Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following facts are found: During the night shift on March 28, 1983, respondent had only one licensed nurse on duty. Two licensed nurses were required by the petitioner's rules governing nursing home facilities. These facts were admitted by the respondent's Administrator. On or about 4:30 A.M. on April 7, 1983, a male intruder entered the respondent's facility and sexually assaulted two female residents. The respondent's facility was inspected on April 8, 1983. It was discovered that an alarm on an exit door adjacent to the rooms of the victims was not functioning properly. The alarm is designed to visually and audibly alert persons at the nursing station. On April 8th, the alarm would not sound at the nurses station. As soon as the respondent became aware of the defective alarm, it was replaced temporarily by a local alarm, and then was repaired to function as designed. A door closer on another exit door was found to be defective in that the door would not latch properly. Respondent immediately adjusted this door to work properly upon notice of the defect.
Recommendation Based upon the findings of fact and conclusions of law recited herein, it is RECOMMENDED: That respondent be found guilty of violating Rules 10D-29.108(4) and 10D- 29.122, Florida Administrative Code, and that an administrative fine in the total amount of $375.00 be imposed against the respondent. Respectfully submitted and entered this 22nd day of September, 1983, in Tallahassee, Florida. DIANE D. TREMOR Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of September, 1983. COPIES FURNISHED: Amelia Park District VI Legal Counsel Department of Health and Rehabilitative Services 4000 West Buffalo Avenue Tampa, Florida 33614 Mr. Albert Shepard Administrator The Ambrosia Home 1709 Taliaferro Avenue Tampa, Florida 33602 Jay Kassack, Director Department of Health and Rehabilitative Services Office of Licensure and Certification Post Office Box 210 Jacksonville, Florida 32231 David Pingree, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32301
Findings Of Fact At all times material hereto, Plantation was a licensed nursing home facility and participated in the Medicaid program. A nursing home that receives a superior rating is entitled to incentives based on the Florida Medicaid Reimbursement Plan. Plantation has met all the requirements for a superior rating that are enumerated in Rule lOD-29.128, Florida _Administrative Code. The only reason Plantation was not granted a superior rating was based on the Medicaid Inspection of Care, Team report. (stipulated facts) From August 21 through August 31, 1984, Plantation underwent a routine inspection by the HRS Medicaid Inspection of Care (IOC) Team. The purpose of the inspection was to review the care and treatment of Medicaid recipient patients in accordance with state and federal standards in order for the facility to receive Medicaid payment for those individuals. During the course of the inspection, several deficiencies were found by IOC Team. The deficiencies were summarized in the Medicaid Inspection of Care Team report, entitled Facility Evaluation Summary, prepared by Ms. Tranger. The report listed the deficiencies as follows: Fifteen skilled and two intermediate out of 46 medical records reviewed failed to have medication revalidated by the attending physician within the proper time frame Four of forty-six records reviewed failed to have available documentation that laboratory tests were completed in accordance with doctors' orders and medication regimen, Fourteen skilled and thirteen intermediate out of 46 medical records reviewed failed to have the Plan of Care reviewed within the proper time frame: Ten medical records were not certified within the proper time frames and fifteen medical records were not current for recertification. As to the first deficiency noted, the problem was not that the physician failed to revalidate medication, but that Ms. Tranger did not think that the physician appropriately dated the revalidation. In almost all of the cases, the problem was that Ms. Tranger did not think that the physician had personally entered the date because the date was written with a different color of ink than the doctor's signature or the handwriting appeared to be different. Ms. Tranger did not know whether the dates were written by someone in the physician's office or someone at the nursing home. It is very difficult for a nursing home to get a physician to sign and date orders properly. Plantation had a procedure for securing the doctor's signature and having records dated. When a record was received that was not properly signed and dated, Plantation returned the record to the doctor with a letter or note telling the doctor what needed to be done. When returned by the doctor to Plantation, the record would bear the later date, which caused some records to be out of' compliance with the required time frames. The return to the doctor of records that were not properly dated may also explain why some of he dates were written in a different color ink than the doctor's signature. In those few cases where the dates on the report were not within the proper time frame, the dates were only a few days off. In one case a 34 day period, from July 7, 1984 to August 10, 1984, elapsed before the medication was revalidated. In another case, there were 33 days between the dates. In both cases the medication should have been revalidated every 30 days. The problem with the revalidation dates was strictly a paperwork problem and not one that affected the care of the patients. As stated before, in the majority of the cases the medication was revalidated within the proper time frame. The problem was simply that it appeared that someone other than the doctor had written down the date. The second deficiency was a finding by the surveyors that 4 of the 46 medical records reviewed failed to have available documentation regarding laboratory tests being completed in accordance with doctors' orders. However, Jean Bosang, Administrator of Plantation, reviewed all of the records cited by the