The Issue Whether Respondent's licenses to operate two group homes should be renewed, or whether renewal should be denied for the reasons charged in the administrative complaints issued by Petitioner.
Findings Of Fact APD is the state agency charged with licensing and regulating group home facilities. The statewide headquarters, or "central office," is in Tallahassee. Regional offices carry out the licensing and regulatory functions within their designated regions, or "areas," in coordination with the central office. APD Area 14 covers Polk, Hardee, and Highlands Counties. Beginning in 2007 and at all times material to this proceeding, HIOTW has been a provider of various residential and non-residential services to developmentally disabled persons in Lakeland, Polk County, Florida, within APD Area 14. In 2007, HIOTW was licensed by the Agency for Health Care Administration (AHCA) to provide non-residential homemaker and companion care services. In November 2008, HIOTW became licensed by the APD Area 14 office to operate Paces Trail Group Home to provide residential habilitation services to developmentally disabled adults. Shortly thereafter, HIOTW was licensed by the APD Area 14 office to operate its second group home, Hampton Group Home. HIOTW was licensed by the APD Area 14 office to operate Timbergreen in May 2009. In February 2010, the APD Area 14 office issued a license to HIOTW to operate its fourth group home in Lakeland--Lake Miriam. The group home license renewal of these two group homes, each with a capacity to serve six adult male residents with developmental disabilities, is at issue in this proceeding. After initial licensure of a group home, the license must be renewed annually. All of HIOTW's group homes successfully have gone through the license renewal process one or more times, except for Lake Miriam, which is seeking its first license renewal. On November 12, 2010, HIOTW submitted an application to the APD Area 14 office to renew its license to operate Lake Miriam. On March 3, 2011, HIOTW submitted an application to renew its license to operate Timbergreen. By letter dated March 25, 2011, Petitioner denied the Lake Miriam license renewal application (March 25 Denial Letter). Petitioner relies on the following charges alleged in the March 25 Denial Letter as the basis for Petitioner's decision: On or about April 14, 2010, an employee of the applicant left two vulnerable adult group home residents alone in a car for at least ten minutes while that employee conducted business inside a bank. One of the adult residents who was left unsupervised in the car had a history of sexually molesting children and other vulnerable adults. The other resident who was left unsupervised in the car was non-verbal. This instance threatened the health, safety, and well being of the applicant's residents in violation of page A-8 of the Developmental Disabilities Waiver Services Coverage and Limitations Handbook and Rule 65G-2.012(15)(b), F.A.C. On or about September 29, 2010, an employee of the applicant was transporting group home residents when one of the residents left the vehicle without the driver's knowledge. The vulnerable adult resident was later located at a neighborhood store. This instance threatened the health, safety, and well being of the applicant's residents in violation of page A-8 of the Developmental Disabilities Waiver Services Coverage and Limitations Handbook and Rule 65G- 2.012(15)(b), F.A.C. The March 25 Denial Letter also alleged that HIOTW failed to submit a current approved emergency management plan as a third reason to deny the license renewal application. However, Petitioner abandoned the third charge at the outset of the final hearing. Petitioner sought to support its proposed denial of the Lake Miriam license renewal application solely as a penal measure based on the two alleged incidents quoted above. As such, but for these two alleged incidents, Petitioner acknowledges that Lake Miriam's license renewal application is otherwise entitled to approval. By letter dated April 29, 2011, Petitioner denied the Timbergreen license renewal application (April 29 Denial Letter). The April 29 Denial Letter set forth the same two charges that were alleged in the March 25 Denial Letter as the basis for Petitioner's decision. In other words, the same two incidents were asserted as grounds for denying both the Lake Miriam license renewal application and the Timbergreen license renewal application. But for these two incidents, Timbergreen's license renewal application, like Lake Miriam's application, is otherwise entitled to approval. First Alleged Incident (on or about April 14, 2010) The credible evidence established the following facts relevant to the first charged incident. In early April 2010, an employee of HIOTW's licensed companion care service, Frank Davis, was providing companion care to R.O., a developmentally disabled adult. R.O. was not a resident of any HIOTW group home. Instead, R.O. received only non-residential companion services through HIOTW from its employee Frank Davis. As previously noted, companion care services are licensed and regulated by a different agency, AHCA. R.O. was classified as developmentally disabled due to mild mental retardation and behavioral problems. R.O. had a history of sexually abusing children and vulnerable adults. R.O. also had a known tendency of "telling big whoppers," i.e., he was known to be a habitual liar. R.O. apparently told someone two stories of alleged incidents involving his companion, HIOTW employee Frank Davis. On April 14, 2010, the person to whom R.O. told the stories reported the two alleged incidents to the hotline operated by the Department of Children and Families (DCF), which fields reports of possible abuse or neglect.2/ One story told by R.O., as reported to DCF, was that Mr. Davis had left R.O. alone with Mr. Davis's three-year-old daughter. The other story told by R.O., as reported to DCF, was that Mr. Davis had left R.O. alone in a car with a non-verbal vulnerable adult for a period of time while Mr. Davis went into a bank to conduct some business. If true, these allegations of R.O. allegedly being left alone with a child in one instance and with a non-verbal vulnerable adult in the other instance would be of great concern. Both the child and the non-verbal vulnerable adult with whom R.O. was allegedly left alone would have to be considered at great risk of abuse by R.O., given R.O.'s known history of sexually abusing both children and vulnerable adults. With regard to R.O.'s first story, involving Mr. Davis's three-year-old daughter, a DCF adult protective investigator (API) was able to quickly determine that the allegation was completely baseless. In screening this allegation to determine if a formal investigation was warranted, the API spoke with R.O. and then with Samuel Cooper, one of the owners of HIOTW, on April 15, 2010, the day after the hotline call. Mr. Cooper provided a detailed description of the physical appearance of Frank Davis's daughter. When Mr. Cooper's description of Mr. Davis's daughter was compared to R.O.'s description of the girl with whom he was supposedly left alone, the two descriptions were so vastly different that the API was able to, and did, immediately determine that R.O. had fabricated the story, and the matter was closed without a formal investigation. The same API conducted an investigation of R.O.'s second story that he was left in Mr. Davis's car with a non-verbal vulnerable adult while Mr. Davis went into a bank. However, the API did not mention this story when he spoke with Mr. Cooper, nor did the API inform anyone from HIOTW that he was conducting a formal investigation. In conducting his investigation, the API spoke with R.O., twice with Mr. Davis, and with O.J. Bennett, another owner of HIOTW. HIOTW initially learned of R.O.'s story about the bank trip by a phone call from R.O.'s waiver support coordinator. Mr. Bennett immediately investigated the matter, speaking with Mr. Davis and also with the bank manager who was present and had personally observed the events that day. Mr. Bennett's report from his investigation was that when Mr. Davis drove up to the bank with R.O., he left R.O. in the car only to walk about nine feet from the car to the bank's glass entrance area. Mr. Davis signaled to a bank employee who came to the door. Mr. Davis told the employee he wanted to set up an account to make direct deposits of his paycheck. When Mr. Davis was told he would have to come into the bank and it would take a few minutes, Mr. Davis went back to the car for R.O. and brought him into the bank to wait while Mr. Davis set up the account. R.O. remained in Mr. Davis's sight at all times. Based on Mr. Bennett's report, which he reviewed with Mr. Cooper, HIOTW determined an unusual incident report (UIR) was not required, because there was no reason to suspect neglect of R.O. Several weeks later, when HIOTW learned from an APD employee that DCF was conducting a formal investigation, HIOTW submitted a UIR that set forth the details of Mr. Bennett's investigation and concluded that R.O. had been in Mr. Davis's sight and adequately supervised at all times. The APD Area 14 administrator confirmed in her testimony that if the facts were as Mr. Bennett found them to be in his investigation, there would not have been inadequate supervision, and there would have been no reason to submit a UIR. Of greatest significance with regard to R.O.'s story about the bank incident, the API determined that R.O. had lied about being left with a non-verbal vulnerable adult. Instead, the API found that Mr. Davis drove to a bank with R.O., and no one else, in the car. The DCF investigator's report summarized the differing versions of events told to him by R.O. and by Mr. Davis. R.O.'s version was that Mr. Davis left him in the car for the whole time that he went into the bank. Of course, R.O. also said that he was left with another adult, and that was not true. Therefore, R.O.'s statement to the DCF investigator could not be considered credible or reliable. According to the DCF investigator, Mr. Davis told him that he left R.O. alone in the car to go into the bank, but came back out of the bank to get R.O., who he then brought into the bank to wait while he conducted his business. However, Mr. Davis testified that he only told the DCF investigator that he walked up to the bank while R.O. was in the car. Mr. Davis's version of what happened and what he told the DCF investigator is more credible than the DCF investigator's report of what Mr. Davis told him. Mr. Davis's version was corroborated by the hearsay account of the bank manager, who told Mr. Bennett that Mr. Davis brought R.O. in the bank with him, only having left R.O. alone to walk up to the bank entrance. The bank manager confirmed Mr. Davis's testimony that R.O. was in Mr. Davis's sight at all times. In crediting Mr. Davis's version of events, corroborated by the bank manager, the undersigned finds it significant that Mr. Bennett told the DCF investigator about the bank manager eyewitness, and Mr. Bennett was under the impression that the DCF investigator would follow up by calling the bank manager. But the DCF investigator did not attempt to interview anyone at the bank, despite the fact that persons at the bank would have been the only other eyewitnesses besides Mr. Davis, who had a self-interest in the incident, and R.O., the habitual liar whose other story about Mr. Davis had been proven false. Petitioner did not undertake its own investigation of the facts, either at the time of the incident or at the time it was considering whether to rely on the incident as grounds to, in effect, revoke two of HIOTW's group home licenses. Instead, according to the area administrator for APD Area 14, Petitioner simply relied on the DCF investigation report. Indeed, the area administrator did not even seem to understand the DCF report, because at the hearing, she was adamant in her belief that DCF confirmed the allegation that Mr. Davis left R.O. in a car with a vulnerable non-verbal adult group home resident. The area administrator conveyed her misimpression to the central office in discussions to consider whether to non-renew two HIOTW group home licenses based on this incident. Ultimately at hearing, the area administrator conceded that she was improperly interpreting the DCF report, thinking that the allegation portion of the report contained the actual DCF findings. Even so, she steadfastly (and erroneously) asserted that she did not give any false information to the central office regarding HIOTW.3/ In addition to the misimpression conveyed about the R.O. incident, the area administrator testified that she had an employee convey numerous reports of allegations or suspicions of HIOTW improprieties to the central office in a single packet for the purpose of a decision on whether to renew the two HIOTW group home licenses. The area administrator explained other information about allegations and suspicions were sent in the same package so that the central office could also consider whether to terminate HIOTW's Medicaid waiver provider agreement at the same time. However, she admitted that the whole packet of material was sent for the purpose of review and a decision on whether to non-renew HIOTW's two group home licenses. As such, it would be difficult to ignore the extraneous allegations when making decisions regarding the license renewal applications, "[o]f course, you have all of that in your mind[.]" The actual transmittal package to the central office was not produced, apparently because it was sent by electronic mail, and there were some APD email system problems that got in the way of producing the email transmittal package. Nonetheless, the area administrator's description of what she believes was sent in a single package to the central office was sufficient to paint the picture of a litany of negative missives regarding HIOTW, intended, in part, to support the area administrator's recommendation to deny license renewal.4/ Petitioner did not allege in the administrative complaints and did not prove at the hearing that HIOTW itself was blameworthy for the R.O. incident. The APD Area 14 administrator testified that in recommending non-renewal of the two HIOTW group home licenses, a significant factor that she took into account was that HIOTW failed to promptly submit a UIR to report the R.O. incident. The facts found with respect to the R.O. incident do not demonstrate that a UIR was required. Moreover, HIOTW was not charged, in either administrative complaint, with a violation of its UIR reporting obligations. The DCF incident report concluded with a verified finding of inadequate supervision. The DCF investigator testified that it was his finding that "[p]rimarily, Mr. Davis was responsible for the inadequate supervision" of R.O. When asked whether HIOTW was also responsible as Mr. Davis's employer, the investigator said, "being his employer, and trainer, yes." However, neither the DCF investigator, nor Petitioner, presented any evidence to suggest that HIOTW was negligent in its hiring, training, or supervision of its companion care employees, generally, or Mr. Davis, in particular. Nor was there any evidence that HIOTW failed to appropriately respond to the R.O. incident once it was made aware of the incident. The DCF incident report found that Mr. Davis was an appropriately screened employee with no adverse history. Petitioner presented no evidence to the contrary. Both the DCF investigator and the area administrator for APD Area 14 concluded that HIOTW took appropriate action regarding the R.O. incident, by removing Mr. Davis from serving as R.O.'s companion and by putting Mr. Davis through additional "zero-tolerance" training. Mr. Davis's employment was terminated shortly thereafter for reasons unrelated to the R.O. incident. Although the DCF incident report verified a finding of inadequate