The Issue The issue is whether Respondent should approve Petitioner's family day care license application.
Findings Of Fact Based upon observation of the witnesses and their demeanor while testifying in person and the documentary materials received in evidence, stipulations by the parties, evidentiary rulings made pursuant to Chapter 120.57, Florida Statutes, and the entire record compiled herein, the following relevant and material facts are found: Before December 15, 2000, Petitioner, Freddie Mae Law (Ms. Law) submitted an application for a family foster care license to Respondent, the Department of Children and Family Services (Department). Gloria Mathews (Ms. Mathews), who was at that time assigned to the Department's family foster care license unit, conducted the requisite pre-license investigation and found that Ms. Law met the mandatory requirements and that Ms. Law was qualified for a family foster care license. Based solely upon the results of Ms. Mathews' investigation of Ms. Law's background and qualifications, the Department issued Ms. Law a family foster care license on December 15, 2000. Thereafter, Ms. Law provided family foster childcare service out of her home in Mulberry, Florida. At some undetermined time after December 15, 2000, Ms. Mathews transferred from the Department's family foster care license unit to the Department's family day care license unit where she is currently working. Ms. Law's family foster care license was valid from December 15, 2000 to December 15, 2001, and was renewable on or before its anniversary date. On December 15, 2001, the Department took no action regarding the renewal of Ms. Law's foster home license. With the Department's consent and approval, Ms. Law operated her family foster care out of her home until February 21, 2002, at which time she voluntarily surrendered her foster care license to the Department. For more than eight years before she acquired her "foster care license" Ms. Law worked at the Cornerstone Youth Shelter. This residential shelter home, through contract with the Department, and the Department of Juvenile Justice, accepted referrals of children in need of housing and foster care services. On September 11, 2001, four months before the expiration date of Ms. Law's family foster care license on December 15, 2001, the required renewal investigation was conducted by Cheryl Dishong (Ms. Dishong), who was then a foster care license unit caseworker. Prior to the initial renewal visit by a foster care license unit caseworker, the Department requires the assigned caseworker to secure a copy of a foster care visit report form that contains the names and ages of the foster children in the foster home to be visited by the caseworker. Additionally, caseworkers are required to record the results of their foster care home visit on the foster care visit report form. Uncertain of the time of her prearranged visit with Ms. Law and of her arrival time at Ms. Law's residence, Ms. Dishong recalled arriving at the Law's residence at approximately 3:00 p.m. or 3:30 p.m. in the afternoon. According to Ms. Dishong, Ms. Law was not home upon her arrival, but arrived within five to ten minutes thereafter. During the short five to ten-minute interval before Ms. Law arrived, Ms. Dishong saw several teenaged children walking home from school. Ms. Dishong observed the two teenaged children approach Ms. Law's home, and she spoke with them outside Ms. Law's home. Neither Ms. Dishong nor the children entered Ms. Law's home at that time. Upon Ms. Law's arrival, she and Ms. Dishong entered the home while the two teenaged children stayed outside on the porch. During this visit, Ms. Dishong discussed with Ms. Law her one concern; the five-minute interval between the arrival of the two teenagers home and Ms. Law's arrival home. Ms. Law explained to Ms. Dishong that the one teenage foster child along with her biological daughter attended school within walking distance from their home. The normal family school day routine was for the teenagers to walk to and from school each day. The entire family would leave home together in the mornings and would normally arrive home in the evenings at about the same time Ms. Law arrived home from work. Ms. Law further explained to Ms. Dishong that her family's school day routine consisted of her transporting the younger foster children to school each morning on her way to work and picking them up from school on her way home each afternoon. This routine of a mother transporting young children to and from school each day is a routine of many mothers with young school children. The routine of teenaged children walking home from school and arriving a reasonably short time before their parents arrive home from work is also that of normal families. The Department proffered no rule or known and accepted standard that was violated by the hereinabove Law foster family school day routine. Ms. Law's determination of personally transporting the younger foster children to and from school and her determination that the teenaged foster child and her biological child should walk to and from school do not reflect a lack of supervision nor do they demonstrate faulty decision- making. Ms. Dishong, the Department's chief witness and a foster care license unit relicensure caseworker for three and one-half years, testified exclusively from memory. Her testimony, with exception of her face-to-face conversations with Ms. Law and her several telephone conversations with Ms. Law, consisted primarily of conclusions and generalizations. Ms. Dishong was unable to accurately recall names of specific foster children with whom she allegedly had conversations, and she could not recall specific dates, times, or places. Her recollection of statements allegedly made to her by foster children and other children lacks support and, therefore, lacks credibility. Ms. Dishong's recollection and testimony of statements allegedly made by the several children, foster, biological and others, is unobjected to as hearsay not supported by any other evidence of record and, in itself, cannot support a finding of fact.1 Accordingly, that testimony is disregarded in the preparation of this Recommended Order. On September 21, 2001, Nacara Daniels (Ms. Daniels), the Department's investigator of abuse report 2001-051113, visited Ms. Law's foster care home for an investigation of allegations contained in abuse report 2001-051113. Before her visit to Ms. Law's home, Ms. Dishong told Ms. Daniels of allegations of a lack of supervision and faulty decision-making purportedly contained in three other unidentified abuse reports. On October 9, 2001, and as the direct result of Ms. Daniels' investigation, interview, and discussion with Ms. Law regarding her foster care supervision, the Department entered into a Partnership Development Plan (PDP) agreement with Ms. Law. This partnership agreement and its cooperative working relationship between Ms. Law and the Department's caseworkers are designed to provide foster care that is in the best interest of the foster children. The PDP agreement reduced to writing the Department's agreed acceptance to continue its foster care partnership with Ms. Law and Ms. Law's agreed acceptance to continue working with the Department. Ms. Law complied with the terms and conditions contained in the PDP agreement from the date she signed the agreement on October 9, 2001, to the date Ms. Law voluntarily surrendered her foster care license to the Department on February 21, 2002. On or after October 9, 2001, and after completing her investigation and discussions with Ms. Law, Ms. Daniels closed abuse report 2001-051113 with a finding that allegations contained in abuse report 2001-051113 were uncorroborated. Ms. Daniels recalled, at some unspecified time subsequent to October 9, 2001, sharing her abuse report findings of uncorroborated allegations, the conditions and terms of the PDP, and her abuse report closure status with Ms. Dishong. Before the two-week Christmas break of December 2001, Ms. Law telephoned the Department and spoke to each foster child's caseworker. By mutual agreement between Ms. Law and each caseworker with whom she spoke, a Christmas vacation plan was developed for sharing the daily care and responsibilities for Ms. Law's foster children over the two-week Christmas holiday period. It was agreed that during the two-week 2001 Christmas break, Ms. Law would leave her foster children at the Department's office each morning on her way to work, and she would pick them up from the Department's office each evening on her way home after she finished work. During this two-week Christmas holiday period, Ms. Law continued to provide the foster children breakfast before leaving home each morning, and the Department's caseworkers provided each child with their midday lunch meals. On January 4, 2002, Jayme Sprouse (Ms. Sprouse), a Department investigator, received abuse report 2002-001260. Before her initial visit to the Law family foster care home, Ms. Sprouse reviewed all the information contained in the Department's foster care unit licensing renewal case file. On February 4, 2002, one month after receiving abuse report 2002-001260, Ms. Sprouse spoke with Ms. Law concerning the general allegations to have occurred during an unspecified time span before December 2001 regarding her use of unscreened foster care sitters. This inexplicable month delay is significant in that it evidences the fact that allegations contained in abuse report 2002-001260 did not constitute an immediate danger to the health, safety, and welfare of the foster children in Ms. Law's foster care home. Had abuse report 2002-001260's allegations been sufficient to create an immediate danger or threat to the safety and well-being of the foster children, Ms. Sprouse was required to conduct an investigation on January 5, 2002, within 24 hours after receiving the abuse report on January 4, 2002. Ms. Sprouse inquired of Ms. Law's use of an unapproved foster child sitter. Ms. Law explained to Ms. Sprouse that she had a Department-approved foster child sitter, Chastity Griffin, who sat her foster children and who transported both biological and foster children to outings and entertainment activities. During this period, Ms. Law had also submitted an application to the Department for another approved sitter named Jocelyn (whose last name was not provided in the record) for approval. Not knowing that approval by the Department was required before a sitter could be used to sit foster children, Ms. Law permitted Jocelyn to sit with the foster children during the pendency approval of her foster care sitter application. After February 4, 2002, Ms. Sprouse advised Ms. Law that that the Department had denied Jocelyn's pending sitter screening application. Responding to this information, Ms. Law immediately discontinued the use of Jocelyn as a foster care sitter, evidencing her willing readiness to comply with the Department's requirements once they were made known to her by the Department's staff. After Ms. Law satisfied Ms. Sprouse's concern regarding the use of an unapproved sitter, Ms. Sprouse closed her investigation of abuse report 2002-001260 with a finding of no indicators of inadequate supervision based on the Florida Statute definition of inadequate supervision for abuse purposes. Ms. Sprouse voiced no other concerns regarding Ms. Law's foster care supervision to Ms. Law. After the February 4, 2002, meeting