STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. AHCA No.: 2017002182 AVANTE AT ORLANDO, INC. Respondent. / ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against the Respondent, Avante at Orlando, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges as follows: NATURE OF THE ACTION This is an action to impose administrative fines totaling $16,000.00 from a $10,000.00 fine based upon one Class I violation, and a $6,000 fine based upon a 6-month survey cycle; and to affirm conditional licensure status commencing on January 5, 2017 and expiring on May 31, 2018, for the Respondent. PARTIES 1. The Agency is the licensing and regulatory authority that oversees skilled nursing facilities (also called nursing homes) and enforces the state statutes and rules governing such facilities. Ch. 408, Part II, Ch. 400, Part II, Fla. Stat.; Ch. 59A-4, Fla. Admin. Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121, and 400.23, Fla. Stat., (2016), assign a conditional license pursuant to Subsection 400.23(7), Fla. Stat., (2016), and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Fla. Stat., (2016). 2. The Respondent was issued a license by the Agency to operate a nursing home located at 2000 North Semoran Boulevard, Orlando, Florida 32807, and was at all times material required to comply with the applicable statutes and rules governing nursing homes. COUNT I Right to Adequate and Appropriate Health Care 3. Under Florida statutes, in pertinent part: qd) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: * * * dd) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. * * * (n) The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis. (0) The right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety. § 400.022(1)(1), (n), (0), Fla. Stat. (2017). Facts 4. On or about December 27, 2016 to December 30, 2016 the Agency conducted a complaint survey at Respondent’s Facility. 5. Based on interview, record review, and policy review, the Agency determined Respondent’s Facility failed to provide adequate and appropriate care and services for 1 resident (Resident #4). 6. The facility's failure to monitor kidney status to identify the need for hemodialysis resulted in a Class | deficiency, starting on November 8, 2016. 7. On or about December 27, 2016, the Agency reviewed documentation from a long- term care hospital (““LTCH”), dated September 23, 2016, which indicated Resident #4 was hospitalized after a motor vehicle accident and apparent cardiac arrest. The resident was intubated and suffered an Anoxic Brain Injury. 8. Resident #4 was also assessed to be in Acute Renal (kidney) Failure, and in need of hemodialysis. 9. The LTCH history and physical, dated September 28, 2016, indicated the plan was to continue hemodialysis and incorporate the services of Nephrology and monitor the resident for kidney function. 10. On or about December 27, 2016, the Agency reviewed a “Mobil Dialysis Hemodialysis Run Sheet”, which indicated that Resident #4 required dialysis treatments up until the time he/she was admitted to the facility on November 8, 2016, with the exception of a one- time hold order on November 7, 2016. 11. The LTCH's nephrology orders revealed Resident #4's laboratory blood work values (labs) were being closely monitored to for kidney function to determine duration and frequency of the hemodialysis treatments. 12. An LTCH physician’s order, dated November 4, 2016, indicated dialysis was needed three (3) times a week on Monday, Wednesday, and Friday for Resident #4. 13. The LTCH’s nephrology notes, dated November 7, 2016, the day before the resident was transferred to the facility, reflected that the resident's labs showed some signs of kidney recovery, but the resident was still dependent upon hemodialysis. The nephrology order also indicated the resident required potassium supplementation. 14. The LTCH's “Discharge Summary”, dated November 7, 2016, indicated Resident #4 had been closely monitored and would be discharged from the LTC hospital to a Skilled Nursing Facility (SNF). The summary reflected that a discussion was conducted with the family addressing diagnosis of Anemia in Chronic Kidney Disease along with the need for hemodialysis and to be followed by the kidney doctors. The family understood and wished to get the resident to a SNF for further care, including hemodialysis. 15. The Agency reviewed the Resident #4’s medical documentation. 16. The review revealed that Resident #4 was discharged from the LTCH and admitted to Respondent’s Facility November 8, 2016, with diagnoses including Anemia in Chronic Kidney Disease, Dependence on Renal Dialysis, Respiratory Failure, Anoxic Brain Injury, a Pressure Ulcer of the Sacral Region, and Seizures. The Respondent included these diagnoses on their Admission Record. 17. Resident #4's admitting physician orders, dated November 8, 2016, did not contain any documentation that the resident was to receive hemodialysis, and did not contain any orders for labs to monitor kidney function. 18. The resident's admitting nurses’ notes, dated November 8, 2016, did not contain any documentation that the resident was to receive hemodialysis. 