACTION This is an action to revoke the home health agency license of the Respondent. THE PARTIES 1. The Agency is the licensure and regulatory authority that oversees home health agencies in Florida and enforces the applicable state statutes and rules governing home health agencies. Chs. 400, Part III, and 408, Part II, Fla. Stat.; Ch. S9A-8, Fla. Admin. Code. The Agency is authorized by statute and rule to deny, revoke, or suspend a license, and impose an administrative fine against home health agencies. §§ 400.474, 400.484, 408.813, 408.815, 408.831, Fla. Stat. (2013), Fla. Admin. Code R. 59A-8.003. 2. The Respondent was issued a license by the Agency to operate a home health agency located at 120 East Oakland Park Boulevard, Suite 208, Fort Lauderdale, Florida 33334, Page 1 of 7 and was required to comply with the state statutes and rules governing home health agencies. COUNTI Termination For Cause from the Medicare or Medicaid Program 3, Under Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: ... (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. § 408.815(1)(e), Fla. Stat. (2013). 4, Under Florida law, a controlling interest is, “A person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee.” § 408.803(7)(b), Fla. Stat. (2013). America Home Health, Inc. 5. In its license application submitted to the Agency, Sulman Bonilla was listed as the Director, Chief Executive Officer and 30% owner of America Home Health, Inc., a home health agency that was previously licensed by the Agency, License No. 299992104. Ex. A. 6. On June 13, 2012, Palmetto GBA, a contractual agent of Medicare, sent a letter to America Home Health, Inc., that it had revoked the provider’s Medicare billing privileges effective July 12, 2012. Ex. B. The stated reason given for revocation was: “The supplier submitted claims for payments that were based on orders, treatment plans, or other documents some of which were created by the enrolled supplier that contain the altered or forged signature of the treating physician.” Ex. B. 7. On the effective date of the revocation of its Medicare billing privileges, Sulman Bonilla was listed in the Agency’s licensure file as a 30% shareholder and a controlling interest Page 2 of 7 of this provider. Ex. A. 8. In July 2012, America Home Health, Inc. surrendered its license to the Agency. 9, Per the correspondence of the Centers for Medicare and Medicaid Services (“CMS”) dated January 9, 2013, America Home Health, Inc.’s Medicare billing privileges were revoked pursuant to 42 CFR 424.545(a) effective July 12, 2012, and it was terminated from the Medicare program. Ex. C. North Beach Home Health Care, LLC 10. On April 10, 2014, the Agency issued a letter to the Respondent indicating that it was investigating allegations that its 50% Owner and Administrator, Daniel Ocampo, was charged with health care fraud. Ex. D. 11. In response, the Respondent notified the Agency that it had removed Mr. Ocampo from his position as the Administrator and that he had sold his 50% ownership of the Respondent to Sulman Bonilla on March 20, 2014. Ex. E. 12. Under Florida law, a person who has a 5% or greater ownership interest in an applicant or licensee is considered to be a controlling interest of the applicant or licensee as defined by Section 408.803(7), Florida Statutes. 13, Because Sulman Bonilla acquired a 50% ownership interest in the Respondent and took a position with the Respondent which makes Sulman Bonilla a controlling interest of the Respondent. 14. Sulman Bonilla is ineligible to be a controlling interest of the Respondent under Florida law. § 408.815(1)(e), Fla. Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s home health agency license. Page 3 of 7 CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the relief set forth above. Respectfully submitted on this v day of July, 2014. Bradford C. Herter, Senior Attorney Florida Bar No. 69060 Office of the General Counsel Agency for Health Care Administration NOTICE 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 120.573, 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. Page 4 of 7 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights Form was served to the below named individuals or entities by the method designated on this | day of July, 2014. Bradford C. Herter, Senior Attorney Florida Bar No. 69060 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 Administrator North Beach Home Health Care, LLC 120 East Oakland Park Boulevard, Suite 208 Fort Lauderdale, FL 33334 (Certified Mail 91 7199 9991 7033 2242 7998) Page 5 of 7 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: AHCAvy. North Beach Home Health Care, LLC AHCA No, 2014005122 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 representative prefer to reply according to Chapter120, 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 THESE 3 OPTIONS OPTION ONE (1) I admit the allegations of fact