supervision, the report concluded that the overall risk associated with the finding was low because of appropriate corrective action taken by HIOTW.5/ The area administrator for APD Area 14 candidly admitted at the final hearing that HIOTW handled the R.O. incident appropriately and took corrective action that was deemed sufficient by APD and alleviated any health and safety concerns. Inexplicably, she continued to support the charges in the two denial letters, which alleged that the R.O. incident "threatened the health, safety, and well being of the applicant's residents," because R.O., with his history of being sexually abusive, had allegedly been left alone with a vulnerable, non-verbal adult group home resident. Since the R.O. incident did not involve any HIOTW group home residents, but rather, involved non-residential services provided under HIOTW's companion care license, one would expect that if licensure disciplinary action was warranted against HIOTW at all for this incident, it would have been initiated by AHCA as the licensing agency for companion care services. No evidence was presented that AHCA took any disciplinary action against HIOTW's companion care license. Instead, the evidence established that HIOTW's companion care license remained in good standing as of the final hearing, more than one and one-half years after the R.O. incident. Notwithstanding APD's knowledge in June 2010 of the DCF report and findings regarding the R.O. incident, APD proceeded to renew annual licenses for the period of October 1, 2010, through September 30, 2011, for two other HIOTW group homes--Pace's Trail Group Home and Hampton Group Home. The license certificates state that the facilities comply with the licensure rules of APD. No evidence was presented that APD issued administrative complaints seeking to revoke these group homes' licenses; however, the area administrator made clear that she did not intend to renew any licenses for any HIOTW group homes in the future. Second Alleged Incident (on or about September 29, 2010) The facts regarding the second alleged incident involving HIOTW employee Donyell Goodman, were not disputed. At the time of the incident, Ms. Goodman had been employed by HIOTW for three years, with a very good, unblemished employee record. On the day in question, she was serving as a van driver to transport several HIOTW companion care clients to various sites within the local community. E.K. was one of those clients receiving companion care services that day; E.K. also was a resident of HIOTW's Lake Miriam Group Home. E.K. is developmentally disabled due to his diagnosis of mental retardation. Ms. Goodman stopped to let off one client, and she watched the client walk to the appropriate destination and go inside. She then resumed driving. When she had driven for about five minutes, she glanced in her rear view mirror and realized that E.K. was not there. Ms. Goodman immediately called LaDonna Bennett, the third owner of HIOTW, to report that E.K. must have snuck out of the van at her last stop, and she was going back to find him. Ms. Bennett also headed over to where Ms. Goodman said she had stopped, to assist. When Ms. Goodman returned to the site of her last stop, she found E.K. there, inside the corner store. E.K. was fine and returned to the van without incident. E.K. apparently admitted to sneaking out of the van, saying he just wanted some fresh air. The entire incident spanned about ten minutes. Ms. Bennett and Ms. Goodman both immediately prepared and submitted UIRs to report the incident. Ms. Goodman received a written reprimand in her HIOTW personnel file and was suspended for several days. When she resumed work, she underwent additional training, was removed from the van driver position, and reassigned to the "third shift" with no direct interaction with residents. The UIR reports triggered a DCF investigation. The AIP who conducted the investigation confirmed the facts that were set forth in the two UIRs. The AIP's investigation included an assessment of E.K. at the Lake Miriam Group Home where E.K. was a resident. The DCF incident report concluded as follows: Victim Safety Factors Implications: No implications for the [victim's] safety. [Perpetrator] Factors Implications: Based on the informaiton [sic] rec'd, API has determined the [adult perpetrator] to pose no threat to the [victim]. No implication [sic] for the [victim's] safety. Facility Factors Implications: Based on the [victim] to the grouphome [sic], API has determined the [victim] to not be at any risk. The API found that the overall safety assessment was low; however, based on the UIRs and interviews with Ms. Goodman and Ms. Bennett, the incident report concluded with a verified finding of inadequate supervision. The API who conducted the investigation testified at hearing and confirmed that the inadequate supervision finding was directed to Ms. Goodman. When asked if HIOTW was also responsible because it was Ms. Goodman's employer, the API said he did not know and could not answer that question. Petitioner did not allege in the administrative complaints, and did not prove at the hearing, that HIOTW itself was blameworthy for the E.K. incident. Neither the DCF investigator, nor Petitioner, offered any evidence that HIOTW had negligently hired, trained, or supervised its employees, including Ms. Goodman in particular. Both the DCF investigator and the APD Area 14 area administrator agreed that HIOTW acted appropriately in response to the E.K. incident to alleviate any concerns about health and safety, by imposing appropriate discipline against Ms. Goodman for her lapse that caused the incident, and by taking steps to ensure no reoccurrence of the incident. In 2011, well after APD had knowledge of the DCF reports and findings on both the R.O. and E.K. incidents, APD issued a series of temporary or conditional licenses to both Lake Miriam and Timbergreen during the license renewal process to give HIOTW time to respond to certain identified omissions in the renewal applications, such as dental records, fire inspection reports, and the like. The temporary and conditional license certificates issued in February and March 2011 state on their face that the facilities comply with the licensure rules of APD. According to the APD Area 14 administrator, each of the DCF reports on the R.O. and E.K. incidents resulted in "a verified abuse finding." The area administrator testified that any DCF report resulting in a verified abuse finding is classified as a Class I offense, which is the most serious class of offenses and is sufficient, without more, to give APD legal authority to deny licensure or renewal of a license to a licensed applicant named in the report. Yet, despite the verified finding regarding the R.O. incident, Petitioner did not deny license renewal applications for other HIOTW group homes. Despite the verified findings in both the R.O. and E.K. incidents, Petitioner issued temporary and conditional licenses to Timbergreen and Lake Miriam during the license renewal process. Thus, Petitioner has not exercised its discretion consistently in dealing with HIOTW. Petitioner has not exercised its discretion consistently in contexts far more egregious than the two incidents charged here. For example, Petitioner acknowledged that a recent incident of abuse and neglect, resulting in the death of a group home resident, did not trigger action by Petitioner to take away all of the group home licenses held by the licensee. Instead, Petitioner only acted to suspend the license of the specific group home where the deceased resident had resided. Petitioner did not attribute this very serious incident to all facilities licensed by the same entity. It would be unreasonable for APD to automatically, without discretion, equate all verified findings--whether of abuse or neglect, whether deemed low risk or high risk, whether risk of death or imminent bodily injury was found or not found. A protracted period of abuse or neglect that actually causes death of a group home resident is on a different plane, in terms of seriousness, from a brief employee lapse in which an individual is not caught when he sneaks away, but is recovered without harm or incident ten minutes later. No explanation was offered by Petitioner as to why, in the more serious situation where a verified incident resulted in death, action was not taken to revoke all group home licenses held by the licensee, whereas here, two incidents verified as low risk situations by DCF (one of which was not proven at the hearing), would cause Petitioner to act more harshly.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by Petitioner, Agency for Persons with Disabilities, approving Respondent's applications to renew its annual licenses to operate Lake Miriam Group Home and Timbergreen Group Home and issuing standard licenses for one-year terms to those facilities. DONE AND ENTERED this 3rd day of February, 2012, in Tallahassee, Leon County, Florida. S ELIZABETH W. MCARTHUR Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 3rd day of February, 2012.
Findings Of Fact VNA Healthcare Group of Florida, Inc. is a non- profit parent corporation with four health-related subsidiaries. Visiting Nurse Association, Inc. is a Florida not-for-profit corporation which is licensed and Medicare- certified to provide home health care in the District VII, counties of Orange, Seminole and Osceola. VNA Respite Care, Inc. (hereafter "VNA Respite") is a licensed and non-Medicare certified subsidiary of VNA Healthcare Group which presently Provides private duty nursing services across District borders to residents of Orange, Seminole, Osceola, Lake, Marion, Sumter, Volusia, Polk, and Brevard counties. VNA Respite currently has offices in Orlando, Sanford, Longwood, Kissimmee, and Leesburg. Community Health Services, Inc. d/b/a VNA of Brevard, provides licensed Medicare- certified home health services in Brevard County. VNA of Central Florida, Inc. is the Community Care for the Elderly program provided in Orange and Seminole counties. On or before December 15, 1985, Visiting Nurse Association, Inc. (A) timely filed a CON application to establish a Medicare-certified home health care agency in District III. The application clearly identified Leesburg, Lake County, Florida, which is within District III, as the existing base of operations for the proposed agency. VNA applied for a CON to make its existing local home health agency, VNA Respite, Inc. eligible for Medicare reimbursement. The application, identified as CON number 4356, was denied by the State Agency Action Report (SAAR) of July 16, 1986. VNA's was the sole home health care agency application reviewed in this batching cycle, which contemplated a July, 1987 planning horizon. Since that time, HRS takes the position that it cannot tell what the horizon would be because its rules and policies have been invalidated. (TR 270-271). HRS is the agency responsible for certification and licensure of home health agencies in Florida. A home health agency in Florida must obtain a CON from HRS before it can become eligible to receive Medicare reimbursement. Medicare is a federally funded health program for elderly and disabled persons. Medicare reimbursement of home health agencies is on a cost reimbursement basis with a cap for each specific discipline covered. Home health agency costs in excess of the Medicare caps must be absorbed by the home health agency. This affects financial feasibility of individual applicants. Conversely, it also insures that traditional concepts of price competition have no applicability to home health agencies to the extent they provide Medicare reimbursable services and further establishes that there is negligible impact on competition among these labor (as opposed to capital) intensive providers. On August 15, 1906, VNA timely petitioned for a formal administrative hearing to challenge the denial. The only issue at the final hearing was whether VNA should be granted a CON. Both parties agreed that the only criteria remaining to be litigated were Florida Statutes subsections 381.494(6)(c) 1,2, 3, 4, 9, and 12 and 381.494 (6)(c) 8 as it relates to the extent to which the proposed services will be accessible to all residents of the service district. Presently, HRS has no rule or policy designating a numeric methodology to determine the need for new home health agencies in any given district. Review of CON applications for home health agencies is based upon statutory criteria of Section 384.494(6)(c), the merits of the proposal, and the district need demonstrated by the applicant. At final hearing, VNA, through its expert in need analysis for purposes of CON review, Sharon Gordon-Girvin. Presented two numeric methodologies to calculate need in District III. The method represented as the state's policy or "approach" for determining need was based upon an invalidated proposed rule which is no longer utilized by HRS and which, although pronounced reasonable" by both Ms. Gordon-Girvin and Respondent's spokesman, Reid Jaffee, cannot be legitimately used here as a reasonable methodology. (See Conclusions of Law. The other methodology presented by Gordon-Girvin was the District III Health Council need methodology. Gordon-Girvin and Jaffee each opined that District III's methodology is a very conservative procedure because of its use of a 5 year horizon line to project home health agency need. It is applied on a county by county basis and reveals a need on each of Alachua, Columbia, Hamilton, Lake and Marion counties for 1989. Jaffee concedes these foregoing figures. The plan also reveals a net need in 1987 for an additional agency in Alachua, Lake, Hamilton, and Columbia counties and in 1988 for an additional agency in Alachua, Lake, Hamilton, Columbia, and Marion counties. The District III Health Plan provides for a separate sub-district for each county. However, a county basis for subdistricting District III is not required by statute or rule and no part of the District III Health Plan has been adopted by HRS as a rule. The SAAR addressed the entire district as the service area. Although District III's need methodology does not establish a need for a home health agency for every county within the District, it provides that there are some circumstances in which the local need methodology may be set aside. District III's Review Guidelines provide that additional home health agencies may be granted certificates of need for counties within District III if certain circumstances are documented. The Review Guidelines propose that if residents of a specific area have not had access to home health services for the past calendar year preceding the proposal for new services or residents of a county have not had access to home health services for the past calendar year preceding the proposal for new services due to a patient's ability to pay or source of payment and the CON applicant documents an ability and willingness to accept patients regardless of payment source or ability to pay, the applicant may be approved as an additional home health agency. Although not a rule, this portion of the District III Health Plan is probative of need. In the absence of numeric need, it recommends additional home health agencies based upon a demonstration of unmet need for Medicaid and indigent patients. As of the date of hearing, HRS resisted granting the CON to VNA primarily because of unspecified prior batched applicants still in litigation (TR 232-233). Applicants in litigation are neither approved nor established and their existence, even had it been demonstrated, which it has not, is irrelevant. HRS' post-hearing proposals submit that neither of the proposed need methodologies suggested by VNA is applicable here. HRS urges the determination that VNA has thereby failed to establish numerical need for an additional District-wide home health agency and further submits that there is no compelment substantial