19, Resident #4’s admitting care plan, dated November 8, 2016, did not contain documentation that the resident was to receive hemodialysis, and did not contain interventions to guide hemodialysis care and to monitor kidney function. 20. On or about December 27, 2016, the Agency reviewed a physician’s order given by a Nurse Practitioner (“NP”) dated November 9, 2016. 21. The order stated in-house hemodialysis was to begin on Tuesday, Thursday and Saturday starting on November 10, 2016. 22. The order was then discontinued before the resident received dialysis on November 10, 2016, and an order was written to hold hemodialysis for seven days, November 10, 2016 through November 17, 2016. There were no orders for any lab work to monitor kidney function. 23. On or about December 27, 2016 the Agency reviewed the Admitting Minimum Data Set (“MDS”) for Resident #4, dated November 15, 2016. 24. The MDS reflected Resident #4 was assessed to have severely impaired cognitive skills for daily decision making and rarely/never able to understand or be understood. 25. | The MDS stated Resident #4 was bedridden and totally dependent on a staff of two for all activities of daily living. Resident #4 required an indwelling urinary catheter, and was incontinent of bowels. 26. | The MDS included the dependence on kidney dialysis in the diagnosis section of the assessment, but the assessment did not include the resident’s dialysis treatments in the timeframe just prior to admission to Respondent’s Facility. 27. | Onor about December 27, 2016, the Agency interviewed Respondent’s director of nursing (“DON”). 28. The DON explained the process of the facility’s “in-house” hemodialysis treatments, She said, “in order for a resident to receive hemodialysis in-house, the hemodialysis company has to review their records and accept the resident prior to admission. Our hemodialysis company had no record to begin dialysis for Resident #4.” 29. The DON then confirmed the resident was admitted to the facility from a LTCH on November 8, 2016, along with documentation the resident was receiving hemodialysis at the hospital. 30. The DON further stated that the resident’s last treatment for hemodialysis was on November 5, 2016 at the LTCH. She said the discharge orders from the LTCH contained an order to “hold the dialysis on November 7, 2016,” the day before Resident #4 was transferred to the facility from the LTCH. 31. The DON additionally said she spoke with a social worker at the LTCH and the nephrologist, and maintained the patient was removed from hemodialysis based on improved kidney lab values. 32. On or about December 27, 2016 at the Agency interviewed the North Wing Unit Manager Licensed Practical Nurse (“LPN A”). 33. LPN A stated she received the new physician orders regarding hemodialysis for Resident #4, after calling the Facility’s on-call physician. 34, LPN A said the Nurse Practitioner ordered her to start and "hold" the hemodialysis for Resident #4. 35. LPN A further explained she had called the Facility’s on-call physician on November 9, 2016, and received the order to start hemodialysis because she did not see an order for it on the day the resident entered the facility on November 8, 2016. LPN A then said a nurse took the order to hold the hemodialysis for seven (7) days from the Nurse Practitioner on November 10, 2016. 36. LPN A additionally stated that she had called the hemodialysis company who would be performing the in-house hemodialysis treatments, but the hemodialysis company had no record regarding hemodialysis treatment for Resident #4. 37. LPN A finally said she informed the Nurse Practitioner, and he gave her the order to hold dialysis for seven (7) days without any other orders or inquiry. 38. On or about December 28, 2016 the Agency interviewed Nephrologist E, who treated Resident #4 while at the LTCH. 39. Nephrologist E said that he had written the “hold the hemodialysis” order on November 7, 2016 to hold hemodialysis based on Resident #4's laboratory value for creatinine, which was normal at that time. 40. Nephrologist E further stated there was no conversation with the family of Resident #4 regarding the discontinuation of hemodialysis because there would have needed to be more lab work obtained at a later date to make the decision if anymore hemodialysis was necessary. He also indicated he was not made aware of the Resident #4’s discharge to Respondent’s Facility, and would have continued close monitoring, additional lab work, and hemodialysis sessions. 41. On or about December 29, 2016, the Agency interviewed the Respondent’s Admissions Coordinator. 42. The Admissions Coordinator confirmed she received the initial paperwork regarding Resident #4's referral to Respondent’s Facility via fax from the LTCH on November 1, 2016. 43. The Admissions Coordinator said the DON reviews the admission packets. 44. The Admissions Coordinator further stated when a resident comes to the Facility, the resident gets a new nephrologist to follow kidney care. She did not know if the nephrologist was ever contacted regarding Resident #4. 45. On or about December 29, 2016, the Agency interviewed the Respondent’s Nurse Practitioner who gave the dialysis orders for Resident #4. 