STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos.: 2019004612 2019018094 vs. 2020003566 2020006720 2020009818 WELLSPRINGS RESIDENCE LLC, 2020018539 License No.: 12479 Respondent. Facility Type: ALF / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Wellsprings Residence LLC (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2019), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of sixteen thousand five hundred dollars ($16,500.00) and survey fees in the amount of one thousand dollars ($1,000.00), for a total of seventeen thousand five hundred dollars ($17,500.00), based upon four unclassified deficient practices, four uncorrected Class III deficient practices, and four Class II deficient practices. JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2019). 2. Venue lies pursuant to Rule 28-106.207 of the Florida Administrative Code. PARTIES 35 The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 59A-36, Florida Administrative Code, respectively. 4. Respondent operates a nineteen (19) bed assisted living facility located at 700 East Welch Road, Apopka, Florida 32712, and is licensed as an assisted living facility, license number 12479. 5: Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Section 435.12(2)(b-d), Florida Statutes, provides: (b) Until such time as the fingerprints are enrolled in the national retained print arrest notification program at the Federal Bureau of Investigation, an employee with a break in service of more than 90 days from a position that requires screening by a specified agency must submit to a national screening if the person returns to a position that requires screening by a specified agency. (c) An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. (d) An employer must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee for electronic fingerprint submission to the Department of Law Enforcement. The registration must include the employee’s full first name, middle initial, and last name; social security number; date of birth; mailing address; sex; and race. Individuals, persons, applicants, and controlling interests that cannot legally obtain a social security number must provide an individual taxpayer identification number. 8. On or about November 26, 2018, the Agency completed a complaint investigation survey (#2018011372) of Respondent’s facility. 9. Based upon interview and the review of records by the Agency’s representative, Respondent failed to maintain the employment status of all employees within the background screening clearinghouse, the same being contrary to the mandates of law. 10. The Agency’s representative reviewed Respondent’s personnel records for Staff B and noted that Staff B had a hire date of July 21, 2018 and had an eligible background screening result dated May 7, 2015. 11. The Agency’s representative reviewed the Agency’s background screening website on November 26, 2018, at 9:00 a.m., and noted the following: a. Staff B was not listed on Respondent’s background screening clearinghouse roster; and b. Staff B did have background screening results that were dated May 7, 2015. 12. On or about November 26, 2018, at 3:00 p.m., the Agency’s representative interviewed Respondent’s Administrator who confirmed the Agency representative’s findings. 13. The above reflect Respondent’s failure to maintain the employment status of all employees within the background screening clearinghouse. 14. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider other than class I, class II, class III, or class IV violations and cited Respondent for an unclassified violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(e), Florida Statutes (2019). 6. herein. 7. COUNT II The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth Section 429.26(1, 9), Florida Statutes, Provides: (1) The owner or administrator of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident’s representative or designee or the resident’s family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the department or the Department of Children and Families, the administrator must notify the appropriate contact person in the applicable department. (9) A terminally ill resident who no longer meets the criteria for continued residency may remain in the facility if the arrangement is mutually agreeable to the resident and the facility; additional care is rendered through a licensed hospice, and the resident is under the care of a physician who agrees that the physical needs of the resident are being met. Rule 59A-36.006(4)' of the Florida Administrative Code provides: (4) CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (c) of this subsection, criteria for continued residency in any licensed facility must be the same as the criteria for admission. As part of the continued residency criteria, a resident must have a face-to-face medical examination by a health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change is defined in rule 59A-36.002, F.A.C. The results of the examination must be recorded on AHCA Form 1823, which is incorporated by reference in paragraph (2)(b) of this rule and must be completed in accordance with that paragraph. Exceptions to the requirement to meet the criteria for continued residency are: (a) The resident may be bedridden for no more than 7 consecutive days. (b) A resident requiring care of a stage 2 pressure sore may be retained provided that: 1. The resident contracts directly with a licensed home health agency or a nurse to provide care, or the facility has a limited nursing services license and services are provided pursuant to a plan of care issued by a health care provider, 2. The condition is documented in the resident’s record; and, 3. If the resident’s condition fails to improve within 30 days, as documented by a health care provider, the resident must be discharged from the facility. | Prior to July 1, 2019, Rule 59A-36.006(4) of the Florida Administrative Code was located at Rule S8A-5.0181(4). (c) A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: 1. The resident qualifies for, is admitted to, and consents to receive services from a licensed hospice that coordinates and ensures the provision of any additional care and services that the resident may need; 2. Both the resident, or the resident’s legal representative if applicable, and the facility agree to continued residency; 3. A licensed hospice, in consultation with the facility, develops and implements a interdisciplinary care plan that specifies the services being provided by hospice and those being provided by the facility; and, 4. Documentation of the requirements of this paragraph is maintained in the resident’s file. (d) The facility administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility at all times. (e) A hospice resident that meets the qualifications of continued residency pursuant to this subsection may only receive services from the assisted living facility’s staff which are within the scope of the facility’s license. (f) Assisted living facility staff may provide any nursing service permitted under the facility’s license and total help with the activities of daily living for residents admitted to hospice; however, staff may not exceed the scope of their professional licensure or training. (g) Continued residency criteria for facilities holding an extended congregate care license are described in rule 59A-36.021, F.A.C. On or about June 12, 2019, the Agency conducted a re-licensure survey of Respondent’s facility. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to update a resident’s Health Assessment Form after a significant change in condition and failed to ensure that a licensed hospice, in consultation with the facility, developed and implemented an interdisciplinary care plan that specifies the services being provided by hospice and those being provided by the facility, the same being contrary to the mandates of law. The Agency’s representative reviewed Respondent’s records for Resident #1 and noted the following: a. Resident #1 was admitted to Respondent’s facility on September 6, 2016; b. a hospice admission notification to Respondent, dated March 18, 2019, indicated that Resident #1 was admitted to hospice services; c. Resident #1’s Health Assessment Form 1823 was dated December 20, 2018, and there was no new Health Assessment Form 1823 obtained after Resident #1 was admitted to hospice, which indicates a significant change in condition; and d. Resident #1’s records did not contain an interdisciplinary care plan developed and implemented by hospice, in consultation with the facility, as required. 12. On or about June 12, 2019, at 2:15 p.m., the Agency’s representative interviewed Respondent’s Administrator who confirmed the Agency representative’s findings. 13. The above reflects Respondent’s failure to update a resident’s Health Assessment Form after a significant change in condition and failed to ensure that a licensed hospice, in consultation with the facility, developed and implemented an interdisciplinary care plan that specifies the services being provided by hospice and those being provided by the facility. 14. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 15. The same constitutes a Class III offense, and Respondent was cited with a Class III deficient practice. 16. A provider must correct a deficient practice within thirty (30) days. See § 408.811(4), Fla. Stat. (2019). 17. On or about August 7, 2019, the Agency conducted a revisit to the June 2019 survey of Respondent’s facility. 18. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to ensure that a licensed hospice, in consultation with the facility, developed and implemented an interdisciplinary care plan that specifies the services being provided by hospice and those being provided by the facility, the same being contrary to the mandates of law. 19. The Agency’s representative reviewed Respondent’s records for Resident #8 and noted the following: a. Resident #8 was admitted to hospice services on April 6, 2018; and b. Resident #8’s record did not contain an interdisciplinary care plan, as required. 20. On or about August 7, 2019, at 11:15 am., the Agency’s representative interviewed Respondent’s Administrator who confirmed the Agency representative's findings. 21. The above reflects Respondent’s failure to ensure that a licensed hospice, in consultation with the facility, developed and implemented an interdisciplinary care plan that specifies the services being provided by hospice and those being provided by the facility. 22. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 23. The same constitutes an uncorrected Class III deficiency, and Respondent was cited with a Class III deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(c), Florida Statutes (2019). COUNT Il 24. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. Florida law provides: 5) MEDICATION RECORDS. (a) For residents who use a pill organizer managed in subsection (2), the facility must keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider’s name, the resident’s name, the date dispensed, the name and strength of the drug, and the directions for use. (b) The facility must maintain a daily medication observation record for each resident who receives assistance with self-administration of medications or medication administration. A medication observation record must be immediately updated each time the medication is offered or administered and include: 1. The name of the resident and any known allergies the resident may have; 2. The name of the resident’s health care provider and the health care provider’s telephone number; 3. The name, strength, and directions for use of each medication; and, 4. A chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. (c) For medications that serve as chemical restraints, the facility must, pursuant to section 429.41, F.S., maintain a record of the prescribing physician’s annual evaluation of the use of the medication. Rule 59A-36.008(5), Florida Administrative Code. 26. On or about June 12, 2019, the Agency conducted a biennial re-licensure survey upon Respondent’s facility. 27. Based on the electronic medication observation record (MOR) review and interview, the facility failed to maintain an accurate MOR for 1 of 2 sampled residents (Resident #3) who received assistance with the self-administrator of medications, the same being contrary to the mandates of law. 28. On 6/12/19 at 12 PM, Staff C said she had worked at the facility for about 90 days and was in training. She said she had not received her medications training. 29. Review of the June MOR for Resident #3 revealed Staff C's initials were documented on the MOR as assisting with the resident's medications as follows: Acetaminophen 500 milligrams (mg) one twice daily at 9 AM on 6/7 and 7 PM on 6/6 and 6/11 Amlodipine Besylate 10 mg -1 daily at 9 AM on 6/7 Atorvastatin Calcium 10 mg at 7 PM on 6/6 and 6/11 Calcium Magnesium and Zinc over the counter at 9 AM on 6/7 Chlorthalidone 50 mg 2 once daily at 9 AM on 6/7 Complete Multivitamin over the counter at 9 AM on 6/7 Fish Oil 500 mg soft gel over the counter at 9 AM on 6/7 Labetalol HCL 300 mg one twice daily at 9 AM on 6/7 and at 7 PM on 6/6 and 6/11 Losartan Potassium 100 mg one daily at 9 AM on 6/7 30. On6/7/19 at 3 PM Staff C said she would shadow other caregivers when the medications were given at 7 PM and she did not assist the resident with her medications, she said when the other caregivers assisted the resident with her medications she would sign the electronic MOR using her initials not the staff who actually assisted with the medication as required. Staff C further stated that during the mornings at 9 AM, she would shadow the Administrator (a nurse) who would administer the medications and she would sign the electronic MOR as given although she did not assist with the medications. 31. On 6/12/19 at 3:30 PM, the Administrator said she was training Staff C to do the medications, she said Staff C did not assist the residents with their medications because she did not have the medication training. The Administrator said she actually administered the medications to the resident and Staff C would sign the electronic MOR's. 32. | The Administrator was informed at the time by Agency’s representative that the MORs did not accurately reflect who gave the medications. She was informed that whoever assisted or administered the medications was the one required to sign the electronic MOR. 33. The above reflects Respondent’s failure to maintain an accurate MOR for 1 of 2 sampled residents (Resident #3) who received assistance with the self-administrator of medications, the same being contrary to the mandates of law. 34. | The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 35, The same constitutes a Class II] offense, and Respondent was cited with a Class III deficient practice. 36. A provider must correct a deficient practice within thirty (30) days. See § 408.811(4), Fla. Stat. (2019). 37. On or about August 7, 2019, the Agency conducted a revisit to the June 2019 biennial survey of Respondent’s facility. 38. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to ensure the Medication Observation Record (MOR) for 1 of 4 sampled residents (Resident #1) was properly updated, the same being contrary to the mandates of law. 39, Resident #1's current 1823 health assessment form, dated 7/15/19, indicated that she requires assistance with self-administration of medications. A review of her July 2019 MOR revealed that on 7/31 both her Furosemide and Potassium Chloride were not signed as given. Neither the MOR nor her record contained documentation to indicate why. 40. On 8/07/19 at 12:33 p.m. the Administrator confirmed the finding and was unable to provide additional documentation. {Photographic evidence obtained}. 10 41. The above reflects Respondent’s failure to ensure the Medication Observation Record (MOR) for ! of 4 sampled residents (Resident #1) was properly updated, the same being contrary to the mandates of law. 42. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 43. The same constitutes an uncorrected Class III deficiency, and Respondent was cited with a Class III deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred doilars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(c), Florida Statutes (2019). COUNT IV 44. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 45. That Florida law provides: (2) STAFF PRESERVICE ORIENTATION. (a) Facilities must provide a preservice orientation of at least 2 hours to all new assisted living facility employees who have not previously completed core training as detailed in subsection (1). (b) New staff must complete the preservice orientation prior to interacting with residents. (c) Once complete, the employee and the facility administrator must sign a statement that the employee completed the preservice orientation which must be kept in the employee’s personnel record. (d) In addition to topics that may be chosen by the facility administrator, the preservice orientation must cover: 1. Resident’s rights; and, 2. The facility’s license type and services offered by the facility. (3) STAFF IN-SERVICE TRAINING. Facility administrators or managers shall provide or arrange for the following in-service training to facility staff: (a) Staff who provide direct care to residents, other than nurses, certified nursing assistants, or home health aides trained in accordance with rule 59A-8.0095, F.A.C., 11 must receive a minimum of | hour in-service training in infection control, including universal precautions and facility sanitation procedures, before providing personal care to residents. The facility must use its infection control policies and procedures when offering this training. Documentation of compliance with the staff training requirements of 29 CFR 1910.1030, relating to blood borne pathogens, may be used to meet this requirement. (b) Staff who provide direct care to residents must receive a minimum of 1 hour in- service training within 30 days of employment that covers the following subjects: 1. Reporting adverse incidents. 