The Issue The issue for consideration in this case is whether Petitioner should be granted an exemption from disqualification from working with residents or patients of nursing homes, home health agencies, homemaker-companion-sitter services, or nursing registries, because of the matters set out in the Agency’s letter of denial dated June 29, 1998.
Conclusions Having reviewed the administrative complaint dated March 5, 2009, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration ("Agency") has entered into a Settlement Agreement (Ex. 2) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows: ORDERED: The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. Respondent shall pay an administrative fine in the amount of $5,000.00. The administrative fine is due and payable within thirty (30) days of the date of rendition of this Order. Filed June 30, 2009 2:08 PM Division of Administrative Hearings. Checks should be made payable to the "Agency for Health Care Administration." The check, along with a reference to this case number, should be sent directly to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, MS# 14 Tallahassee, Florida 32308 Unpaid amounts pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available. Respondent's petition for formal administrative proceedings is hereby dismissed. Each party shall bear its own costs and attorney's fees. The above-styled case is hereby closed. DONE and ORDERED this &day of- ------= - --, 2rx:;[j, in Tallahassee, Leon County, Florida. , Secretary ealth Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Jeffrey G. Schneider, Esq. Attorney for Respondent Hogan & Harston LLP 875 Third Avenue . New York, NY 10022 (U. S. Mail) Finance & Accounting Agency for Health Care Administration Revenue Management Unit 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Interoffice Mail) Jan Mills Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS #3 Tallahassee, Florida 32308 (Interoffice Mail) Nelson E. Rodney Assistant General Counsel Agency for Health Care Administration 8350 NW 52nd Terrace, Suite 103 Miami, Florida 33166 (Interoffice Mail) Hon. John C. Van Laningham Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Home Care Unit Agency for Health Care Administration 2727 Mahan Drive, MS #34 Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the y of =: Je-,1'\Q_..- , 20&. Richard Shoop, Cler Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA
The Issue Whether the Respondent's rejection of the Petitioner's Application for Licensure dated August 8, 1986, was proper?
Findings Of Fact The Petitioner was issued a license dated July 1, 1985 (hereinafter referred to as the "License"), to operate a home health agency in Franklin County, Florida. On the face of the License it was indicated that the "Expiration Date" of the License was June 30, 1986. By letter dated April 2, 1986, the Respondent notified the Petitioner that its License would expire on June 30, 1986. The Petitioner was also informed that if an application for renewal of the License was not filed on or before May 2, 1986, the Petitioner would be subject to an administrative fine. An application to be used to renew the License was also sent with the letter. In April or May of 1986, the Petitioner filed for Chapter 11 bankruptcy. On May 8, 1986, the United States District Court for the Northern District of Florida, Tallahassee Division, entered an order pursuant to 11 U.S.C. s. 362, which, among other things, stayed the commencement or continuation of any legal proceedings against the Petitioner. The Petitioner began discussions with Charles Hecht, Jim Palmer and a group called the Well Springs group about the possibility of selling the Petitioner. The Well Springs group was represented by John Branch and Ann Morgan. On June 16, 1986, Marilyn Nevado of the Respondent's Jacksonville Office of Licensure and Certification called the Petitioner's office. Ms. Nevado talked with Denise Putnal, the secretary and bookkeeper of the Petitioner. Ms. Nevado called to remind the Petitioner that its License was going to expire on June 30, 1986, and to ask why no application to renew the License had been filed. Ms. Putnal explained to Ms. Nevado that the Petitioner was involved in a bankruptcy proceeding. Virginia Schorger, the Administrator of the Petitioner, asked Ms. Putnal to call the Respondent on June 16, 1987, and find out what the Petitioner should do about its License. Ms. Putnal called the Respondent's Jacksonville office. She spoke with a