STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2015005680 v. Return Receipt Requested: 7002 2410 0001 4240 2834 LOS ANOS DORADOS, INC. Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration “CAHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Los Afios Dorados ALF, Inc. (hereinafter “Los Afios Dorados” or “Respondent”), pursuant to Chapter 429, Part I, Chapter 408, Part II and Section 120.60, Florida Statutes, (2014), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $2,500.00 pursuant to Sections 408.813 and 429.19, Florida Statutes (2014), and a survey fee of $199.87 pursuant to Section 429.19(7), Florida Statutes, for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 429, Part I, Florida Statutes (2014), and Chapter 584-5, Florida Administrative Code. 5. Respondent, Los Afios Dorados, operates a 6-bed assisted living facility located at 11461 SW 214" Street, Miami, Florida 33169, under license number AL11958, with an expiration date of 02/16/2017. Los Afios Dorados was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I RESPONDENT FAILED TO COORDINATE THE DELIVERY OF SERVICES TO RESIDENTS BY THIRD PARTY PROVIDERS FOR TWO RESIDENTS Section 429.28(1)(j), Florida Statutes (RESIDENT CARE-RIGHTS AND FACILITY PROCEDURES) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During a complaint investigation conducted. on 4/17/2015, Respondent was cited for failure to coordinate the delivery of services to residents by third party providers for two out of four sampled residents (#1 and #2). 8. Resident #1's Health Assessment (dated 03/26/2014) showed the resident's diagnoses were Dementia, Chronic Renal Failure (Dialysis), hypertension, diabetes mellitus, osteoarthritis, and GERD; cognitive or behavioral status: Memory loss. Resident #1 needed assistance with self-administration of medications. 9. Review of Resident #1's medication showed an order for Novolin R 100 units/ml vial, apply according to sliding scale twice a day, at 8:00 AM and 8:00 PM. Review of doctor’s notes for Resident #1, revealed the doctor ordered (signed and dated on 11/21/2014) for home health care to administer Novolin R -100/ml (sliding scale) subcutaneous twice a day, 151- 200=2u,201-250= 4u, 251-300= 6u, 301-350= 8 units, 351-400= 10 units,+ 400= 12 units and call the doctor. The medication observation record (MOR) was initialed by Caregiver C and Caregiver B, from 04/01/2015 to 04/15/2015. Neither staff was a Nurse license to administer medication to residents. 10. On 04/14/2015 at 12:00 PM, Caregiver C stated that the facility did not have additional documentation for review. Facility did not have home health agency (HHA) record for ‘review for insulin because Resident #1 administered insulin to himself. 11. Review of the home health agency record for Resident #1 revealed that comprehensive nursing assessment dated 12/29/2014 noted on page 6 that the caregivers monitored blood sugar level daily. 12. Review of Resident #1's MOR revealed that Caregiver C and B initialed the MOR for Novolin R 100 Unit two times a day, at 8:00 AM and 8:00 PM. Review of page 6 of the facility and comprehensive adult nursing assessment provided by the home health agency to start of care dated 12/19/14 at 8:10 AM stated that Insulin dose: Novolin R per sliding scale twice a day administered by caregiver, did not have blood sugar levels monitored daily for Resident #1. Review doctor order dated 01/23/2015 for physical therapy. Home Health Care record was reviewed on 04/17/2015 for Resident #1. Staff Record Review showed that neither caregiver B nor C had a Nurse license to administer medication to residents. 13. On 04/15/2015 at 12:03 PM, Caregiver C stated that the facility did not have a blood sugar log for Resident #1 and that Resident #1 forgets everything and caregivers need to remind him. She further stated that Resident #1 was able to read blood sugar results and that the caregivers put everything for the insulin administration on the table. The resident would then administer the insulin to himself. ‘Sometimes when the resident comes back from dialysis, we prepare his insulin according to doctor instructions”. At 12:05 PM Caregiver C stated that Resident #1 did not receive insulin in the past three days because his blood sugar level was under control. Today (referring to 04/17/2015) his blood sugar level was 167. On 04/15/2015 at 1:35 PM, Caregiver C stated that the initials on the medication observation record were hers. 14. During a phone interview with Resident #1's primary physician on 04/16/2015 at 1:24 PM, he stated he was the physician for the residents at the facility. That Resident #1 goes to dialysis three times a week and has to have insulin regularly. The physician stated that he has made a face-to-face health assessment and saw Resident #1 regularly when he went to the facility. Sometimes, however, Resident #1 was at the dialysis center. He ordered home health services to provide administration of medication for Resident #1 and gave it to the facility. The physician further stated that Resident #1 could not administer the medication to himself. 15. During an interview on 04/14/2015 at 12:05 PM, Resident #1 was asked if he received insulin injections. Resident #1 stated that sometimes the person comes “but not now”. Caregiver C intervened and stated; "You do your insulin every day by yourself." She stated; "I prepare the syringe for you and you inject yourself every day; why do you tell her that you don't do it." 16. Interview with Resident #2's daughter on 04/14/2015 at 10:06 AM revealed that Resident #2 was diabetic and unlicensed staffs were assisting Resident #2 with administration of his insulin. 17. Review of Resident #2's medication order for Insulin reflected 100 units/ml subcutaneous solution sliding scale <60 follow hypoglycemic protocol; 61-150= 0 units, 151- 200=0 units, 201-250=2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, >400= 10 units and call physician. This was dated and signed on 01/21/2015. 