2. Facility emergency procedures including chain-of-command and staff roles relating to emergency evacuation. (c) Staff who provide direct care to residents, who have not taken the core training program, shall receive a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1, Resident rights in an assisted living facility. 2. Recognizing and reporting resident abuse, neglect, and exploitation. The facility must use its abuse prevention policies and procedures when offering this training. (d) Staff who provide direct care to residents, other than nurses, CNAs, or home health aides trained in accordance with rule 59A-8.0095, F.A.C., must receive 3 hours of in- service training within 30 days of employment that covers the following subjects: 1. Resident behavior and needs. 2. Providing assistance with the activities of daily living. (e) Staff who prepare or serve food, who have not taken the assisted living facility core training must receive a minimum of 1-hour-in-service training within 30 days of employment in safe food handling practices. (f) All facility staff shall receive in-service training regarding the facility’s resident elopement response policies and procedures within thirty (30) days of employment. 1, All facility staff shall be provided with a copy of the facility’s resident elopement response policies and procedures. 2. All facility staff shall demonstrate an understanding and competency in the implementation of the elopement response policies and procedures. 46. (12) TRAINING DOCUMENTATION AND MONITORING. (a) Except as otherwise noted, certificates, or copies of certificates, of any training required by this rule must be documented in the facility’s personnel files. The documentation must include the following: 1. The title of the training program, 2. The subject matter of the training program, 3. The training program agenda, 4. The number of hours of the training program, 5. The trainee’s name, dates of participation, and location of the training program, 6. The training provider’s name, dated signature and credentials, and professional license number, if applicable. (b) Upon successful completion of training pursuant to this rule, the training provider must issue a certificate to the trainee as specified in this rule. (c) The facility must provide the Department of Elder Affairs and the Agency for Health Care Administration with training documentation and training certificates for review, as requested. The department and agency reserve the right to attend and monitor all facility in-service training, which is intended to meet regulatory requirements. Rule 59A-36.011(2), (3), and (12), Florida Administrative Code. 47. On or about June 12, 2019, the Agency conducted a biennial re-licensure survey of Respondent's facility. 48. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to ensure that three (3) of four (4) sampled staff (Staff A, B and C) received the required in-service training, the same being contrary to the mandates of law. 49. That the personnel record review for Staff A, a caregiver hired 8/31/17 revealed there was no documentation to confirm she had completed a training that covered the facility's emergency procedures including chain-of-command and staff roles relating to emergency evacuation. 50. That the personnel record review for Staff B, a caregiver hired 4/1/19 revealed a certificate for the pre-service orientation that was for 8 hours, the certificate was not dated and was not signed by Staff B. Further personnel record review for Staff B, revealed a certificate for abuse training dated 6/11/19 that was an online training. There was no documentation to confirm that she had received training on the facility's abuse prevention policies and procedures, facility's resident elopement response policies and procedures and training that covered the facility's emergency procedures including chain-of-command and staff roles relating to emergency evacuation. 51. That the personnel record review for Staff C, a caregiver hired 1/1/19 revealed a certificate for the pre-service orientation that was for 4 hours, the certificate was not dated and was not signed by Staff C. Further personnel record review for Staff C, revealed a certificate for 13 abuse training certificate and a certificate for elopement training that were both dated 12/6/18 and was an online training. There was no documentation to confirm that she had received training on the facility's abuse prevention policies and procedures, or the facility's resident elopement response policies. 52. That on 6/12/19 at 2:30 PM, the Administrator was provided the opportunity to provide the above trainings. 53. That on 6/12/19 at 3:30 PM, the Administrator presented pre-service orientation certificates for Staff B that was dated 3/13/19 and now included Staff B's signature on it and also for Staff C that was dated 11/16/18 that included Staff C's signature. 54. That the Administrator said on 6/12/19 at 3:30 PM she had both Staff B and C sign the certificates the day of the survey and used past dates because that was when the training was provided. 55. That the Administrator said at the time she could not provide any additional training. 56. The above reflects Respondent’s failure to ensure that three (3) of four (4) sampled staff (Staff A, B and C) received the required in-service training, the same being contrary to the mandates of law. 57. | The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 58. | The same constitutes a Class III offense, and Respondent was cited with a Class III deficient practice. 59. A provider must correct a deficient practice within thirty (30) days. See § 408.811(4), Fla. Stat. (2019). 14 60. On or about August 7, 2019, the Agency conducted a revisit to the June 2019 survey of Respondent's facility. 61. Based upon interviews and the review of records by the Agency’s representative, Respondent failed to ensure that two (2) of three (3) sampled staff (Staff C and F) received the required in-service training as described in S8A-5.0191(2-3) FAC. 62. That Caregiver C was hired on 1/01/19. Her personnel record contained documentation of a 2-hour pre-service orientation, dated 7/12/19. 63. That Caregiver F was hired on 7/05/19. Her personnel record contained documentation of a 2-hour pre-service orientation, dated 7/05/19. 64. | However, neither of their trainings was signed by the Administrator, as required. 65. That on 8/07/19 at 12:10 PM the Administrator confirmed the findings and was unable to provide additional documentation. {Photographic evidence obtained. } 66. The above reflects Respondent's failure to ensure that two (2) of three (3) sampled staff (Staff C and F) received the required in-service training as described in 58A-5.0191(2-3) FAC. 67. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 68. | The same constitutes an uncorrected Class III deficiency, and Respondent was cited with a Class III deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(c), Florida Statutes (2018). 15 69. herein. 70. COUNT V The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth That Florida law provides: (2) STAFF. (a) Within 30 days after beginning employment, newly hired staff must submit a written statement from a health care provider documenting that the individual does not have any signs or symptoms of communicable disease. The examination performed by the health care provider must have been conducted no earlier than 6 months before submission of the statement. Newly hired staff does not include an employee transferring without a break in service from one facility to another when the facility is under the same management or ownership. 1. Evidence of a negative tuberculosis examination must be documented on an annual basis. Documentation provided by the Florida Department of Health or a licensed health care provider certifying that there is a shortage of tuberculosis testing materials satisfies the annual tuberculosis examination requirement. An individual with a positive tuberculosis test must submit a health care provider’s statement that the individual does not constitute a risk of communicating tuberculosis. 2. If any staff member has, or is suspected of having, a communicable disease, such individual must be immediately removed from duties until a written statement is submitted from a health care provider indicating that the individual does not constitute a risk of transmitting a communicable disease. (b) Staff must be qualified to perform their assigned duties consistent with their level of education, training, preparation, and experience. Staff providing services requiring licensing or certification must be appropriately licensed or certified. All staff must exercise their responsibilities, consistent with their qualifications, to observe residents, to document observations on the appropriate resident’s record, and to report the observations to the resident’s health care provider in accordance with this rule chapter. (c) All staff must comply with the training requirements of rule S8A-5.0191, F.A.C. (d) An assisted living facility contracting to provide services to residents must ensure that individuals providing services are qualified to perform their assigned duties in accordance with this rule chapter. The contract between the facility and the staffing agency or contractor must specifically describe the services the staffing agency or contractor will provide to residents. (e) For facilities with a licensed capacity of 17 or more residents, the facility must: 1. Develop a written job description for each staff position and provide a copy of the job description to each staff member; and, 2. Maintain time sheets for all staff. (f) Level 2 background screening must be conducted for staff, including staff contracted by the facility to provide services to residents, pursuant to sections 408.809 and 429.174, F.S. 16 R. 59A-36.010(2), Fla. Admin. Code. 71. On or about June 12, 2019, the Agency conducted a biennial re-licensure survey of Respondent’s facility. 