woman, whose name she could not recall, and was told by the woman that she would have someone who could answer Ms. Putnal's questions call Ms. Putnal. Later that day, Arthur Harberts called the Petitioner and spoke with Ms. Putnal. According to a memorandum from Mrs. Putnal dated July 23, 1986, Ms. Putnal told Mr. Harberts the following: I explained in detail to the man that our agency had filed bankruptcy and was in the process of being sold to either of two bidders with this decision being made by the Federal Bankruptcy Court. Mr. Harberts told Ms. Putnal the following: He told me that FCVNA [the Petitioner] should not renew the license in that name. He said to have the agency write a letter to Mr. John Adams' office detailing all of what I had explained to him via telephone. With this letter he requested the agency send a copy of our current license. He also explained that the new owner would have to obtain a license in the new agency name. . . . Mr. Harberts had been told that the sale of the Petitioner was to take place before June 30, 1986. Ms. Putnal reported her conversation with Mr. Harberts to Ms. Schorger and made a copy of the License. The Petitioner did not send a letter with a copy of the License to the Respondent as suggested by Mr. Harberts. As of July 1, 1986, no application to renew the License was filed by the Petitioner. On June 30, 1986, the Petitioner's License expired by operation of law. On July 17, 1986, a sale of the Petitioner to the Well Springs group was approved by the bankruptcy court. On July 23, 1986, Ms. Schorger was informed by Ms. Morgan that she had been told that the License had expired. Upon learning that the License had expired, Ms. Schorger sent a letter dated July 23, 1986 to Amy Jones, Director of the Office of Licensure and Certification of the Respondent. In part, Ms. Schorger indicated the following in her letter: Early in June our Secretary/Bookkeeper called your office to inform you of our bankruptcy with reorganization plans and to ask about renewing the license. She was told that as soon as the court decided who the new owner would be to send a copy of the present license and the name of the new owner. Ms. Schorger also had Ms. Putnal write a memorandum memorializing her telephone conversation of June 16, 1986, with Mr. Harberts. Ms. Putnal completed the memorandum on July 23, 1986. A copy of this memorandum was sent with the July 23, 1986 letter. A check for $500.00 was also included with the July 23, 1986, letter. After July 23, 1986, Ms. Schorger had several telephone conversations with Ms. Jones. In a letter dated August 5, 1986, Ms. Jones recommended that the "new owner" of the Petitioner apply for a new license as an "uncertified" home health agency. This action was suggested so that the Petitioner could continue to operate. Ms. Jones told the Petitioner that the Petitioner would not, however, be entitled to bill Medicaid/Medicare and, therefore, it was also recommended that the new owner apply for a certificate of need. Once the certificate of need was approved, it was recommended that an application be filed for a license as a "certified" home health agency. In the interim, Ms. Jones recommended that the Petitioner contact other certified home health agencies "in an effort to see if you can solicit their assistance in serving the Medicaid/Medicare clients in your area." On or about August 8, 1986, Ms. Schorger filed an Application for Licensure as a home health agency. Under Section I.D. of the application Ms. Schorger indicated that the application was for a license as a "certified agency" and not a "non-certified agency" as Mr. Jones had suggested. The check for $500.00 previously sent to the Respondent on July 23, 1986 and subsequently returned to the Petitioner was also included with the application. By letter dated September 2, 1966, the Respondent informed the Petitioner that the Application for Licensure submitted on August 8, 1986, for a license as a certified agency was denied. The Petitioner was aware that its License would expire on June 30, 1986. The evidence failed to prove that the Petitioner was told that the expiration date of the Petitioner's License would be extended or waived, that failure to file an application for renewal of the License would be excused or that the date for filing an application for renewal would be extended. The Petitioner did not hold a certificate of need for a home health agency at the time its Application for Licensure was filed on August 8, 1986.