with Ms. Sprouse, the record contains no credible evidence that Ms. Law continued to use unscreened sitters at the foster home or used unscreened persons for any other purposes. Ms. Sprouse shared her abuse report findings of fact and her closure of the abuse report with Ms. Dishong, the case worker assigned the task of the renewal investigation of Ms. Law's foster care licensure process. At no time during the period of September 11, 2001, throughout January 28, 2003, did Ms. Dishong inform Ms. Law that the Department's foster relicensing unit had received, in addition to abuse report 2001-051113 and abuse report 2002- 001260, three additional abuse reports alleging that she inadequately supervised the foster children in her home. Petitioner's Family Day Care Application On or about November 6, 2002, Ms. Law made application to the Department for a family day care license. The November 6, 2002, application is the subject of this de novo proceeding. In December 2000, Ms. Mathews was assigned to the Department's foster care license unit. While there, it was she who approved Ms. Law's foster care license application. In November of 2002, Ms. Mathews was assigned to the Department's family day care license unit. Ms. Mathews again conducted the requisite pre-licensure investigation of Ms. Law's minimum qualifications and criminal background check. For the second time within less than two years, Ms. Mathews again found Ms. Law to have met all statutory requirements and was, therefore, qualified to have a family day care license issued to her. Specifically, Ms. Mathews confirmed that Ms. Law met mandatory minimum standards as required by statute. She visited and otherwise assured herself that Ms. Law's home met minimum standards. She ascertained that Ms. Law had completed 30 hours of childcare training at Polk Community College upon receiving Ms. Law's certificate of completion from Polk Community College. Ms. Mathews was satisfied the Ms. Law's criminal background check found Ms. Law free from any criminal convictions. Ms. Mathews satisfied herself the Ms. Law's substitute family day person was qualified and had completed a minimum of three hours of childcare training as required. Having completed and approved Ms. Law's foster care license application, Ms. Mathews was aware that Ms. Law's long- time employment at Cornerstone Youth Shelter was her sole source of income. Ms. Mathews advised Ms. Law that at the time her family day care license was issued, she would be prohibited from all other employment. To assist Ms. Law in determining the appropriate time to submit her two-week notice of resignation to Cornerstone Youth Shelter, Ms. Mathews was the person to whom Ms. Law would inquire regarding the status of her forthcoming family day care license. Ms. Mathews informed Ms. Law of her successful compliance with minimum requirements and told her the Department was in the process of signing her family day care license. On January 17, 2002, in reliance on Ms. Mathews repeated assurances that her family day care license was forthcoming and to comply with the "no other work outside the home" requirement, Ms. Law gave her two-week notice of resignation to Cornerstone Youth Shelter. Notwithstanding the fact that Ms. Mathews was assigned to the Law application and was working in the Department's family day care licensing unit, the Department's foster care unit's relicensing investigator, Ms. Dishong, never informed Ms. Mathews that the Department's foster care relicensing unit had concerns of such magnitude that they could be the bases for the denial of her family day care license application. The Department's foster care license unit did not inform the family day care license unit that since November 6, 2002, the Department purportedly had received three additional abuse reports (bringing the total abuse reports to five) that would ultimately adversely impact Ms. Law's family day care license application. This is significant in that Ms. Mathews was the person who at that time had determined that Ms. Law met minimum standards for a family day care license. This inexplicable lack of information sharing between the Department's foster unit and its family day care unit continued from January 17, 2002 to January 2003. Ms. Dishong, Ms. Law's foster care unit investigator and the Department's primary witness, (1) could not identify from memory the three abuse reports allegedly filed against Ms. Law, (2) could not find the three abuse reports in her foster unit renewal investigation file, (3) could not proffer any evidence that allegations contained in those three reports were investigated and corroborated by Department investigators, and (4) did not inform Ms. Law that allegations supposedly contained in those three unidentified abuse reports would adversely impact her pending family day care application. This complete failure to identify, investigate, inform, and discuss with Ms. Law the three abuse reports is significant when the Department's processing of abuse reports 2001-051113 and 2002-001260 that were filed against Ms. Law is compared to its processing of the three unidentified abuse reports. In processing abuse reports 2001-051113 and 2002- 001260, the Department first investigated each report. Second, the Department discussed the allegations of each report with Ms. Law. Third, the Department closed each report with a written finding. Lastly, of the three unidentified three abuse reports testified to by Ms. Dishong, and that constituted the primary basis for denial of Ms. Law's family day care license application, the Department did not follow its previous procedure of identification, investigation, advising, and discussion with Mr. Law and the investigator's recorded finding regarding allegations contained in those three reports. According to Ms. Dishong, the Department's foster care license unit held a foster staff committee meeting during some unidentified time in 2002. Ms. Dishong did not provide the names of her foster care unit coworkers who attended the staffing committee nor did she provide the names of the Department's other employees who attended the staffing committee. It is clear that the Department, in part based upon the foster care staff committee results, determined that Ms. Law's family day care license application would be denied. It is also clear that Ms. Mathews did not attend the Department's foster licensing care unit's staffing committee meeting. Ms. Mathews first became aware of the Department's foster care unit's license renewal investigation file on Ms. Law when she reviewed that file in preparation for this final hearing. Upon completion of her review, Ms. Mathews did not change her prior approval and finding that Ms. Law met minimum standards. Based on her review of that file, she did however qualify her prior approval of granting Ms. Law a family day care license to a "but for" the content of the foster care unit's license renewal investigation file. The record contains no evidence from which to determine how the Department's foster care licensing unit's conclusions and decision to not renew Ms. Law's foster care license were conveyed to the Department's family care license unit. It is clear, however, that the Department's decision denying Ms. Law a family day care license was based on uninvestigated and uncorroborated allegations purportedly contained in three unidentified abuse reports. The Department's denial letter of January 29, 2003, unequivocally confirms the fact that the Department's decision to deny Ms. Law's family day care license application was based upon its consideration as fact, uninvestigated and uncorroborated allegations contained in three unidentified abuse reports. The Department's licensure staffing committee's consideration of Ms. Dishong's personal observations and conclusions contained in her foster care closure form, in its deliberations and its ultimate decision to deny Ms. Law's family day care application, were not based on fact and are, therefore, not justified. Ms. Law has, by a preponderance of the evidence, proven that she successfully met the Department's statutory minimum requirements for a family day care licensee.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Children and Family Services issue a final order granting Petitioner, Freddie Mae Law, a family day care license. DONE AND ENTERED this 23rd day of July, 2003, in Tallahassee, Leon County, Florida. S FRED L. BUCKINE 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 23rd day of July, 2003.
Findings Of Fact Based upon my observation of the witnesses and their demeanor while testifying, documentary evidence received and the entire record compiled herein, I make the following relevant factual findings. Petitioner, Stacey Health Care Centers, Inc., is licensed to operate Riverside Care Center, located at 899 Northwest Fourth Street, Miami, Florida, as a nursing home in compliance with Chapter 400, Part I, Florida Statutes, and Chapter 10D-29, Florida Administrative Code. On July 9, 1986, James A. Bavetta, assistant area supervisor, Office of Licensure and Certification, made a visit of Riverside's facility and determined that Ralph Stacey, Jr., the administrator of record, was acting in the capacity of administrator for two facilities, the subject facility and another facility in Kentucky, without having a qualified assistant administrator to act in his absence. (Respondent's Exhibit 1) Ralph L. Stacey Jr., is a licensed nursing home administrator in the States of Ohio, Kentucky and Florida. He has been licensed in Kentucky and Florida since 1974. At the time of Mr. Bavetta's visit and inspection during July, 1986, Ralph Stacey, Jr., was in Cincinnati, Ohio preparing the payroll for Stacey Health Care Centers. During this time period, Ralph Stacey, Jr., served as the administrator for the subject facility, Riverside Care Center, and another facility in Kentucky and did not have a qualified assistant administrator employed to act in his absence. However, once Mr. Bavetta issued his recommendation for sanctions, Petitioner, as part of its plan of correction, has employed a licensed administrator who is presently on staff and serves as Riverside's assistant administrator during the administrator's absence.
Recommendation Based on the foregoing findings of fact and conclusions of lawn it is RECOMMENDED: The Department of Health and Rehabilitative Services enter a Final Order imposing an administrative fine in the amount of One Thousand Dollars ($1,000.00) upon Stacey Health Care Centers- Inc., d/b/a Riverside Care Center, which amount shall be payable to Respondent within thirty (30) days after entry of Respondent's Final Order. RECOMMENDED this 18th day of September, 1987, in Tallahassee, Leon County, Florida. JAMES E. BRADWELL 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 18th day of September, 1987. COPIES FURNISHED: Kenneth S. Handmaker, Esquire MIDDLETON & REUTLINGER 2500 Brown & Williamson Tower Louisville, KY 40202-3410 Leonard T. Helfand, Esquire Office of Licensure and Certification Department of Health and Rehabilitative Services 5190 Northwest 167th Street Miami, Florida 33014 Gregory L. Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 R. S. Power, Esquire Agency Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard -Building One, Room 407 Tallahassee, Florida 32399-0700
The Issue The issue is whether Respondent's license to operate a family day care home should be revoked.