72. Based upon on personnel record reviews and interview, the facility failed to ensure 2 of 4 sampled staff (Staff B and C) submitted a written statement from a health care provider documenting freedom from communicable diseases within 30 days after beginning employment and failed to ensure staff were qualified to perform their assigned duties consistent with their level of education, training, preparation, and experience by allowing 1 of 3 unlicensed caregivers (Staff C) to assist a resident (#1) with self-administered medications prior to receiving the required training, the same being contrary to the mandates of law. 73. That Caregiver B was hired on 4/01/19. 74. That Caregiver C was hired on 1/01/19. 75. That neither of their personnel records contained a written statement from a health care provider documenting freedom from communicable diseases, as required. 76. That in addition, Caregiver C's initial 4-hour training on assistance with self- administration of medications was dated 6/08/19 however, review of Resident #1's May 2019 Medication Observation Record (MOR) revealed that she signed the medications as being given on 5/01, 5/08, 5/09, 5/15, 5/17, 5/22, 5/23, 5/27, and 5/31. 77. That on 6/12/19 at 3:15 PM both the Human Resource Director and Administrator confirmed the findings and the Administrator said Caregiver C assisted Resident #1 with medications prior to receiving the required initial training. {photographic evidence obtained. } 17 78. The above reflects Respondent’s failure to ensure 2 of 4 sampled staff (Staff B and C) submitted a written statement from a health care provider documenting freedom from communicable diseases within 30 days after beginning employment and failed to ensure staff were qualified to perform their assigned duties consistent with their level of education, training, preparation, and experience by allowing 1 of 3 unlicensed caregivers (Staff C) to assist a resident (#1) with self-administered medications prior to receiving the required training, the same being contrary to the mandates of law. 79. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 80. The same constitutes a Class III offense, and Respondent was cited with a Class III deficient practice. 81. A provider must correct a deficient practice within thirty (30) days. See § 408.811(4), Fla. Stat. (2019). 82. Onor about August 7, 2019, the Agency conducted a revisit to the June 2019 survey of Respondent’s facility. 83. Based upon interviews and the review of personnel records by the Agency’s representative, Respondent failed to ensure 1 of 2 sampled staff (Staff C) submitted a written statement from a health care provider documenting freedom from communicable diseases within 30 days after beginning employment, the same being contrary to the mandates of law. 84. | That Caregiver C was hired on 1/01/19. Her personnel record did not contain a written statement from a health care provider documenting freedom from communicable diseases, as required. 18 85. That on 8/07/19 at 12:34 PM the Administrator confirmed the finding and was unable to provide additional documentation. 86. | The above reflects Respondent’s failure to ensure 1 of 2 sampled staff (Staff C) submitted a written statement from a health care provider documenting freedom from communicable diseases within 30 days after beginning employment, the same being contrary to the mandates of law. 87. | The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 88. The same constitutes an uncorrected Class III deficiency, and Respondent was cited with a Class Ill deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(2)(c), Florida Statutes (2018). COUNT VI 89. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count I above as if fully set forth herein. 90. That Unannounced Complaint Investigations #2019016716 and #2019016180 were conducted 11/8/2019 upon Respondent. 91. That based upon record review and interview, the facility failed to ensure all employees were listed on the background screening roster. 92. That on 11/08/19 at 7:40 AM, Staff E stated the maintenance for the facility is conducted by Staff F. Staff E stated he does the work inside the facility. 19 93. That on 11/08/19 at 12:25 PM, the Administrator stated Staff F works for their property management company which provides maintenance and lawn care at the facility. 94. — That on 11/08/19 at 12:45 PM, Staff F stated he works for the facility and is paid by the facility. Staff F stated his maintenance duties include lawn care, changing a/c filters and work inside of the facility around residents. 95. That a review of the facility background-screening roster found that Staff F's end date from the facility roster was 11/03/19. 96. That a review of the State of Florida Sunbiz web site found that the property management company that Staff E states Staff F works for is controlled by the owners of the facility, Staff E and the Administrator, and shows the same physical address. 97. The Respondent’s actions or inactions constituted a violation of §§ 429.174 and 408.809, Florida Statutes (2018), and the Respondent was cited with an unclassified deficient practice. 98. Under Florida law, in addition to the requirements of Part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2019). 99, Under Florida law, regardless of the class of violation cited, instead of the fine amounts listed in paragraphs (a)-(d), the agency shall impose an administrative fine of $500 if a facility is found not to be in compliance with the background screening requirements as provided in s. 20 408.809. § 429.19(2)(e), Fla. Stat. (2019). 100. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2019). 101. The Agency cited Respondent for an unclassified violation. 102. That the same constitutes an unclassified deficiency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of five hundred dollars ($500.00) against the Respondent an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2019). COUNT VII 103. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 104. Under Florida law, the Agency shall require level 2 background screening for personnel as required in § 408.809(1)(e) pursuant to Chapter 435 and Section 408.809. § 429.174, Fla. Stat. (2019). 105. Under Florida law, level 2 background screening pursuant to Chapter 435 must be conducted through the Agency on each of the following persons, who are considered employees for the purposes of conducting screening under Chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the Agency has reason to believe that such person has been convicted of any offense prohibited by Section 435.04. For each controlling interest who has been convicted of any such offense, the 21 licensee shall submit to the Agency a description and explanation of the conviction at the time of license application. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor’s employer or the licensee. § 408.809(1), Fla. Stat. (2019). 106. Under Florida law, every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person’s fingerprints to the Federal Bureau of Investigation for a national criminal history record check unless the person’s fingerprints are enrolled in the Federal Bureau of Investigation’s national retained print arrest notification program. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h), the person must submit fingerprints electronically to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints shall be retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h) and enrolled in the national retained print arrest notification program when the Department of Law Enforcement begins participation in the program. The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. Until a specified agency is fully implemented in the clearinghouse created under s. 435.12, the agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Department of Elderly Affairs, the Agency for Persons with Disabilities, the Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, 22 provided that: (a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s. 435.04 and this section; (b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and (c) Such proof is accompanied, under penalty of perjury, by an attestation of compliance with chapter 435 and this section using forms provided by the agency. (3) All fingerprints must be provided in electronic format. Screening results shall be reviewed by the agency with respect to the offenses specified in s. 435.04 and this section, and the qualifying or disqualifying status of the person named in the request shall be maintained in a database. The qualifying or disqualifying status of the person named in the request shall be posted on a secure website for retrieval by the licensee or designated agent on the licensee’s behalf. § 408.809(2), Fla. Stat. (2019). 