STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2017008735 Petitioner, License No.: 4045095 File No.: 25910050 v. License Type: Intermediate Care Facility MACTOWN, INC., Respondent. / ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against the Respondent, Mactown, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine of $7,500.00 against an intermediate care facility for the developmentally disabled based upon one class I patterned deficiency. PARTIES 1. The Agency is the licensing and regulatory authority that oversees intermediate care facilities in Florida and enforces the state statutes and rules governing such facilities. Ch. 408, Part Il, Ch. 400, Part VIIL, Fla. Stat. (2016). The Agency may deny, revoke, and suspend any license issued to an intermediate care facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable tules. §§ 408.813, 408.815, Fla. Stat. (2016). In addition to the requirements of part II of Chapter 408, and except as provided in section 400.967(3), a violation of any provision of this part, part II of chapter 408, or applicable rules is punishable by payment of an administrative or civil penalty not to exceed $5,000. § 400.969(1), Fla. Stat. (2016). 2. The Respondent was issued a license by the Agency to operate an intermediate care facility for the developmentally disabled (“the Facility”), and was at all times material required to comply with the applicable statutes and rules governing such facilities. COUNTI Dietary Services 3. Under Florida law, a registered dietician must oversee dietary services and must provide medical nutritional therapy. Fla. Admin. Code R. 59A-26.009(1). Survey Findings 4. On 06/19/2017 through 06/23/2017, the Agency conducted a survey of the Facility. 5: Based upon observation, interview and record review, the Facility failed to ensure appropriate oversight over dietary services and appropriate medical nutritional therapy. As a result, the Facility staff did not have access to sufficient food for a client’s hypoglycemic episode. This failure represented a pattern of noncompliance for which immediate corrective action was necessary in order to prevent serious injury, harm or death. 6. A record review revealed the Client #12 was admitted to the Facility on 08/25/16 with multiple diagnosis, including hypertension, bipolar disorder, hypothyroidism, intellectual disability and diabetes mellitus. The May 13, 2017 Episode 7. A review of the Facility records dated 05/12/2017 at 11:54 P.M., revealed that when the Facility staff was performing room checks, the staff walked into Client #12’s room and witnessed Client #12 having a seizure. 8. The staff paged code blue and 911 was called. Client #12 was transported to a hospital. 9. A review of the hospital emergency/urgent care summary dated 05/13/2017 revealed that Client #12 presented to the Emergency Room (“ER”) and was diagnosed with hypoglycemia — symptomatic. The onset was that day. The course/duration of the symptom was constant. Client #12’s blood sugar was 36 mg/dl and the method of detection was emergency medical services (“EMS”). Client #12’s associated symptom was listed as seizure. Client #12 had had a seizure by the time EMS arrived at the Facility. EMS checked Client #12’s blood sugar, which was low at 36 mg/dl. 10. Client #12 reported a history of diabetes and insulin. Client #12 also reported the last time of eating was at around dinner during the prior night, consisting of a sandwich. 11. A review of the Facility nursing notes dated 05/13/2017 at 9:15 P.M., revealed that the Client's mother was notified about Client #12 being transported to the ER and subsequently returning to the Facility. The mother was also informed that Client #12 was in stable condition. The May 18, 2017 Episode 12. A review of the nursing notes dated 05/18/2017 at 6:05 A.M., revealed that Client #12 was sent to nursing and assessed. 13. Client #12’s blood sugar was 395 mg/dl. The Client complained of a headache, and was given two Tylenol. 14. The staff noted that 911 was called and that EMS arrived due to the Client having low blood sugar and seizure activity. Medications were given as ordered. 15. A review of the nursing notes on the date of the hypoglycemic episodes did not indicate that the Client’s primary care physician had been notified. 