The Issue The issue for consideration at this hearing was whether Petitioner, HCA Health Services of Florida, Inc., d/b/a HCA L. W. Blake Hospital has standing to oppose the Department's issuance of CON #6258, for a medical office building, to Manatee Hospitals and Health Systems, Inc., d/b/a Manatee Memorial Hospital.
Conclusions By Petition For Formal Hearing, filed with the Department of Health and Rehabilitative Services, (Department), on October 5, 1990, L. W. Blake Hospital (Blake), opposes the Department's approval of a Certificate of Need (CON) number 6258 to Respondent, Manatee Memorial Hospital (Manatee) to acquire a medical office building via a long-term ground lease on the basis that the proposed facility will adversely impact Blake's medical office building currently operating on its campus. Thereafter, the matter was forwarded to the Division of Administrative Hearings for appointment of a Hearing Officer. Respondents thereafter filed a Joint Motion to Dismiss Blake's Petition and a hearing was set on the motion for December 19, 1990. On that date, at the hearing, at which counsel for all parties were present, Blake filed a Motion For Leave to Amend its Petition, which was granted. The Amended Petition was filed on December 21, 1990, and the Respondents' Joint Motion to Dismiss the Amended Petition was filed on December 27, 1990. The instant hearing was held on that Joint Motion. In its Amended Petition, Blake seeks standing on it's assertion that "it appears" Manatee intends to provide new inpatient services in the new facility without Blake having the opportunity to investigate what the "new services" are and without the safeguard of a CON review. Blake claims that it is most likely that its established programs will be substantially affected by the inclusion of these "new inpatient services." In addition, Blake claims that its medical office building will be adversely impacted by Manatee's acquisition of a competing medical office building because Manatee will use its new building to attract physicians to its hospital, possibly away from Blake's campus. In ruling on a motion such as here, the Hearing Officer is bound to accept as true allegations of fact contained in the pleadings. However, here, no facts were alleged by Blake to indicate that Manatee's application calls for the providing of any new inpatient services. While Manatee's application does indicate a "direct linkage between the acute inpatient facility with the physician's [sic]" will be provided which will "enhanc[e] patient access to a range of diagnostic and treatment services" there is no indication that any new inpatient services will be provided in the new facility. Further, Blake's claim that that portion of the lease agreement, which provides Manatee the ". . . opportunity to locate certain present or anticipated hospital services and facilities in [the] new structure . . .," means new inpatient services, does not necessarily infer or imply that these "anticipated" services will be "inpatient." Here, Manatee applied for a CON for the building only - not for any new services. Any new regulated inpatient service going beyond the parameters of existing CON authorization may be implemented only upon approval after CON review at which Petitioner, or any other substantially affected provider, may have standing to contest the approval of the certificate. Initiation of such a proscribed service, without benefit of that review, would subject Manatee to the possibility of both sanctions and injunctive action. Blake's reliance on what it describes as the "ambiguity" of Manatee's application, and Manatee's use of the term, "anticipated" in its lease is not justified. Taken together, review of the pleadings herein demonstrates, at best, a substantially speculative approach by Blake which is not supported by any specifics. Alone, it is insufficient to support standing. St. Joseph Hospital of Port Charlotte, Florida, Inc., v. Department of Health and Rehabilitative Services, 559 So.2d 595 (Fla. 1st DCA 1989). Based on the foregoing Findings of Fact and Conclusions of law, it is, therefore: RECOMMENDED THAT: the Amended Petition For Formal Administrative Hearings in opposition to the Department's award of CON 6258 to Manatee Memorial Hospital, filed by HCA Health Services of Florida. Inc., d/b/a HCA L. W. Blake Hospital, be dismissed. RECOMMENDED in Tallahassee, Florida this 4th day of January, 1991. ARNOLD H. POLLOCK, Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 4th day of January, 1991. COPIES FURNISHED: Robert A. Weiss, Esquire John M. Knight, Esquire Parker, Hudson, Rainer & Dobbs The Perkins House 118 N. Gadsden Street Tallahassee, Florida 32301 Edward G. Labrador, Esquire DHRS 2727 Mahan Drive Tallahassee, Florida 32308 John Radey, Esquire Jeffrey L. Frehn, Esquire Elizabeth McArthur, Esquire Aurell, Radey. Hinkle & Thomas Suite 1000, 101 North Monroe Street Post Office Drawer 11307 Tallahassee, Florida 32302 Linda K. Harris General Counsel HRS 1323 Winewood Blvd. Tallahassee, FL 32399-0700