107. Under Florida law, in addition to the offenses listed in Section 435.04, all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the offenses or any similar offense of another jurisdiction listed in Section 408.809(4). § 408.809(4), Fla. Stat. (2019). 108. Under Florida law, if an employer or Agency has reasonable cause to believe that grounds exist for the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity. § 435.06(1), Fla. Stat. (2019). 109. Under Florida law, (a) an employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the 23 employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the Agency as provided under Section 435.07. (b) If an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to Section 435.07. (d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. § 435.06(2){a) - (d), Fla. Stat. (2019). 110. Under Florida law, any employee who refuses to cooperate in such screening or refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. § 435.06(3), Fla. Stat. (2019). 111. Under Florida law, Level 2 background screening must be conducted for staff, including staff contracted by the facility to provide services to residents, pursuant to Sections 408.809 and 429.174, F.S. Rule 58A-5.019(3)(f), Florida Administrative Code. 112. Under Florida law, a person who serves as a controlling interest of, is employed by, or contracts with a licensee on July 31, 2010, who has been screened and qualified according to standards specified in s. 435.03 or s. 435.04 must be rescreened by July 31, 2015, in compliance with the following schedule. If, upon rescreening, such person has a disqualifying offense that was not a disqualifying offense at the time of the last screening, but is a current disqualifying offense and was committed before the last screening, he or she may apply for an exemption from the appropriate licensing agency and, if agreed to by the employer, may continue to perform his or her duties until the licensing agency renders a decision on the application for exemption if the person is eligible to apply for an exemption and the exemption request is received by the agency 24 within 30 days after receipt of the rescreening results by the person. The rescreening schedule shall be: (a) Individuals for whom the last screening was conducted on or before December 31, 2004, must be rescreened by July 31, 2013. (b) Individuals for whom the last screening conducted was between January 1, 2005, and December 31, 2008, must be rescreened by July 31, 2014. (c) Individuals for whom the last screening conducted was between January 1, 2009, through July 31, 2011, must be rescreened by July 31, 2015. § 408.809(5), Fla. Stat. (2019). 113. Under Florida law, “Staff’ means any person employed by a facility; or contracting with a facility to provide direct or indirect services to residents; or employees of firms under contract to the facility to provide direct or indirect services to residents when present in the facility. The term includes volunteers performing any service which counts toward meeting any staffing requirement of this rule chapter. Rule 58A-5.0131(34), Florida Administrative Code. 114. That Unannounced Complaint Investigations #2019016716 and #2019016180 were conducted 11/8/2019 upon Respondent. 115. That based on record review and interview, the facility placed residents at-risk by failing to ensure two staff members had successfully completed the required level 2 background- screenings (Staff N and O), contrary to the mandates of law. 116. That on 11/08/19 at 7:40 AM, the employment file for Staff N was requested. The Administrator stated they could not provide an employment file for Staff N because he does not work for the facility but rather their property management company. Staff E stated he is paid by the property management company and could provide proof. 117. That a review of the State of Florida Sunbiz web site found that the property management company Staff E stated Staff N works for is controlled by the owners of the facility, Staff E and the Administrator, and shows the same physical address. 118. That on 11/08/19 at 11 AM, Staff N stated, "He did inside work at the facility on the a/c unit's, but staff would always watch him." Staff N stated he is paid cash by Staff E for his work. 25 Staff N stated the Administrator and Staff E are aware of his arrest for domestic violence but did not think they were aware of his conviction for lewd and lascivious behavior on a child. Staff N stated he did not know what his last day was at the facility but could confirm he was inside the building on 11/07/19 doing work. 119. Review of the Agency for Health Care Administration's (AHCA) background screening found that Staff N was not cleared to work at a facility. 120. That on 11/08/19 at 1:40 PM, Participant H, an AHCA analyst, confirmed Staff N was not cleared to work at any AHCA licensed facility. 121. That on 11/08/19 at 12:25 PM, the Administrator stated she was aware Staff O did not have a cleared level 2 background screen. The Administrator stated Staff O is a cook and does not have access to residents. The Administrator stated Staff O does not require a level 2 background screening. 122. That on 11/08/19 at 8:05 AM, Participant I, an AHCA analyst, stated Staff O's level 2 background screen was not cleared by AHCA because of prohibited offenses. 123. That on 11/08/19 at 12:30 PM, on the facility employee board, located for residents and families to see pictures of all the employees, Staff O's picture was on display (photographic evidence #1). 124. That on 11/08/19 at 12:36 PM, Staff L stated she is on the dietary staff and works with Staff O. Staff L stated they help serve meals to residents. 125. The Respondent’s actions or inactions constituted a violation of §§ 429.174 and 408.809, Florida Statutes (2018), and the Respondent was cited with an unclassified deficient practice. 126. Under Florida law, in addition to the requirements of Part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative 26 fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2019). 127. Under Florida law, regardless of the class of violation cited, instead of the fine amounts listed in paragraphs (a)-(d), the agency shall impose an administrative fine of $500 if a facility is found not to be in compliance with the background screening requirements as provided in s. 408.809. § 429.19(2)(e), Fla. Stat. (2019). 128. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2019). 129. The Agency cited Respondent for an unclassified violation. 130. That the same constitutes an unclassified deficiency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of one thousand dollars ($1,000.00) against the Respondent an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2019). 27 COUNT VIII 131. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count VI and VII above as if fully set forth herein. 132. Pursuant to section 429.19(7), Florida Statutes (2019), “[iJn addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or five hundred dollars ($500), to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted to verify the correction of the violations.” 133. Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2019). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(7), Florida Statutes (2019). COUNT IX 134. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count VII above as if fully set forth herein. 135. That an unannounced Revisit to Complaint Investigations #2019016716 and #2019016180 was conducted on 1/22/2020 and 2/04/2020 upon Respondent. 136. That based on record reviews, interviews and observations, the facility placed residents at-risk by failing to ensure two staff members had successfully completed the required level 2 background screening (Staff N & O), contrary to the mandates of law. 28 137. That on 1/21/2020, in preparation for the complaint revisit at the facility, a record review of the level 2 background screening web site was conducted. The web site reflected that Staff N and Staff O had not completed level 2 background screens as noted in the prior citation. 138. That on 1/22/2020 at 11:20 AM, Staff R stated Staff N does the building maintenance and Staff O works as the cook. 139. That on 1/22/2020 at 11:25 AM, Staff O's picture had been removed from the display of employee photos. While touring the kitchen, Staff O was working at preparing lunch. 