Findings Of Fact Based upon the testimony and evidence received at the hearing, the following findings are made: Parties The Department is the state agency responsible for licensing and regulating child care facilities, including family day care homes. The Department routinely conducts inspections of licensed family day care homes to determine whether the home is in compliance with the applicable statutes and rules. Any problems found during the inspection are noted on a report which is provided to the home's operator immediately following the inspection. When appropriate, the inspection report provides a time frame within which the problems must be corrected. Regular inspections are conducted approximately twice a year. More frequent inspections -- monthly or every six weeks - - are conducted on family day care homes which have a provisional license rather than a standard license. The Department also conducts inspections in response to complaints it receives, and it has the authority to inspect family day care homes at any time with or without notice. Respondent is the owner and operator of a licensed family day care home located at 1218 Jordan Avenue in Orlando, Florida (hereafter "Respondent's facility" or "the facility"). Respondent and her husband reside at that address as well. Respondent has operated day care homes in Florida since 1992, and she has been involved in child care for approximately 21 years. As a result, she is or should be familiar with the rules regulating family day care homes. Respondent keeps children in the back portion of her home. The children also play in Respondent's backyard, which is enclosed by an approximately six-foot high wooden fence. A wooden gate in the fence connects Respondent's backyard to the backyard of the house immediately behind Respondent's home. That house has been rented by Annette Rodgers since November 2002. Respondent does not have a pool in her yard. Ms. Rodgers' yard does have a pool, which at the time of the Department's February 27, 2003 inspection (discussed below), was only partially filled with water. Ms. Rodgers' pool is not visible from Respondent's back yard because of the wooden fence and gate. The photographs and videotape received into evidence show that Ms. Rodgers' pool is now completely enclosed by a series of fences.4 The evidence does not clearly and convincingly establish that the fences were not in place on February 27, 2003. Indeed, the weeds and high grass which can be seen along the base of and around the posts of the chain-link fence and the discoloration on some of the fence posts indicate that at least that fence has been in place for quite some time.5 Previous Inspections of Respondent's Facility and Actions Taken by the Department Respondent's facility was inspected on May 28, June 14, and September 30, 2002. Several areas of noncompliance were identified during each of those inspections, including inadequate supervision of children, unsafe storage of chemicals, evidence of roaches in the home, and incomplete enrollment and health records for the children at the home. On each occasion, Respondent was given a period of time within which to correct the areas of noncompliance. The inadequate supervision for which Respondent was cited in June 14, 2002, involved several children playing unsupervised in Respondent's carport area, which has access to the street; several children playing in the backyard under the "supervision" of Respondent's mother, who was not an authorized caregiver; and several children playing unsupervised on the porch area in the vicinity of tools and small screws. The Department issued Respondent a provisional license on October 28, 2002, presumably as part of the license renewal process. The provisional license was based upon Respondent's history of noncompliance with the Department's minimum standards, and it was valid through April 2, 2003, unless Respondent applied for an received a change in license status (which she apparently did not) or "if the license is suspended or revoked by the Department." A provisional license is issued where the Department has continued concerns regarding the day care home's compliance with the applicable statutes and rules. A provisional license is issued in lieu of denying a license renewal or suspending or revoking the home's license. A provisional license gives the licensee an opportunity to correct the areas of noncompliance, and because such homes are inspected more frequently, the Department has an opportunity to monitor the licensee's progress. On October 29, 2002, Respondent was assessed an administrative fine of $100.00 based upon deficiencies identified during the May 28 and June 14, 2002, inspections. The fine was based primarily upon the incident described above involving inadequate supervision of the children at the home. Respondent apparently did not contest the administrative fine or the issuance of the provisional license rather than a standard license. Despite the provisional license and the administrative fine, the Department's inspections continued to identify areas of noncompliance at Respondent's facility. For example, the November 14, 2002, inspection identified "evidence of rodents/vermin in the home" as well as incomplete enrollment and immunization records for the children in the home. The December 18, 2002, inspection identified these same deficiencies, including "live roaches in the children's area and the kitchen," as well as the storage of plastic shopping bags and chemicals which can pose dangers to children in an unlocked cabinet accessible to the children. These violations were the same as or similar to those for which Respondent had been previously cited and which led to the imposition of the administrative fine and issuance of the provisional license. The Department did not take immediate action to suspend or revoke Respondent's license based upon the results of the November 14 and December 18, 2002, inspections. Instead, the Department continued to give Respondent an opportunity to bring her home into compliance with the minimum standards in the Department's licensing rules and statutes. Inspection of Respondent's Facility on February 27, 2003 The Department next inspected Respondent's facility on February 27, 2003. That inspection was conducted by Department employee Brandi Blanchard. Ms. Blanchard had been responsible for inspecting Respondent's facility since at least September 2002, so she was familiar with the layout of the facility and its history of noncompliance. Respondent testified that Ms. Blanchard, unlike the prior inspector, had been "very good to her." Ms. Blanchard arrived at Respondent's facility by car between 8:30 a.m. and 8:45 a.m. As she arrived, Respondent was pulling her car into the driveway/carport at the facility. Ms. Blanchard parked her car directly behind Respondent's car. Ms. Blanchard got out of her car as Respondent was getting out of hers, and she said, "Hello, Ms. Alli," to Respondent. Upon seeing Ms. Blanchard, Respondent quickly went into the house through the carport door. Ms. Blanchard followed Respondent into the facility. Ms. Blanchard lost sight of Respondent as she went down a hallway towards the back of the house where the children were located. The backdoor of the house was open, and by the time that Ms. Blanchard caught up with Respondent, Respondent was directing the children through the facility's backyard towards the back gate connecting Respondent's yard to Ms. Rodgers' yard. Several of the children, led by Ms. Rodgers' 14-year-old son carrying an infant in a car seat and Ms. Rodgers' 13-year-old son carrying a toddler had already reached Ms. Rodgers' yard. Ms. Blanchard told Respondent to stop and return to the facility with the children, which she did. Ms. Blanchard went through the open gate onto Ms. Rodgers' property and directed Ms. Rodgers' sons to return to Respondent's facility with the children, which they did. While on Ms. Rodgers' property, Ms. Blanchard saw a partially-filled swimming pool and other ongoing construction. Ms. Blanchard did not notice any fencing around the pool and saw one of the children, which she estimated to be three or four years old, walking in the construction area close to the edge of the pool. After the children had been returned, Ms. Blanchard assessed the situation and commenced her inspection of the remainder of Respondent's facility. Ms. Blanchard found roach droppings in the bathtub and in other locations in the facility. Respondent acknowledged a roach problem, but claimed that she had an exterminator working on the problem and that he was due to come out and treat the facility. Respondent did not present any documentation to Ms. Blanchard to corroborate her claims regarding the exterminator, nor did she introduce such documentation at the hearing. Ms. Blanchard found plastic bags in an unlocked cabinet accessible to the children. Respondent acknowledged at the hearing that the bags were in the cabinet and further acknowledged the suffocation danger that they posed to young children. Ms. Blanchard's review of the facility's records identified missing enrollment and immunization records for the children in the home. However, Ms. Blanchard did not document the children whose records were missing and she did not determine whether, as Respondent claimed at the time and in her testimony at the hearing, any of the missing records were for students who had enrolled in Respondent's facility within the prior two weeks. Ms. Blanchard documented the results of her inspection, including the events surrounding the movement of the children to Ms. Rodgers' yard on her inspection report. The inspection report identified each of the violations that she observed, including inadequate supervision based upon Respondent's absence from the facility, unsafe storage of materials dangerous to children (i.e., plastic bags) in a location accessible to the children, evidence of roaches, incomplete enrollment and immunization records, and more than the allowed number of children in the home. Ms. Blanchard also cited Respondent's facility for the dangers posed by Ms. Rodgers' pool since the children were being taken onto Ms. Rodgers' property. With respect to the citation for having too many children, Ms. Blanchard's inspection report did not include any detailed information about the children such as their names (or initials), ages, or descriptions. The report simply stated that Ms. Blanchard counted seven children at the facility -- i.e., "3 infants, 3 preschool and 1 school age child." Ms. Blanchard's testimony at the hearing referred to only two infants, which was consistent with Respondent's testimony on that issue. As a result, the evidence is not clear and convincing that there were seven children in Respondent's care at the facility rather than the authorized six children. During the course of her inspection, Ms. Blanchard did not see any adults (other than Respondent, who arrived as Ms. Blanchard was arriving) at the facility. It is undisputed that Respondent's husband, who is the designated substitute caregiver, was not at the facility that morning. There is no credible evidence that Respondent's 22- year-old son, Abdel, was at the facility that morning. He did not testify at the hearing, and, if as Respondent claims, Abdel was at the facility that morning, Ms. Blanchard would have seen him at some point during the commotion surrounding Respondent's rushing the children out the back door or during her subsequent inspection of the facility. In any event, Abdel was not the substitute caregiver designated by Respondent. He was not even authorized to watch the children because, although he had been background screened by the Department, he had not taken the Department's mandatory child care training program and was not certified in cardiopulmonary resuscitation (CPR). It is more likely than not that Ms. Rodgers' teenage sons were actually left to supervise the children at Respondent's facility during the time that Respondent was gone on the morning of February 27, 2003. Indeed, that is the most likely explanation of their presence at the facility and their involvement in the movement of the children to Ms. Rodgers' yard. However, the evidence on this issue is not clear and convincing. Respondent's explanation of her actions on the morning of the inspection -- i.e., that she hurried into the house upon her arrival and directed all of the children to Ms. Rodgers' yard so she could convey an important message to Ms. Rodgers -- is not credible. Her explanation of the roach droppings that Ms. Blanchard found in the bathtub -- i.e., that it was actually dirt from washing one of the children's feet -- is also not credible. By contrast, Respondent's explanation of the incomplete records -- i.e., that the missing records were for those children who had enrolled in the facility within the prior two weeks -- is reasonable. Because Ms. Blanchard's inspection report did not identify the children whose records were missing and did not document the date of their enrollment, the evidence is insufficient to prove this violation. Respondent admitted at the hearing that she "was taking a chance" by leaving the children at the facility without her husband, the designated substitute caregiver, being present. Respondent testified that she was gone only 15 minutes to drop one of her children off at school, and that she follows that same routine every day although her husband is usually at the facility while she is gone. After Ms. Blanchard completed her inspection, she discussed the results with Respondent and provided Respondent a copy of the inspection report. Ms. Blanchard then went back to her office and discussed the results of the inspection with her supervisor, Patricia Richardson. Based upon the results of the February 27, 2003, inspection and the history of noncompliance at Respondent's facility (both before and after the provisional license), Ms. Richardson determined that Respondent's license should be revoked. Thereafter, on February 28, 2003, Ms. Richardson sent a letter to Respondent informing her that her license was being revoked and advising Respondent of her right to "appeal" that decision through the administrative process.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Children and Family Services issue a final order revoking Respondent's license to operate a family day care home. DONE AND ENTERED this 12th day of June, 2003, in Tallahassee, Leon County, Florida. S T. KENT WETHERELL, II 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 12th day of June, 2003.