evidence of unmet need for Medicaid and indigent patients. However, by a prehearing stipulation ratified at hearing, HRS agreed that, Although DHRS agrees that there is a need in District III for at least 18 other home health agencies, it contends that VNA should be denied its application because of certain other deficiencies in its proposals. (TR 14) VNA's principal office for HRS Service District VII is in Orlando, Orange County, Florida. HRS witness, Reid Jaffee, was the HRS reviewer of VNA's CON application. He candidly admitted that HRS' initial denial was based in part on his Failure to note the existence of VNA's local base of operations for its proposed home health agency. Most of HRS' concerns and reasoning for denial contained within the SAAP were based upon Mr. Jaffe's erroneous cognitive leap that VNA intended to "cover" the entire 16 county geographic area designated as HRS District I II From its corporate headquarters in District VII. Actually, VNA seeks certification of its existing licensed home health agency in District III. VNA Respite, VNA's existing licensed but non-certified home health agency in Leesburg, Lake County, a county within HRS District III, was established in January, 1985, and licensed in July 1986. Its office has continuously been located in and has operated out of Leesburg, Lake County, Florida, and it has continuously provided, without Medicare reimbursement, the same types of home health services as VNA now proposes to provide for Medicare reimbursement if the sought-for CON is granted. If granted a CON, VNA proposes to initially provide medical home health care services to patients in Lake, Citrus, Sumter, Marion, and Alachua counties. Services will initially be coordinated through the existing office of VNA Respite in Leesburg, Lake County, Florida. VNA would later phase in the remaining counties of District III by establishing another base office located in Alachua County. Reid Jaffee stated HRS probably would not have any cause to oppose the CON on the basis of anticipated geographic problems impinging on feasibility or quality of care if the service area were Lake, Sumter, Citrus, and Marion counties serviced from the existing Leesburg, Lake County base. (TR 256-258). In the first year VNA estimates 6,000 visits. In the second year it estimates 12,000 visits. A visit" is defined as the provision of service to meet the needs of a patient at his place of residence. In their Leesburg office, VNA Respite has received an average of 10 calls per week for Medicare reimbursable services which they currently must turn down. VNA submitted corrected financial information because of some inadvertent errors that had been made in the initial application. This was accepted by HRS and permitted by the Hearing Officer because it did not constitute a substantial amendment. It will cost VNA a maximum of $50,000 in start-up costs to operate in District III, although many of these costs have already been met by VNA Respite's previous and existing presence in Lake County. The initial application mistakenly submitted VNA's actual operating budget for a two year period in the place in the application designated for start-up costs. VNA's charges for a visit in the existing service area would be $55 the first year and $60 per visit the second year. The corrected financials reflect a net income projection of $10,442 in the first year and of $19,078 the second year. The project is financially feasible on both a short and a long term basis. Significant economies of scale will be realized by virtue of VNA's size in District VII which affords and will afford VNA Respite in District III the benefits of centralized accounting, billing, personnel services, nurse education services, and quality assurance programs while the use of VNA Respite in Leesburg as a dispatching base will assume quick, quality responsiveness to District III patients' needs. In the past, VNA has never exceeded Medicare cost caps. The projected costs of the VNA application are less than the cost caps in effect for District III. VNA will be operating cost effectively in District III in part because its cost per visit will be less than the Medicare cap. VNA's proposed home health agency will operate with reasonable efficiency if it is phased in as projected by VNA planners and economic experts. VNA proposes to offer the full six-core range of Medicare reimbursable services. It will provide, among other services, skilled nursing and medical supplies, physical therapy, occupational therapy, speech therapy, home health aid, and medical social services to patients in their homes. These are now offered out of VNA Respite's Leesburg office but are not Medicare reimbursable without a CON. VNA currently offers and proposes to offer high-tech home health services including enterostomal therapy, psychiatric nursing, parenteral-enteral therapy, and oncology and pediatric services. Additionally, homemakers and medical supply services are offered and are proposed to be offered. They are now, and if the application is granted, will continue to be made available 24 hours a day, 7 days a week. VNA proposes a voluntary advocacy program. The program anticipates added support to service elderly patients by coordination of volunteers who make daily telephone calls to the elderly or visit them at home. A similar program is working successfully in VNA's District VII operation at the present time. No other similar program is offered by other existing District III providers. By competent, substantial evidence, VNA has demonstrated considerable community and professional health care provider support for approval of its application. VNA Respite has a modest but positive record of community involvement in the areas of citizen education and continuing medical education. It offers health fairs on a regular basis and offers blood pressure clinics and diabetic screening programs weekly. VNA offers special training programs for home health aides which meet the State criteria. Graduates of the program are then employable by any Florida home health agency. The program is taught by VNA's Director of Education and VNA staff members. VNA offers clinical nursing programs ( internships) to students of the nursing schools of the University of Central Florida and University of Florida for nursing, dietary, and medical social worker master level programs. VNA is also a community-based agency, that is, it is governed by a board of directors which is comprised of community members who without pay, serve on the board and set policy. The District Health Plan, Table Home Health 6 entitled "Estimate of Population in Need of Home Health Services District III 1984 and 1989" reveals that: The licensed and approved home health agencies in District III in 1984 were only able to meet 72 percent of the existing need for home health services in District III. In 1984 only 66 percent of the need for home health services was met by licensed and approved home health agencies in Lake County. In 1984 only 59 percent of the need for home health services was met by licensed and approved home health agencies in Marion County. In 1984 only 58 percent of the need for home health services was met by licensed and approved home health agencies in Alachua County. In 1934 only 51 percent of the need for home health services was met by licensed and approved home health agencies in Sumter County. There was no hint that more recent figures (i.e. figures for the calendar year immediately preceding the proposal) are in existence or available. There is no minimum amount of indigent care required by Statute or rule which must be provided by a Medicare-certified home health agency. VNA committed at formal hearing to serve the following mix of patients by payor class from its VNA Respite base in District III if a CON is granted: 37 percent Medicare; 7.2 percent Insurance; 2.5 percent Medicaid; 2.3 percent Indigent. This revised commitment is more than eight times greater than the other District III home health agencies average commitment of .28 percent for indigent and three times their average for Medicaid patients. There was uncontroverted testimony that occasionally in instances when a patient's funding has been depleted or a patient is temporarily off Medicare for some reason, other District III home health agencies have discontinued all or select services even though the patient was still in need of the services. The VNA Respite office in Leesburg has provided indigent care in many past situations despite its lack of Medicare and Medicaid funding. VNA proposes to expand its service area to include District III in part to meet the need it perceives in District III for a nonprofit charitable home health agency. VNA's application states a commitment to provide totally uncompensated care to indigents. This noble ideal has to be taken with a grain of salt, however. A more realistic commitment is contained in VNA's Mission Statement, which reflects the basic philosophy and direction for VNA. It states that based upon the financial ability of the agency through available charity monies, VNA will provide select services to those patients having medical need regardless of their ability to pay. Absent a greater demonstration of guaranteed public and private beneficiary funding than appears in this record, the former lofty goal cannot be accepted as credible. However, the latter Mission Statement may be taken as a credible and valid commitment which is reasonably capable of fulfillment by VNA Respite for the reasons set out in the next Finding of Fact. VNA's dedication to providing indigent care and its Mission Statement policy have been implemented beyond the ramifications set forth in the Mission Statement through a policy of VNA's board of directors which transfers proceeds from other VNA subsidiaries to meet the service requirements of the certified home health agency. This policy allows VNA to provide more charity care than that for which it has been reimbursed by charitable contributions. VNA is one of only two nonprofit licensed home health agencies in District III. Due to VNA's non- profit status, it has opportunities to obtain charity monies to provide care to patients who have no payment source. In District VII, VNA typically receives monies from the public United Way and other private foundations. VNA`s dedication to service of indigents is reflected by its service in District VII. In District VII, in 1985, 70 percent of all charity visits were provided by VNA, although there were five other certified agencies. VNA maintains a professional advisory group which reviews the voluntary board's policy and VNA's provision of services. Such a professional advisory group is mandated under Medicare. It is made up of physicians and social workers but also includes lay members from the counties served. Qualifications for all members, but particularly for lay membership, was not sufficiently explored at hearing to make it possible to determine how "professional" the advisory group is, but it will be expanded to include representatives from District III counties if a CON is granted. VNA has established several internal departments and agency policies to insure a high quality of the home health services it provides. The intent behind VNA's Quality Assurance Department program is to oversee quality review controls and monitor nursing services through utilization and clinical record reviews to assure adherence to professional standards, corporate goals, and statements of policy (including the Mission Statement.) The evidence as to the implementation of each part of this lofty intent in actual practice in the Leesburg office of VNA Respite is hardly overwhelming, however, VNA has adequately demonstrated by competent substantial evidence that each VNA staff member receives a 3-week orientation upon initial employment and that after 3 months each staff member is evaluated by a quality assurance staff member accompanying the newcomer on home visits to review and verify the newcomer's clinical skills. It is also established that VNA's Community and Staff Education Department trains and orients staff and develops continuing medical education programs as discussed above. VNA publishes and provides its contract nurses and therapists with a detailed Policy and Procedure Manual, thereby providing further quality assurance, uniformity of care, and further staff training beyond that already described. The "track record" of its existing home health agency offices elsewhere provides some further insight for predicting the quality of care to be offered if the present CON application is granted. In 1985, VNA, Inc. made 144,000 visits or 48 percent of the total 297,000 visits made by home health agencies in Orange, Osceola, and Seminole counties. VNA, Inc. was formed in 1951 and has been Medicare-certified since 1966. Annual state licensing surveys conducted for VNA operations in Osceola, Orange and Seminole Counties have revealed either no deficiencies in operations or minimum deficiencies, none of which have ever addressed the quality of care provided. VNA demonstrated that accessibility of residents of certain counties within District III to certain types of core home health services is currently limited, particularly as to certain high-tech services and certain non- traditional forms of nursing. VNA has demonstrated that the 19 existing providers within District III have often failed to render certain types of high- tech and specialty nursing services within District III. It has been stipulated that two of the 19 existing providers have home offices located outside District III. They are Central Florida Home Health Service based in Volusia County and Gulf Coast Home Health Service based in Pinellas County. Lakeview Terrace Christian Retirement's CON and license limit it to providing home health care only to its residents, rather than to the general population of District III. Unfortunately, the evidence of record on the inaccessibility of services does not always follow the same county lines and this factor together with the variation of types of service which are sometimes inaccessible renders reaching any determination with regard to inaccessibility and unmet need on a District- wide basis difficult. The evidence is, however, clear that VNA has received a number of pediatric referrals because of the inability of other home health agencies to provide this nursing service. These remain a continuing need. Another continuing need is for long term intermittent visits which are difficult to obtain in District III, particularly11 for the elderly. Referrals to VNA Respite in District III have also been made from HRS in Lake and Marion Counties because of VNA's proven ability to provide otherwise inaccessible and unavailable high-tech services. Some of these latter referrals are somewhat remote in time from the date of hearing but there was no contrary HRS evidence that these situations of unmet need have alleviated. Seasonal fluctuations of population and the inadequacies of competing home health agency staffs put an increased strain on the existing District III home health agencies' ability to meet the current population's needs. VNA provides nurses specially trained and certified in a variety of the high-tech specialties. For example, VNA Respite in Leesburg offers certified enterstomal therapists, as well as certified intravenous (I.V.) therapy nurses with specialized training. From this specialization, it may be inferred that VNA is able to offer a higher level of care, increase the continuity of patient care, and decrease the amount of time necessary for each home visitation with certain patients within counties within a reasonable radius of Leesburg. VNA's application, as modified, satisfies the applicable planning guidelines established by the most recent District III Plan. There is negligible impact on competition in labor intensive providers such as home health agencies.