IOC Team as the basis for these deficiencies and could only find two instances in which laboratory tests were not performed. HRS did not present any evidence to establish the two other alleged instances. Dr. Lopez reviewed the medical records of the two residents in question and determined that there was no possibility of harm to the patient as a result of failure to perform these tests. One of the two residents is Dr. Lopez' patient, and he normally sees her every day. He stated that the test, an electrolyte examination, was a routine test, that the patient had had no previous problems, and if any problem had developed, she would have had symptoms which would have been observable to the nurses. The tests performed before and after the test that was missed were normal, and the failure to perform the one test had absolutely no effect on the patient. Dr. Lopez was familiar with the other resident upon whom a test was not performed and had reviewed her records. This resident was to have a fasting blood sugar test performed every third month. Although this test was not performed in April of 1984, it was performed timely in every other instance. All tests were normal, and the failure to perform this test did not have any effect on the resident. Had she been suffering from blood sugar problems, there would have been physical signs observable to the nurses. The fourth deficiency listed in the report was a paperwork problem similar to the first deficiency. Patients in a nursing home are classified by level of care and must be recertified from time to time. Certification does not affect the care of the resident. The recertification must be signed and dated by the physician. Again, there was a problem on the recertification because some of the dates were in a different color ink than the physician's signature. Again, the problem was primarily caused by difficulty in getting proper physician documentation. The deficiency did not affect the care of the residents. Mr. Maryanski, who made the decision not to give Plantation a superior rating, testified that of the four deficiencies cited in the IOC report, he believed that only the third deficiency listed, in and of itself, would have precluded a superior rating. An analysis of that deficiency, however, shows that it also was mainly a paperwork deficiency and had no impact on patient care. The third deficiency listed involved a purported failure to have the plans of care reviewed within the proper time frames. Patient care plans are to be reviewed every 60 days for "skilled" patients, those that need the most supervision, and every 90 days for "intermediate" patients, those that need less supervision. A patient's plan of care is a written plan establishing the manner in which each patient will be treated and setting forth certain goals to be reached. A discharge plan is also established, which is basically what the nursing home personnel believe will be the best outcome for the patient if and when he or she leaves the hospital. The patient plan of care is established at a patient care plan meeting. Patient care plan meetings are held by the various disciplines in the nursing home, such as nursing, dietary, social work and activities, to review resident records and discuss any problems with specific residents. The manner in which the problem is to be corrected is determined and then written down on the patient's plan of care record. The evidence revealed that the basis of the deficiency was not a failure to timely establish or review a plan of care, but a failure to timely write down and properly date the plan of care. During the time in question, care plan meetings were held every Wednesday, and all of the disciplines attended the meetings. However, all disciplines did not write their comments on the patients' records at the meeting; some wrote them later. Usually, when they were added later, the comments were dated on the day they were written, rather than on the day the meetings were held. The evidence presented did not show any case in which all disciplines were late in making notes, but revealed only that specific disciplines were tardy. Since all the disciplines attended one meeting, it is apparent that when the date for any discipline was timely, the later dates of other disciplines merely reflected a documentation or paperwork problem. In late 1984 or early 1985, Plantation changed its system to avoid the problem in the future. There appeared to be problems with some of the discharge plans being untimely. The discharge plan is not utilized in the day-to-day care of the resident. Discharge plans at Plantation were kept in two places, and Ms. Tranger recognized that she may have overlooked some plans if they had been written only on the separate discharge sheet. The four deficiencies cited all involved time frames. There are innumerable time frames that must be met by a nursing home. The great majority of the deficiencies involved a failure to properly document. None of the deficiencies affected the care of the patients. Indeed, Ms. Tranger indicated that the patients were all receiving proper nursing care. The decision to give Plantation a standard rating was made by Mr. Maryanski based solely on the IOC report. He relied upon section 400.23,(3) Florida Statutes, which states: "The department shall base its evaluation on the most recent annual inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations and inspections." There are no regulations or written or oral policies implementing this provision. Mr. Maryanski looked solely at the face of the IOC report and did not do any independent investigation. He never visited the nursing home, and he never talked to the on-site surveyors to determine whether the deficiencies cited by the IOC Team were significant. He never saw the underlying documentation which formed the basis of the report. Mr. Maryanski has no background either in nursing or medicine and had no knowledge of purpose the tests that were allegedly not performed. On October 4, 1984, the HRS Office of Licensure and Certification (OLC) conducted the annual survey of the facility. Mr. Maryanski