The Issue The issue is whether the renewal application for a family day care home license filed by Petitioner should be denied based upon alleged violations of Florida Administrative Code Rule 65C-20.10(1)(f), stated in Respondent's letter of proposed denial dated August 3, 2005.
Findings Of Fact Based upon the observation of and the demeanor of the witnesses while testifying, documentary materials in evidence, stipulations of the parties, and evidentiary rulings during the hearing, the following relevant, material, and substantial facts are determined: Petitioner was initially granted her first family day care home license to operate a family day care home at 2829 Kathryn Drive, Lakeland, Florida 33805, on August 3, 2003, and her family day care home license was renewed by Respondent for operation at the above address for one additional year on August 3, 2004. At the time of the 2004 family day care home license renewal, Petitioner was in compliance, with no noncompliant items noted in her record from 2003 through 2004 that would have justified denial of the license renewal. On an unspecified date prior to August 3, 2005, Petitioner made an application to renew her family day care home license. On August 3, 2005, Respondent notified Petitioner by letter of the proposal to deny her application for renewal of her family day care home license. Petitioner contested the proposed denial resulting in this administrative hearing on November 7, 2005. The denial letter of Respondent indicated that the decision was based upon, "[y]our inability to ensure the safety of children in your care." The letter continued stating: "Your Family Day Care Home was found to be out of compliance in regards to the fencing requirements as stated in 65C-20.10(1)(f), Florida Administrative Code (F.A.C.), on 07/28/03, 03/22/04, 01/12/05, 01/20/05, and 06/10/05." Petitioner acknowledged that the fence was missing a few boards during the above period. It is undisputed that the January 12, 2005, inspection by Timothy Graddy, child care licensing inspector, found numerous violations. Upon reinspection by Mr. Graddy on January 20, 2005, the violations noted during his January 12, 2005, inspection were corrected, but for repair of the fence around the home and the undated fire extinguisher inspection certification. Mr. Graddy was not called to testify regarding the severity of the noncompliance violations, the probability of harm to health or safety of the children nor actions taken by Petitioner to correct the cited violations. No other witness testified regarding these mandatory items. It is likewise undisputed that Respondent imposed an administrative fine on Petitioner for noncompliance items identified during an undated inspection in 2004. Petitioner, without requesting a Chapter 120, Florida Statutes, hearing, paid the administrative fine of $100 on December 9, 2004, for violations noted in compliance inspections that occurred between January and December of 2004. It is likewise undisputed that the Department imposed a second administrative fine on Petitioner for those violations noted from inspections that occurred between January 1, 2005, and June 21, 2005. Again, and without requesting a Chapter 120, Florida Statutes, hearing, Petitioner paid the administrative fine of $250 on June 1, 2005. William Wright, child care licensing inspector and a member of the license application review committee, reviewed the relicensing application filed by Petitioner, voiced as his primary concern a July 2005 central abuse hotline report of an incident that occurred July 11, 2005. In the abuse report, a two-year-old male child was reported to have had bruises on both facial cheeks. The allegations narrative reflected the child received the bruises by falling/tripping over his shoes. Petitioner called the father of the child, who came by, observed the bruise on his child's cheeks, signed an incident statement prepared by Petitioner, and took his child home. The father did not return his child to Petitioner's family day care home. During the subsequent investigation of the abuse incident, bruises were found on the child's thigh(s). Two or three days after the July 11, 2005, incident report, a subsequent investigation by local law enforcement and follow-up investigation by Respondent's personnel resulted in conflicting and unresolved accounts of how the child received the bruises, where the child received the bruises, and who was at fault for the bruises. It was unclear to the investigators where and how the child received the bruises on his thighs. What is clear is that the child did not receive thigh bruises while in Petitioner's family day care home. Respondent closed the abuse report with "[S]ome indicator of bruises, welts and marks. No intervention services were needed." There is insufficient evidence to conclude, infer or establish that while in Petitioner's care the child sustained bruises on his thighs that were discovered several days after the July 11, 2005, abuse report and, thus, to conclude the child's safety was at risk while in Petitioner's family day care home. Another review committee member, Patricia Hamilton, child care licensing supervisor, opined the proposed denial was based upon "the Department's belief" that Petitioner was not able to operate a day care without violating one or more Florida Administrative Code rules. It is her belief that children in Petitioner's family day care home would not be safe because the historical inspection record compiled by Respondent, in her opinion, demonstrated Petitioner could not consistently comply with the rules of operating a safe family day care home. This is a reasonable inference drawn from a historical review of Petitioner's family day care home inspection record. Petitioner, as of November 28, 2005, filed a Notice of Change of Address. Petitioner now resides at 7354 Beaumont Drive, Lakeland, Florida. By moving to a new residence, Petitioner effectively withdrew the family day care home license application for license of the residence at 2829 Kathryn Avenue, Lakeland, Florida 33805, the subject of this case.
Recommendation Based upon the foregoing findings of fact and conclusions of law hereinabove, it is RECOMMENDED that the Department of Children and Family Services enter a final order dismissing the petition filed by Tarsha Seay, d/b/a Seay Family Day Care Home. DONE AND ENTERED this 24th day of February, 2006, in Tallahassee, Leon County, Florida. S FRED L. BUCKINE 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 24th day of February, 2006.
The Issue The issues are whether Petitioner is entitled to recover Medicaid funds paid to Respondent pursuant to section 409.913(1), Florida Statutes, for hospice services Respondent provided during the audit period between September 1, 2009, and December 31, 2012; and the amount of sanctions, if any, that should be imposed pursuant to section 409.913(15), (17).