16. There were no physician progress notes to indicate the primary care physician was aware of the Client’s incidents. The most recent progress note was dated 03/01/2017. Qualified Intellectual Disabilities Professional — Staff E 17. During an interview with the Qualified Intellectual Disabilities Professional (QIDP”) (Staff E) on 06/22/2017, at approximately 10:30 A.M., the QIDP stated that there was an incident involving a client. Whoever witnesses the occurrence writes the report. 18. All incident reports, regardless of whether they are behavioral or medically related, are reviewed by nursing for evaluation and comments. 19. After they are reviewed by nursing, they come back to the QIDP for additional comments. 20. The QIDP conducts the internal investigation, which includes speaking to all staff present, including the night staff. 21. The Residential Supervisor (Staff F) was present for both incidents involving Client #12 and completed the incident reports. 22. The QIDP interviewed the Residential Supervisor after these two incidents for Client #12 and reviewed the camera footage. 23. It was reported that Client #12's blood sugar was very low when taken by EMS. 24. Client #12 was given fluid intravenously and a snack on 05/18/2017, but refused to go to the ER. 25. | When the nurse came in in at 6 A.M., Client #12’s blood sugar was 395 mg/dl, which was high. 26. On 05/13/2017, EMS checked Client #12’s blood sugar and it was low, so Client #12 was taken to the hospital. This incident started at 11:54 P.M. Client #12 was having a seizure and low blood sugar. 27. The hospital discharge papers indicated that Client #12’s diagnosis was seizures and hypoglycemia. Licensed Practical Nurse — Staff G 28. During interview with the Licensed Practical Nurse (staff G) on 06/22/2017 at 1:46 P.M., she reported that if a client is on sliding scale insulin coverage, it is written on the medication administration record (“MAR”) how often to check their blood sugar level. For example, it will say 7 A.M. and 5 P.M. 29. In addition, the LPN stated that there will be a written prescription that will specify what type of insulin should be given, how much to be given according to the sliding scale and how often to check the client's blood sugar level. 30. The Facility had in-service training on how to recognize signs and symptoms of hypo and hyperglycemia. The LPN was not sure if the direct care staff received this training. 31. | The LPN stated that for an insulin-dependent diabetic client, the parameters are written on the MAR to indicate when the doctor needs to be called for abnormal BS results. 32. On her shift, she checked Client #12's blood sugar once in the morning and gave Client #12 the required coverage based on the sliding scale. 33. The LPN gave Client #12 the base routine Insulin ordered plus the coverage. 34. | When asked when she would alert the doctor regarding Client #12's blood sugar being too high or low, the LPN stated that there were no parameters ordered. For Client #12, the LPN would call for a blood sugar less than 80 or over 490 or so based on her nursing judgment. 35. Upon review of the physician order sheet (POS) with the LPN, the LPN stated that there should be a prescription for how often the blood sugar should be checked, but there was no order. 36. When she checked Client #12’s blood sugar in the morning, she wrote the result on the log. The amount of coverage given was written on the back of the MAR. 37. The LPN stated that she was present on the morning of 05/18/2017 and remembered the night staff reporting Client #12 would not go to the hospital for low blood sugar, so they gave Client #12 food. 38. When the LPN saw Client #12 in the morning at 6:05 A.M., Client #12 reported having a headache. The LPN checked Client #12’s blood sugar and noted it as 395. The LPN gave Client #12 Tylenol and insulin coverage. Residential Supervisor Staff F 39. During an interview with the Residential Supervisor (Staff F) on 06/23/2017 at 8:12 A.M., she said that on 05/18/2017, one of the other staff members called her upstairs. 40. When the Resident Supervisor arrived, she found Client #12 sitting on the floor in another client's room crying and sweating. The Resident Supervisor called 911. 41. Client #12 was acting very strange and confused. Client #12 ran from the room to the exit door. Client #12 said that he or she was hot, then cold. 42. The Residential Supervisor did not see a seizure, but Client #12 was perspiring strongly. 43. When the paramedics arrived, they checked Client #12’s blood sugar and it was 47 mg/dl. 44. EMS started an IV (intravenous therapy) to give Client #12 a sugar boost. 45. EMS said that Client #12 needed something to eat, but the Facility did not have anything available. 