Recommendation Upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that HRS enter a Final Order granting VNA a CON to establish a District-wide home health agency as set forth in the proposal and conditioned upon its fulfilling its 2.3 percent indigent and 2. 5 percent Medicaid percentage commitments and upon phasing in its services in two stages, beginning with its first base at VNA Respite in Leesburg, Lake County. DONE and ORDERED this 21st day of May, 1987, at Tallahassee, Florida. ELLA JANE P. DAVIS 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 21st day of May, 1987. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 86-3558 The following constitute rulings pursuant to Section 120.59(2), Florida Statutes, upon the respective proposed findings of fact (FOF): Petitioners proposed FOF: 1-6 Covered in FOF 1. 8-14 Accepted but as stated subordinate to the facts as found. 15-17 Covered in FOF 16. 18 Accepted but subordinate to the facts as found. 19-21 Covered in FOF 17. Rejected as conclusionary and not supported by credible competent substantial evidence. Covered in FOF 18. Covered in FOF 16. Covered in FOF 24. Covered in FOF 14. 27-23 Covered in FOF 24. 29 Covered in FOF 18. 30-35 Covered in FOF 24. 36-37 Covered in FOF 18. 38 Rejected as a conclusion of law of facts as found 25-26. 39-40 Covered in FOF 16, 22 and 25. 41-52 Except as covered in FOF 16, 22, and 25-26, these proposals are subordinate and unnecessary to the facts as found, or to the degree indicated in those FOF, are not supported by direct competent substantial evidence. 53-55 Except as covered in FOF 3, 25-26, these proposals are subordinate to the facts an found and unnecessary. 56-57 Covered in FOF 19. 58 Rejected as stated as not supported by the direct credible evidence as a whole. 59-68 Covered in FOF 22-23. Covered in FOF 21. Covered in FOF 20. 71-74 Subordinate and unnecessary to the facts as found in FOF 21. 75-86 In large part these proposals are irrelevant for the reasons stated in the facts as found; that material which is not irrelevant is CUMULATIVE, subordinate and unnecessary to the facts as found. Additionally these proposals are so unsatisfactorily numbered or otherwise delineated as to be something apart from proposals of findings of ultimate material fact. See FOF 10, 19, and 27. 87-94 Covered in FOF 15. 95-96 Covered in FOF 14. 97-98 Subordinate and unnecessary to the facts as found. 99-101 Covered in FOF 15. 102-105 Rejected in part for the reasons set out in FOF 4 and 28 in part as not supported by the record as a whole and in part as subordinate and unnecessary. 106-110 Except as covered in FOF 7-12, 19, 22, and 25, and the conclusions of law (COL), these proposals are rejected as not supported by the record as a whole. 111. Rejected as not supported by the record as a whole. See FOF 2 and 8. 112-118 Except as covered in FOF COL, these proposals are the record as a whole. 7-12, 19, 22, aid 25, and the rejected as not supported by 119 Covered in FOF 2. 120 Covered in FOF 10-12 and the COL. 121-129 Except as covered in FOF 7-12 and 14, rejected as not 1-131 Supported by the record as a whole. Covered in FOF 22 and 25. 132 Covered in FOF 21-23. 133-134 Rejected as conclusions of law. Respondent's proposed FOF: Covered in FOF 2. Covered in FOF 5. Covered in FOF 6. Covered in FOF 1. Covered in FOF 2-3. Covered in FOF 16. Covered in FOF 17. Covered in FOF 21. Covered in FOF 3. Covered in FOF 2-3. Covered in FOF 4. Covered in FOF 7. Covered in FOF 8-12. COPIES FURNISHED: Gregory L. Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Leo P. Rock, Jr., Esquire Linda D. Schoonover, Esquire Suite 1200 201 East Pine Street Orlando, Florida 32801 John Rodriguez, Esquire, Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 John Miller, Esquire Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700
The Issue The issues to be determined are whether Respondent, Miracles House, Inc. (Respondent or Miracles), as licensee of Miracles House, Inc., a group home facility, violated provisions of section 393.0673, Florida Statutes (2017), and administrative rules,1/ as alleged in the Administrative Complaint; and, if so, what is the appropriate sanction.
Findings Of Fact APD is responsible for regulating the licensing and operation of group home facilities in the state of Florida. APD's clients include vulnerable individuals with developmental disabilities attributed to autism, cerebral palsy, intellectual disabilities, Phelan-McDermid syndrome, Prader-Willi syndrome, or spina bifida. APD's clients can choose to live in an institutional setting, group home, or independently. A client is assisted in this choice by a residential placement coordinator. A group home is a licensed facility providing a living arrangement similar to a family setting. It is the provider's responsibility to provide not only room and board but also safety, transportation, assistance with the activities of daily living, and to attempt to provide all residential habilitation services at the level needed by the client, as established by the client with a waiver support coordinator. A waiver support coordinator is an independent contractor for APD who acts as a case manager and is responsible for coordinating the services provided to a client. Support plans are prepared and submitted to APD by a client's waiver support coordinator. A support plan is a "snapshot" of a client's life. It includes a summary of events and activities that have occurred throughout the year, including hospitalizations, medications, and the client's goals. The resources and capabilities available to a client and his support givers are not always sufficient to meet all of the client's needs. The support plan is implemented to maximize the attainment of habilitative goals. The support plan is periodically reviewed to assess progress toward habilitative and medical objectives and revised annually after consultation with the client. Each client is assigned a level of care code that relates to payment made to the group home on the client's behalf. As its name suggests, there is some correlation between the level of care code that is assigned and the level of care to be given by the provider, but because additional services may be provided by other individuals and resources, the assigned level of care does not necessarily reflect all needs and services necessary for, or being provided to, the client. If a group home believes that it cannot provide the required residential habilitation services or meet its responsibilities with respect to a particular client, it can make this known to the waiver support coordinator. Adjustments are periodically made to the support plan, including the level of care code. If adjustments sufficient to address the provider's concerns are not made, a group home may request that a client be placed in another facility. APD issued license number 11-1088-GH to Miracles for the purpose of operating a group home located at 113211 Northwest 26th Court, Miami, Florida. Ms. Whipple is a corporate officer of Miracles and the on-site manager of its group home. There was no evidence introduced indicating that Miracles had previously received discipline based upon its group home license. Client R.H. At all times material to this case, Client R.H. was a resident of Miracles' group home, where he has lived for several years. Client R.H. has an intellectual disability. Mr. Lumumba was a contracted waiver support coordinator working with APD. He began work in this capacity in July of 2016 and was assigned to Client R.H. at that time. Mr. Lumumba prepared support plans and many incident reports for Client R.H. after that date. Incident reports prior to Mr. Lumumba's service were also admitted into evidence. Successive support plans repeat much of the narrative from prior plans, and because only selected plans were introduced into evidence, it is difficult to determine exactly when many of the additions or entries were made. Client R.H. is reported as having suicidal thoughts, and it is noted that when he is under the influence of drugs, he requires support and direction to be safe. He is described as needing reminders, instruction, redirection, and support to avoid danger and to remain healthy and safe. Notations in the support plans and numerous incident reports document a distinct pattern of behaviors by Client R.H. In an incident report dated January 26, 2015, it was reported that Client R.H. became agitated, left the group home alone, and walked to the Mental Health Center located at Northwest 27th Avenue and 151st Street. He was later transported by the Mental Health Center staff to Jackson Memorial Behavioral Health Unit and admitted. In an incident report dated February 11, 2015, it was reported that Client R.H. became agitated and left the group home to go to the store, refusing to be accompanied by staff. He later presented himself at North Shore Medical Center where he was admitted to the Crisis Stabilization Unit. In an incident report dated February 17, 2015, it was reported that Client R.H. visited his mother, got into an argument with her, left her home, and went to Memorial Regional Hollywood Emergency Room (ER). He was later discharged in the care of Miracles' group home staff. In an incident report dated March 30, 2015, it was reported that Client R.H. became argumentative and left the group home unaccompanied under the pretext of going to the nearby corner store. He traveled to the North Shore Medical Center ER and was admitted to the Behavioral Health Unit. He was discharged on March 25, 2015, and returned to Miracles by hospital staff. A July 19, 2015, update to the Client R.H.'s support plan indicates that Client R.H. reported that he was not abused at the Miracles' group home, and that he felt safe and wanted to stay there. In an incident report dated August 14, 2015, it was reported that Client R.H. left the group home and went to the North Shore Medical Center ER, where he was admitted as a psychiatric patient. The group home was informed he would be kept for 72 hours and then discharged. In an incident report dated August 18, 2015, it was reported that Client R.H. "eloped" from the group home. He later made contact with his mother, began acting in bizarre ways, and said he needed drugs. He ran into the street shouting, began to undress, and lay down in front of cars. He was taken to Aventura Hospital and admitted as a psychiatric patient. A September 21, 2015, update to the support plan reflects that Client R.H. had moved out of the Miracles group home to stay with his sister. In September of 2015, Client R.H. was removed from Miracles at Dr. Whipple's request, made 30 days earlier, according to Mr. Lumumba. A December 14, 2015, entry in the support plan indicates that Client R.H. went to jail in October 2015 for trespassing and petty theft. When he was released on December 6, 2015, he asked to return to Miracles' group home. The support coordinator was unable to place Client R.H. in another group home, and Miracles' group home was requested to take him back, which it did. In an incident report dated February 12, 2016, it was reported that Client R.H. became agitated, argumentative, and uncontrollable. He walked to the street, pulled down his pants, screamed, and began to roll around in the street. Police were called, and he was arrested and transported to the North Shore Medical Center. In an incident report dated March 9, 2016, it was reported that Client R.H. was verbally and physically out of control. He went to the street in front of the house, fell to the ground, and began rolling around. He could not be physically restrained or verbally redirected. The police were called, and he was restrained and taken to North Shore Medical Center where he was admitted for psychiatric treatment. In an incident report dated March 17, 2016, it was reported that police arrived at the facility and arrested Client R.H. for a 2014 charge of stealing church equipment. During the annual support plan meeting on June 1, 2016, Client R.H. indicated that he still felt comfortable at the group home and said that "Ms. Felicia" (Whipple) was like a mother to him. Client R.H. indicated he had been going to church with her every Sunday since he returned to the group home in December. The July 1, 2016, support plan prepared by Mr. Lumumba suggested that the rate for client R.H. be changed from minimal to moderate and stated: [Client R.H.] requires 24 hours' supervision to ensure health and safety as he suffers from insomnia, seizures, psychosis and mood disorder, Bipolar, depression, and drug addictions. The approval of this services request will ensure that [Client R.H.] receives the support that he needs to achieve his goal and maintain a healthy life style. The July 1, 2016, support plan also noted: Consumer has had history of abuse in the past when he was living with his mother. He was abused by mother's boyfriend. However since he has been at Miracle House, there was an abuse allegation made by [Client R.H.'s] mother, however it was investigated and they have find that the mother was the one who initiated the allegation. There was no foundation on those allegations. No history of abuse or neglect that has been documented in his records. Mr. Lumumba testified that the notations in the support plans that Client R.H. required 24-hour supervision were "recommendations" as opposed to "requirements." In an incident report dated July 13, 2016, it was reported that Client R.H. went to his mother's housing complex unannounced, where security was unable to reach his mother, and he was denied access. He became agitated, verbally aggressive, and out of control. The police were called, and he was taken to Hialeah Hospital. In an incident report dated July 23, 2016, it was reported that Client R.H. left the group home without stating where he was going. He failed to return to the group home overnight. His mother called the group home to inform staff that he had been arrested after police approached him and found crack cocaine in his possession. A support plan update dated December 1, 2016, indicates that Miracles requested a change from "minimal" to "moderate" behavioral focus to provide additional services to Client R.H. In an incident report dated