and 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 the allegations of fact contained in the 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 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. Page 6 of 7 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 number 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: Page 7 of 7 AHCA USE ONLY: File #: Application #; rT Check #: Check Amt: Batch #: Health Care Licensing Application HOME HEALTH AGENCY Under the authority of Chapters 408, Part I! and 400, Part lil, Florida Statutes (F.S.), and Chapters 59A-35 and 59A- 8, Florida Administrative Code (F.A.C.), an application is hereby made to operate a home health agency as Indicated below: 1. Provider / Licensee Information OO€e? Suro Seas wiaiive Fm 402: | POX DOA AMEN COVLL @ Peal + CO Gontact Person for this application Contact e-mail address or (“J Do not have e-mail nsee Name fray bo same as ‘provider name ‘above) Fax Number E-mail Address , , f (20S UC AN en Description. of Licensee (check one): a Corporation i Corporation a C) (C] Limited Liability Company Religious Affillation (1) City/County (C) Partnership {/] Limited (ability Company () Hospital District C1 Individual (CJ Cthier [1] Other EXHIBIT AHCA Farm 3110-1011, Rev July 2008 Section 58A-35.060(1), Florida Administrative Code Page 1 of 12 Forms available at: hito-//ahcs.mvflorda.com/Publleations/FarmattOa ehimt 2. Application Type and Fees Indicate the type of application with an "X." Applications wiil not be processed ff all appilcable fees are not included. All fees are nonrefundable. C7 Initial Licensure Was this entity previously licensed as a Home Health Agency in Florida? YES & noO If yes, please provide the name of the agency (if different), the EIN # and the year the prior license expired or closed: NAME: eine Year Expired/Closed: 8 Renewal Licensure () Change of Ownership Proposed Effective Date: () Change during licensure period - Name/address change of the facility Proposed Effective Date: (2) Change during licensure period - Add/delete counties Proposed Effective Date: Change During Licensure Periad/Replacement License Level 2 Background Screening for Administrator Level.2 Background Screening for Chief Financial Officer RECEIVED 3. Controlling Interests of Licensee JAN 12 2012 Centrat Systern: AUTHORITY: Managemant Unt Pursuant to section 408.806(1)(a) and (b), Florida Statutes, an application for licensure must Include: the name, address and Social Security number of the applicant and each controlling interest, if the applicant or controlling interest ts an individual; and the name, address, and federal employer identification number (EIN) of the applicant and each controlling interest, if the applicant or controling Interest fs not an individual. Disclosure of Social Security number(s) Is mandatory. The Agency for Health Care Administration shall use such Information for purposes of securing the proper identification of persons ilsted on this application for licensure. However, in an effort to protect all personal information, do not Include Soctal Security numbers on this form. All Soctal Security numbers must be entered on the Health Care Licensing Application Addendum, ANCA Form 3110-1024, DEFINITIONS: Controlling interesta, as defined in subsection 408,803(7), Florida Statutes, are the applicant or licensee; a person or entity that serves as an officer of, is on the board of directors of, or has a 6-percent or greater ownership interest In the applicant or licensee; or a person or entity that serves as an officer of, is on the board of directors of, or has a §-percent or greater ownership intarest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member. AHGA Fonn 3110-1011, Rev July 2008 : Page 2 of 12 Forms availabie at COnVP ub Section 694-35.080(1) plfah onuP Monga, . Florida Voluntary Board Member, as defined in subsection 408.603(13), Florida Statutes, means a board member or officer of a not-for-profit corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the board of directors, and has no financial interest in the corporation or organization. In Spetions A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the ficensee. Attach additional sheets ff necessary. B. Board Members and Officers of Licensee is af : Director/CEO RECEIVED JAN 12 2012 Cc. Voluntary Board Members and Officers of Licensee Central Systems Management Unit if the licensee Is @ not-for-profit corporation/organization, provide the requested information for each individual that serves as a voluntary board member. Attach additional sheets If necessary. AHCA Form 3110-1011, Rev July 2009 Section §9A-3§.060(1), Florida Administrative Code Pana 2 nf 19 Fors available at; httov/ahca.mvilorida.com/Publications/Foms/HOA shtm! (A ALY Ne t Pal metto G B A . Part A Intermediary PARTNERS IN EXCELLENCE. Part B Carrier Provider Enrollment June 13, 2012 America Home Health, Inc. 