140. That on 1/22/2020 at 12:15 PM, Staff O stated he is responsible for cooking the meals. Staff O stated he does have resident interaction while they are in the dining room by helping with set up, especially in the morning and talking with residents about what foods they like and if they were pleased with the meal. Staff O stated the morning set up is done alone. 141. That on 1/22/2020 at 12:25 PM, Resident #5 stated Staff N is in the building, is not sure what he does but he has been in the building since Christmas. 142. That on 1/22/2020 at 12:35 PM, Resident #6 stated she has seen Staff N in the building working on projects like cleaning. Resident #6 stated it was sometime after Christmas. 143. That on 1/22/2020 at 1 PM, the Administrator denied Staff N works in the building but did say regarding that "He comes into the building to work on projects, but they provide close supervision." The Administrator would not provide any contact information for Staff N. 144. That on 2/04/2020 at 6:40 AM, Staff O was observed setting up the dining room for breakfast, making coffee and cooking the breakfast meal. 145. That on 2/04/2020 at 6:57 AM, Resident #9 stated they have seen Staff N in the building, is not sure what he does but he has been in the building since Christmas. 29 146. That on 2/04/2020 at 7:20 AM, the Administrator was asked about contact information for Staff N. The Administrator stated Staff N works for Staff E and they would have to provide any information. The Administrator stated Staff E runs the private property management company which is owned by the Administrator and Staff E. Staff E was called, and stated he would not provide any additional information about Staff N. 147. The above reflects that Respondent failed to ensure two staff members had successfully completed the required level 2 background screening (Staff N & O), contrary to the mandates of law. 148. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class [ violations. 149. That the same constitutes a Class II offense as defined in § 408.813(2)(b), Florida Statutes (2019). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2019). COUNT X 150. The Agency re-alleges and incorporates paragraphs (1) through (5) above as if fully set forth herein. 151. That Florida law provides: (1)(a) A resident shall be given the option of using his or her own belongings, as space permits; choosing his or her roommate; and, whenever possible, unless the resident is adjudicated incompetent or incapacitated under state law, managing his or her own affairs. (b) The admission of a resident to a facility and his or her presence therein shall not confer on the facility or its owner, administrator, employees, or representatives any authority to manage, use, or dispose of any property of the resident; nor shall admission 30 152; or presence confer on any such persons any authority or responsibility for the personal affairs of the resident, except that which may be necessary for the safe management of the facility or for the safety of the resident. § 429.27, Florida Statutes (2019). That Florida law states: (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: (a) Live ina safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. (d) Unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall make provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar situations. (e) Freedom to participate in and benefit from community services and activities and to pursue the highest possible level of independence, autonomy, and interaction within the community. (f) Manage his or her financial affairs unless the resident or, if applicable, the resident’s representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide safekeeping for funds as provided in s.429.27. (g) Share a room with his or her spouse if both are residents of the facility. (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. (i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any resident. (j) Assistance with obtaining access to adequate and appropriate health care. For purposes of this paragraph, the term “adequate and appropriate health care” means the management of medications, assistance in making appointments for health care services, the provision of or arrangement of transportation to health care appointments, and the performance of health care services in accordance with s. 429.255 which are consistent with established and recognized standards within the community. 31 153. (k) At least 45 days’ notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 45 days’ notice of a nonemergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show good cause in a court of competent jurisdiction. (1) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. (2) The administrator of a facility shall ensure that a written notice of the rights, obligations, and prohibitions set forth in this part is posted in a prominent place in each facility and read or explained to residents who cannot read. The notice must include the statewide toll-free telephone number and e-mail address of the State Long-Term Care Ombudsman Program and the telephone number of the local ombudsman council, the Elder Abuse Hotline operated by the Department of Children and Families, and, if applicable, Disability Rights Florida, where complaints may be lodged. The notice must state that a complaint made to the Office of State Long-Term Care Ombudsman or a local long-term care ombudsman council, the names and identities of the residents involved in the complaint, and the identity of complainants are kept confidential pursuant to s. 400.0077 and that retaliatory action cannot be taken against a resident for presenting grievances or for exercising any other resident right. The facility must ensure a resident’s access to a telephone to call the State Long-Term Care Ombudsman Program or local ombudsman council, the Elder Abuse Hotline operated by the Department of Children and Families, and Disability Rights Florida. § 429.28(1) and (2), Florida Statutes (2019). That Florida law also provides: (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Program must be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to rule 59A-36.006, F.A.C. (b) In accordance with section 429.28, F.S., the facility must have a written grievance procedure for receiving and responding to resident complaints and a written procedure to allow residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a 32 complaint. (c) The telephone number for lodging complaints against a facility or facility staff must be posted in full view in a common area accessible to all residents. The telephone numbers are: the Long-Term Care Ombudsman Program, 1(888)831-0404; Disability Rights Florida, 1(800)342-0823; the Agency Consumer Hotline 1(888)419-3456, and the statewide toll-free telephone number of the Florida Abuse Hotline, 1(800)96-ABUSE or 1(800)962-2873. The telephone numbers must be posted in close proximity to a telephone accessible by residents and the text must be a minimum of 14-point font. (d) The facility must have a written statement of its house rules and procedures that must be included in the admission package provided pursuant to rule 59A-36.006, F.A.C. The rules and procedures must at a minimum address the facility’s policies regarding: 1. Resident responsibilities; 2. Alcohol and tobacco use; 3. Medication storage; 4. Resident elopement; 5. Reporting resident abuse, neglect, and exploitation; 6. Administrative and housekeeping schedules and requirements; 7. Infection control, sanitation, and universal precautions; and, 8. The requirements for coordinating the delivery of services to residents by third party providers. (e) Residents may not be required to perform any work in the facility without compensation. Residents may be required to clean their own sleeping areas or apartments if the facility rules or the facility contract includes such a requirement. If a resident is employed by the facility, the resident must be compensated in compliance with state and federal wage laws. (f) The facility must provide residents with convenient access to a telephone to facilitate the resident’s right to unrestricted and private communication, pursuant to section 429.28(1)(d), F.S. The facility must allow unidentified telephone calls to residents. For facilities with a licensed capacity of 17 or more residents in which residents do not have private telephones, there must be, at a minimum, a readily accessible telephone on each floor of each building where residents reside. (g) In addition to the requirements of section 429.41(1)(k), F.S., the use of physical restraints by a facility on a resident must be reviewed by the resident’s physician annually. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance, is not considered a physical restraint. Rule 58A-5.0182, Florida Administrative Code. 154. That an unannounced Revisit to Complaint Investigations #2019016716 and #2019016180 was conducted on 1/22/2020 and 2/04/2020 upon Respondent. 