Findings Of Fact Based upon the stipulations of the parties and the evidence presented at hearing, the following relevant Findings of Fact are made. Parties Petitioner, AHCA, is the state agency responsible for administering the Florida Medicaid Program. § 409.902, Fla. Stat. (2016). Medicaid is a joint federal and state partnership to provide health care and related services to certain qualified individuals. Respondent, Halifax, is a provider of hospice and end- of-life services in Volusia and Flagler counties. During the audit period of September 1, 2009, through December 31, 2012, Halifax was enrolled as a Medicaid provider and had a valid Medicaid provider agreement with AHCA. Hospice Services Hospice is a form of palliative care. However, hospice care is focused upon patients at the end-of-life-stage while palliative care is for any patient with an advanced illness. Both hospice and palliative care patients are amongst the sickest patients, generally. Hospice is focused upon serving the patient and family to provide symptom management, supportive care, and emotional and spiritual support during this difficult period when the patient is approaching their end-of-life. Hospice care, as with Halifax, uses an inter-disciplinary team (IDT) to provide comfort, symptom management, and support to allow patients and their families to come to terms with the patient’s terminal condition, i.e., that the patient is expected to die. Each patient is reviewed in a meeting of the IDT no less than every two weeks. For hospice, a terminally-ill patient must choose to elect hospice and to give up seeking curative care and aggressive treatments. At all times relevant to this proceeding, Petitioner was authorized to provide hospice services to Medicaid recipients. AHCA Audit A Medicaid provider is a person or entity that has voluntarily chosen to provide and be reimbursed for goods or services provided to Medicaid recipients. As an enrolled Medicaid provider, Halifax was subject to federal and state statutes, regulations, rules, policy guidelines, and Medicaid handbooks incorporated by reference into rule, which were in effect during the audit period. AHCA is required to oversee the integrity of the Medicaid program. Among other duties, AHCA is required to conduct (or cause to be conducted) audits to determine possible fraud, abuse, overpayments, or recipient neglect in the Medicaid program. § 409.913(2), Fla. Stat. Under Florida law, “overpayment” is defined as “any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.” § 409.913(1)(e), Fla. Stat. The federal Department of Health & Human Services, Centers for Medicare and Medicaid (“CMS”), contracted with Health Integrity, LLC (“HI”), a private vendor, to perform an audit of Halifax on behalf of AHCA. HI, in turn, retained a company called Advanced Medical Reviews (“AMR”) to provide physician reviews of claims during the audit process to determine whether an audited claim was eligible for payment. The audit in this matter was conducted to determine whether Medicaid recipients met eligibility for hospice services. To establish the scope of the audit, HI identified patients that had greater than six months of service, and then, excluded recipients with cancer diagnoses and patients who were dual eligible for Medicaid and Medicare. All the claims at issue, along with patient medical records, were first reviewed by a claims analyst, who is a nurse consultant, to determine whether the claims met the criteria for hospice services. The patient records and the nurse consultant's summary for each patient were then forwarded to a peer reviewer, a physician who used his or her medical expertise to determine the medical necessity of the hospice services provided. In this case, AHCA employed the services of two peer reviewers: Dr. Alan Heldman was the peer reviewer who specializes in internal medicine and cardiology, and Dr. Todd Eisner, who specializes in gastroenterology. The peer reviewers prepared reports that offered their opinion as to whether a patient was qualified for hospice services. A draft audit report (“DAR”) was prepared by HI, which initially identified overpayment of Medicaid claims totaling $694,250.75, relating to 12 patients. Halifax provided a response to the DAR, and contested the overpayments for each of the 12 patients. Halifax’s response was provided to the peer review physicians, who, after reviewing the response, maintained their original conclusions. HI then prepared the FAR, upholding the overpayments identified in the DAR, and submitted it to CMS. CMS provided the FAR to AHCA with instructions that AHCA was responsible for initiating the state recovery process and furnishing the FAR to the provider. The FAR contains the determinations of the peer review physicians, specifically, whether each of the 12 patients at issue had a terminal diagnosis with a life expectancy of six or less months if their disease progressed at its normal course. After the FAR had been issued, upon further review, of certain patient files at issue, AHCA determined that four of the original 12 patients were eligible for Medicaid hospice services, and revised the amount of overpayment it seeks to $529,906.88, with a reduction in the fine it seeks to $105,981.38. Halifax is challenging the eligibility determination, i.e., the medical necessity of services provided, regarding the following patients1/: Patient D; Patient H; Patient P; Patient Q; Patient S; Patient U; Patient V; and Patient O. The Florida Medicaid Hospice Services Coverage and Limitations Handbook, the January 2007 edition (“Handbook”), governs whether a service is medically necessary and meets certification criteria for hospice services. MPI instructs each peer reviewer to review the criteria set forth in the Handbook to determine whether services provided to a patient are eligible for Medicaid coverage. To qualify for the Medicaid hospice program, all recipients must: Be eligible for Medicaid hospice; Be certified by a physician as terminally ill with a life expectancy of six months or less if the disease runs its normal course; Voluntarily elect hospice care for the terminal illness; Sign and date a statement electing hospice care; Disenroll as a participant in a Medicaid or Medicare health maintenance organization (HMO), MediPass, Provider Service Network (PSN), Medicaid Exclusive Provider Organization, MediPass Pilot Programs or the Children’s Medical Services Network; Disenroll as a participant in Project AIDS Care; and Disenroll as a participant in the Nursing Home Diversion Waiver. The Handbook also provides certification of terminal illness requirements as follows: For each period of hospice coverage, the hospice must obtain written certification from a physician indicating that the recipient is terminally ill and has a life expectancy of six months or less if the terminal illness progresses at its normal course. The initial certification must be signed by the medical director of the hospice or a physician member of the hospice team and the recipient’s attending physician (if the recipient has an attending physician). For the second and subsequent election periods, the certification is required to be signed by either the hospice medical director or the physician member of the hospice team. Certification documentation requirements used by the peer review physicians are as follows: Documentation to support the terminal prognosis must accompany the initial certification of terminal illness. This documentation must be on file in the recipient’s hospice record. The documentation must include, where applicable, the following: Terminal diagnosis with life expectancy of six months or less if the terminal illness progresses at its normal course; Serial physician assessments, laboratory, radiological, or other studies; Clinical progression of the terminal disease; Recent impaired nutritional status related to the terminal process; Recent decline in functional status; and Specific documentation that indicates that the recipient has entered an end- stage of a chronic disease. The Medicaid hospice provider must provide written certification of eligibility for hospice services for each patient. The certification is also required for each election period. A patient may elect to receive hospice services for one or more of the election periods. The election periods include: an initial 90-day period; a subsequent 90-day period; and subsequent 60-day time periods. The Handbook further provides guidance regarding the election periods as follows: The first 90 days of hospice care is considered the initial hospice election period. For the initial period, the hospice must obtain written certification statements from a hospice physician and the recipient’s attending physician, if the recipient has an attending physician, no later than two calendar days after the period begins. An exception is if the hospice is unable to obtain written certification, the hospice must obtain verbal certification within two days following initiation of hospice care, with a written certification obtained before billing for hospice care. If these requirements are not met, Medicaid will not reimburse for the days prior to the certification. Instead, reimbursement will begin with the date verbal certification is obtained . . . . For the subsequent election periods, written certification from the hospice medical director or physician member of the interdisciplinary group is required. If written certification is not obtained before the new election period begins, the hospice must obtain a verbal certification statement no later than two calendar days after the first day of each period from the hospice medical director or physician member of the hospice’s interdisciplinary group. A written certification must be on file in the recipient’s record prior to billing hospice services. Supporting medical documentation must be maintained by the hospice in the recipient’s medical record. Peer Review Physicians The two peer reviewers assigned to review claims in this matter were Florida-licensed physicians, who were matched by specialty or subspecialty to the claims they were reviewing. Each physician testified as to his medical education, background, and training. Petitioner offered each physician as an expert, and the undersigned accepted each expert as such. Dr. Heldman has been licensed to practice medicine in the state of Florida for 10 years. While in Florida, he worked as a professor and practitioner within the University of Miami Medical School and Health System until 2015. Since 2015 he has maintained an independent private practice. Before practicing in Florida, Dr. Heldman practiced at Johns Hopkins Hospital in Baltimore, Maryland, for 19 years. Dr. Heldman received his training at Johns Hopkins in cardiology and interventional cardiology. He has been board-certified in cardiovascular disease since 1995, and board-certified in interventional cardiology since 1999. Both cardiology specialties are subspecialties of the board of internal medicine. Dr. Heldman was previously board-certified in internal medicine in 1992 but was not certified in that area when he reviewed the claims in this matter.2/ Dr. Heldman has referred patients to hospice. Dr. Eisner, who is board-certified in gastroenterology, has seen numerous patients with liver disease throughout his career and, based upon his experience, Dr. Eisner understands what factors are properly considered when estimating a patient’s life expectancy. He also refers patients to hospice on a regular basis, which routinely requires him to make the type of prognosis determination such as those at issue in this matter. Although Dr. Eisner has some experience dealing with patients who have Chronic Obstructive Pulmonary Disease (“COPD”), he does not have board-certification in pulmonary disease. Also, Dr. Eisner has never provided expert testimony regarding pulmonology conditions. Halifax Hospice Providers Dr. Zimmerman, Halifax’s medical director, authored the provider response to the eight patients at issue and testified at the final hearing in that regard. Although he is board-certified in hospice and palliative medicine, he is not and has never been certified in internal medicine, gastroenterology, or cardiology. Halifax did not elicit testimony from Dr. Zimmerman that he had any experience in examining and treating patients with liver disease, COPD, dementia, or end-stage lung disease. Likewise, none of the other Halifax physicians testified at hearing and there was no evidence of their respective experience in examining and treating patients with the illnesses involved