did not determine whether the deficiencies found by the IOC Team had been corrected at the time of the annual survey. An IOC Team surveyor returned on November 21, 1984, and found that all of the deficiencies cited during the IOC inspection had been corrected. A resurvey of the facility was conducted on December 27, 1984, by OLC. All deficiencies noted in OLC's original inspection had been corrected. All nursing home facilities in Florida are rated by HRS as conditional, standard, or superior. In addition to its financial significance, the rating of a facility is important because it affects the facility's reputation in the community and in the industry. The rating for a facility goes into effect on· the day of the follow-up visit of OLC if all deficiencies have been corrected. Therefore, Plantation would have received a superior rating, effective December 27, 1984, had it not been for the IOC report Mr. Maryanski never tried to determine whether the deficiencies in the IOC report had been corrected subsequent to the report being issued. Under rule lOD-29.128, Florida Administrative Code, there are extensive regulatory and statutory requirements which must be met for a facility to be granted a superior rating. Plantation met all of the enumerated requirements, yet it received only a standard rating. Mr. Maryanski based his determination on the IOC report despite the fact that it was outdated and the deficiencies in that report were corrected by November, 1984, prior to the December, 1984, resurvey by the OLC. There was nothing in the annual survey report of the OLC to preclude a superior rating. This is the first time a facility has been denied a superior rating based upon a report other than the annual report.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Plantation Nursing Home be given a superior rating. DONE AND ENTERED this 3rd day of March, 1986, in Tallahassee, Leon County, Florida. DIANE A. GRUBBS, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 3rd day of March, 1986. COPIES FURNISHED: Jonathan S. Grout, Esquire Post Office Box 1980 Orlando, Florida 32802 Harold Braynon; Esquire District X Legal Counsel, 201 West Broward Boulevard Ft. Lauderdale, Florida 33301 William Page, Jr. Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32301 APPENDIX The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case. Rulings On Proposed Findings of Fact Submitted by the Petitioner Accepted in Finding of Fact 1. 2-3. Accepted in Finding of Fact 2. 4. Accepted as set forth in Finding of Fact 21. 5-6. Accepted in Findings of Fact 22-23. 7-9. Accepted in Finding of Fact 24. 10. Rejected as immaterial. 11-12. Accepted in Findings of Fact 24-25. Accepted in Finding of Fact 19. Accepted in Finding of Fact 26. 15-16. Accepted generally in Findings of Fact 20 and 24. 17-19. Accepted generally as set forth in Finding of Fact 26. In Background section. Cumulative. Accepted in Finding of Fact 18. Accepted in Finding of Fact 12. 25-31. Accepted in substance in Findings of Fact 4-7. 32-43. Accepted in substance in Findings of Fact 8-10. 44. Rejected as not supported by the evidence. 45-46. Accepted in Finding of Fact 11. 47. Accepted in Finding of Fact 3. 48-49. Accepted in Finding of Fact 3. 50-57. Accepted in general in Findings of Fact 13-16. 58. Accepted in Finding of Fact 17. Rulings On Proposed Findings of Fact Submitted by the Respondent Accepted in Finding of Fact 1. Accepted generally in Findings of Fact 1, 20, 24. Accepted in Finding of Fact 1. Accepted generally in Finding of Fact 19 and Background. 5-8. Accepted in Finding of Fact 3. Accepted in substance in Finding of Fact 2. Accepted in Finding of Fact 2. Accepted in Finding of Fact 3. Accepted in Finding of Fact 13 except as to time frame for intermediate patients which should be 90 days. Accepted that the documentation showed a gap, but proposed finding rejected in that the evidence did not show that, in fact, the patient was not reviewed with the proper time frame. Accepted, without naming the patients, and explained in Finding of Fact 6.
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.
Findings Of Fact Respondent is licensed by Petitioner and was so licensed at all times here relevant. On 6-7 August 1979 Petitioner conducted a survey (inspection) of Respondent's facility and upon completion submitted HRS Form 553D (Exhibit 1). This report of inspection listed no Class I deficiency, one Class II deficiency and 19 class III deficiencies. The Class II deficiency noted was that medications are being administered not in accordance with physician's orders. On Exhibits 1 and 2, five examples of this Class II deficiency are listed where specific drugs or other medications were not recorded, not administered in accordance with physician's orders. Or in which the incorrect dosage was administered and/or recorded as having been given. At a follow-up inspection on or about September 27, 1979, the results of which are memorialized in HRS For 553E (Exhibit2), the Class II deficiency is noted as corrected. By letter dated December 17, 1979 Petitioner notified Respondent that despite Respondent's representations made at an informal conference on 6 December 1979 the "C" rating would stand and advised Respondent of his right to appeal by requesting an administrative hearing within 30 days. Such a request was duly made which let to the instant proceedings.
Recommendation DONE AND ORDERED in Tallahassee, Leon County, Florida, this 19th day of June 1980. K. N. AYERS Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 19th day of June, 1980. COPIES FURNISHED: Leonard Helfand, Esquire District XI Legal Counsel, HRS 401 N.W. 2nd Avenue, Room 1040 Miami, Florida 33128 Barry D. Schrieber, Esquire Suite 301, County National Bank Building 801 Northeast 167th Street North Miami Beach, Florida 33162
The Issue The issue in this case is whether Respondent committed the allegations in the notice of intent to assign a conditional license and, if so, whether Petitioner should have changed the rating of Respondent's license from standard to conditional for the period June 14 through August 10, 2001.