46. The Nurse Practitioner stated any resident on hemodialysis is closely monitored and if the creatinine levels were becoming stable, the resident would have repeat labs to monitor the kidney function. 47. | The Nurse Practitioner confirmed that he did not order any labs to evaluate Resident #4’s kidney function while the resident was not receiving any dialysis. 48. The Nurse Practitioner further said, after reviewing records from the LTCH on December 29, 2016, that the LTCH’s nephrologist had no intention of stopping Resident #4's hemodialysis. 49. The Nurse Practitioner confirmed that he gave an order for hemodialysis on November 9, 2016, and then to hold hemodialysis on November 10, 2016 for seven (7) days based on the information provided by the facility. 50. | The Nurse Practitioner further stated that he could not find any evidence that would indicate the hemodialysis was to be stopped, and if he had known that the hemodialysis was only on hold on November 7, 2016, he would have ordered a STAT (immediate) nephrology consult. 51. The Nurse Practitioner finally said that he can only base his decisions on the information provided by the facility, and that he did not see Resident #4 until November 15, 2016. 52. On or about December 29, 2016, the Agency reviewed the Nurse Practitioner’s History and Physical, conducted for Resident #4 on November 15, 2016. 53. The History and Physical indicated Resident #4’s medical record, including: medications verified, reviewed, or discussed with nurse; telephone orders reviewed; lab/radiology; and hospital records reviewed. 54. The History and Physical included diagnoses of AKI (acute kidney injury)/CKD (chronic kidney disease) history/of HD (hemodialysis). It did not include any assessment of kidney status or considering the need for hemodialysis. 55. The History and Physical lacked evidence of any orders to check the resident's kidney function even after review of the LTCH records on November 15, 2016. 56. On December 30, 2016 the Agency interviewed Physician F 57. Physician F stated that he vaguely remembered Resident #4 from the LTCH and could not remember if he had spoken with Respondent’s Nurse Practitioner about Resident #4’s health and treatment options. 58. Physician F stated that he would hope the Nurse Practitioner would consult with him prior to providing care and treatment to Resident #4. 59. On or about December 27, 2016, the Agency reviewed Resident #4 wound care evaluation. 60. The evaluations indicated that Resident #4 was seen by the Respondent’s wound care specialist B weekly throughout his/her stay at the Facility. 61. The Wound Care Specialist Evaluation, dated November 9, 2016, indicated Resident #4 was assessed to have a "non-specific rash" and an unstageable (due to necrosis) sacrum wound measuring 8.7 centimeters by 10.3 centimeters. A Surgical Excisional Debridement of Muscle procedure was performed to remove necrotic tissue and establish the margins of viable tissue. 62. The Wound Care Specialist Evaluation dated November 16, 2016, indicated Resident #4 had developed nine additional unstageable wounds: a wound of the left ear; a wound of the right ear; an unstageable deep tissue injury of the left lateral heel; an unstageable deep tissue injury of the left lateral thigh; an unstageable deep tissue injury of the left upper back; an unstageable deep tissue injury of the left lateral neck; a stage 2 pressure wound of the right lateral neck; an unstageable deep tissue injury of the right lateral calf; and an unstageable deep tissue injury of the right lateral head. 63. On or December 28, 2016 the Agency interviewed the Respondent’s Wound Physician regarding Resident #4's change in condition. 64. The Wound Physician stated she saw Resident #4 specifically for wound management. 65. | The Wound Physician described Resident #4 to be in a vegetative state and did not open his/her eyes. 66. | The Wound Physician confirmed the resident was seen by her twice while at the facility. Initially the Wound Physician saw Resident #4 for one pressure ulcer located on the sacral area; and then the following visit, one week later, the Wound Physician stated Resident #4 had developed nine additional wounds. 67. The Wound Physician stated that at that point, the she called Resident #4’s family to discuss the disease process and proposed Resident #4 go to the emergency room versus end of life care. 68. | The Wound Care Physician further stated she was not aware Resident #4 had been on hemodialysis prior to coming to the facility. 69. Upon reviewing the LTCH records, the Wound Care Physician stated that this 10 resident did not have any dialysis treatments for eleven (11) days-- since November 5, 2016. 70. The Wound Care Physician stated not receiving hemodialysis may have contributed to the rapid decline in skin and could explain why Resident #4 had the nine (9) new wounds all over his/her body within a week. 71. The Wound Care Physician said the wounds were Kennedy ulcers. 72. The Wound Care Physician finally stated that she gave the orders to send Resident #4 to the emergency room at 3 P.M. on November 16, 2016. 73. On or about December 27, 2016, the Agency reviewed Resident #4’s Physician Consultation notes, dated November 16, 2016, the day the resident was sent to the hospital from Respondent’s Facility. 