in this case. Additionally, although Dr. Zimmerman initially certified the patients selected for the audit for hospice services, and attempted to support the other Halifax hospice physicians when they repeatedly recertified the patients as eligible, Dr. Zimmerman admitted he never examined any of these patients himself and was unable to attest that any of his in- house physicians ever personally examined any of the patients. In addition to Dr. Zimmerman, the hospice physicians involved in the certification of the eight patients at issue in this audit were as follows: Dr. Richard C. Weiss: board-certified in internal medicine, oncology, and hospice & palliative medicine Dr. John Bunnell: board-certified in family medicine and hospice & palliative medicine Dr. Arlen Stauffer: board-certified in family medicine and hospice & palliative medicine Dr. Susan Howard: board-certified in family medicine and hospice & palliative medicine Dr. Lyle E. Wadsworth: board-certified in internal medicine, geriatrics, and hospice & palliative medicine Dr. Gregory Favis: board-certified in internal medicine, with subspecialty certification in hematology and oncology; and Dr. Justin Chan: board-certified in family medicine Specific Patient Review At the time of the hearing, the hospice service claims related to eight patients remained at issue. The findings of fact regarding eligibility of each patient for hospice services are set forth below in the following order: D, H, P, Q, S, U, V, and O. Patient D Patient D, a 53-year-old male, was first admitted to Halifax Hospice on February 25, 2011, with a terminal diagnosis of hepatocellular cancer and cirrhosis secondary to hepatitis C. He was discharged on May 29, 2012, and then readmitted on June 13, 2012, through December 31, 2012 (audit period). He had previously been in various hospices for six to seven years. Dr. Eisner noted there was no recent decline in functional status. In June 2011, a nurse noted the patient was ambulating well and went fishing, but he experienced frequent falls. He continued to experience falls (from his couch and bicycle) and also had mild to moderate arm and hand tremors. His weight decreased from 176 to 162 over seven months. Thus, the patient records reflected some indication of functional decline. However, as Dr. Eisner credibly testified, even considering the alleged terminal diagnosis, the patient showed no evidence of having refractory ascites, hepatic encephalopathy nor gastrointestinal bleeding. Further, he indicated there was no documentation of variceal bleeding, hepatorenal syndrome, or spontaneous bacterial peritonitis, which he would expect to see if the patient truly had six or less months to live. The medical records support Dr. Eisner’s conclusion that the patient did not meet the standard of six or less months to live. Throughout the period of the hospice stay, nursing notes indicate that the patient was stable, ambulating well, felt good, and was observed by an ER doctor after a fall off his bike, as “well-nourished, well-developed patient, [and] in no apparent distress.” Even Dr. Weiss, the hospice physician who worked with Patient D, noted in recertification that “It is a difficult case as he clearly has a terminal illness and at the same time is manipulative with no overt progression of disease.” Dr. Eisner credibly testified that the patient was not eligible for hospice services and, thus, the services provided were not eligible for Medicaid reimbursement. The greater weight of the evidence proves that Patient D was not eligible for Medicaid hospice services and that Petitioner is entitled to recover an overpayment of $98,776.63 Patient H Patient H was admitted to Halifax on December 31, 2010, with a terminal diagnosis of end-stage liver disease secondary to chronic hepatitis C. Dr. Eisner determined that Patient H did not have a life expectancy of less than six months. Dr. Eisner opined that there was no clinical progression of the patient’s terminal disease. The patient did not have impaired nutritional or functional status related to the terminal illness. The patient had weight loss but experienced increased abdominal girth. The treating hospice physician was Dr. Wadsworth, who is board-certified in internal medicine. He noted that the patient had cirrhosis and variceal bleeding and hepatic encephalopathy. However, as correctly noted by Dr. Eisner, those conditions were the natural progression of the disease, but would not result in a life expectance of less than six months. Dr. Eisner also testified that patients with chronic liver disease can live up to 10 years and patients with hepatic encephalopathy can live up to 15 years. Patient H was ultimately discharged for drug diversion, and although her discharge note states: “Suspected drug diversion became evident over last 2 months when controlled medication was not available for nurses to check during visit,” the patient records reflect that Halifax was aware of this problem throughout her stay, but did not discharge her for an additional 12 months. The inconsistency of the medical records and Dr. Eisner’s opinions indicate that this patient did not have a terminal diagnosis with a life expectancy of six months or less if her terminal disease progressed at its normal course at initial certification or at any recertification throughout her stay with Halifax. The medical records contained in this patient’s file do not support a finding that the Medicaid hospice eligibility standard was met. Based upon the greater weight of the evidence in this case, it is determined that Patient H was not eligible for Medicaid hospice services and that Petitioner is entitled to recover an overpayment of $50,142.74. Patient P Patient P, a 48-year-old male, was admitted to Halifax on August 25, 2011, with a terminal diagnosis of end-stage liver disease. The first 11 months of his stay were denied, however, the last month was approved. Dr. Eisner testified that although the patient had ascites requiring frequent paracentesis, he did not see documentation indicating there was a progression of the terminal disease until July 2012. Dr. Eisner also determined there was no documentation in the patient records of impaired nutritional status related to the disease or a decline in functional status. However, when the patient did show a decline in functional status, Dr. Eisner agreed the patient was eligible. Further, because, during the denied period, there was no evidence of variceal bleeding, hepatorenal syndrome or recurrent spontaneous bacterial peritonitis, Dr. Eisner opined that the life expectancy of the patient would typically be one to two years, not six or less months. There is also a discrepancy in the medical records for this patient. In the narrative for the recertification for November 24, 2011, Dr. Wadsworth indicates this is a “48 yo ES Dementia, and multiple comorbidities. Has had [hallucinations] has improved.” Certainly this is in error and cannot be the basis for a valid recertification–-this patient did not have dementia nor were there reported hallucinations. This patient did not have a terminal diagnosis with a life expectancy of six months or less if his terminal disease progressed at its normal course at initial certification or at any recertification throughout the first 11 months of his stay with Halifax. The medical records contained in this patient’s file do not support a finding that the Medicaid hospice eligibility standard was met. Based upon the greater weight of the evidence in this case, it is determined that Patient P was not eligible for Medicaid hospice services and that Petitioner is entitled to recover an overpayment of $60,872.04. Patient Q Patient Q was a 56-year-old male admitted with end- stage lung disease. Per the FAR overpayment recalculations, he was deemed ineligible for the first three months of his hospice admission beginning on December 13, 2011, and was thereafter approved through the end of the audit period. As Dr. Eisner reasoned, the medical records did not support hospice eligibility for the first three months that were billed. The patient was stable, using a walker, and had reasonable palliative performance scale scores, and showed no decline in functional status and Transient Ischemic Attacks (“TIA), if any, were stable. However, as Dr. Eisner noted, after three months, the records did contain evidence supporting a progressive deterioration of the patient’s condition and functional status. Much of the issue with this patient appears to be whether the patient actually had ongoing TIA episodes prior to and during the initial certification period. The patient’s medical record from a hospital visit six months prior to hospice admission, where he was seen for chest pains, made no mention of TIAs. Further, Dr. Zimmerman admitted that none of his doctors or nurses had witnessed the patient having a TIA, and the records do not support that the patient had mini-strokes prior to the approved period. While Dr. Zimmerman also attempted to justify his concerns with TIAs based upon one episode during the denied period where the patient reported being dizzy and short of breath, he admitted that these could have been caused by the extensive amount of opiates and other drugs the patient had been given. For the denied period, the patient did not have a terminal diagnosis with a life expectancy of six months or less if his terminal disease progressed at its normal course at initial certification. The medical records do not support a finding that the Medicaid hospice eligibility standard was met. Based upon the greater weight of the evidence, it is determined that Patient P was not eligible for Medicaid hospice services and that Petitioner is entitled to recover an overpayment of $12,716.10. Patient S Patient S, a 51-year-old patient, was admitted to Halifax with a terminal diagnosis of end-stage liver disease. Dr. Eisner determined that hospice services were not appropriate for Patient S. Specifically, he determined that the patient’s disease, while terminal, did not result in a life expectancy of six months or less. In refuting Dr. Zimmerman’s response, Dr. Eisner stated, “In the absence of recurrent, untreated, variceal bleeding, hepatorenal syndrome or recurrent spontaneous bacterial peritonitis, the life expectancy of patients with cirrhosis, ascites, and hepatic encephalopathy is typically 1 to 2 years.” There was no clinical progression of the disease. The Halifax treating physician, Dr. Weiss, noted that the patient’s condition included cirrhosis and hepatic encephalopathy. However, as noted by Dr. Eisner, the condition was the natural progression of the disease. The greater weight of the evidence supports that Patient S was not eligible for hospice services for the period September 1, 2009, through December 1, 2010, and that Petitioner is entitled to recover an overpayment of $63,235.91. Patient U Patient U, a 61-year-old female, was admitted with a terminal diagnosis of dementia. She was first admitted to Halifax hospice in October 2010, however, the claims audit period for this patient did not begin until January 1, 2011. Dr. Heldman indicated that she was not eligible through the end of her initial stay in hospice on January 31, 2012. Dr. Heldman approved her second stay in hospice beginning on May 19, 2012. Dr. Heldman, who indicated he had dealt with dementia patients many times, testified that there were discrepancies throughout her medical records and that the file did not contain documentation showing serial physician assessments, clinical progression of the terminal disease, a decline in functional status, nor of the end stage of a terminal disease. Dr. Zimmerman, in his provider response after the DAR, focused on what he claimed was a significant weight loss with this patient over the period she remained in hospice care. As Dr. Zimmerman stated in the provider response: “when certifying physicians saw consistent weight gain/stabilization they became comfortable that the improvement was not a brief ‘honeymoon’ in her failing nutritional status and they no longer believed that her ‘normal course’ would result in a life expectancy of six months or less and they appropriately discharged her.” It is clear Dr. Zimmerman relied on the patient’s alleged dramatic weight loss to justify continued provision of hospice services to the patient. However, at the final hearing, Dr. Zimmerman conceded that the dramatic weight loss upon which he relied (and his physician who was recertifying the patient relied on) in evaluating this patient, was a mistake. The factor upon which Dr. Zimmerman relied upon to support