46. | There was no back up food for Client #12 to eat. 47. The staff at the Facility did not have access to the kitchen. 48. The only food that the staff had was a Jell-O, but EMS said that Client #12 needed more than that. 49. The staff went out to a fast food restaurant to buy Client #12 two sandwiches. 50. Client #12 was monitored though the night until the nurse came. 51. When EMS left, Client #12’s blood sugar was 400 mg/dl. 52. The Residential Supervisor stated that she had never been trained to handle or even recognize low blood sugar. 53. The staff had no training after two incidents. 54. The Facility now puts food in a small refrigerator in the dining room in case the staff needs something at night. Behavioral Assistant — Staff H 55. During interview with the Behavior Assistant (Staff H) on 06/23/2017 at 8:17 A.M., she said that she works the night shift from 11:45 P.M. to 8:15 A.M. 56. Client #12 went out to the hospital by ambulance on the night of 05/12/2017. 57. The Behavioral Assistant went to the ER with Client #12. We came back home at about 5:00 or 6:00 A.M. The hospital personnel said that Client #12’s blood sugar was very low, which she recalled them saying as in the 30's. 58. The Behavioral Assistant did not have any training to recognize the signs or symptoms of high or low blood sugar. She just reports to the supervisor and calls 911. 59. The Facility does not have a nurse present at night. Registered Dietician 60. During an interview with the Registered Dietitian on 06/23/2017 at 10:50 A.M., she said that the Facility has a refrigerator in the staff break room where the staff keeps Jell-O, fruit and sometimes yogurt. 61. The Facility sends scheduled snacks to certain clients. 62. The Facility had an episode about a month ago with Client #12 who had a hypoglycemic episode. 63. After that incident, the Facility placed a small refrigerator in the dining room where the staff keeps an emergency sandwich and a milk. 64. The staff does not have access to the kitchen at night, but does have access to the emergency refrigerator. 65. This practice was implemented on 05/22/2017 after the incident. 66. The Facility only keeps one sandwich and one container of milk in the refrigerator in case of an emergency. Administrator 67. During an interview with the Facility Administrator on 06/23/2017 at 5:44 P.M., the Administrator reported there are no budgetary constraints related to food. 68. The kitchen is locked at night, but there are snacks available. 69. The clients have an 8 o'clock snack before they go to bed. 70. There was no food available on the night of Client #12’s hypoglycemic episode. 71, The Facility subsequently spoke to the Registered Dietitian and it now has a diabetic snack stocked in the refrigerator in the dining room. 72. The Administrator was made aware there was no food available on the night of the event, but now there is a snack available. 73. The Administrator acknowledged that the Facility needs to make sure there is enough food available for all individuals on insulin, not just one sandwich and one milk. 74. A review of the Facility’s policy and procedure titled "Hypoglycemia" dated November 29, 2000, revealed: 1. PURPOSE 1.1. A recommended standard of care for hypoglycemia, low blood sugar reaction, diagnosis and prompt treatment will be consistent throughout the agency. All hypoglycemic events should be charted on the Blood Glucose Flowsheet as well as the nursing notes and the appropriate physician notified immediately. Please note the sudden changes in mental status could be an indication of hypoglycemia in residents with diabetes. The nursing staff will be able to treat a hypoglycemic reaction when the blood glucose level falls to 60 mg or lower, with or without symptoms using the following format. 2. PROCEDURE 2.1 For individuals who exhibit a conscious reaction, nursing staff will obtain a blood glucose (BG) reading by bedside glucose meter. 2.2 Treat only if blood glucose is 60-80 mg/dl with symptoms; or below 60 even without symptoms. Give 4 ounces of juice if mealtime is less than 1 hour away. If more than 1 hour remains before the meal, treat in a similar fashion and add a protein or bread exchange (snack). Note: (see attached Protocol Table) 2.2.1 Give apple juice to residents with renal disease. 2.2.2. For insulin reactions occurring between the hours of 12 midnight and 4:00 a.m., treat with 4 ounces of juice and one protein and bread exchange. (e.g. 1 oz. cheese and 1 slice of bread) 2.3 Retest the resident’s blood glucose 15 to 30 minutes post treatment, or sooner if warranted, if blood glucose remains 60-80, retreat and again retest 15 to 30 minutes later. 