December 5, 2016, it was reported that Client R.H. was verbally abusive, out of control and agitated, screaming and cursing staff, and running in the street. The report states that police were called, and he was transported to North Shore Medical Center's crisis unit. He was discharged from North Shore Medical Center and returned to the group home on December 7, 2016. In an incident report dated December 28, 2016, it was reported that Client R.H. went to his mother's housing complex unannounced, where security was unable to reach his mother, and he was denied access. He became agitated, verbally aggressive, and out of control. The police were called, and he was taken to Hialeah Hospital. In an incident report dated February 25, 2017, it was reported that Client R.H. informed staff at about 10:00 p.m. that he was going to buy cigarettes from the corner store. He did not return and called the group home from the jail to report that he had been stopped by police, searched, and arrested for possession of crack cocaine. In an incident report dated March 27, 2017, it was reported that Client R.H. told staff he was going to a store to buy cigarettes. He did not return and was assumed to be at his mother's house. His mother called late in the afternoon to report that he had gone to the North Shore Medical Center ER and been admitted to the crisis unit. Ms. Whipple testified that in March of 2017, Client R.H.'s level of care code was changed to Extensive 1. In an incident report dated April 6, 2017, it was reported that Client R.H. became agitated, combative, and threatening. Staff was unable to de-escalate his behaviors. Police were called, and he was taken to North Shore Medical Center. In an incident report dated April 17, 2017, it was reported that Client R.H. went to visit his mother on Easter morning. His mother called in late afternoon to report that he had gone to North Shore Medical Center ER and been admitted to the crisis unit. In an incident report dated April 26, 2017, it was reported that Client R.H. left the group home in the afternoon for cigarettes. He did not return. His mother called at 10:30 p.m. to report that he had called her from Palmetto General Hospital where the police had taken him. In an incident report dated May 7, 2017, it was reported that Client R.H. left the group home for cigarettes but walked to the Jackson Memorial Hospital mental health unit instead, where he was admitted. In an incident report dated May 17, 2017, it was reported that Client R.H. left the group home saying he needed cigarettes from the store. He later called his mother to report that he had been picked up by the police for burglary. In an "annual summary" entry in the support plan, it was noted, in relevant part: [Client R.H.] has not make much progress this year. He has been in and out of Crisis and has been Backer Acted too many times and at the time that I'm writing this Support plan, [Client R.H.] is an crisis since May 17-2017. [Client R.H.] needs another supportive alternative program to rehabilitate him for his constant going to crisis. He need to be a program where he can be monitored and with a restricted rules and regulation and Medical intervention or his constant substance issues. In an incident report dated May 28, 2017, it was reported that Client R.H. left the group home to go to his mother's home on May 27, 2017, and did not return as expected. He called the group home on May 28, 2017, and said he was at Jackson Memorial Hospital in the crisis unit. He was released on May 29, 2017. In an incident report dated June 5, 2017, it was reported that Client R.H. left the group home to go to the store the previous day and failed to return. His mother called to report that he had been arrested for breaking and entering and stealing merchandise from someone's home. Following the 2017 support plan meeting, in which the number of incident reports and alternatives to address Client R.H.'s drug issues were discussed, the July 1, 2017, support plan stated that "[Client R.H.] has been unpredictable and it require a lot of man power to really keep [Client R.H.] living at Miracles House, the group home is asking the Behavior analyst to have [Client R.H.] level of care has been approved to change from Moderate to Extensive Behavior focus [] 1." Mr. Lumumba noted that no abuse or neglect had been reported since he began working with Client R.H. in 2015. In an incident report dated August 5, 2017, it was reported that Client R.H. became verbally agitated and physically aggressive with medical staff while at an appointment at a mental health provider. The report states that police were called, and Client R.H. was "taken under Baker Act." In an incident report dated August 14, 2017, it was reported that Client R.H. left the group home for cigarettes. He called later to say that he had checked himself in at Jackson Memorial Hospital ER. In an incident report dated November 29, 2017, it was reported that Client R.H. left the group home to purchase cigarettes and did not return. His mother called to report that he had been arrested for property theft. In an incident report dated January 27, 2018, it was reported that Client R.H. became agitated and said he wanted to go to the crisis unit. He called the police, and when they arrived, he was outside running up and down in front of the home and saying he wanted to go to the hospital. He was taken to North Shore Medical Center Crisis Unit. In an incident report dated February 12, 2018, it was reported that Client R.H. began screaming uncontrollably. He became verbally aggressive, ran outside the facility, said he wanted to kill himself, and asked for the police to be called. After unsuccessful attempts to de-escalate the situation, police were called, and he was taken to North Shore Medical Center's crisis unit. In an incident report dated March 26, 2018, it was reported that Client R.H. left to get items from the corner store and did not return. North Shore Medical Center called to say he had arrived there. He was admitted. In an incident report dated May 30, 2018, it was reported that Client R.H. left the group home to get items from the store. He called in the afternoon saying he had gone to Jackson Memorial Hospital ER and been admitted into the crisis unit. In an incident report dated June 2, 2018, it was reported that Client R.H. went to his mother's home for a visit, where he initiated an altercation with his mother. He was taken to the North Shore Medical Center Crisis Unit. In an incident report dated June 12, 2018, it was reported that Client R.H. left the group home. His mother later advised that he had walked to Jackson North and checked himself into the Crisis Unit. In an incident report dated June 26, 2018, it was reported that Client R.H. left the group home to go to the store. He wandered in to North Shore Medical Center and stated he was not feeling well. He was admitted as a medical patient. Ms. Whipple testified that Client R.H. was a competent adult and that she was legally unable to restrain him. She testified that he always asked for permission to leave. But when they told him he could not go, she testified, he would get mad and storm out the door anyway. Ms. Whipple recognized that Client R.H. required a great deal of supervision, and she requested that his level of care code be increased, so that she would be compensated in part for her increased responsibilities, but she testified that she was never focused that much on the amount of money she was receiving. Ms. Whipple testified that she trained her staff to redirect Client R.H.'s behaviors to ensure that he would not run off. She stated that an Extensive 1 level meant that he should be closely watched, and that is what the staff at Miracles' group home was trained to do. Mr. Lumumba testified that he had tried to place Client R.H. in other group homes, but that Miracles' group home was the only place that he knew Client R.H. would survive. The notations in these incident reports and support plans strongly support Mr. Lumumba's sentiment that Client R.H. "needs another supportive alternative program to rehabilitate him for his constant going to crisis." APD did not clearly show that the support plan's statement that Client R.H. "requires 24 hours' supervision" created a legal obligation for Miracles to literally provide constant supervision. APD did clearly and convincingly show that Miracles failed to facilitate the implementation of Client R.H.'s support plan, because, taken as a whole, it obviously required a very high level of supervision that Miracles could not, or did not, provide. APD does not argue, and there was no evidence to show, that Client R.H.'s dignity was infringed, that his right to privacy was violated, or that he was subjected to inhumane care, harm, unnecessary physical, chemical or mechanical restraint, isolation, or excessive medication. There was no evidence that the Department of Children and Families (DCF) verified that Miracles was responsible for any abuse, neglect, or exploitation of Client R.H. The record contains evidence of a single DCF investigation into allegations of maltreatment and inadequate supervision, opened on November 30, 2017, and closed on January 22, 2018. That investigation concluded that the allegations were not substantiated, that no intervention services or placement outside the home was needed, and that Client R.H.'s needs were being met. There was no compelling evidence to show that Client R.H. was subjected to abuse or exploitation by Miracles while at the group home. Client J.B. Client J.B. has an intellectual disability and lived at Miracles' group home from May until December of 2017. In an incident report filed by Ms. Loriston dated December 14, 2017, it was reported, in relevant part, that: On 12/14/17 at 6:15 pm wsc received a phone call from Ms. Felicia Whipple stating that she threw the consumer's belonging in the front yard as she is no longer welcome to her group home. Ms. Whipple also stated that [Client J.B.] is on the way home from her part-time job, she contacted [Client J.B.] to let her know of her belongings bein in the front yard. [Client J.B.] contacted law enforcement because she feared for her safety, WSC immediately was able to find an emergency accommodation at Paradise Gaine Group Home. While she testified that her report was accurate, Ms. Loriston described the events a bit differently at hearing. She testified that Ms. Whipple called her to say that Client J.B. could no longer come back to the group home and that her belongings would be waiting for her in front of the door. She specifically testified that Ms. Whipple did not tell her that she threw Client J.B.'s belongings in the front yard, but rather told her that they were at the front door. Ms. Loriston testified that when she arrived at Miracles' group home, she did not see the belongings, that the incident was over, and the police were gone. In an incident report filed by Ms. Whipple, dated December 16, 2017, it was reported that: Consumer receives her Social Security Disability Check and she is currently employed at MACY's. From these funds she refused to pay Room and Board and refused to move from the facility. Following a confrontation requesting payment, she left the facility and returned later with 2 cars loaded with family and associates to the facility to threaten the owner and the facility. Police were called and APD, Residential Services Coordinator, Carey Dashif. He along with the WSC coordinated the transition of consumer to another group home in the interest of safety for Miracles House residents and staff. Ms. Loriston's account of events was less than clear and convincing due to the discrepancies between her statement in the incident report and her testimony at hearing. She did not actually see any of the events of that evening and did not remember distinctly the exact admissions of Ms. Whipple, the critical competent evidence in the case. She was consistent in her testimony that Ms. Whipple admitted she had moved Client J.B.'s belongings. Her remaining testimony was largely hearsay. While Ms. Whipple's account of events was less than credible, it was not her burden to prove what happened. Ms. Llaguno testified that the proper procedure to terminate services to Client J.B. would have been for Miracles to send a 30-day notice terminating the placement. Ms. Loriston similarly testified that this was also her understanding. Remarkably, no APD rule establishing this policy was recognized or identified at hearing, however. Neither were Miracles' written criteria or procedures for termination of residential services introduced. Though Ms. Loriston's testimony that she had to immediately find other housing for Client J.B. is credited, violation of APD rules was not clearly shown. APD did not show that Miracles failed to have written criteria and procedures for termination in place or that they were not consistent with Florida Administrative Code Chapter 65G-3. Medicaid Action As stipulated by the parties, in July of 2017, the Agency for Health Care Administration took action against Miracles by terminating its Medicaid provider number. As stipulated by the parties, Miracles lost its Medicaid provider authorization, and has lost the right to furnish Medicaid services and receive payment from Medicaid in Florida. No evidence as to the basis for, or purposes of, the Medicaid termination was introduced. There was no evidence that Miracles previously had its license to operate a residential facility revoked by APD, DCF, or the Agency for Health Care Administration.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Persons with Disabilities enter a final order finding Miracles House, Inc., as licensee of Miracles House, Inc., Group Home, in violation of Florida Administrative Code Rule 65G-2.009(1)(a)1. and section 393.0673(1)(a)2., Florida Statutes; suspending its license to operate a group home until its right to furnish Medicaid services and receive payment from Medicaid in Florida is restored; and imposing a fine in the amount of $100. DONE AND ENTERED this 17th day of September, 2018, in Tallahassee, Leon County, Florida. S F. SCOTT BOYD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 17th day of September, 2018.