155. That based on record review, observations and interviews, the facility failed to provide a safe and decent living environment for residents, placing them at-risk by failing to ensure two 33 staff members had the required level 2 background screenings ( Staff N & O), contrary to the mandates of law. 156. That on 1/21/2020, in preparation for the complaint revisit at the facility, review of the level 2 background screening web site was conducted. The web site reflected that Staff N and Staff O had not completed level 2 background screens as noted in the prior citation. 157. That on 1/22/2020 at 11:20 AM, Staff R stated Staff N does the building maintenance and Staff O works as the cook. 158. That on 1/22/2020 at 11:25 AM, Staff O's picture was not on display with the rest of the employee photos. He was working at preparing lunch. 159. That on 1/22/2020 at 12:15 PM, Staff O stated he is responsible for cooking the meals. Staff O stated he does have resident interaction while they are in the dining room by helping with set up, especially in the morning and talking with residents about what foods they like and if they were pleased with the meal. Staff O stated the morning set up is done alone. 160. That on 1/22/2020 at 12:25 PM, Resident #5 stated Staff N works in the building, is not sure what he does but it has been since Christmas. 161. That on 1/22/2020 at 12:35 PM, Resident #6 stated she has seen Staff N in the building working on projects like cleaning. Resident #6 stated it was sometime after Christmas. 162. That on 1/22/2020 at 1 PM, the Administrator denied that Staff N works in the building but did say regarding "He comes into the building to work on projects, but they provide close supervision." The Administrator would not provide any contact information for Staff N. 163. That on 2/04/2020 at 6:40 AM, Staff O was setting up the dining room for breakfast, making coffee and cooking the breakfast meal. 34 164, That on 2/4/2020 at 6:57 AM, Resident #9 stated they have seen Staff N working in the building, is not sure what he does, but it has been since Christmas. 165. That on 2/04/2020 at 7:20 AM, the Administrator stated Staff N works for Staff E, and Staff E runs the private property management company which is owned by the administrator and Staff E. Staff E was called and stated he would not provide any additional information about Staff N. 166. The above reflects that Respondent failed to provide a safe and decent living environment for residents, placing them at-risk by failing to ensure two staff members had the required level 2 background screenings (Staff N & O), contrary to the mandates of law. 167. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 168. That the same constitutes a Class II offense as defined in § 408.813(2)(b), Florida Statutes (2019). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2019). COUNT XI 169. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count [X and X above as if fully set forth herein. 170. Pursuant to section 429.19(7), Florida Statutes (2019), “[i]n addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or five hundred dollars ($500), to cover the cost of 35 conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted to verify the correction of the violations.” 171. Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2019). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to section 429.19(7), Florida Statutes (2019). COUNT XI 172. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count X above as if fully set forth herein. 173. That an Infection Control joint visit with the Department of Health was conducted on 04/29/20 upon Respondent. 174. That based on observation and interview, the facility failed to safe-guard residents’ well- being by failing to follow current infection control standards related to COVID-19, and Florida Governor's emergency orders DEM Order 20-006, dated March 15, 2020, delineating minimum screening standards for persons entering identified as residential facilities, contrary to the mandates of law. 175. The COVID-19 virus is a transmissible respiratory infection that presents severe risk to persons who are aged, infirm, or suffer from co-morbidities including, but not limited to, immune system deficiency, respiratory disease, diabetes, and obesity. See generally, Publications of the Centers for Disease Control. 36 176. That on March 1, 2020, the Governor of the State of Florida issued Executive Order 20- 51 designating a Public Health Emergency as a result of COVID-19 and its impact. Pursuant to that authority, emergency orders have been issued by the Florida Division of Emergency Management to implement the protections necessary to assure the health, safety, and well-being of Florida's citizenry, including those most vulnerable to the effects of infection. Among those emergency orders was DEM Order 20-006, dated March 15, 2020, delineating minimum screening standards for persons entering identified residential facilities. 177. That the "State Of Florida Division Of Emergency Management Emergency Order," dated 03/15/20, read, "Whereas, the Governor of the State of Florida issues Executive Order No. 20-52 in response to the COVID-19 Public Health Emergency, which poses a severe threat to the entire State of Florida and requires that timely precautions are taken to protect the communities, critical infrastructure, and general welfare of this State....2. Individuals seeking entry to the facility under the above section 1 will not be allowed to enter if they meet any of the screen criteria listed below.... b. Any person showing, presenting signs or symptoms of, or disclosing the presence of a respiratory infection, including fever, shortness of breath or sore throat....5 The following documentation must be kept for visitation within a facility: a. Individuals entering a facility subject to the screening criteria above may be screened using a standard questionnaire or other form of documentation. b. The facility is required to maintain documentation of all non- resident individuals entering the facility. Documentation must include: 1. Name of the individual; 2. Date and time of entry; and 3. The documentation used by the facility to screen the individual showing the individual did not meet any of the enumerated screening criteria, including the screening employee's printed name and signature..." 37 178. That the Agency for Health Care Administration (AHCA) has issued guidance and clarification on DEM Order 20-006 to providers, and on March 18, 2020, issued an alert notifying all staff and other individuals in a residential facility must don face masks and that caregivers must wear gloves when providing resident care. While the treatment and management of residents with infectious disease and the implementation of isolation precautions for such events are a long-standing health care issues faced by residential facilities, the ease of contagion and the effects of infection presented by COVID-19 mandate that providers exert meticulous practice and procedure to identify resident symptoms and take immediate prophylactic procedures to both assure appropriate treatment of a potentially infected resident and protect the remainder of a facility's population from the risk of spread of the infection. 179. That on 04/29/20 at 10:45 AM, entrance to the facility was obtained after verbally answering several questions by the Administrator. One resident was outside in her wheelchair with her private duty caregiver (CG). The CG has been providing activities of daily living (ADL) care for quite a while prior to the COVID-19 pandemic. The CG's cloth mask was down off her nose and mouth resting on her neck. According to the Administrator, the resident is blind and deaf. The Administrator immediately instructed the CG to put her mask back on, which she did. 180. However, she did not conduct any additional COVID-19 screening, such as using a standardized questionnaire or other form of documentation, and screening temperatures were not completed. When questioned further, she stated that the facility does not use a screening form and does not conduct temperatures or screening on staff and visitors entering the facility. The facility is licensed for 19 residents and there are currently 18 residents residing in the facility. The Department of Health representative recommended to the Administrator that resident temperatures be taken 2-3 times a day as part of the COVID-19 screening process. The 38 administrator replied that resident temperatures are not routinely being taken, and that she would need to contact the physician for orders to complete resident temperatures. "I am not sure the staff would be able to handle completing temperatures on all of the residents." The administrator revealed that the facility had 1/2 box of procedural masks for residents who were coughing or sneezing, 3 washable gowns but no disposable gowns, and she was out of hand sanitizer, so she went online and developed her own "recipe" for hand sanitizer which consisted of 3 parts alcohol and 1 part Aloe Vera. The Administrator stated that she had called the Emergency Operations Center (EOC) and that the EOC was not giving PPE to the assisted living facilities. The Administrator said she never contacted the Department of Heath for assistance with obtaining personal protective equipment (PPE). 