74. The review revealed that Resident #4 had "Severe Azotemia and Uremia causing resident to have a change in mental status, Acidosis from possibly End Stage Renal Disease and Missing Dialysis along with Hyperkalemia from Renal Failure and Acidosis.” 75. The Consultation notes indicated the treating physician ordered Resident #4 to begin hemodialysis immediately with the prognosis of "poor" 76. Resident #4 received hospice care within five (5) days of transfer to the acute care hospital on November 21, 2016. 77. Resident #4 died on December 2, 2016. 78. | Onor about December 27, 2016, the Agency reviewed an undated Resident Rights document. 79. The Resident Rights document stated “The resident has the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers.” 80. The Respondent’s staff were unable to provide any policies regarding hemodialysis care and treatment. 81. The Respondent failed to monitor Resident #4’s kidney function and provide life- sustaining hemodialysis. 82. According to record review and interview, the last time Resident #4 received hemodialysis was on November 5, 2016. 83. Resident #4 did not receive any monitoring of kidney function after admission to Respondent’s Facility, and went eleven (11) days without dialysis. 84. The Facility’s actions and inactions as cited constitute a Class I deficiency. Sanction 85. Under Section 400.23 (8) (a), Florida Statutes, in pertinent part, “[a] class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correct.” § 400.23 (8) (a), Fla. Stat. (2016). 86. Under Section 400.23 (a), Florida Statutes, in pertinent part, “A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency.” § 400.23 (8) (a), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $10,000.00 on the Respondent. COUNT II 6 Month Survey Cycle 87. The Agency re-alleges and incorporates by reference the allegations in Count I. 88. Under Florida law: The Agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class II deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. § 400.19(3), Fla. Stat. (2016). 89. The Agency properly cited the Respondent for a class I deficiency and therefore the Respondent is subject to a six-month survey cycle for a period of two years, commencing on January 5, 2017 through January 4, 2019, and a survey fine of $6,000.00 § 400.19(3) Fla. Stat. (2017). WHEREFORE, The Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose a six-month survey cycle for a period of two years and impose a survey fine of $6,000.00. COUNT III Conditional Licensure 90. The Agency re-alleges and incorporates by reference the allegations in Count I. 91. Due to the citation of a Class I deficiency, the Respondent was not in substantial compliance at the time of the survey with Part II of Florida Statute 400 and the rules adopted by the Agency. 92. Under Florida law, a conditional licensure status is assigned to a Facility due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the Agency, leaving the Facility not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the Facility has no class I, class II, or class III deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. § 400.23(7)(b), Fla. Stat. (2016). 93. | The Agency assigned the Respondent conditional licensure status with an action effective date of January 5, 2017, ending date of May 31, 2018. The standard and conditional licenses are attached to this Administrative Compliant as Composite Exhibit A. WHEREFORE, the Agency requests the assignment of a conditional licensure status to Respondent, a nursing facility, in the State of Florida be confirmed pursuant to §400.23(7), Florida Statutes. 14 CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Renders findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Respectfully Submitted, Andrew B. Thornquest, Assistant‘General Counsel Florida Bar No. 0104832 Agency for Health Care Administration 525 Mirror Lake Drive N., Suite #300 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com 15 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 120.573, 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated 3b on this 4 day of 2017, edu. F — stant Gen¢ral Counsel Andrew B. Thornquest, Assi Florida Bar No. 0104832 Agency for Health Care Administration 525 Mirror Lake Drive N., Suite #300 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com 16 Administrator Registered Agent, Avante at Orlando, Inc. Corporation Service Company 4601 Sheridan Street, Suite #500 1201 Hays Street, Suite 105 Hollywood, Florida 33021 Tallahassee, Florida 32301 (Certified Mail- 7016 2140 0001 1591 9687) | (Certified Mail- 7016 2140 0001 1591 9694) 17 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Avante at Orlando, INC ACHA No. 2017002182 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (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 form 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 to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and request a formal hearing (pursuant to Section 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 18 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) [hereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: 19

Docket for Case No: 17-005626