The Issue Whether the Petitioner, Gwen McClain, meets the requirements of the Respondent, the Department of Health and Rehabilitative Services, for relicensure as an adult foster home sponsor.
Findings Of Fact Ms. McClain's home has been licensed as an adult foster home by the Department for approximately one year prior to April, 1992. Ms. McClain's husband, Jay McClain, resides with her. At the time of the final hearing of this matter, Ms. McClain provided a home for three adults who were mentally retarded or developmentally disabled. On or about October 31, 1991, Ms. McClain, her husband and a neighbor drove a man from Ms. McClain's home to Georgia. The man was not a family member or even a close friend of Ms. McClain. During the final hearing Ms. McClain described the man as someone her husband worked with. Ms. McClain's neighbor drove the vehicle in which the man was taken to Georgia. Ms. McClain and her husband were passengers. Ms. McClain was aware at the time that she rode to Georgia that the man had shot and wounded another man earlier that evening. Although the man that was shot ultimately died, Ms. McClain was not aware of his death at the time she accompanied the man to Georgia. Ms. McClain and her husband were eventually charged with criminal conduct as a result of the incident described in finding of fact 3. The evidence, however, failed to prove when she or her husband were charged or what she or her husband were charged with. The evidence failed to prove that the Department has adopted any rule which required that Ms. McClain disclose to the Department that she or her husband had been involved in the incident described in finding of fact 3 or that she or her husband had been charged with a crime as a result of the incident. At some time prior to April 1, 1992, probably in February, 1992, Ms. Gwen Howell, a Human Services' Counselor III for the Department, read an article in the Jasper News reporting the incident described in finding of fact 3. Ms. Howell had been at Ms. McClain's home at least once between October, 1991, and the date when Ms. Howell read about the incident in the newspaper. Ms. McClain had not mentioned the incident to Ms. Howell. Ms. Howell confronted Ms. McClain about the incident described in finding of fact 3 sometime shortly after reading the newspaper article. Ms. McClain, when asked about the incident, responded "how did you know?" The weight of the evidence failed to prove, however, what Ms. McClain may have meant by this statement. It is not, therefore, apparent whether Ms. McClain made the comment because she was merely curious where Ms. Howell had heard about the incident, because she had been hoping that Ms. Howell would not find out about the incident or for some other reason. When confronted by Ms. Howell, Ms. McClain admitted her involvement in the incident described in finding of fact 3. Ms. McClain also admitted her involvement in the incident to Carter Bass, Ms. Howell's immediate supervisor at some time before April, 1992. Ms. McClain was remorseful for her involvement, admitted she had exercised poor judgement and admitted that she had not thought of the consequences of what she had done. On or about March 31, 1992, Ms. McClain signed an Adult Foster Home Annual Renewal Application (hereinafter referred to as the "Renewal Application"). DHRS exhibit #1. The Renewal Application was received by the Department on or about April 1, 1992. The evidence failed to prove that Ms. McClain did not accurately provide all information requested on the Renewal Application. No where on the Renewal Application was Ms. McClain asked any question concerning whether she or her husband had been charged with any crime or whether she or her husband had been involved in any incident similar to the one described in finding of fact 3. Nor has the Department cited any rule which required that Ms. McClain make such a disclosure on the Renewal Application. At the time that Ms. McClain filed the Renewal Application she had admitted her involvement in the incident to Ms. Howell, the Department's employee responsible for investigating and making the initial recommendation concerning the Renewal Application, and Mr. Bass, the Department's employee responsible for recommending to the Department's district office whether the Renewal Application had been approved. The Department was, therefore, on notice of the incident when Ms. McClain filed the Renewal Application. Ms. McClain and her husband had not been adjudicated guilty of any crime at the time the Renewal Application was filed. On April 20, 1992, Ms. McClain plead, and was adjudicated, guilty of the crime of obstructing an officer without violence as a result of the incident described in finding of fact 3. Ms. McClain was sentenced to one year of supervised probation. The weight of the evidence failed to prove that the crime for which Ms. McClain was adjudicated guilty involved "harm to others." Also on April 20, 1992, Ms. McClain's husband plead, and was adjudicated, guilty of the crime of accessory after the fact to second degree murder as a result of the incident described in finding of fact 3. Ms. McClain's husband was also sentenced to one year of supervised probation. The weight of the evidence failed to prove that the crime for which Ms. McClain's husband was adjudicated guilty involved "harm to others." At some time prior to June 5, 1992, Mr. Bass recommended to James Godwin, a program administrator in the Department's district office, that the Renewal Application not be approved. Mr. Godwin exercised his authority to deny the Renewal Application and instructed Mr. Bass to so inform Ms. McClain. By letter dated June 5, 1992, the Department notified Ms. McClain that the Renewal Application was being denied for the following reason: Your application for relicensure as an Adult Foster Home Sponsor has not been recommended for approval at this time for the following reason: You do not meet the Adult Foster Home Sponsor Qualifications as per HRS Manual 140-11, Page 5-12, Paragraph 5-5d. A foster home sponsor should be free of confirmed reports of abuse, neglect or exploitation or any crime involving harm to others. At the final hearing the Department stipulated that Ms. McClain, except as set out in the Department's letter of June 5, 1992, meet the other requirements for relicensure. HRS Manual 140-11, Page 5-12, Paragraph 5-5d, provides the following requirement for licensure as an adult family home sponsor: d. a foster home sponsor should be free of confirmed reports of abuse, neglect, or exploitation or any crime involving harm to others. At the final hearing, the Department also suggested that the Renewal Application was properly denied because Ms. McClain had shown a lack of judgement. The Department, therefore, suggested that Ms. McClain did not meet the requirements of HRS Manual 140-11, Page 5-12, Paragraph 5-5c, which provides: c. A foster home sponsor should be of suitable physical and mental ability, to the extent that he is able to provide care and supervision appropriate for the clients he serves; be capable of handling an emergency situation promptly and intelligently; and be willing to cooperate with the department staff. Although the Department had not previously informed Ms. McClain that paragraph 5-5c also formed part of the reason for denying the Renewal Application, Ms. McClain raised no objection to the evidence concerning this issue presented by the Department. More importantly, it does not appear that Ms. McClain was prejudiced in any way by not being informed of the issue prior to the final hearing. Based upon the weight of the evidence, Ms. McClain's actions during the incident described in finding of fact 3 evidenced a lack of ability to react to a unusual and surprising situation in a calm and rational manner and to make an appropriate decision as to how to respond to the situation. Ms. McClain's actions, therefore, evidence a lack of ability to handle an emergency situation promptly and intelligently. Based upon the testimony of the mothers of two of the adults currently under Ms. McClain's care and four of the six Department employees who testified in this proceeding, Ms. McClain has provided good care to the adults residing in her home.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED the Department enter a final order denying Ms. McClain's Renewal Application and dismissing, with prejudice, Ms. McClain's petition in this case. DONE and ENTERED this 9th day of October, 1992, in Tallahassee, Florida. LARRY J. SARTIN 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 9th day of October, 1992. APPENDIX The Department has submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted. Ms. McClain did not file a proposed recommended order. The Department's Proposed Findings of Fact Findings of fact 1 and 10. Finding of fact 12. The last sentence is not relevant. See findings of fact 11 and 13. Not relevant. See findings of fact 11 and 13. Findings of fact 14 and 15. See finding of fact 3. The evidence failed to prove that the man was taken to Texas. The only testimony concerning where the man was taken after he was taken to Georgia was hearsay. Findings of fact 6-9. The fact that Ms. McClain had not voluntarily disclosed the charges against her is irrelevant. The Department has failed to cite any authority which requires that she make such a disclosure. The only rule referred to by the Department during the hearing required disclosure after a conviction. The Department was fully aware of the charges and the incident prior to any adjudication of guilt in this case. See finding of fact 8. Finding of fact 9. Finding of fact 23. Hereby accepted. Findings of fact 9 and 16. Finding of fact 16. COPIES FURNISHED TO: Gwen McClain Post Office Box 314 Jennings, Florida 32053 Ralph McMurphy Assistant Legal Counsel District 3 Legal Office Department of Health and Rehabilitative Services 1000 N.E. 16th Avenue Gainesville, Florida 32609 Sam Power, Agency Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407 Tallahassee, Florida 32399-0700 John Slye Department of Health and Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407 Tallahassee, Florida 32399-0700
The Issue The issue in this case is whether Respondents' child- placing agency license should be revoked.