The Issue The issues for determination are: (1) whether the noncompliance as alleged during the August 30, 2001, survey and identified as Tags F324 and F242, were Class II deficiencies; (2) whether the "Conditional" licensure status, effective August 30, 2001, to September 30, 2001, based upon noncompliance is appropriate; and (3) whether a fine in the amount of $5,000 is appropriate for the cited noncompliance
Findings Of Fact Charlotte is a nursing home located at 5405 Babcock Street, Northeast, Fort Myers, Florida, with 180 residents and is duly licensed under Chapter 400, Part II, Florida Statutes. AHCA is the state agency responsible for evaluating nursing homes in Florida pursuant to Section 400.23(7), Florida Statutes. As such, in the instant case it is required to evaluate nursing homes in Florida in accordance with Section 400.23(8), Florida Statutes (2000). AHCA evaluates all Florida nursing homes at least every 15 months and assigns a rating of standard or conditional to each licensee. In addition to its regulatory duties under Florida law, AHCA is the state "survey agency," which, on behalf of the federal government, monitors nursing homes that receive Medicaid or Medicare funds. On August 27 through 30, 2001, AHCA conducted an annual survey of Charlotte's facility and alleged that there were deficiencies. These deficiencies were organized and described in a survey report by "Tags," numbered Tag F242 and Tag F324. The results of the survey were noted on an AHCA form entitled "Statement of Deficiencies and Plan of Correction." The parties refer to this form as the HCFA 2567-L or the "2567." The 2567 is the document used to charge nursing homes with deficiencies that violate applicable law. The 2567 identified each alleged deficiency by reference to a Tag number. Each Tag on the 2567 includes a narrative description of the allegations against Charlotte and cites a provision of the relevant rule or rules in the Florida Administrative Code violated by the alleged deficiency. To protect the privacy of nursing home residents, the 2567 and this Recommended Order refer to each resident by a number (i.e., Resident 24) rather than by the name of the resident. AHCA must assign a class rating of I, II or III to any deficiency that it identifies during a survey. The ratings reflect the severity of the identified deficiency, with Class I being the most severe and Class III being the least severe deficiency. There are two Tags, F242 and F324 at issue in the instant case, and, as a result of the August 2001 survey, AHCA assigned each Tag a Class II deficiency rating and issued Charlotte a "Conditional" license effective August 30, 2001. Tag F242 Tag F242 generally alleged that Charlotte failed to meet certain quality of life requirements for the residents, based on record review, group interviews, and staff interviews, and that Charlotte failed to adequately ensure that the residents have a right to choose activities that allow them to interact with members of the community outside the facility. On or about August 24, 2001, AHCA's surveyors conducted group interviews. During these interviews, 10 of 16 residents in attendance disclosed that they had previously been permitted to participate in various activities and interact with members of the community outside the facility. They were permitted to go shopping at malls, go to the movies, and go to restaurants. Amtrans transportation vans were used to transport the residents to and from their destinations. The cost of transportation was paid by Charlotte. An average of 17 to 20 residents participated in those weekly trips to dine out with other community members at the Olive Garden and other restaurants. During those trips, Charlotte would send one activity staff member for every four to six residents. The record contains no evidence that staff nurses accompanied those select few residents on their weekly outings. The outings were enjoyed by those participants; however, not every resident desired or was able to participate in this particular activity. Since 1985, outside-the-facility activities had been the facility's written policy. However, in August 2000, one year prior to the survey, Matthew Logue became Administrator of the facility and directed his newly appointed Activities Director, Debbie Francis, to discontinue facility sponsored activities outside the facility and in its stead to institute alternative activities which are all on-site functions. Those residents who requested continuation of the opportunity to go shopping at the mall or dine out with members of the community were denied their request and given the option to have food from a restaurant brought to the facility and served in-house. The alternative provided by the facility to those residents desiring to "interact with members of the community outside the facility" was for each resident to contact the social worker, activity staff member, friends or family who would agree to take them off the facility's