Findings Of Fact Petitioner is the state agency responsible for licensing and regulating nursing homes inside the state. Respondent operates a licensed nursing home at 1120 West Donegan Avenue, Kissimmee, Florida (the "facility"). Petitioner conducted an annual survey of the facility from May 7, through May 10, 2001 (the "May survey"). Petitioner conducted a follow-up survey of the facility on June 14, 2001 (the "June survey"). The May survey cites one Class III violation. The June survey cites a repeat deficiency of a Class III violation. Subsection 400.23(8)(b) and (c), Florida Statutes (2000), refers to deficiency classifications as Class I-III deficiencies. All statutory references are to Florida Statutes (2000) unless otherwise stated. Section 400.23(8)(c) defines Class III deficiencies as those deficiencies . . . which the agency determines to have an indirect or potential relationship to the health, safety, or security of the nursing home facility residents, other than class I or class II deficiencies. The statutory definitions of Class I and II deficiencies are not relevant to this case because this case involves only a Class III deficiency. Florida Administrative Code Rule Rule 59A-4.1288 requires nursing home facilities licensed by the State of Florida to adhere to federal regulations in Section 483 of the Code of Federal Regulations ("CFR"). All references to rules are to rules promulgated in the Florida Administrative Code on the date of this Recommended Order. In relevant part, Rule 59A- 4.1288 provides: Nursing homes that participate in Title XVIII or XIX must follow certification rules and regulations found in 42 CFR 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. Applicable federal regulations require Petitioner to assign a scope and severity rating to the deficiencies alleged by Petitioner. Petitioner assigned a "D" rating to the deficiencies alleged in the May and June surveys. A “D” rating means that there is no actual harm with potential for more than minimal harm that is not actual jeopardy. When Petitioner alleges that the Class III deficiency from the May survey was not corrected within the time established by the agency, the agency may change the rating of the facility license from standard to conditional. Petitioner determined in the June survey that the facility had not corrected the deficiency alleged in the May survey. Effective June 14, 2001, Petitioner changed the rating of the facility's license from standard to conditional. Petitioner noted the results of the May and June surveys on a Health Care Federal Administration form entitled "Statement of Deficiencies and Plan of Correction." The parties refer to the 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 identifies each alleged deficiency by reference to a tag number (the "Tag"). Each tag on the 2567 includes a narrative description of the allegations against Respondent and cites a provision of relevant state rules violated by the alleged deficiency. There is only one tag at issue in the May and June surveys. It is Tag F282. In order to protect the privacy of nursing home residents, Tag F282, the 2567, and this Recommended Order refer to each resident by a number rather than by the name of the resident. Tag F282 alleges in the May and June survey that the facility failed to satisfy the requirements of 42 CFR Section 483.20(k)(ii). In relevant part, the federal regulation provides: Comprehensive Care Plans. (3). The services provided or arranged by the facility must— (ii) Be provided by qualified persons in accordance with each resident’s written "plan of care." This standard is made applicable to nursing homes in Florida pursuant to Rule 59A-4.1288. Tag F282 does not allege that the facility provided care to residents by unqualified persons. Rather, Tag F282 alleges that Respondent failed to follow the plan of care for two residents. Tag F282 alleges in the May survey that the facility failed to provide care and services in accordance with the plan of care for Residents 3 and 1. Tag F282 alleges in the June survey that Respondent failed to follow the plan of care for Resident 1. The resident identified as Resident 1 is not the same resident in the May and June surveys. Before proceeding to the merits of the allegations in Tag F282, two policy issues must be resolved in order to make findings of fact in a manner that is consistent with Petitioner's officially stated agency policy. One issue is procedural and the other involves the definition of terms. Petitioner promulgates an officially stated policy in written guidelines entitled the State Operations Manual (the "Manual"). The Manual states agency policy regarding the interpretation and application of the regulatory standards surveyors must enforce. The Manual authorizes surveyors to determine whether a facility has complied with Tag F282 only after surveyors have identified violations of standards relating to: quality of care, defined in 42 CFR Section 483.25(a)–(m); quality of life, defined 42 CFR Section 483.15(a)–(h); or residents rights, defined 42 CFR Section 483.10(a)–(o). The state agency's written policy set forth in the Manual requires its surveyors to identify an issue of quality of care, quality of life, or residents’ rights before proceeding to a determination of whether the facility has violated Tag F282. The second issue involves the interpretation of the terms "inadequate", "incorrect", and "consistent." The Manual indicates that violations occur if surveyors can demonstrate inadequate or incorrect implementation of the care plan. The Manual does not define the term “inadequate.” The common meaning of the term suggests that something less than perfect implementation satisfies the requirements of the regulatory standard. That construction is consistent with other provisions in the Manual. The Manual further provides that violations of standards occur only if a facility fails to “consistently” implement the plan of care for a resident. Petitioner's surveyors acknowledged in their testimony that the goal for the quality of care regulations is to achieve positive resident outcomes and is identical to the goal of Tag F282. Petitioner offered no credible reason, within the meaning of Section 120.68(7)(e)3, why the standard for implementation of a resident’s care plan under Tag F282 should be stricter than that required by the quality of care regulations. Resident 3 had many compromising conditions and was near death at the time of the May survey. Resident 3 had 10 to 12 care plans to address his various medical problems and conditions. Each care plan contained an average of 15 separate interventions. One of the care plans for Resident 3 addressed the risk of developing pressure sores and contained 20 separate interventions for staff to implement. One intervention required staff to turn and reposition the resident every two hours. On May 7, 2001, a surveyor stationed herself outside of Resident 3’s room from 1:00 p.m. to 4:00 p.m. in the afternoon to observe who entered the resident’s room and what care was given to the resident. During that time, the surveyor observed that no staff member entered the room to turn and reposition the resident. The care plan required staff to turn the resident once during the three-hour period. The allegations in Tag F282 pertaining to the failure to reposition Resident 3 during a three-hour