181. That on 04/29/20 at 11:30 AM, a tour of the supply room was conducted with the Administrator. Three bottles of hand sanitizer gel were found in the supply room. The Administrator confirmed that the 3 bottles was hand sanitizer and stated that she was "saving them". 182. The above reflects that Respondent failed to safe-guard residents' well-being by failing to follow current infection control standards related to COVID-19, and Florida Governor's emergency orders DEM Order 20-006, dated March 15, 2020, delineating minimum screening standards for persons entering identified as residential facilities, contrary to the mandates of law. 183. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 184. That the same constitutes a Class II offense as defined in § 408.813(2)(b), Florida Statutes (2019). 39 WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2019). COUNT XIII 185. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count X and Count XII above as if fully set forth herein. 186. That a revisit to Complaint Investigations # 2019016716 and #2019016180 was conducted upon Respondent on 10/6/2020. 187. That based on record review, observations and interviews, the facility failed to provide a safe and decent living environment for residents, placing them at-risk by failing to ensure 1 of 1 sampled staff had the required eligible level 2 background screening result (Staff O), contrary to the mandates of law. 188. That an observation on 10/6/2020 by Agency Representative revealed a picture of Staff O was on the wall along with other facility staff. 189, That on 10/6/2020 at 10 AM, the Administrator said Staff O worked in the kitchen. She said he would enter through the front door of the facility at 6:30 AM and go directly to the kitchen and exit through the back door. She said he did not serve food to the residents of the facility. The front of the facility where Staff O would enter included the common area where residents would congregate. 190. That a review of the background screening results provided by the Administrator revealed on 9/12/2018 Staff O result was noted to be not eligible. 40 191. That a review of the agency's background screening website on 10/6/2020 at 10 AM, confirmed that Staff O had a ‘not eligible" background screening result and could not work in the facility. 192. That on 10/6/2020 at 10:15 AM, the Administrator was informed that Staff O could not work in the facility due to his ineligible background screening results because he did have access to resident's personal property and living areas. 193. The Administrator said she did not agree because she stated that Staff O remained in the kitchen and did not go into the resident's rooms. 194. The above reflects that Respondent failed to provide a safe and decent living environment for residents, placing them at-risk by failing to ensure 1 of 1 sampled staff had the required eligible level 2 background screening result (Staff O), contrary to the mandates of law. 195. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class | violations. 196. That the same constitutes a Class II offense as defined in § 408.813(2)(b), Florida Statutes (2019). WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2019). COUNT XIV 197. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count VII and Count IX above as if fully set forth herein. 41 198. That a revisit to Complaint Investigations # 2019016716 and #2019016180 was conducted upon Respondent on 10/6/2020. 199. That based on the agency's background screening website, observations and interview the facility failed to ensure 1 of 1 staff (Staff O), who was in a role that required a background screening (BGS), did not have any disqualifying offenses and allowed Staff O to continue to work without meeting the background screening requirements, contrary to the mandates of law. 200. That an observation on 10/6/2020 by Agency Representative revealed a picture of Staff O was on the wall along with other facility staff. 201. That on 10/6/2020 at 10 AM, the Administrator said Staff O worked in the kitchen. She said he would enter through the front door of the facility at 6:30 AM and go directly to the kitchen and exit through the back door. She said he did not serve food to the residents of the facility. The front of the facility where Staff O would enter included the common area where residents would congregate. 202. That a review of the background screening results provided by the Administrator revealed on 9/12/2018 Staff O result was noted to be not eligible. 203. That a review of the agency's background screening website on 10/6/2020 at 10 AM, confirmed that Staff O had a 'not eligible” background screening result and could not work in the facility. 204. That on 10/6/2020 at 10:15 AM, the Administrator was informed that Staff O could not work in the facility due to his ineligible background screening results because he did have access to resident's personal property and living areas. 205. The Administrator said she did not agree because she stated that Staff O remained in the kitchen and did not go into the resident's rooms. 42 206. The Respondent’s actions or inactions constituted a violation of §§ 429.174 and 408.809, Florida Statutes (2019), and the Respondent was cited with an unclassified deficient practice. 207. Under Florida law, in addition to the requirements of Part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2019). 208. Under Florida law, regardless of the class of violation cited, instead of the fine amounts listed in paragraphs (a)-(d), the agency shall impose an administrative fine of $500 if a facility is found not to be in compliance with the background screening requirements as provided in s. 408.809. § 429.19(2)(e), Fla. Stat. (2019). 209. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class lV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2019). 210. The Agency cited Respondent for an unclassified violation. 211. That the same constitutes an unclassified deficiency. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of five hundred dollars ($500.00) against the Respondent 43 an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2019). Agency for Health Care Administration 525 Mirror Lake Drive, 330B St. Petersburg, FL 33701 727.552.1929 (office) Facsimile 727.552.1440 Belisa.Oliveira@ahca.myflorida.com NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No.7019 2970 0001 3240 6450 on December _/ ¥, 2020, to Susan Kornegay, Administrator, Wellsprings Residence LLC, 700 E. Welch Rd., Apopka, Florida 32712, and by Regular U.S. Mail to Reginald Kornegay, Registered Agent for Copy furnished to: squire Theresa DeCanio Field Office Manager Agency for Health Care Administration STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Wellsprings Residence LLC AHCA Nos. 2019004612 2019018094 2020003566 2020006720 2020009818 2020018539 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. The Election of Rights form 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 received the Administrative Complaint. If your Election of Rights form with your selected option (or request for hearing) is not timely received by the Agency Clerk, the right to an administrative hearing to contest the proposed agency action will be waived and an adverse Final Order will be issued. In addition, please send a copy of this form to the attorney of record who issued the Administrative Complaint. (Please use this form unless you, your attorney or your qualified representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) The address for the Agency Clerk is: Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3, Mail Stop #7 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I waive the right to a hearing to contest the allegations of fact and conclusions of law contained in the Administrative Complaint. 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 fine, sanction or other agency action. OPTION TWO (2) I admit the allegations of fact contained in the Administrative Complaint, but I wish to be heard at an informal hearing (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, sanction or other agency action should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the 45 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. | Astatement 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 | 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: 46 USPS Tracking® Tracking FAQs Track Another Package + Track Packages Anytime, Anywhere Get the free Informed Delivery® feature to receive automated notifications on your packages Learn More Remove Tracking Number: 70192970000132406450 Your item was delivered to an individual at the address at 12:53 pm on December 16, 2020 in APOPKA, FL 32712. Status: Delivered December 16, 2020 at 12:53 pm Delivered, Left with Individual APOPKA, FL 32712 Get Updates Delivered

Docket for Case No: 21-001268