the patient’s stay in hospice, including his initial certification and at least two recertifications, did not actually exist. Dr. Heldman likewise provided credible testimony regarding the inconsistencies in Halifax’s records for Patient U’s file and that the records did not contain sufficient documentation to support the initial certification and recertifications. The preponderance of the evidence proves that Patient U was not eligible for Medicaid hospice services and that Petitioner is entitled to recover an overpayment of $47,159.40. Patient V Patient V, a 56-year-old male, was initially admitted to Halifax on May 22, 2012, with a terminal diagnosis of end- stage liver disease. Dr. Eisner testified that although this patient did have ascites, they are part of the normal progression of the disease and the condition was appropriately treated with paracentesis. Further, he indicated that throughout the course of the patient’s stay, there was no documentation to show a clinical progression of the terminal disease. Dr. Eisner also noted there was no evidence of impaired nutritional status related to the terminal disease or any decline in functional status. More importantly, Dr. Eisner opined that there was no evidence that the patient had entered the end stage of a chronic disease. Finally, he saw no evidence that the patient had variceal bleeding, hepatorenal syndrome, or recurrent spontaneous bacterial peritonitis, which would have indicated six months or less to live. Dr. Zimmerman testified that his team was extremely worried about the patient’s prior episode of ventricular tachycardia and the chance of another episode that would be fatal, and that this chance supported keeping him in hospice. Dr. Zimmerman highlighted this grave concern repeatedly through his written response to the DAR. However, on cross-examination, he admitted that the patient did not have a history of the tachycardia but rather had one episode that lasted 20 beats or less and that Halifax did not send the patient to be further evaluated by a cardiologist. He also admitted that the opiates Halifax treatment providers were giving Patient V could have caused the dizziness that prompted their concern and allegedly supported the prognostication of limited life expectancy. Patient V did not have a terminal diagnosis with a life expectancy of six months or less if his terminal disease progressed at its normal course at initial certification or at any recertification throughout his stay with Halifax during the audit period. The medical records contained in this patient’s file do not support a finding that the Medicaid hospice eligibility standard was met. Based upon the greater weight of the evidence in this case, it is determined that Patient V was not eligible for Medicaid hospice services and that Petitioner is entitled to recover an overpayment of $38,769.20. Patient O Patient O, a 57-year-old female, was first admitted to Halifax on October 16, 2009, with a terminal diagnosis of COPD, a common breathing disorder. She was discharged November 9, 2012, because Halifax determined she did not meet the criteria for hospice. Although Patient O had COPD, Halifax never presented her for a FEV1 test which would have been a good indicator of the degree of COPD and would have assisted in properly obtaining a prognosis of life expectancy. Patient O was recertified for hospice 16 times, with little or no narrative from the recertifying Halifax physician present in the medical records. Patient O also regularly showed oxygen saturation levels within the normal range for a COPD patient. In May 2010, seven months into her hospice stay, there was no evidence of impaired nutritional status, no signs or symptoms of respiratory distress, no change in chest pain, residual weakness, fair appetite, no swallowing difficulties and her pain was well controlled. Additionally, in September 2010, there were notes that the patient’s lungs were clear, she had been removed from oxygen for activities, and had showered without difficulty. Between December 2010 through September 2012, the nurse’s notes reflect that patient O stated that she was doing better and had not experienced shortness of breath. It appears from the medical records that while the patient may have had COPD, it was not progressing. Dr. Eisner testified that other than intermittent upper respiratory infections, the patient’s pulmonary status remained stable and showed no progression over the course of time. Further, he saw no proof that her coronary heart disease or diabetes deteriorated over the three years and that, although she had some weight loss, there was no documentation of a decline in her functional status. However, Dr. Eisner provided an opinion regarding this patient outside his expertise. That a COPD terminal diagnosis was beyond his experience was made clear when Dr. Eisner could not identify the specific indicators for when a COPD patient was decompensating. Although Dr. Eisner may have treated patients with COPD, his primary practice treating patients was related to gastroenterological conditions. He was not board-certified in pulmonology and was not trained in the specialty. Therefore, AHCA has not met its burden by the greater weight of the evidence that Patient O was not eligible for Medicaid hospice services, and Petitioner is not entitled to recover an overpayment of $158,234.66. Fine Calculation When calculating the appropriate fine to impose against a provider, MPI uses a formula based on the number of claims that are in violation of rule 59G-9.070(7)(e). Specifically, the formula involves multiplying the number of claims in violation of the rule by $1,000 to calculate the total fine.3/ The final total may not exceed 20 percent of the total overpayment, which resulted in a fine of $64,981.38. Summary of Findings of Fact At the time of the hearing, AHCA sought from Respondent overpayments in the amount of $529,906.88 for eight patients who received hospice services at Halifax during the audit period. The findings of fact above upheld AHCA's denial of hospice services for patients: D, H, P, Q, S, U, and V. The Respondent rebutted the evidence regarding eligibility of Patient O. Therefore, AHCA is entitled to recover overpayment of $371,672.22. Each expert credibly testified as to when each patient was admitted and the certification for each patient. The experts provided the requisite support to both the DAR and FAR for the patients where there was a finding of ineligibility for hospice services.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that that the Agency for Health Care Administration enter a final order directing Halifax to pay $371,672.22 for the claims found to be overpayments and a fine of $67,981.38. The undersigned reserves jurisdiction to award costs to the prevailing party. DONE AND ENTERED this 30th day of June, 2017, in Tallahassee, Leon County, Florida. S YOLONDA Y. GREEN 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 30th day of June, 2017.
The Issue The primary issue in this case is whether Petitioner's application for licensure as a home health agency was complete upon Petitioner's submission of additional information to Respondent within 21 days after Respondent had timely notified Petitioner of the need to provide additional information. If Petitioner failed to provide Respondent with information which Respondent timely requested, then Respondent may deny Petitioner's application as incomplete, as it intended to do, provided the information Respondent sought is information Respondent is permitted by law to require. On the other hand, if Petitioner's application was complete, then Petitioner's application is "considered approved," because Respondent failed to grant or deny the application within 60 days after receiving additional information from Petitioner; in that event, a license must be issued to Petitioner, subject to reasonable conditions authorized by law.
Findings Of Fact The Agency for Health Care Administration ("Agency" or "AHCA") is the state agency responsible for regulating home health agencies in Florida. In this capacity, the Agency determines whether to approve applications for licensure as a home health agency, and it has administrative jurisdiction to enforce the laws governing such licensees, including the authority to take disciplinary measures against licensees who violate the applicable statutes and rules. MVP Health, Inc. ("MVP"), is a corporation which, for a time relevant to this case, held a license to operate as a home health agency. On June 11, 2009, MVP filed an application with AHCA seeking to obtain a new home health agency license, notwithstanding that it was already licensed. Prompting this seemingly unusual maneuver was the recent acquisition of 100 percent of the company's equity by an individual named Rey Gomez, who had bought out the other shareholders. About one week after submitting its application to AHCA, MVP voluntarily stopped operating as a home health agency under its then- existing license. Pursuant to Sections 120.60(1) and 408.806(3), Florida Statutes, which will be examined below, the Agency was required to notify MVP, within 30 days after receiving MVP's application for licensure, of any errors, omissions, or requests for additional information. By letter dated July 10, 2009 (the "Omissions Letter"), the Agency timely gave MVP such a notice, which provided, in pertinent part, as follows: Your application for a home health agency license has been reviewed and was found to be incomplete. Applicants for licensure will receive only one omission letter describing the corrections, omissions or revisions needed to complete the application. If the response to the omission letter does not satisfactorily address what is outlined below, the application will be denied. Therefore, pursuant to section 408.806(3)(b), Florida Statutes, no further action can be taken until the following is received: * * * Include a separate list showing all health care entities licensed or registered in the State of Florida that are also owned in whole or in part by each of your controlling interests as required by subsection 400.471(2)(g), F.S. Controlling interests as defined in [section] 408.803, F.S., include the applicant or licensee; a person or entity that serves as an officer of, is on the board of directors[,] or has a 5 percent or greater ownership interest in the management company or other entity, related or unrelated[,] with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member. * * * You have listed Rey Gomez as the sole owner of MVP Health Inc. We currently have a licensed home health agency, MVP Health Inc., HHA #29992195, which our records show as being owned by Virginia Duby, Michael Lee, and Priscilla Lee. We cannot process an initial application for licensure from a company for which we currently have an active license if the owners of record on that existing license differ from the owners of record on the new application. A change of ownership application was recently filed for that agency but that application was denied and withdrawn. Since then we have come to understand that this company's ownership was in dispute. Please submit documentation that the legal issues of ownership of this company have been finally resolved. Please eliminate any inconsistencies in the ownership of this company regarding this initial licensure application and HHA #29992195. Please complete #2A Individual and/or Entity Ownership of Licensee on Health Care Licensing Application page 2 of 5 per reporting requirements of Chapter 408, Part II, Florida Statutes. * * * Please send the required information no later than 21 days from the receipt of this letter. If the applicant fails to submit all of the information required in the application within 21 days of being notified by AHCA of the omissions, the application will be denied and the fees shall be forfeited as required in subsection 408.806(3)(b), Florida Statutes. (Boldface and underlining in original.) There were, listed in the Omissions Letter, other items as to which the Agency wanted additional information, but none of these later became the subject of dispute, and thus they require no further mention. Following instructions, MVP filed the requested additional information with AHCA on July 24, 2009, a date which was well within 21 days after MVP's receipt of the Omissions Letter. In its supplemental filing, as it had done previously in its application, MVP identified Mr. Gomez and his wife, Zenaida, as the corporation's only "controlling interests," and represented that neither of them owned any part of any other health