period on May 7, 2001, deviate from Petitioner's written agency policy in two respects. First, Petitioner did not cite the facility for any violation relating to quality of care, quality of life, or resident rights. Second, a single isolated failure to implement one intervention prescribed in one of 12 care plans for Resident 3, during a three-hour period, on one of four days of a survey, does not demonstrate inadequate care by failing to consistently implement a care plan. Petitioner failed to explain by a preponderance of the evidence why it deviated from its official written policy in its determination that Respondent violated the standard prescribed in Tag F282. The surveyor provided no credible explanation to justify a deviation from agency policy with respect to Resident 3. Nor did Petitioner present any evidence that Resident 3 developed any pressure sores or had any pressure sores worsen as a result of the failure to turn and reposition the resident on May 7, 2001. The evidence shows that the failure to turn and reposition Resident 3 presented nothing more than a minimal chance of negative impact. Tag F282 alleged in the May survey that the facility failed to provide care for Resident 1 in accordance with the care plan. Resident 1 suffered from a condition that caused his chin to droop toward his chest. The condition caused positioning problems for the resident while he was in his wheelchair. The physical therapist for the facility examined Resident 1 and recommended periodic placement of a Futuro cervical collar while the resident was in his wheelchair in order to elevate the resident's chin. The recommendation required staff to place the collar on the resident when he was in his wheelchair for two hours and then to remove it for two hours. Staff was not to place the collar on the resident during meals or while the resident was in bed. The resident would sometimes remove the collar after it was placed on him. On May 8, 2001, Petitioner’s surveyor made five observations of the resident between 10:45 a.m. and 1:50 p.m. The surveyor did not see the resident wearing the collar during any of the observations. The observations of the surveyor were intermittent. The surveyor did not observe Resident 1 continuously from 10:45 a.m. until 1:50 p.m. The surveyor did not know if or when the collar should have been placed on the resident during the observations on May 8, 2001. It is uncontroverted that the resident would have eaten lunch for one hour during the time that the surveyor observed the resident and that the care plan did not require staff to place the collar on the resident during meals. Petitioner offered no evidence that the failure to put the collar on the resident during the observed instances presented potential for any harm to the resident. Petitioner failed to show by a preponderance of the evidence that the facility failed to implement Resident 1’s care plan. Even if it were determined that the facility failed to consistently implement the care plan or inadequately implemented the care plan, Tag F282 deviates from Petitioner's officially stated agency policy because the tag does not charge the facility with any violation of quality of care, quality of life, or resident rights. Petitioner failed to explain why it deviated from its policy. Finally, the observed circumstances presented no more than a minimal chance of minor negative impact to Resident 1. On May 9, 2001, Petitioner's surveyor observed Resident 1 on three different occasions between 10:00 a.m. and 11:05 a.m. without the collar. The surveyor did not know if or when the collar should have been placed on the resident during that time-period. The observations of the surveyor were intermittent. The surveyor did not observe Resident 1 continuously from 10:00 a.m. until 11:05 a.m. The preponderance of the evidence failed to sustain the charge that the facility did not implement Resident 1’s care plan on May 9, 2001. The observations are insufficient to demonstrate a consistent failure to implement the care plan. Petitioner provided no credible explanation for deviating from its officially stated agency policy. Finally, the circumstances presented no chance of any harm other than minimal negative impact to the resident. Tag F282 alleges in the June survey that the facility failed to follow doctor’s orders for Resident 1 that required multi-podus boots to be applied every shift. Resident 1 in the June survey is not the same resident identified as Resident 1 in the May survey. Resident 1 in the June survey had pressure sores on his feet, and one of the interventions prescribed in the care plan required Resident 1 to wear multi-podus boots. On June 13, 2001, at 2:45 p.m., Petitioner's surveyor observed Resident 1 lying in bed without the required multi- podus boots. Resident 1 was lying on a pressure-relieving mattress so that his heels were receiving pressure relief without the need for multi-podus boots. On June 14, 2001, Petitioner's surveyor observed Resident 1 in his wheelchair in the activities room with black, hard-soled shoes on his feet instead of the multi-podus boots. The resident had dressings on his heels that protected them and was sitting so that his heels bore no weight. The facility maintained medical records that described the size and appearance of the pressure sores on Resident 1's heels. The records indicated that the pressure sores healed progressively after Respondent admitted Resident 1 to the facility. The area on the right heel was completely healed by June, 2001, and the area on the left heel was closed by July 2001. Petitioner deviated from its officially stated policy in two respects. First, Petitioner did not charge the facility with any violation of a quality of care, quality of life, or residents rights. Second, the instances observed by the surveyor do not demonstrate a failure to consistently implement the plan of care or a failure to provide adequate care. Petitioner offered no credible explanation for deviating from its policy. The events observed by Petitioner's surveyor, at most, presented the potential for causing no more than a minor negative impact on the resident.
Recommendation Based on the forgoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration should enter a final order revising the May 10 and June 13, 2001, survey reports to delete the deficiency described under Tag F282, and replace the previously issued Conditional rating with a Standard rating. DONE AND ENTERED this 5th day of March, 2002, in Tallahassee, Leon County, Florida. DANIEL MANRY 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 5th day of March, 2002. COPIES FURNISHED: Dennis L. Godfrey, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Room 310L St. Petersburg, Florida 33701 R. Davis Thomas, Jr. Broad & Cassel 215 South Monroe Street, Suite 400 Post Office Box 11300 Tallahassee, Florida 32302-1300 Diane Grubbs, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308 William Roberts, Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
The Issue Whether Respondent committed deficient practices as alleged in violation of 42 C.F.R. Section 483.13(b) and 42 C.F.R. Section 483.13(c)(1)(ii), adopted by reference in Florida Administrative Code Rule 59A-4.1288; and if so, whether Petitioner should impose a civil penalty in the amount of $5,000 and issue a conditional license to Respondent.