premises. Otherwise, the facility would assist each resident to contact Dial-A-Ride, a transportation service, for their transportation. The facility's alternative resulted in a discontinuation of all its involvement in "scheduling group activities" beyond facility premises and a discontinuation of any "facility staff members" accompanying residents on any outing beyond the facility's premises. As described by its Activities Director, Charlotte's current activities policy is designed to provide for residents' "interaction with the community members outside the facility," by having facility chosen and facility scheduled activities such as: Hospice, yard sales, barbershop groups for men and beautician's day for women, musical entertainment, antique car shows, and Brownie and Girl Guides visits. These, and other similar activities, are conducted by "community residents" who are brought onto the facility premises. According to the Activities Director, Charlotte's outside activities with transportation provided by Amtrans buses were discontinued in October of 2000 because "two to three residents had been hurt while on the out trip, or on out-trips."1 Mr. Logue's stated reason for discontinuing outside activities was, "I no longer wanted to take every member of the activities department and send them with the resident group on an outing, thereby leaving the facility understaffed with activities department employees." The evidence of record does not support Mr. Logue's assumption that "every member of the facility's activities department accompanied the residents on any weekly group outings," as argued by Charlotte in its Proposed Recommended Order. Charlotte's Administrator further disclosed that financial savings for the facility was among the factors he considered when he instructed discontinuation of trips outside the facility. "The facility does not sponsor field trips and use facility money to take people outside and too many staff members were required to facilitate the outings." During a group meeting conducted by the Survey team, residents voiced their feelings and opinions about Charlotte's no longer sponsoring the field trips on a regular basis in terms of: "feels like you're in jail," "you look forward to going out," and being "hemmed in." AHCA's survey team determined, based upon the harm noted in the Federal noncompliance, that the noncompliance should be a State deficiency because the collective harm compromised resident's ability to reach or maintain their highest level of psychosocial well being, i.e. how the residents feel about themselves and their social relationships with members of the community. Charlotte's change in its activities policy in October of 2000 failed to afford each resident "self- determination and participation" and does not afford the residents the "right to choose activities and schedules" nor to "interact with members of the community outside the facility." AHCA has proved the allegations contained in Tag F242, that Charlotte failed to meet certain quality of life requirements for the residents' self-determination and participation. By the testimonies of witnesses for AHCA and Charlotte and the documentary evidence admitted, AHCA has proven by clear and convincing evidence that Charlotte denied residents the right to choose activities and schedules consistent with their interests and has failed to permit residents to interact with members of the community outside the facility. Tag F324 As to the Federal compliance requirements, AHCA alleged that Charlotte was not in compliance with certain of those requirements regarding Tag F324, for failing to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. As to State licensure requirements of Sections 400.23(7) and (8), Florida Statutes (2000), and by operation of Florida Administrative Code, Rule 59A-4.1288, AHCA determined that Charlotte had failed to comply with State established rules, and under the Florida classification system, classified Tag F324 noncompliance as a Class II deficiency. Based upon Charlotte's patient record reviews and staff interviews, AHCA concluded that Charlotte had failed to adequately assess, develop and implement a plan of care to prevent Resident 24 from repeated falls and injuries. Resident 24 was admitted to Charlotte on April 10, 2001, at age 93, and died August 6, 2001, before AHCA's survey. He had a history of falls while living with his son before his admission. Resident 24's initial diagnoses upon admission included, among other findings, Coronary Artery Disease and generalized weakness, senile dementia, and contusion of the right hip. On April 11, 2001, Charlotte staff had Resident 24 evaluated by its occupational therapist. The evaluation included a basic standing assessment and a lower body assessment. Resident 24, at that time, was in a wheelchair due to his pre-admission right hip contusion injury. On April 12, 2001, two days after his admission, Resident 24 was found by staff on the floor, the result of