care entities. MVP asserted also that Mr. Gomez was its sole shareholder, just as it had done in the application. On August 13, 2009, MVP voluntarily relinquished its then-existing home health agency license. This was done in response to the Agency's assertion, in the Omissions Letter, that the Agency "cannot process an initial application for licensure from a company for which we currently have an active license if the owners of record on that existing license differ from the owners of record on the new application." At the time, Mr. Gomez believed that AHCA soon would issue MVP a new license, whereupon MVP would be authorized to resume operations as a home health agency. The Agency, however, did not soon issue a license to MVP. Instead, by letter dated October 20, 2009, which was captioned, "Notice of Intent to Deem Application Incomplete and Withdrawn From Further Review" (the "Withdrawal Notice"), the Agency informed MVP that its application had been deemed incomplete and would be withdrawn from further consideration.1 The Agency described the "outstanding issues remaining for licensure" as follows: The applicant could not provide proof of ownership of MVP Health Inc. The ownership of this company has been in dispute for over a year. The applicant was asked to provide proof of ownership of the company but did not do so. A call to the Clerk of Courts in Miami revealed that there is an ongoing legal dispute that has not been resolved regarding the ownership of MVP Health Inc. Rey Gomez claims to be the sole owner, however, there are three previous owners who are involved in the ownership dispute that is ongoing. The Agency cannot issue a license to a corporation where the ownership is not clear. * * * The applicant's accreditation was terminated due to not providing services since June of 2009. The home health agency submitted a change of ownership application which was subsequently withdrawn and the license was voluntarily terminated. The applicant applied for an initial home health license after the original license was voluntarily terminated. In so doing, the applicant needed to secure accreditation within 120 days of receipt of the initial application in the Home Care Unit. That date would have been October 8, 2009. * * * The applicant did not provide a list of all health care entities licensed or registered in the State of Florida that are also owned by each controlling interest. In its Proposed Recommended Order, which was filed after the final hearing in this case, the Agency conceded that because "no evidence was entered to contradict" Mr. Gomez's testimony that "neither he nor MVP Health, Inc. had an ownership interest in any other health care facility," MVP "has met [its] burden and must prevail on this point." The undersigned agrees that, with regard to Item #3 in the foregoing list of alleged deficiencies, MVP's application was complete, as a matter of ultimate fact, no later than July 24, 2009, contrary to AHCA's preliminary determination. No further discussion of this point is required. Regarding Item #1, it is the Agency's position that MVP did not——and indeed could not possibly have——provided "proof" that "the legal issues of ownership of [MVP] have been finally resolved." This contention is based on several undisputed facts (to which the parties stipulated), namely: (1) Several persons brought suit in the circuit court in Miami-Dade County seeking to establish that they own, in the aggregate, 40 percent of MVP's equity, as against Mr. Gomez's claim to be the company's sole shareholder; (2) On October 28, 2009, the trial court entered a judgment in Mr. Gomez's favor in this litigation, determining that he owns 100 percent of MVP's shares; and (3) As of the final hearing in this case, an appeal from that judgment was pending in the Third District Court of Appeal. The Agency argues that the mere existence of the ongoing litigation clouds the issue of MVP's ownership, which in turn necessarily makes MVP unable to "prove" Mr. Gomez's claim of ownership, and that, without such proof, the Agency is precluded from issuing a license. There are two problems with AHCA's contention. First, the mere fact that some persons (who are not parties to, and did not testify in, this proceeding) dispute certain statements in MVP's application, i.e., that (a) Mr. Gomez owns 100 percent of MVP's shares, and (b) Mr. Gomez and his wife are the only two "controlling interests" of the company, is not terribly persuasive evidence that MVP's statements, which were made under oath, are untrue. In this case, Mr. Gomez testified credibly that he is MVP's sole owner, and that he and Mrs. Gomez are the company's officers. Mr. Gomez's testimony in this regard is corroborated by the stipulated fact that a judgment vindicating Mr. Gomez's claim of ownership was rendered in a legal proceeding brought specifically to defeat such claim. On the present record, the undersigned does not hesitate to find, based on a preponderance of the evidence, that the statements in MVP's application regarding its owner and officers were true and complete. Second, however, and more important, the issue in this case is not whether MVP's statements regarding ownership were true and complete, but whether such statements were complete. This is because AHCA did not deny MVP's application on the grounds that Mr. Gomez is not, in fact, the sole shareholder; that MVP made a material misrepresentation in, or omitted a material fact from, its application2; or even that the ongoing litigation is a per se barrier to the issuance of a license (although the Agency seems to believe that this latter proposition is true). Rather, the Agency deemed incomplete MVP's application, and on that basis refused to consider whether the application should be granted or denied "on the merits." To be sure, the effect of AHCA's intended action, if implemented, would be indistinguishable from denial; indeed, such action——the withdrawal of an allegedly incomplete application——properly can be (and sometimes is3) called a denial. But the basis of the action would be materially different from that justifying the denial of a completed application. Simply put, the failure of an applicant to meet the criteria for a license, which results in a denial on the merits, is not, as a logical matter, equal to the failure of an applicant to timely provide requested information (or correct an identified error or omission), which results, as a procedural matter, in a refusal to consider (or to deny) an application consequently deemed to be incomplete. It is one thing, in other words, to say, based on all the necessary information, that a person is ineligible for licensure. It is another thing to say that the person's eligibility cannot and will not be determined because the person has failed to provide all of the necessary information upon which such a determination must be based. Because the Agency has taken the position that MVP failed to submit all of the information that the Agency needed in order to make a decision whether or not to grant MVP's application for licensure, the question in this case is not whether MVP in fact meets the criteria for licensure, but whether MVP timely provided AHCA with all of the information which the Agency requested and was permitted by law to require. The evidence in this case establishes clearly, and the undersigned finds, that MVP timely provided AHCA with all of the legally required information concerning its owner and officers for which it was asked. As will be discussed below, the law neither requires that an applicant provide, nor authorizes the Agency to demand, as a prerequisite to licensure, "proof of [corporate] ownership" in the form of a final judicial determination of such issue where a legal dispute has arisen. To the extent AHCA sought to require such information from MVP, AHCA was not permitted by law to do so, and thus MVP's application cannot be "deemed incomplete" based on MVP's "failure" to provide such proof (which in this instance did not even exist). MVP identified its owner and officers and provided AHCA with identifying information about them in accordance with the applicable law. No more was required of MVP to make its application complete in regard to matter of ownership.4 It is determined as a matter of ultimate fact that, with regard to Item #1 in the Withdrawal Notice, MVP's application was complete as of July 24, 2009, at the latest. Item #2 in the Withdrawal Notice, which raised the issue of accreditation for the first time, requires consideration of additional facts not previously discussed. At the time MVP submitted its application to AHCA, MVP was fully accredited by an appropriate accrediting organization known as The Joint Commission. This accreditation was effective beginning February 3, 2009, and was valid for up to 39 months. MVP's accreditation remained in effect up to, and beyond, the date of AHCA's Withdrawal Notice, wherein the Agency mistakenly stated that MVP's accreditation had been terminated (as of October 20, 2009). In fact, MVP's accreditation remained valid until at least October 27, 2009, on which date The Joint Commission issued a letter to Mr. Gomez that provided as follows: The Joint Commission was notified that MVP Health, Inc. closed effective 6/19/2009 and that your organizations [sic] license was surrendered to the state on 8/13/2009. In order to complete the process of removing the organization, MVP Health, Inc., and all of its services from our records, please return to the Joint Commission the Certificate of Accreditation, since the certificate and all copies remain the property of The Joint Commission. We will update our records accordingly. The parties stipulated that, as of the final hearing in this case, MVP was not accredited by The Joint Commission or any other accrediting organization. As will be discussed below, Section 400.471(2)(h), Florida Statutes, provides unambiguously that a home health agency must maintain accreditation to maintain licensure. Mr. Gomez believes, based on conversations he has had with The Joint Commission, that The Joint Commission would reinstate MVP's accreditation, without the need for MVP to reapply for accreditation, if AHCA were to indicate that MVP will be licensed. While Mr. Gomez's testimony in this regard is not a legally sufficient basis upon which to find that The Joint Commission is, in fact, prepared to reinstate MVP's accreditation, Mr. Gomez's credibly articulated belief nevertheless persuades the undersigned to find that the possibility of such reinstatement exists, should a clear path to MVP's licensure emerge. The posture of this case is such that the question at hand is not whether MVP's application should be denied for failure to maintain accreditation, as the Agency urges; the question is whether MVP's application should be withdrawn from further consideration as incomplete. The answer to that question is clearly no because, as will be seen, the law prohibits an agency from denying an application for licensure for failure to correct an error or omission or to supply additional information unless the agency notified the applicant of the error, omission, or need for additional information within 30 days after receiving the application. In this case, the Agency did not notify MVP that there was any issue regarding MVP's accreditation until long after this statutory deadline had passed. Indeed, MVP was still accredited 30 days after submitting its application, and the company remained accredited for more than three months after that. It is determined as a matter of ultimate fact that, with regard to Item #2 in the Withdrawal Notice, MVP's application was complete as of June 11, 2009. The upshot of the foregoing findings of fact is that, as a matter of ultimate fact, AHCA had received from MVP a completed application for licensure as a home health agency no later than July 24, 2009.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order which, first, acknowledges that MVP's application for licensure as a home health agency is considered approved by the terms of Section 120.60(1), Florida Statutes; and, second, directs the Agency Clerk to issue MVP a conditional license, which shall be subject to MVP's (a) providing satisfactory proof of accreditation upon such reasonable conditions as the Agency may prescribe, and (b) meeting such additional reasonable conditions, if any, as AHCA is authorized by law to impose. DONE AND ENTERED this 22nd day of April, 2010, in Tallahassee, Leon County, Florida. JOHN G. VAN LANINGHAM 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 22nd day of April, 2010.