2.4 Recheck blood glucose with a well-calibrated meter. 2.5 If blood glucose remains below 60 mg after two attempts at resolving hypoglycemia, call physician immediately. Chief Executive Officer 15: During an interview with the Chief Executive Officer (CEO) on 06/23/2017 at 5:20 P.M., he said that with respect to staff training, the Facility needed to start doing some proficiency checks for both licensed staff and support staff. 76. The Facility used to have a training calendar, but no longer did any periodic competency training for nursing. The CEO could not answer the question concerning a current training schedule. 77. The Facility’s actions or inactions constituted a Class I patterned deficiency. 78. The Facility was informed of the existence of the Class 1 patterned deficiency and provided and mandatory correction date. Sanction 79. Under Florida law, Class I deficiencies are those which the Agency determines present an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical harm would result therefrom. ... A Class I deficiency is subject to a civil penalty in an amount not less than $5,000 and not exceeding $10,000 for each deficiency. A fine may be levied notwithstanding the correction of the deficiency. § 400.967(3)(a), Fla. Stat. (2016). 80. Under Florida law: 59A-26.003 Classification of Deficiencies. (1) Violations of Chapter 400, Part VIII, and Chapter 408, Part II, F.S., shall be classified according to the nature of the violation and the gravity of its probable effect on clients as required in Section 408.813(2), F.S. Violations shall be classified on the written notice as follows: (a) A class I deficiency is subject to a civil penalty of $5,000 for an isolated deficiency, $7500 for a patterned deficiency and $10,000 for a widespread deficiency. A fine may be levied notwithstanding the correction of the deficiency. 10 (b) A class II deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $3000 for a patterned deficiency and $5,000 for a widespread deficiency. A citation for a class [I deficiency shall specify the time within which the deficiency must be corrected. (c) A class HI deficiency is subject to a civil penalty of $500 for an isolated deficiency, $750 for a patterned deficiency and $1,000 for a widespread deficiency. A citation for a class III deficiency shall’ specify the time within which the deficiency must be corrected. If a class II deficiency is corrected within the time specified, no civil penalty shall be imposed, unless it is a repeated offense. (d) A class IV deficiency is subject to a civil penalty of $100 for an isolated deficiency, $300 for a patterned deficiency and $500 for a widespread deficiency. If a class [V violation is corrected within the time specified, a fine may not be imposed. Fla. Admin. Code R. 59A-26.003 (emphasis supplied). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration. seeks to impose an administrative fine of $7,500.00 against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Makes findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Respectfully Submitted, Teresita A. Vivo, Senior Attorney Florida Bar No. 563056 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, MS #7 Tallahassee, Florida 32308 Telephone: (850) 412-3690 Facsimile: (850) 922-9634 Teresita. Vivo(@ahca.myflorida.com 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 on this | b day of August, 2017. Van" Teresita A. Vivé, Senior Attorney Florida Bar No. 563056 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #7 Tallahassee, Florida 32308 Telephone: (850) 412-3690 Facsimile: (850) 922-9634 Teresita. Vivo(@ahca.myflorida.com Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration (Electronic Mail) Catherine Drake, Administrator Mactown, Inc. 6250 NE First Place Miami, FL 33138 Certified Mail # | 91 7108 2133 3932 8687 2878 Bernard Hudson, Unit Manager Long Term Care Unit Agency for Health Care Administration (Electronic Mail) Catherine Drake, Administrator Mactown, Inc. 151 NE 62nd Avenue Miami, FL 33138 Certified Mail # 91 7108 2133 3932 8687 2861 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: MACTOWN, INC. ACHA No.: 2017008735 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 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. 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 form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title:

Docket for Case No: 18-000652

Orders for Case No: 18-000652