an unobserved fall, and thus, no details of the fall are available. On April 23, 2001, Resident 24 was transferred to the "secured unit" of the facility. The Survey Team's review of Resident 24's Minimum Data Set, completed April 23, 2001, revealed that Resident 24 required limited assistance to transfer and to ambulate and its review of Resident 24's Resident Assessment Protocols (RAPs), completed on April 23, 2001, revealed that Resident 24 was "triggered" for falls. Charlotte's RAP stated that his risk for falls was primarily due to: (1) a history of falls within the past 30 days prior to his admission; (2) his unsteady gait; (3) his highly impaired vision; and (4) his senile dementia. On April 26, 2001, Charlotte developed a care plan for Resident 24 with the stated goal that the "[r]esident will have no falls with significant injury thru [sic] July 25, 2001," and identified those approaches Charlotte would take to ensure that Resident 24 would not continue falling. Resident 24's care plan included: (1) place a call light within his reach; (2) do a falls risk assessment; (3) monitor for hazards such as clutter and furniture in his path; (4) use of a "Merry Walker" for independent ambulation; (5) placing personal items within easy reach; (6) assistance with all transfers; and (7) give Resident 24 short and simple instructions. Charlotte's approach to achieving its goal was to use tab monitors at all times, to monitor him for unsafe behavior, to obtain physical and occupational therapy for strengthening, and to keep his room free from clutter. All factors considered, Charlotte's care plan was reasonable and comprehensive and contained those standard fall prevention measures normally employed for residents who have a history of falling. However, Resident 24's medical history and his repeated episodes of falling imposed upon Charlotte a requirement to document his records and to offer other assistance or assistive devices in an attempt to prevent future falls by this 93-year-old, senile resident who was known to be "triggered" for falls. Charlotte's care plan for Resident 24, considering the knowledge and experience they had with Resident 24's several falling episodes, failed to meet its stated goal. Charlotte's documentation revealed that Resident 24 did not use the call light provided to him, and he frequently refused to use the "Merry Walker" in his attempts of unaided ambulation. On June 28, 2001, his physician, Dr. Janick, ordered discontinuation of the "Merry Walker" due to his refusal to use it and the cost involved. A mobility monitor was ordered by his physician to assist in monitoring his movements. Charlotte's documentation did not indicate whether the monitor was actually placed on Resident 24 at any time or whether it had been discontinued. Notwithstanding Resident 24's refusal to cooperatively participate in his care plan activities, Charlotte conducted separate fall risk assessments after each of the three falls, which occurred on April 12, May 12, and June 17, 2001. In each of the three risk assessments conducted by Charlotte, Resident 24 scored above 17, which placed him in a Level II, high risk for falls category. After AHCA's surveyors reviewed the risk assessment form instruction requiring Charlotte to "[d]etermine risk category and initiate the appropriate care plan immediately," and considered that Resident 24's clinical record contained no notations that his initial care plan of April 23, 2001, had been revised, AHCA concluded that Charlotte was deficient. On May 13, 2001, Dr. Janick visited with Resident 24 and determined that "there was no reason for staff to change their approach to the care of Resident 24." Notwithstanding the motion monitors, on June 17, 2001, Resident 24 fell while walking unaided down a corridor. A staff member observed this incident and reported that while Resident 24 was walking (unaided by staff) he simply tripped over his own feet, fell and broke his hip. Charlotte should have provided "other assistance devices," or "one-on-one supervision," or "other (nonspecific) aids to prevent further falls," for a 93-year-old resident who had a residential history of falls and suffered with senile dementia. Charlotte did not document other assistive alternatives that could have been utilized for a person in the condition of Resident 24. AHCA has carried its burden of proof by clear and convincing evidence regarding the allegations contained in Tag F324.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that: The Agency enter a final order upholding the assignment of the Conditional licensure status for the period of August 30, 2001 through September 30, 2001, and impose an administrative fine in the amount of $2,500 for each of the two Class II deficiencies for a total administrative fine in the amount of $5,000. DONE AND ENTERED this 13th day of February, 2003, in Tallahassee, Leon County, Florida. 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 13th day of February, 2003.