The Issue Whether Petitioner, Presbyterian Retirement Communities, Inc., d/b/a Westminster Towers: (1) should be given a "conditional" or "standard" license effective June 17, 2002; and whether Petitioner is subject to an administrative fine of $2,500.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing, the following findings of fact are made: Petitioner is a long-term, skilled nursing facility located in Orlando, Florida. Respondent is a State of Florida agency responsible for surveying nursing homes to ensure compliance with applicable state and federal requirements. An annual survey was conducted by Respondent on Petitioner during June 17 through 20, 2002. As a result of the survey, Respondent asserted that Petitioner failed to adequately notify the attending physician of Resident No. 13's urinary tract infection, resulting in a delay in treatment of the infection. This resulted in citing Petitioner for a Class II deficiency, Tag F309, as follows: "Respondent failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care." A federal scope and severity rating of level "G" was assigned to this deficiency. "Scope and severity" levels are identified by letters A through L. A level "G" rating requires that "harm or pain has come to the resident," more specifically, the resident must "have more than minimal harm with discomfort." If a level "G" scope and severity is assigned, a Class II deficiency is cited. Resident No. 13 was a 108-year-old female with a history of urinary tract infections. She was alert, oriented and articulate. She was capable of advising caregivers of her wants, needs, and physical condition. On May 27, 2002 Resident No. 13 complained of "some burning upon urinating." Petitioner's staff called Resident No. 13's attending physician by calling the "on-call" physician. The "on call" physician ordered a urinalysis and culture; a urine sample was obtained by Petitioner's staff noting that the urine was "cloudy." The laboratory that performs the testing is at a remote location. On May 28, 2002, the urinalysis results were received by Petitioner and transmitted by facsimile to the attending physician's office on the same day. The culture results were received by Petitioner on May 30, 2002, a Thursday, but were not faxed to the attending physician's office until June 1, 2002, a Saturday. On May 29, 2002, the attending physician performed a routine assessment and evaluation of Resident No. 13. His notes of the examination read as follows: No complaints. Feels well. Appetite is adequate. Otherwise, non-ROS. An extremely elderly lady doing quite well. Will continue to monitor and keep close tabs on her. On June 5, 2002, the nurses notes reflect that Resident No. 13 stated, "it hurts when I urinate." Her urine was discolored and was odiferous. Petitioner's staff notified the attending physician's office. The attending physician ordered the antibiotic, oxacillin, on June 6th. This antibiotic was inappropriate for Resident No. 13. On June 7, 2002, the attending physician ordered a second antibiotic, dioxicillin; this was also inappropriate, as there is no such antibiotic. Again, the physician was notified, and on June 8, 2002, he ordered an antibiotic, dicloxicillin, which was administered to Resident No. 13 during the early morning hours of the following day, June 9, 2002. Notwithstanding the administration of dicloxicillin, a broad spectrum antibiotic, the urinalysis and culture reports of the specimen taken on May 28, 2002, indicated colonized, saprophytic organisms and did not indicate pathologic organisms. The administration of an antibiotic is an optional treatment. The symptoms exhibited by Resident No. 13, burning sensation on urination, odiferous urine and a change in urine color can be caused by conditions other than urinary tract infections. Burning sensations can be caused by atrophic vaginitis and other non-pathogenic causes. Typical symptoms of a geriatric patient suspected of having a urinary tract infection are: fever, abdominal and flank pain, change in mental status, and fatigue. There is no indication in the records of Resident No. 13, during the relevant period, of the presence of these symptoms; the examination of the attending physician on May 28, 2002, does not indicate any symptoms typical of a urinary tract infection; in fact, he reports that Resident No. 13 is "doing quite well." Individuals familiar with Resident No. 13 observed no changes in her physical or mental status during the period from May 27 through June 8, 2002.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is Recommended that Respondent enter a final order determining that the deficiency described under Tag F309 in the June 17 through 20, 2002, survey did not occur, issue a Standard licensure rating to Petitioner, and that the Administrative Complaint seeking a fine be dismissed. DONE AND ENTERED this 15th day of July, 2003, in Tallahassee, Leon County, Florida. S JEFF B. CLARK Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 15th day of July, 2003. COPIES FURNISHED: Joanna Daniels, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 Alex Finch, Esquire Goldsmith, Grout & Lewis, P.A. 2180 North Park Avenue, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building III, Suite 3431 Tallahassee, Florida 32308