Findings Of Fact The Department is the state agency responsible for licensing and monitoring child-placing agencies. The Center, whose address is 1602 East Third Avenue, Tampa, Florida, received its initial child-placing agency license from DCF in 2004. The license was renewed October 12, 2006. Susan Morgan has been the director of the Center since its inception. DCF contracts with HKI to provide community-based child welfare services in Hillsborough County. HKI contracts with Camelot Community Care for the performance of adoption related services. DCF received complaints about Respondent and issued an Administrative Complaint with the following categories of violations: A foster parent home study was finalized after only one home visit lasting half an hour. The home study document indicates four home consultations for that client. Files relating to clients were left in an unsecured environment at the Center with unauthorized persons having access to them. An adoptive home study was completed without a visit being made to the prospective adoptive parents' home. Respondent lost or misplaced paperwork from clients which contained confidential information. Respondent failed to timely provide foster parents with a copy of their foster parent licenses once the licenses were issued. Regarding the first violation, two home studies are required to finalize a foster parent home study. The subject family was provided a template for filling in information about their home. This is a reasonable means of gathering information about a family. The family was directed to fill in the template using the third person format (so that anyone reading the document might infer that someone other than the family had written the information). Morgan did not visit the home at issue, but did send her associate (Wendy Martinez) who conducted a brief 30 to 40-minute visit. The home study was signed by Morgan and dated March 13, 2007, some four or five weeks prior to Martinez's visit. The home study included the following table concerning visits and consultations: Contact Information Inquiry Date 01/05/06 Inquiry Home Visit 02/10/06 Initial Home Consultation 03/15/06 MAPP Graduation 02/26/06 2nd Home Consultation 04/02/06 Final Home Consultation 03/08/07 Date Application Signed 03/08/07 The table seems to indicate a single home visit on February 10, 2006, and three home "consultations" on later dates. Morgan says the date of the home visit is a typographical error; it should say April 18, 2006, i.e., the date of Martinez's visit. Morgan admits only one home visit was made, but says the home study was not final. Her testimony on that topic is not credible. The home study appears complete, has references to several home visits and/or consultations, and is signed by Morgan subsequent to the dates appearing in the aforementioned table. DCF considers the references to home consultations to be tantamount to home visits. Inasmuch as at least two home visits are required for a foster parent home study, this interpretation makes sense.1 A discussion of the differences, if any, between home visits and home studies follows. There was much testimony at the final hearing as to whether a home visit and a home study are the same thing. Each of the experienced social workers and managers who testified (other than Morgan) seemed to believe the two were synonymous. Even the two witnesses called by Respondent to address the issue opined that home visit and home consultation mean essentially the same thing. Respondent introduced definitions from The Social Worker's Dictionary, but there is nothing in those definitions to suggest they apply to foster care or adoption situations. None of the social workers who testified indicated they would rely on that source to define home visits versus consultations. The home study at issue appears to suggest that four home visits/consultations were conducted, when in fact only one (of the required two) was done. The second category of rule violation concerns unsecured client records. Files belonging to clients of child- placing agencies are extremely confidential in nature. Respondent moved into a new office in the Ybor City section of Tampa during September 2006. The office was shared with a company that specializes in estimating construction project costs. The estimating company had two employees, a receptionist and the owner of the company. The office was set up so that the receptionist was in the same room as Respondent's employee, Martinez. Morgan had a separate office for herself, and the owner of the estimating company had an office upstairs. The Ybor City office had been inspected by DCF in October 2006 and was found to be sufficient for its intended purposes. A client, Angela Ferguson, visited the Center in early April 2007. Morgan was not present when Ferguson arrived, but Martinez was there, as were employees from the other business. Martinez called Morgan on the client's behalf so that Morgan could come to the office. While waiting for Morgan, the client noticed 50 to 60 file folders lying around the office. Some of the files belonged to other clients whose names were visible to Ferguson. Some of the files were probably forms and other non- confidential documents. The client files were not locked in a cabinet or otherwise protected from persons using Respondent's office. On or about May 2, 2007, another client, Jennifer Moody, also visited the Center to get her file (so that she could transfer to another adoption agency). She walked into the office and found the estimating company's receptionist, but no one from the Center was there. The receptionist called Morgan because Moody wanted to wait for her to arrive. While waiting, Moody observed files lying around the office in plain view. When Ferguson expressed her concerns to DCF about the way files were being handled, a licensing specialist was sent out to investigate. DCF employee Melissa Leggett made an unannounced visit to the Center on May 16, 2007, at 10:00 in the morning. Martinez was in the office when Leggett arrived; Martinez called Morgan for Leggett, and Morgan arrived shortly thereafter. Leggett noticed confidential files lying around the office, including files for some clients who she personally knew. Leggett advised Morgan that the files would have to be protected by placing them in a locked file cabinet or locked room. Morgan agreed to remedy the situation and seems to have done so by the date of the final hearing. Files are now being protected from public scrutiny. Each employee of the estimating company has signed a Confidentiality Office Policy agreeing to keep all records of the Center confidential. The third category of violation concerned an adoptive home study for Moody (the same client who had visited the Center). The home study for this family was also sent in blank template form with instructions to fill it out using the third person. Moody filled out the form and sent it back to Morgan. In April 2006, Moody and her husband were scheduled to attend a meeting with prospective adoptee children at Splitsville, a Tampa bowling alley. In order to attend such meetings, prospective adoptive parents must have a home study completed in advance. This serves the purpose of making sure that such parents actually qualify as adoptive parents before they are exposed to the children. The home study for Moody and her husband was finished by Morgan in time for the Moodys to attend the Splitsville function. Although several home visits were scheduled, each of them was cancelled due to various circumstances. No home visit was ever made. However, the home study was completed and signed by Morgan with a recommendation that the family be approved to adopt. The recommendation section of the home study included as its basis: "Based on MAPP training, personal interviews, home consultations . . .". The home study contains a thorough description of the home, including the pool and yard, presumably based on details provided by the Moodys. Moody decided to terminate her relationship with Morgan and the Center after not hearing from Morgan during the period of July through November. As stated earlier herein, Moody picked up her file, which included the signed home study, from the Center. Morgan maintains the home study was still a "work in progress" at that time. However, it had already been signed and was dated April 18, 2006. (Moody was scheduled to attend the Splitsville event on April 22, 2007, and would have needed a completed home study in order to attend.) By Morgan's own admission, she was never in the home of Moody and did not "effectively or efficiently manage" that client's case. It was, as Morgan admitted, wrong to sign the home study without having visited the home. It appears the home study was finished so that the family could attend the MAPP event. The next category of violation had to do with lost or misplaced paperwork. A child placing agency must protect all information provided to it by clients so that confidentiality is maintained. LaClair and her husband submitted a large packet of information to Morgan as part of their attempt to adopt a child through the Center. The information was lost or misplaced by the Center on at least two (but possibly three) occasions. The submitted information contained extremely confidential information, including: marriage licenses, divorce decrees, birth certificates, social security numbers, military identification numbers, and insurance information. The last category of violation concerned failure by Respondent to timely provide licenses to approved foster parents. One of Respondent's clients, Barry Plesch, indicated a long interval between verbal approval and receipt of his paper license. However, he could not quantify the number of times nor specifically remember what dates he may have called Respondent to ask about the license. Another client, Brad Farber, made numerous requests for his license. When he expressed an urgent need for it, the license was produced forthwith. On May 17, 2007, Morgan met with representatives of HKI to discuss the Moody home study and the situation relating to confidential records. At that time, Morgan admitted to falsifying the Moody home study. Morgan acknowledged the gravity and severity of that mistake. She did explain that her office was undergoing reorganization at the time of Leggett's visit, which was the reason so many files were lying around the office.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by the Department of Children and Family Services upholding the revocation of Respondent's child-placing agency license. DONE AND ENTERED this 29th day of November, 2007, in Tallahassee, Leon County, Florida. S R. BRUCE MCKIBBEN 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 29th day of November, 2007.
The Issue Whether the Agency for Persons with Disabilities (APD) properly denied the application for licensure renewal sought for the group home facility license held by Tracy Court Group Home, owned and operated by V-Agape, LLC.
Findings Of Fact Petitioner is the state agency charged with regulating the licensing and operation of foster care facilities, group home facilities, and residential habitation centers pursuant to section 20.197 and chapter 393, Florida Statutes. At all times material to this complaint, Respondent held foster or group home facility licenses issued by APD. The current group home license issued for V-Agape, LLC, located at 19103 Tracy Court, Lutz, Florida 33548, is owned by Tonya Nelson, the sole managing member. Respondent has contracted with APD to provide the residents with Medicaid waiver developmental disability residential habitation services. HCSO conducts investigations of reports of abuse, neglect, abandonment, and threats of harm to children on behalf of DCF. Investigations of abuse, neglect, abandonment, and threats of harm are initiated by reported incidents through the Florida Abuse Hotline. Karen Gonzalez is the supervisor of the Specialized Investigating Unit. She supervises the CPIs who perform the abuse hotline investigations. Ms. Gonzalez supervised Robert Hoon and Jennifer Campbell, both CPIs. A report was made to the Florida Abuse Hotline on January 24, 2014, that a minor female resident of Respondent’s Tracy Court Group Home sustained bruising and a red mark on the back of her hand from being struck on her hands by Tonya Nelson. The resident is non-verbal and intellectually disabled. The subsequent investigation by CPI Hoon, on behalf of DCF, was ultimately closed with verified indicators for physical injury upon the minor resident living in the Tracy Court Group Home, but did not identify the caregiver responsible. CPI Hoon reviewed and discussed the investigation with Supervisor Gonzalez before he prepared the Investigative Summary (IS). When conducting investigations, the CPI reviews the prior history of incidents reported on a group home and its owner/operator. In subsection “D. Prior Reports and Service Records Implications for Child Safety,” CPI Hoon reported that: There are prior reports on the facility that include concerns for physical discipline in the foster home and to her o[w]n children. There is a verified report in 2012 for physical injury and the aps [adult perpetrators] where [sic] Tonya Nelson and the aunt as it is unknown who caused the injuries. Ms. Gonzalez testified that prior reports are reviewed in conducting their investigations to determine whether a pattern of concern for the health and safety of the children placed in that home and for the caretakers caring for the children in the home exists. The CPIs utilize DCF Operating Procedure (CFOP) 175-28, Child Maltreatment Index, as a guideline in conducting their investigations. A “verified finding” is made when a preponderance of the credible evidence results in a determination that the specific harm or threat of harm was the result of abuse, abandonment, or neglect. CPI Campbell explained the application of CFOP during an investigation: [I]t . . . breaks down the different maltreatments that are investigated under the umbrella of abuse, neglect, and abandonment, and it provides a guideline for the definitions of what the different maltreatments are, and the different types of supporting evidence and documents that may be needed when supporting a maltreatment when the investigator comes up with the findings. It’s basically a guideline for investigations, because when a report comes in it may not be just one maltreatment, there may be a number of different maltreatments; or an investigator may identify a maltreatment during the course of an investigation, and so this provides a guideline for the investigator. On May 20, 2014, a report was made to the Florida Abuse Hotline about a minor resident of Respondent’s Tracy Court Group Home. An investigation was commenced concerning unexplained bruises observed on the resident, a vulnerable minor. CPI Campbell completed the investigation and prepared the IS. She discussed the verified findings with Supervisor Gonzalez. CPI Campbell is an experienced investigator, having had 11 years of service with HCSO following five years’ experience as a CPI in Michigan. The report of May 20, 2014, was a “Supplemental” report since, according to Supervisor Gonzalez, it came in right after the initial risk sequence. Rather than creating an entire new report, this one became supplemental to the prior one. The IS stated that the resident had a large bruise on her left thigh and bruises on her left arm and the back of her leg. Ms. Nelson was not able to explain how the minor resident sustained the bruises on her leg and arm. CPI Campbell became involved with Ms. Nelson and the investigation of the group home when Supervisor Gonzalez gave her the task of completing the investigation initiated by CPI Krisita Edwards. At the time CPI Campbell took over the investigation, CPI Edwards had been assigned to other duties. CPI Campbell explained that it was not unusual for a second investigator to complete work begun by another since all their notes are kept on a central database known as the Florida Safe Families Network (FSFN), where all contacts are noted, as well as the investigative summary. CPIs Edwards and Campbell collaborated on the investigation in this case. CPI Edwards entered her initial findings in the FSFN, which was picked up and continued by CPI Campbell when she took over the case. The two CPIs have collaborated on other cases in a similar fashion. The initial documentation by CPI Edwards was performed within 48 hours of the call coming into the abuse hotline as required. CPI Campbell’s completion of the report and investigation occurred after she had spoken with CPI Edwards and discussed the matter with Supervisor Gonzalez. The result of the investigation concerning the bruises on the minor resident was that the bruises were “indeterminate for physical abuse” and “indeterminate for supervisory neglect” due to the fact that a specific cause of the injuries could not be determined. Further, since the minor resident had been removed to another group home, the report concluded that there existed no continuing threat to the resident’s well-being. Even though the resident had been removed from the Tracy Court Group Home and, therefore, was not in any danger of being further harmed, CPI Campbell continued to have serious concerns about the care of residents in the group home. She believed that several allegations of the same type of harm were being made in the group home and that they could not ask the resident how she received her injuries since she was non-verbal. Myra Leitold, an APD residential licensing supervisor, had monitored the Tracy Court Group Home for the previous nine and one-half years. On December 28, 2012, she observed that a door lock to the office and bedroom was keyed so that it could be readily opened from the inside which, she believed, created a safety hazard. Between December 2012 and August 2014, the group home was cited for ten violations of Medication Administration Procedures. On one of her visits, in December 2012, Ms. Leitold noted that no current prescription was present for one of the residents, and that the label on the prescription bottle did not match the prescription drugs inside the bottle. Additionally, she found that the accounting for one of the resident’s finances was not current and that the temperature inside the group home was a chilly 65 degrees Fahrenheit. Mitchell Turner, human services program specialist for APD, recorded numerous medication administration violations at the group home. He noted on May 30, 2013, that the medication prescriptions and instructions for the Medical Administration Record (MAR) did not match. On June 18, 2013, he discovered that the wrong dosage of prescription was being given to a resident, and Ms. Nelson admitted this mistake. Mr. Turner grew so concerned about the prescription irregularities that he requested Pamela Lassiter, a medical case management registered nurse, to review the group home. Nurse Lassiter was sent to the home where she discovered and cited the home for three additional prescription violations. Even following Nurse Lassiter’s visit, on another trip to the group home on April 9, 2014, Mr. Turner cited an additional MAR violation. He believed these violations posed a health and safety risk to the residents affected and exhibited a pattern of neglect by Respondent to the health and safety of vulnerable children. During the period when prescription and other violations were noted, on January 11, 2013, Ms. Nelson exceeded the maximum licensed capacity of three in the group home when she accepted a fourth resident. She did not have prior written approval from APD to exceed her licensed capacity of residents. On September 25, 2013, Mr. Turner issued a Notice of Non-Compliance (NNC) because Ms. Nelson again exceeded the licensed capacity for the number of residents in the group home without prior written approval from APD. Mr. Turner expressed his concerns over the repeated violations by Respondent. Ms. Nelson testified that she had received verbal approval for the placements in excess of the home’s licensed capacity from Meisha Stewart, residential placement coordinator for APD, and that on a prior occasion in 2012, she had accepted a resident after receiving verbal approval. This testimony was rebutted by both Geraldine Williams, the former regional operations manager for APD’s Suncoast Region, and Ms. Leitold, who testified she had never known APD to give verbal approval for a placement of a resident in a group home. With the high volume of referrals APD makes to group homes, they cannot operate in a system where verbal placements occur. All placements must be made in writing. When a provider receives a NNC, the provider is required to submit and successfully complete a Corrective Action Plan (CAP). Mr. Turner testified that Ms. Nelson did not submit or successfully complete a CAP for the MAR violations. On January 17, 2013, Ms. Leitold visited the group home and observed the following violations: volatile materials were not stored in approved metal containers and three prescriptions for a resident’s medications were not present. The gasoline, charcoal, and lighter fluid found by Ms. Leitold were required to be stored in approved metal containers. Keeping these materials in the open posed a safety hazard for the minor residents by giving them access to volatile materials. On November 4, 2014, Ms. Nelson sent an email to Meisha Stewart advising her she intended to accept a non-APD client for placement in the Tracy Court Group Home without APD’s prior approval. Ms. Nelson testified that since that same resident had been placed in the Tracy Court Group Home for a six-month period in 2013, she believed she did not need a new approval in 2014.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Persons with Disabilities enter a final order denying V-Agape, LLC, d/b/a Tracy Court Group Home’s application for license renewal. DONE AND ENTERED this 6th day of November, 2015, in Tallahassee, Leon County, Florida. S ROBERT S. COHEN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 6th day of November, 2015. COPIES FURNISHED: Brian F. McGrail, Esquire Agency for Persons with Disabilities 4030 Esplanade Way, Suite 380 Tallahassee, Florida 32399-0950 (eServed) Lindsey Ann West, Esquire The Plante Law Group, PLC 806 North Armenia Avenue Tampa, Florida 33609 (eServed) Gerald D. Siebens, Esquire Agency for Persons with Disabilities 1313 North Tampa Street, Suite 515 Tampa, Florida 33602-3328 (eServed) Barbara Palmer, Executive Director Agency for Persons with Disabilities 4030 Esplanade Way, Suite 380 Tallahassee, Florida 32399-0950 (eServed) Richard D. Tritschler, General Counsel Agency for Persons with Disabilities 4030 Esplanade Way, Suite 380 Tallahassee, Florida 32399-0950 (eServed) David De La Paz, Agency Clerk Agency for Persons with Disabilities 4030 Esplanade Way, Suite 380 Tallahassee, Florida 32399-0950 (eServed)
The Issue Whether Petitioner is entitled to a Foster Home License.