6595 NW 36" ST, 222-3 Virginia Gdns, FL 33166-6966 Dear Provider: This is to inform you that your Medicare Provider Transaction Access Number (PTAN) 10-8231, that is associated to the National Provider Identifier (NPI) 1982669149 has been revoked effective July 12, 2012. Pursuant to 42 CFR 424.545(a), this action will also terminate your corresponding provider agreement. Legal Business Name: America Home Health, Inc. PTAN: 10-8231 NPI(s): 1982669149 FACTS: Under 42 CFR 424.535 (a)(1) CMS may revoke a currently enrolled provider or supplier’s Medicare billing priviledges and any corresponding provider agreement when the suppliers are not in compliance with the enroliment requirements specifically outlined in Section 15 (a)5 (Certification Statement for 855A application) that states: “I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare, and I will not submit claims with deliberate ignorance or reckless disregard for their trust or falsity”. The supplier submitted claims for payments that were based on orders, treatment plans, or other documents some of which were created by the enrolled supplier that contain the altered or forged signature of the treating physician. If you believe that you are able to correct the deficiencies and establish your eligibility to participate in the Medicare program, you may submit a corrective action plan (CAP) within 30 calendar days after the postmark date of this letter. The CAP should provide evidence that you are in compliance with Medicare requirements. The reconsideration request must be signed and dated by the authorized or delegated official within the entity. CAP requests should be sent to: RECEIV ED Centers for Medicare & Medicaid Services Center for Program Integrity WN 18 are EXHIBIT : ; Provider Enrollment Operations Group i systems 4 7500 Security Blvd. Contra ment Unit : managem Mailstop: AR-18-50 Baltimore, MD 21244-1850 If you believe that this determination is not correct, you may request a reconsideration before a contractor hearing officer. The reconsideration is an independent review and will be conducted by a person who was not involved in the initial determination. You must request the reconsideration in writing to this office within 60 calendar days of the postmark date of this letter. The request for reconsideration must state the issues, or the www.palmettogba.com | 2300 Springdale Drive, Building One §SO 9001:2000 | Camden, South Carolina 20020-1728 Page 2 findings of fact with which you disagree and the reasons for disagreement. You may submit additional information with the reconsideration request that you believe may have a bearing on the decision. The reconsideration request must be signed and dated by the authorized or delegated official within the entity, Failure to timely request a reconsideration is deemed a waiver of all rights to further administrative review. You may not appeal through this process the merits of any exclusion by another Federal agency. Any further permissible administrative appeal involving the merits of such exclusion must be filed with the Federal agency that took the action. The request for reconsideration should be sent to: Centers for Medicare & Medicaid Services Center for Program Integrity Provider Enrollment Operations Group 7500 Security Blvd. Mailstop: AR-18-50 Baltimore, MD 21244-1850 Pursuant to 42 CFR 424.535(c), Palmetto GBA is establishing a re-enrollment bar for a period of three years. This enrollment bar only applies to your participation in the Medicare program. In order to re-enroll, you must meet all requirements for your provider or supplier type. If you have any questions regarding this determination, please contact me at 803-763-4021. Sincerely, Samuel Rivera Supervisor, Provider Enrollment cc: Sandra Pace, CMS Atlanta Regional Office Zabeen Chong, PEOG CMS Central Office Cynthia Ibrahaim, Florida Agency of Health Care Administration cn? www.palmettogba.com | Post Offica Box 100144 ISO 9001:2000 | Columbia, South Carolina 28202-3134 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, SW, Suite 4720 Atlanta, Georgia 30309 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES January 9, 2013 American Home Health, Inc. 6595 NW 35th Street, 222-3 Virginia Gardens, FL. 33166 Re: CMS Certification Number (CCN) 10-9313 Dear Provider: The Centers for Medicare and Medicaid Services (CMS) was notified by Palmetto, GBA that the agency’s Medicare billing privileges were revoked pursuant to 42 CFR 424.545(a). This action also terminates your corresponding Medicare provider agreement per 489.53. Your provider agreement is terminated retroactive to the date of revocation, July 12, 2012. A public notice of termination will be published in a local newspaper. If you believe this action is not correct, please refer to the letter which was sent to you on June 13, 2012 by Palmetto GBA, notifying you of the revocation of your Medicare