Findings Of Fact At all times pertinent to the allegations set out in the Administrative Complaint, Licensee held a valid license issued by the State of Florida to operate the Roseland Park Adult Care Center, at 4137 Badger Road, West Palm Beach, Florida. Rose land Park Adult Care Center is a Type II facility, as defined by the rules of the Department. A Type II adult care center is one that is equipped to provide a greater degree of assistance to and observation of its residents ,than the Type I facility, and the requirements for resident supervision are more stringent. Both types of facility are subject to various periodic inspections by representatives of the Department's licensing staff and other agencies. Whenever an inspection is accomplished, the reason for an inspection is announced to representatives of the facility. When the inspection has been completed, an out-briefing is conducted. Inspections are normally done once a year by the Department either for initial licensing or prior to relicensing. In addition, there is usually one additional off-cycle inspection per year. When complaints are received about a facility by the Department or a report of patient abuse, inspections are also done. The Licensee's facility was first licensed in 1980 for six residents. Since March, 1981, to the date of the hearing, the Department's local office has received six or seven complaints as to patient care at this facility. One came from a former resident, one from the daughter of a resident, one from Dr. Crews, and several anonymous complaints. Of the approximately 20 other facilities of similar size in this general geographic area, Licensee's facility gets a much higher incidence of complaints than the others. According to Ms. Cook, a supervisor for Aging Adult Services for the Department (specialist), some complaints, such as personal care of the residents, are repeats, even after having been previously brought to the attention of Licensee. On or about June 30, 1982, Dr. Crews, a physician, notified the Department of his concerns about one particular resident of Licensee's facility, a Mrs. Opal Russell, a 76-year-old woman who was a resident of Licensee's facility since April 1, 1981, and who had been a patient of his. Mrs. Russell had been brought to his office by Licensee on several occasions, the last of which was that same date, when she was brought in for a checkup, not a full physical. When she came into the office, she was walking under her own power and was responsive to the nurse. Licensee was not present when the vital signs were taken. The nurse noticed bruises on Mrs. Russell, and when she asked what had happened, Mrs. Russell replied that they were mean to her, without indicating who "they" were. During this visit, the Licensee indicated to the doctor that Mrs. Russell had been falling a lot. Dr. Crews indicated his concern that Mrs. Russell appeared to have seriously deteriorated in condition since he had last seen her on May 20, 1981, and he questioned the level of care she was receiving. Mrs. Russell had extensive bruising on her face, chest and upper forearm, and he felt she needed more care than she could get in a facility such as Licensee's. He advised Licensee of this fact and suggested she be moved to a hospital, but she was not. When he questioned Licensee about the bruises, she replied that Mrs. Russell was falling a lot. The facial bruises appeared to be about five days old and the other bruises somewhat more recent. The physician's certificate justifying keeping this patient on the premises was not filed with the Department as required by Rule 10A-5.18(1)(d), F.A.C. Ms. Loehndorf went back for a follow-up visit on July 7, 1982. When she arrived at mid-morning, it was naptime, and almost every resident was in bed resting, but only Mrs. Russell was in what appeared to be a very deep sleep. During the entire half hour Ms. Loehndorf was there, Mrs. Russell did not move. When Ms. Loehndorf again visited the facility on July 9, 1982, shortly after Mrs. Russell was admitted to the hospital, Licensee told her that Mrs. Russell had been in a coma for 36 hours prior to admission to the hospital, and when she asked if there had been any recent trauma or falls, Licensee replied there had not been. Barbara Trigg came to work at Licensee's facility on July 1, 1982. When she first started working there, Mrs. Russell appeared to be fine, considering her age. Her speech was somewhat incoherent, but she could feed herself and watch television, etc., though she had to be helped to go to the bathroom. Ms. Trigg noticed a deterioration in Mrs. Russell over the period of time she worked there. She noticed several bruises on Mrs. Russell's head, but does not know how they got there. She never saw Mrs. Russell fall. When she left work on July 6, Mrs. Russell appeared to be well. When she returned the next time, at 11:00 a.m. on July 9, 1982, she immediately noticed that Mrs. Russell was not the same. She was still in bed and appeared to be drowsy. At the request of Licensee, she helped her take Mrs. Russell to the kitchen, where Licensee