18. Observation on 04/14/2015 at 12:45 PM revealed that there were two small plastic . bags with four boxes of insulin in the refrigerator door for Resident#2. The medications were two boxes of Lantus Solostar 18 units once daily, and two and boxes of Novolog Flex Pen by sliding scale. There was also a medication for Resident #1 found unlocked in the facility's medication cabinet: Novolin R 100 units by sliding scale. 19. _—_ Review of dietitian recommendation from dialysis center to the ALF on 04/17/2015 for Resident #1, revealed that foods with high sodium, potassium and phosphorus have to be - avoided (all kinds of beans, pasta and tomato sauces). Further review of dietitian progress notes for Resident #1 dated 9/19/2014, reflected Low Kidney Diet and Center provided a copy to the Assisting living facility (ALF) with the recommendations to increase protein. Review of home health agency record for Resident #1 revealed that comprehensive nursing assessment dated 12/29/2014 noted on page 10 that Resident #1 has a diet of no concentrated sugar, low sodium, low fat, renal diet, and avoid high potassium food. The facility did not have a dietitian menu to follow at the time of survey (menu expired on 08/02/14). The facility did not have a renal diet menu for review. 20. Observation on 04/14/2015 at 12:00 PM, Caregiver B served the following lunch to Resident 1: spaghetti with chicken, mixed vegetable, plantain chips, and Apple Juice. 21. During an interview on 04/14/2015 at 11:31 AM, Caregiver C stated that breakfast is served to residents at 7:30 AM to 8:30 AM; snack at 10:00 AM; lunch at 12:30 PM to 1:30 PM, snack at 3:00 PM (juices, cookies, ices cream) and Dinner from 5:00 PM to 6:00 PM. Medications are made available from 7:00 PM to 8:00 PM (juices and yogurts, puddings). Caterer Company delivers the food before 11:00 AM for Lunch and Dinner. She stated the catering company delivered a lot of food so they divided it for lunch and dinner. She stated sometimes we cook here at the facility like today for example we made spaghetti with chicken and mix salad. We just make spaghetti's because we felt like eating that for a change. She revealed that caregivers would not know what foods would be delivered to residents the next day. 22. During observation on 04/15/2015 at 2:05 PM, Resident #1 sat at the dining table and Caregiver C served white rice, black beans, mix salad, ground beef and apple juice for Resident #1. 23. The Registered Nurse from the dialysis center on 04/16/2015 at 1:50 PM, stated that they have recommended that Resident #1 bring a snack but he never did and that the Facility knew about the diet that this resident needed to follow. 24. | During a phone interview on 04/15/2015 at 12:52 PM, the Administrator/ owner stated he did not recall the information from dialysis center because he had twelve residents from all his facilities. 25. Based on the foregoing Los Afios Dorados violated Section 429.28(1)(), Florida Statutes, a Class II deficiency that carries, in this case, an assessed fine of $2,500.00. SURVEY FEE Section 429.19(7), Florida Statutes 26. Asurvey fee of $199.87 has been imposed pursuant to Section 429.19(7), as the fine subject of this case was the result of a complaint that was substantiated by the Agency. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $2,500.00 against Respondent on Count I, pursuant to Sections 429.19(2)(b), Florida Statutes (2014). Cc. Assess a survey fee of $199.87 against Respondent pursuant to Section 429.19(7), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2014). Specific options for administrative action are set out in the attached Election of Rights Form. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. ie od Radu oj Assistant General Counsel Agency for Health Care Administration 8333 NW 53” Street, Room 300 Miami, Florida 33166 Copies furnished to: Field Office Manager Agency for Health Care Administration 8333 NW 53" Street, Suite 300 Miami, Florida 33166 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by US. Certified Mail, Return Receipt Requested to Rafael Garcia del Prado, Administrator, Los Afios Dorados, 11461 SW 214" Street, Miami, Florida 33189,on__©/25 __,2015. Alba M. ge = t y 6 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Los Anos Dorados, Inc. AHCA No: 2015005680 ELECTION OF RIGHTS This Election of Rights form is. attached to a proposed 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 must be returned by mail or by fax within 21 days of the day you receive the attached Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed 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 (2008) and Rule 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. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts 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 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 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 Subsection 120.57(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 administrative 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. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. 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: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) [hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC USPS.com® - USPS Tracking™ Page 1 of 1 English Customer Service GSPS Mobile Register! Sign in BaUSPS.COM Customer Service > . Have questions? We're here to heip. USPS Tracking™ = } i ! Get Easy Tracking Updates > Sign up for My USPS. Tracking Number: 70022410000142402834 Product & Tracking Information Available Actions | Postal Product: Features: i Certified Mail” Text Updates i DATE & TIME | STATUS OF ITEM : LOCATION / Email Updates i June 26, 2018 , 4:16 pm H Departed USPS Facility : MIAMI, FL 33162 i “— . — | Your tem departed our USPS facility in MIAMI, FL. 33462 on June 26, 20165 at 4:16 pm. 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Docket for Case No: 15-006627