Findings Of Fact Petitioner is the state agency charged with licensing and regulating nursing homes in Florida under state and federal statutes. Petitioner is charged with evaluating nursing homes facilities to determine their degree of compliance with established rules as a basis for making the required licensure assignment. Additionally, Petitioner is responsible for concluding federally-mandated surveys of those long-term care facilities receiving Medicare and Medicaid funds for compliance with federal statutory and rule requirements. These federal requirements are made applicable to Florida nursing home facilities. Pursuant to the statute, Petitioner must classify deficiencies according to the nature and scope of the deficiency when the criteria established under the statute are not met. The classification of any deficiencies discovered is determinative of whether the licensure status of a nursing home is "standard" or "conditional." Respondent is a 98-bed nursing home located at 1024 Willow Springs Drive, Winter Springs, Florida, and is licensed as a skilled nursing facility. On May 30, 2003, Petitioner's staff conducted an inspection, also known as a survey, at Respondent's facility. Upon completion of the survey, Petitioner issued a document entitled, Center for Medicare and Medicaid Services, CMS Form 2567L, also known as a "2567," which contains a statement of the alleged violations of regulatory requirements, also referred to as "deficiencies," titled "Statement of Deficiencies and Plan of Correction." The evaluation or survey of a facility includes a resident review and, depending upon the circumstances, may consist of a record, reviews, resident observations, and interviews with family and facility staff. Surveyors note their findings on the 2567 Form, and if violations of regulations are found, the violations are noted and referred to as "Tags." A tag identifies the applicable regulatory standard that the surveyors believe has been violated, provides a summary of the violation, sets forth specific factual allegations that they believe support the violation, and indicates the federal scope and severity of the noncompliance. Petitioner's surveyors use the "State Operations Manual," a document prepared by the United States Department of Health and Human Services, Center for Medicare and Medicaid Services, as guidance in determining whether a facility has violated 42 C.F.R. Chapter 483. Count I In Count I of the Administrative Complaint, Petitioner alleges that Respondent's staff subjected three residents (Resident Nos. 6, 13, and 18) to verbal and mental abuse in violation of 42 C.F.R. Section 483.13(b), which provides that a nursing home resident has the right to be free from verbal and mental abuse. As to Resident No. 6, Petitioner contends that this resident stated to a surveyor that the resident had "overheard" a certified nursing assistant (CNA) loudly tell another staff member that the resident was "going to the bathroom 25 times a day." Petitioner believes the CNA's statement, which was allegedly "overheard," occurred sometime during the month of March 2003, based upon nurses' notes which indicate Resident No. 6 had an episode of diarrhea during this time. However, the nurses notes also reveal that during this time Resident No. 6 was subject to confusion and nonsensical outbursts. Petitioner's belief that Resident No. 6 was a reliable historian is based on Petitioner's mistaken belief that Resident No. 6 was admitted about March 30, 2003, and was alert and oriented and not confused upon admission. Petitioner's staff exhibited a lack of understanding of the timing and significance of the Multiple Data Set (MDS) forms describing Resident No. 6's mental condition upon which they relied. In fact, Resident No. 6 was admitted in mid-February 2003 and exhibited confused and eccentric behavior. The "overheard" comment was not reported to Respondent until the survey. Therefore, the evidence that this incident occurred as described by Petitioner is unreliable hearsay. Surveyors reviewed Respondent's records, which contained a complaint from a family member of Resident No. 6 that the same CNA had noticed that the resident had a physical anomaly. The CNA called other CNAs to view this anomaly, which was located in Resident No. 6's genital area. Respondent learned of the allegations relating to Resident No. 6's physical anomaly on April 21, 2003, from a family member of Resident No. 6. Respondent immediately began an investigation, including an interview with and physical examination of Resident No. 6 and an interview with the CNA. The resident only stated that she did not want this CNA taking care of her any longer. The CNA denied the allegations. The CNA was suspended pending investigation and later terminated based upon directions from Respondent's corporate office based on additional, unrelated information. The incident was reported to the Department of Children and Families (DCF) Abuse Hot Line on April 22, 2003. Although Resident No. 6 and her family member had frequent contact and conversation with Respondent's director of nursing (DON), neither had ever complained about the CNA's conduct. Respondent's DON observed no mental distress on the part of Resident No. 6 after Respondent's DON learned of the allegations. Petitioner alleges that this CNA had observed the physical anomaly for the first time. If that is true, it would be expected that the CNA would consult other nursing staff to address potential nursing issues. As to Resident No. 13, Petitioner alleges verbal abuse based upon the allegation that Resident No. 13 reported to a surveyor that she found a male resident sitting on her bed in her room. When this was reported by Resident No. 13 to one of the Respondent's nurses, the resident alleged that the nurse "laughed at" the resident. This incident was reported by Resident No. 13 to Respondent's DON shortly after it happened. Respondent's DON interviewed the resident and the two nurses who were on duty at the time. The nurses reported that they assured Resident No. 13 that everything was okay, escorted the male resident to his room, and Resident No. 13 went to bed with no complaint or distress. This incident was reported by Resident No. 13 to Respondent's DON in a joking manner, as an event and not as a complaint. Although Respondent's DON was concerned that the nurses should respond appropriately and was also concerned