unsuccessfully tried to get Mrs. Russell to drink some coffee. Then, Licensee directed Ms. Trigg to help her try to walk Mrs. Russell around outside. This amounted to no more than dragging her, as Mrs. Russell could neither walk nor support herself. Ms. Trigg advised Licensee's husband when he got home that Mrs. Russell should be in the hospital. Mr. Willis replied, as had Licensee on several occasions, that Mrs. Russell "got that way" sometimes. Ms. Trigg, who was often left alone in the facility with the residents, is not trained in cardio-pulmonary resuscitation (CPR). She would have had a very difficult time in saving the residents in case of a fire or other emergency. When Licensee and her husband returned from dinner and checked on Mrs. Russell, she noticed Mrs. Russell had developed a deep, yellow color which alarmed her, as did Mrs. Russell's vital signs. Licensee immediately called Dr. Daisey Mercy, who had treated some of the residents in Licensee's facility and who advised Licensee to immediately take Mrs. Russell to the hospital. Licensee admits that she did not call the doctor earlier on July 8 or 9 when Mrs. Russell would not eat or when she could not walk, but justifies that inaction on the basis that her condition had changed back and forth before, and this did not appear to be significantly different. She began to believe something out of the ordinary had happened when she and Ms. Trigg were walking Mrs. Russell around outside, but even then she did not call because she did not think there was any reason to do so. Licensee also called Mrs. Russell's son, reaching him after some difficulty, who directed Licensee to take his mother to JFK Hospital. When they got there, Licensee told the admitting nurse that Mrs. Russell had been comatose for 36 hours. She also made this statement to Ms. Loehndorf and Ms. Cook later that day when they came to the facility, though she does not recall saying that and now states she used the term "comatose" without knowing what it meant. I find, however, that she used the term as indicated by the witness and that in fact Mrs. Russell was comatose at the time of admission to the hospital. Licensee's use of the term was accurate. Dr. Albert Auld, a neurological surgeon, saw Mrs. Russell on July 10, 1982, after her admission to the hospital. At that time, she was comatose. A CAT scan revealed that she had a large subacute subdural hematoma on the left side of her brain, which he subsequently removed. The hematoma was classified as subacute because the clot had already begun to form out of the mass of blood that had collected, usually as the result of an injury to the head. The clot had already begun to the on a black, oily a black, oily consistency, which indicated the causing injury had taken place up to 12 days to two weeks previously. In the case of subdural hematomas, by the time they are subacute, the bleeding has already stopped. The blood that has gathered breaks down and absorbs fluids from the body, which makes it bigger. The trauma causing the injury may be rather trivial as opposed to significant, and the older the patient is, the less trauma it may take to cause a subdural hematoma. It usually stops bleeding the day of the injury, but with the absorption of body fluids, it gets bigger. This does not necessarily result in an immediate comatose state. In fact, there may be few symptoms for several days or several months, and as the clot becomes larger and larger, the patient becomes lethargic and sleepy, and gradually ingresses to a comatose condition, and death follows. In the case of Mrs. Russell, there was bruising around the left eye, which is consistent with a subdural hematoma on the left side as she had and which in the opinion of the doctor could have been caused prior to June 28, 1982. Mrs. Russell improved considerably after the operation, though Dr. Auld could not get her to talk. This absence of speech could have been volitional or as the result of the subdural hematoma. She was released from the hospital to a nursing home on August 8, 1982, and died sometime thereafter. At no time, either prior to or subsequent to June 28, 1982, did Licensee obtain and/or forward to the Department a signed statement, from Mrs. Russell's physician, Dr. Crews, or any other physician or person identified by the rule, as required, that Mrs. Russell should remain in Licensee's facility. Licensee categorically denied any knowledge of any falls or blows subsequent to June 8, 1982, the date of the injury that was the subject of the last report to the Department and which, according to Licensee, caused the bruise around the eye. Investigation by the Palm Beach County Health Department of Licensee's facility on several occasions and specifically on June 28, 1982, revealed the continued use of butcher paper on the beds, the storage of vitamins with food stuffs and the fact that the residents' beds were not made by 11:30 a.m., both of which facts had previously been brought to the attention of Licensee, but on the latest visit were found to be still in evidence. There was also evidence of the use of restraints that were lockable and bedside toilets.