Findings Of Fact Petitioner, Marion Hanes, had for a number of years been granted custody of two very troubled female foster children by a Pennsylvania court. Ms. Hanes grew to care a great deal for these two foster children and while they were in her custody helped the two children feel loved and cared for. When Ms. Hanes and her husband moved to Florida, she asked the court to grant her permission to take the girls to Florida to live with her and her husband. Because of Ms. Hanes' good care of these children and the desires of Ms. Hanes, the children, the Pennsylvania social service agency and the Pennsylvania court, in order to maintain a consistent environment for these children, the court granted Ms. Hanes permission for the girls to live with her in Florida. After arriving in Florida, Petitioner discovered that the girls' Pennsylvania Medicaid cards would not be accepted by Florida Medicaid providers. Therefore, in order to obtain school and medical services for her foster children in Florida, Ms. Hanes had to obtain Florida Medicaid cards for her charges. In pursuit of the Medicaid cards, Ms. Hanes was informed that she would have to have a foster home license for the home in which the girls would be living. Ms. Hanes made application to the Department of Health and Rehabilitative Services for a Foster Home License for her residential home located at 1015 Edison Drive, Pensacola, Florida. The home is located in a middle-income residential area and is an ordinary brick house resembling the other homes in the neighborhood. The front bedroom windows in the house measure 15 inches in height and 34 inches in width. The bottom of the windows are approximately 46 inches off the ground. The children in Ms. Hanes' care would occupy one of the bedrooms with the 15 by 34 inch windows. On June 24, 1991, Robert Herron, Fire Prevention Specialist and licensed Fire Inspector inspected the Petitioner's home located at 1015 Edison Drive. The purpose of the inspection was to determine whether the residential home met fire safety requirements applicable to houses which will serve as foster homes. The Fire Inspector testified that the Department's long-standing, statewide policy was to require that foster homes meet Chapter 22 of the NFPA 101 Life Safety Code. The NFPA 101 Life Safety Code, Chapter 22-2.21(b), requires that windows in a residential home have a clear opening of not less than twenty-four (24) inches in height and twenty (20) inches in width, with the bottom of the opening not less than forty-four (44) inches above the floor. Mr. Herron further testified that exceptions for good cause had been granted to the window size requirement, but only when a window's dimension varied by one or two inches. The Hanes' windows were denied an exception. The Life Safety requirement has not been adopted by HRS as a rule. Nor has the Life Safety requirement been adopted as a rule applicable to residential or foster homes by the State Fire Marshals office. Additionally, the evidence did not show that the Life Safety requirement has been adopted by any local building authority which would have code authority over the Hanes' home. The agency did not put on any evidence which would demonstrate the reasoning behind this unadopted rule requirement. Mr. Herron's inspection of the Hanes's home revealed that the bedroom windows in the Hanes' home did not meet the NFPA 101 Life Safety Code standards. Specifically, the fifteen (15) inch height of the windows was short by nine inches from the NFPA Life Safety Code's standard. Importantly, the evidence did not show that the Hanes' home was unsafe. In fact, the better evidence in this case demonstrates that the Hanes' home presents a safe and secure environment for the Hanes and the foster children and the windows in their present condition appear to be big enough to allow passage in an emergency. As of the date of the hearing, the Hanes had not increased the size of the bedroom windows to twenty-four (24) inches. Mr. Hanes stated the reason these windows had not been enlarged following Mr. Herron's inspection was because other neighborhood houses were similar in style to the Hanes' house and the esthetic changes were undesirable to the Hanes. More importantly, the evidence demonstrated that removing these foster children from Ms. Hanes' care would not be in their best interest and could cause more harm than good. Put simply, the needs of these children for a consistent and loving environment outweigh the need for strict compliance with an unadopted safety standard given the fact that the home is safe. Therefore, Ms. Hanes is entitled to a foster home license for her home located at 1015 Edison Drive, Pensacola, Florida.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is accordingly, RECOMMENDED: that the Petitioner's application for licensure as foster parents be granted. ENTERED this 9th day of August, 1993, in Tallahassee, Florida. DIANE CLEAVINGER 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 9th day of August, 1993. APPENDIX TO RECOMMENDED ORDER, CASE NO. 92-5134 The facts contained in paragraphs 1, 5 and 6 of Respondent's Proposed Findings of Fact are adopted in substance insofar as material. The facts contained in paragraphs 2, 3, 4 and 7 of Respondent's Proposed Findings of Fact are subordinate. 4. The facts contained in Petitioner's letter dated April 4, 1993, are adopted in substance, insofar as material. The characterization of Respondent's Proposed Recommended Order and testimony at the hearing are not ruled upon since no factual matters are involved. COPIES FURNISHED: Marion Hanes 1015 Edison Drive Pensacola, FL 32505 Christopher R. Hunt Assistant District Legal Counsel Department of Health and Rehabilitative Services Post Office Box 8420 Pensacola, FL 32505 Robert L. Powell, Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407 Tallahassee, FL 32399-0700 John Slye General Counsel Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, FL 32399-0700
The Issue Whether Petitioner's foster care license should be revoked because she allegedly lacks the ability to provide for the psychological development of foster children as required in Section 409.175(4)(a)2, Florida Statutes and Rule 10M-6.005(3)(i), Florida Administrative Code.
Findings Of Fact Based upon my observation of the witnesses and their demeanor while testifying, documentary evidence received, and the entire record compiled herein, the following relevant facts are found. Petitioner, State of Florida, Department of Health and Rehabilitative Services, is the licensing and regulatory agency in Florida for the issuance of foster home licensing. On January 16, 1991, Petitioner issued to Respondent, Pauline Cole, a provisional certificate of license for a foster home for her residence situated at 3501 River Grove Drive in Tampa, Florida indicating that she had complied with the minimum standards set by Petitioner for a foster home and approved her foster home application. By its terms, the license was effective for a period of one year from the above-referenced date unless renewed, extended, withdrawn, or revoked for cause. To demonstrate her eligibility for licensure, Respondent successfully completed several courses including "a clinical interventions for psychiatric nurses: frameworks for success" sponsored by the Florida Mental Health Institute in Tampa, Florida with six contact hours on June 15, 1990. On December 17, 1990, Respondent successfully completed 30 hours of training in "model approach to partnership and parenting (MAPP)". Additionally, Respondent took several other courses dealing with parenting and caring for foster children. On November 21, 1991, Petitioner filed an application to renew her license to provide for foster home care for dependent children. As a result of that application, Petitioner's agents visited Respondent's home to determine whether it still complied with standards set by Petitioner for licensure. During a foster parents meeting in June, 1992, Respondent inquired of one of Petitioner's agents whether or not Petitioner had a policy of surveilling foster parents by following them or otherwise monitoring their activities and particularly their vehicular travels. Petitioner's agent advised Respondent that that was not HRS's policy, i.e., to surveil foster care parents whereupon Respondent related that she felt that she had been followed by Petitioner's child protective investigators. Respondent related several steps that she undertook to determine whether or not she was in fact being followed. Specifically, Respondent would change directions or would make turns from main thoroughfares to see if the car that she considered to be following her would make a similar change in direction. Respondent did not take any evasive measures which in any manner endangered the lives of the foster children that were in her care. During the time of her foster care licensure, Respondent had two foster care children ages three and four. During the sessions wherein Respondent's application for licensure was discussed with Petitioner's agents, Respondent again expressed concern that she was being followed, however, during the last session during March 1992, Respondent advised Petitioner that while she still had her doubts that she was not being followed, she was no longer concerned that she was being followed to the point of taking evasive actions to try to verify her concerns. During the final meeting wherein Petitioner's agents inquired of Respondent if she still had the paranoid ideation that she was being followed, Respondent basically advised Petitioner's agents that "she was leaving the matter in the hands of the Lord." Petitioner's agents basically advised Respondent that if they (Petitioner's agents and Respondent) could put to rest their concern that Respondent no longer had the paranoia of being followed, Respondent could be relicensed. 1/ Respondent earned a bachelor of science degree in nursing from Tuskeege Institute in 1958. She earned a master's degree from the University of South Florida in industrial and technical education during 1979. She is certified as a registered nurse and a community education instructor. Respondent was employed as a registered nurse and nursing instructor at the Veteran's Administration (VA) Hospital in Montgomery, Alabama, Gainesville and Tampa, Florida during the years 1962 through 1980. She retired from the VA in 1980. From 1989 to the present time, Respondent has been employed as a community education instructor at Hillsborough Community College in Tampa, Florida. Respondent holds memberships in several professional and civic organizations and has been very active in community service organizations in Hillsborough County. Among the awards and honors she received was a nominee in Who's Who in American Nursing during 1993-94, a nominee for the achievement award for advocacy/public service at the Tuskeege National Alumni Association during 1992; co-founder, Minority Nurses Association of the Tampa Bay Area and an award for dedicated service, Iota Phi Lambda Sorority, Southern Region, during the years 1983-1987, among others. Respondent has been able to provide a great deal of parenting and inspiration to her two foster children during the times that she cared for them until they were separated from her by Petitioner's agents during 1992. Based on her nursing background and the amount of time that she has been able to devote to her children, she has served as a model foster parent since the time that she was issued a provisional license during 1991.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that: Petitioner enter a final order granting Respondent's application to be relicensed as a foster home provider assuming, of course, that she complies with other licensing requirements. DONE AND ENTERED this 12th day of July, 1993, in Tallahassee, Leon County, Florida. JAMES E. BRADWELL 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 12th day of July, 1993.