that the wandering resident be identified, Respondent's DON did not believe that the incident constituted any form of abuse. Respondent's DON did not observe this incident to have any adverse impact on Resident No. 13. During the survey, Petitioner's surveyor advised Respondent that the incident should have been investigated and reported to the DCF Abuse Hot Line. Respondent's DON completed a written report and called the DCF Abuse Hot Line and related the incident. The incident did not meet the DCF guidelines for the reporting of abuse. On or about March 30, 2003, two surveyors observed Resident No. 18 in her wheelchair as she approached the nurse's station. One of Respondent's nursing staff spoke in a "curt, loud voice" to Resident No. 18. The resident had approached the nurses' station to ask for her medication, to which the nurse replied: "I told you I will give you your medicine." Resident No. 18 was hearing-impaired and was documented in her medical record as one to whom staff "must speak loudly." This resident did not wear any hearing assistance devices. Respondent's staff credibly described this resident as one to whom staff had to speak loudly and in clipped words for the resident to understand. Petitioner's surveyors did not speak to this resident after the alleged incident. There is no evidence that this incident had any effect on the resident or even that the resident heard the staff member. The incident does not rise to the level of verbal abuse of the resident. Count II Count II of the Administrative Complaint alleges a violation of 42 C.F.R. Section 483.13(c)(1)(ii), which provides that a nursing home must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse; and that the nursing home must not employ individuals who have been found guilty of abuse or neglect or are listed in the state nursing aide registry with a finding of abuse, neglect, or mistreatment. Count II is based on the allegation that Respondent failed to report to Petitioner (the appropriate "state agency") the incidents involving Resident No. 13 and 18 and other allegations of abuse or neglect, which the surveyor allegedly identified in Respondent's log of grievances. Respondent has in place written policies and procedures regarding abuse and neglect and its staff receive regular training regarding these policies and procedures. Petitioner has offered no evidence that these written policies and procedures or the staff's knowledge of these policies and procedures is inadequate. With regard to Resident No. 13, when Respondent's DON learned of the incident from the resident, Respondent's DON made inquiries of nursing staff who were on duty at the time, in addition to interviewing the resident. Respondent's DON did not consider any aspect of the incident to constitute abuse or neglect. Later, after Petitioner alleged, during the survey, that the incident should have been reported to DCF, Respondent's DON prepared a written report of the incident and called and related the incident to the DCF Abuse Hot Line. Respondent's DON was advised by DCF that the incident did not meet DCF's requirements for reporting. Respondent is required to report all allegations of abuse and neglect to the DCF's Abuse Hot Line. Petitioner does not dispute this fact. Instead, Petitioner contends that Respondent is also required to report allegations of abuse and neglect to the "state agency" and that Respondent failed to do so. The "state agency" for the purpose of federal regulations is Petitioner. Petitioner's allegations are based upon its review of Respondent's grievance log, which Petitioner's surveyors say allegedly records 18 incidents of alleged abuse, none of which was reported to the state agency. At the time of the survey, Respondent was a part of the Mariner Corporation. It has since disassociated from that corporation and changed its name to Tuskawilla Nursing and Rehabilitation Center, effective October 1, 2003. At the time of the survey, all reporting of abuse allegations were done by the corporate regional risk management department, and it is not known if they reported any of the incidents cited by the surveyors to Petitioner. However, the document received in evidence, which has many more than 18 entries in summary style, is almost completely illegible. Petitioner's witness was unable to identify any entries on this document which could be identified as alleged abuse and which had not been properly reported. Understanding this document requires substantial explanation, which was never provided. Standing alone, this document is not probative of any fact. Petitioner offered no evidence that Respondent employed any individuals who had been found guilty of or who had been listed on the nurse aide registry of abusing, neglecting, or mistreating residents. Even if it is assumed that Respondent should have reported but did not report to Petitioner the 18 alleged incidents or the incident regarding Resident No. 13, Petitioner offered no evidence that reporting this information to DCF, but not to Petitioner, had any impact on any resident or prevented a resident from maintaining or achieving the resident's highest practicable physical, mental, or psychosocial well-being. Count III Since there is no proof of Class II deficiencies, there is no basis for imposing a conditional license status on Respondent for the period May 30, 2003, until July 8, 2003.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that a final order of dismissal of the Administrative Complaint be entered in this case. DONE AND ENTERED this 31st day of March, 2004, in Tallahassee, Leon County, Florida. S DANIEL M. KILBRIDE 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 31st day of March, 2004. COPIES FURNISHED: Alfred W. Clark, Esquire 117 South Gadsden Street, Suite 201 Post Office Box 623 Tallahassee, Florida 32302-0623 Gerald L. Pickett, Esquire Agency for Health Care Administration Sebring Building, Suite 330K 525 Mirror Lake Drive, North St. Petersburg, Florida 33701 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
The Issue Whether Respondent violated the duly promulgated rules of the Department of Health and Rehabilitative Services by designating and continuing to designate the same person as the Assistant Administrator and the Director of Nursing of the Bonifay Nursing Home, Inc., after having been cited for such deficiency and allowed sufficient time to correct the deficiency.