enrollment. This letter included your rights to appeal. If you have questions, please contact Jackie Whitlock at 404-562-7437 or Jacqueline.whitlock@cms.hhs.gov. Sincerely, Sandra M. Pace Associate Regional Administrator Division of Survey and Certification ce: Florida Agency for Healthcare Administration Palmetto GBA EXHIBIT ic —_— Certified Article Number 729) 9008 93343 8871 0363 | SENDERS RECORD] af =0n@] 210) FLORIOA AGENCY FOR HEALTH CARE ADMINGTRATION RICK SCOTT GOVERNOR ELIZABETH DUDEK Better Health Care for all Fioridians SECRETARY April 10, 2014 North Beach Home Health Care LLC Ni ile Number: 19966762 120 E Oakland Park Bivd, Ste 208 License Number: 299993811 Fort Lauderdale, Fl 33334 Re: Background Screening Clarification — Daniel OCampo Dear Administrator: The Agency for Health Care Administration (Agency) is investigating information showing that the above referenced individual may no longer be qualified to have a controlling interest at this facility, or be employed by this provider. Since the above individual is disqualified based on background screening results, the licensee must place them in a position for which background screening is not required pursuant to Chapter 435, Florida Statutes, or terminate them immediately. For more information on Background Screening requirements, please see hi fl te.gov/Laws/Statutes/2012/408.809 The individual may be eligible to apply for an exemption from disqualification when the individual has a final court disposition and has completed or been lawfully released from confinement, supervision, or sanction for a felony offense for at least 3 years. For more information on filing an exemption application please visit the Agency’s website at: http://ahca.myflorida.com/MCHQ/Central_ Services/Background Screening/exemption,shtml. Mr. Ocampo is a 50 % controlling interest owner of North Beach Home Health Care LLC according to our records. He is also the current administrator. He has either been arrested or convicted of a disqualifying offense and can no longer be a controlling interest for your agency. Florida statutes allow the Agency to revoke a license if the controlling interest does not get an exemption from AHCA or is not removed as a controlling interest. Please provide the consultant below with a written statement within 21 days of the date of this letter, indicating what measures the facility will take to assure that this individual does not have access to clients, or has been removed as a controlling interest in accordance with Chapter 408.809, Florida Statutes. re RECEIVED 4 APR 17 2014 | Centra Management Unt 2727 Mahan Drive e Mail Stop #XX Visit AHCA online at Tallahassee, FL 32308 AHCA. MyFlorida.com Please contact the Agency's Background Screening Unit at (850) 412-4503, for further information regarding the referenced individual. Sincerely, 4 Ja Benesh, OMC Manager (850) 412-4386 (850) 922 5374 (fax) Janet.Benesh@ahca.myflorida.com RECEIVED APR 17 2014 Central Systems Management Unit NORTH BEACH HOME HEALTH CARE LLC 120 E. OAKLAND PARK BOULEVARD SUITE 208 FORT LAUDERDALE, FL 33334 TEL: 954-390-7902 April 14, 2014 Agency for Healthcare Administration 2727 Mahan Dr. Mail Stop # 34 Tallahassee, Florida 32308 Dear Jah Benesh: This letter is to submit the changes of the agency North Beach Home Health Care, LLC did to assure that the individual Mr. Daniel Ocampo does not have access to clients or having any control interest in this agency. On 03/20/2014 Mr. Daniel Ocampo transfer the 50% of the shares to Sulman Bonilla. Attached is the copy of the bill of sale and corporations papers. Also the agency appointed a new administrator Ms. Dayleen Diaz; the changes have been submitted previously to the agency via fax on 04/08/2014. Attached the copy of the resume and background screening. Please feel free to contact us if you need any additional information. Thanks; RECEIVED Sincerely —— APR 17 2014 i Central Sys Sulman Bonilla rage Z rage 1 Or Z Reclpent Details Attention To: Administrator Phone #: 954/390-7902 Email: ; Package Details Waybill #: 9171999991703322427998 Weight: 1 Reference One: 2014005122 Package ID: 855 Two: North Beach Home Status: Delivered Three: Customer: Shipping Cost: 0.66 0.66 Accessorial: 4.35 4.35 Other: 0.00 0.00 Total Cost: 5.04 5.01 Date Description 2014-07-08 13:41 FORT LAUDERDALE,FL DELIVERED 2014-07-03 08:23 FORT LAUDERDALE,FL ARRIVAL AT UNIT 2014-07-02 18:20 OPA LOCKA,FL PROCESSED THROUGH USPS SOR’ 2014-07-01 23:00 TALLAHASSEE,FL ELECTRONIC SHIPPING INFO RE 2014-07-01 21:57 TALLAHASSEE,FL PROCESSED THROUGH USPS S( 2014-07-01 16:55 TALLAHASSEE,FL ACCEPT OR PICKUP e > I Void Package . _-Reprint Label - | Track Package . gp fines ent cet gs PACKAGE COMEMS as ssn ! i Part# ¥ | Quantity i Description I Unit Price [total Value | i No records found. j 1 ) 1 } ' } 4 § i Proof of Delivery http://hq3pbsvip01/SendSu... 2 07/24/2014

Docket for Case No: 14-003650