Recommendation Based on the foregoing, it is RECOMMENDED: That the Department of Health and Rehabilitative Services' revocation of Mary E. Willis's revocation of Mary E. Willis's license to operate the Roseland Park Adult Care Center dated July 16, 1982, be sustained and a final order of revocation be entered. RECOMMENDED this 5th day of August, 1983, in Tallahassee, Florida. ARNOLD H. POLLOCK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 5th day of August, 1983. COPIES FURNISHED: K. C. Collette, Esquire Department of Health and Rehabilitative Services 111 Georgia Avenue West Palm Beach, Florida 33401 Bruce J. Daniels, Esquire Lesser, Daniels & Shalloway, P.A. 909 North Dixie Highway West Palm Beach, Florida 33401 Mr. David H. Pingree Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32301
Conclusions THIS CAUSE comes before the State of Florida, Agency for Health Care Administration (‘the Agency") concerning the preliminary approval of Certificate of Need (“CON”) Application No. 10220, submitted by Palm Coast Behavioral Health, LLC’s (“Palm Coast”) to establish a 63- bed adult inpatient psychiatric hospital in Service District 4, Flagler County. 1. On June 9, 2014, the Agency published its preliminary approval of Application No. 10220 submitted by Palm Coast Behavioral Health, LLC’s (“Palm Coast”) to establish a 63- bed adult inpatient psychiatric hospital in Service District 4, Flagler County. 2. In response, Halifax Hospital Medical Center (“Halifax”) filed a petition for formal hearing contesting the approval of CON Application 10220. The case was forwarded to the Division of Administrative Hearings. 3. Halifax subsequently voluntarily dismissed its petition for formal hearing. It is therefore ORDERED: 1. The preliminary approval of CON Application No. 10220 is upheld subject to the conditions in the State Agency Action Report for Application No. 10220. Filed October 2, 2014 11:06 AM Division of Administrative Hearings ORDERED in Tallahassee, Florida, on this 27 _ day ot Seem foec ans Elizabeth Dutek, Secretary Agency for Health Care Administration NOTICE OF RIGHT TO JUDICIAL REVIEW. A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I CERTIFY that a true and correct copy of this Final Order was served on the below- on named persons by the method designated on this ate PRAL 2014. CSCO Richard J. Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 (850) 412-3630 Jan Mills Lorraine M. Novak, Esquire Facilities Intake Unit Agency for Health Care Administration Office of the General Counsel Agency for Health Care Administration (Electronic Mail) (Electronic Mail) James McLemore, Supervisor Marisol Fitch Certificate of Need Unit Health Services & Facilities Consultant Agency for Health Care Administration Certificate of Need Unit (Electronic Mail) Agency for Health Care Administration (Electronic Mail) 2 Karen A. Putnal, Esquire Susan C. Smith, Esquire Robert A. Weiss, Esquire Corinne T. Porcher, Esquire Moyle Law Firm, P.A. Geoffrey D. Smith, Esquire Kputnal@moylelaw.com Smith and Associates Rweiss@moylelaw.com Susan@smithlawtlh.com (Electronic Mail) Corinne@smithlawtlh.com Geoffi@smithlawtlh.com (Electronic Mail) R. Bruce McKibben Administrative Law Judge Division of Administrative Hearings (Electronic Mail)
Findings Of Fact Cilla McCray, is a resident of Gadsden County. The parties have stipulated that on December 3, 1977, she was admitted to the Tallahassee Memorial Hospital in an emergency medical condition, and that the treatment performed by the hospital was of an emergency nature. The parties have further stipulated that the Tallahassee Memorial Hospital is a regional referral hospital within the meaning of Section 154.304(4) , Florida Statutes (1977). Cilla McCray was admitted to the Tallahassee Memorial Hospital on December 3, 1977, and was discharged on January 9, 1978. The total bill for her services amounted to $8,753.80. The Hospital submitted a bill to Gadsden County in the amount of $1,521.48 for the services. This latter amount is the maximum allowed to be billed in accordance with the Florida Health Care Responsibility Act. Gadsden County has refused to pay the bill, contending that the patient was not indigent. The patient has not paid the bill. Cilla McCray is married to Lawrence McCray. They have three children but only two of them reside at home. The oldest child is not supported by his parents. During the six months preceding the hospitalization of Cilla McCray her husband had average earnings of $80.00 per week as a logger. Mrs. McCray had earned a total of $732.60 for employment during the six months prior to her hospitalization. The McCray's thus had average monthly earnings during that period in excess of $450.00 per month.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is, RECOMMENDED: That a final order be entered rejecting the bill submitted by the Tallahassee Memorial Hospital for medical services performed for Cilla McCray. RECOMMENDED this 16th day of June, 1978, in Tallahassee, Florida. G. STEVEN PFEIFFER, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: John Shaw Curry, Esquire Post Office Box 706 Quincy, Florida 32351 John D. Buchanan, Jr., Esquire Post Office Drawer 1049 Tallahassee, Florida 32302 Chairman Board of County Commissioners Gadsden County Courthouse Quincy, Florida