Findings Of Fact An Administrative Complaint was filed by Petitioner Department of Health and Rehabilitative Services on October 27, 1980 notifying Respondent Bonifay Nursing Home, Inc., a skilled nursing care home, that Petitioner intended to impose a civil penalty of $100 for violating duly promulgated rules by designating the same person to act as Assistant Administrator and Director of Nursing of the nursing home. At the formal administrative hearing the Administrator admitted that he served more than one health facility, that at all times pertinent to the hearing the acting Assistant Nursing Home Administrator was also designated as the Director of Nursing, and that she was the only registered nurse on duty. It was admitted that no change had been made after the inspector for the Petitioner Department had called attention to this alleged violation until after the time period allowed for correcting this situation had expired and after the Petitioner had informed Respondent it intended to impose a $100 civil penalty. In mitigation Respondent presented testimony and adduced evidence showing that as the owner and operator of the nursing home he had made an effort to employ registered nurses at the home and that on the date of hearing the nursing home was in compliance with the statutes, rules and regulations. It was evident to the Hearing Officer that the nursing home serves a need in the community and that the residents appreciate the service. Petitioner Department submitted proposed findings of fact, memorandum of law and a proposed recommended order, which were considered in the writing of this order. Respondent submitted a memorandum. To the extent the proposed findings of fact have not been adopted in or are inconsistent with factual findings in this order, they have been specifically rejected as being irrelevant or not having been supported by the evidence.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law the Hearing Officer recommends that a final order be entered by the Petitioner assessing an administrative fine not to exceed $50. DONE and ORDERED this 10th day of February, 1982, in Tallahassee, Leon County, Florida. DELPHENE C. STRICKLAND Hearing Officer Division of Administrative Hearings 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 10th day of February, 1982. COPIES FURNISHED: John L. Pearce, Esquire Department of Health and Rehabilitative Services 2639 North Monroe Street, Suite 200-A Tallahassee, Florida 32301 Mr. J. E. Speed, Administrator Bonifay Nursing Home 108 Wagner Road Bonifay, Florida 32425 David H. Pingree, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32301
The Issue The issue to be determined in this case is whether Respondent, Department of Health and Rehabilitative Services, should grant the application of Health Care and Retirement Corporation of America, d/b/a Heartland of Hillsborough (HCR), Petitioner in Case No. 85-3217, or Forum Group, Inc., sponsor of Retirement Living of Hillsborough County (Forum), Petitioner in Case No. 85-3376, or both, for a certificate of need to construct and operate a 60-bed nursing home in Hillsborough County. Paddock Meadows Convalescent Centers, Florida Convalescent Centers, Inc., and Angel1 Care, Inc., petitioners in Case Nos. 85-3362, 85-4124 and 86-0905, respectively, voluntarily dismissed their petitions shortly before the final hearing in this case. (Health Quest Corporation and Health Quest Realty (Hillsborough County), petitioners in Case No. 85-2923, voluntarily dismissed their petition on or about April 1, 1986.
Findings Of Fact The HCR Proposal. Health Care and Retirement Corporation of America, d/b/a Heartland of Hillsborough (HCR), Petitioner in Case No. 85-3217, has been in the business of nursing home construction and operation for over 20 years. HCR currently operates approximately 10,000 beds in 17 states. It has developed over 200 facilities. HCR's proposed project would benefit financially to some extent from economies of scale of having a network of similar facilities. HCR originally applied for a certificate of need to construct and operate a 120-bed nursing home in Hillsborough County. During the pendency of this proceeding, HCR down-sized its proposed project to 60 beds and made other amendments. The down-sizing and amendments are reflected in a supplemental application which was served on Respondent, Department of Health and Rehabilitative Services (HRS), but was not filed with the local health council. It is not clear whether the supplemental application was filed with HRS's Office of Community Medical Facilities. The supplemental application adopts by reference but does not re-type certain portions of the original application. Those portions of the original application were not introduced in evidence or otherwise made a part of the record of this proceeding. In HCR's supplemental application, the down-sized 60-bed nursing home is accompanied by a 60-bed adult congregate living facility housed in the part of the building originally proposed to house another 60 nursing home beds. In addition, the supplemental application reflects a new emphasis on treatment of patients with Alzheimer's and related diseases (dementia). HCR proposes a facility which will include a 60-bed nursing home, an adult congregate living facility, and an adult day-care component. The facility will offer programs specially designed for Alzheimer's disease victims, and, in its adult day care and assisted living areas, will provide programs which are designed to delay institutionalization as long as possible. The facility will provide staffing and special capabilities to accommodate the unique characteristics of dementia (Alzheimer's) patients, to allow the wandering Alzheimer's patient more freedom, and to shelter the non-dementia (non-Alzheimer's) patient from unnecessary contact with the dementia (Alzheimer's) patient. Alzheimer's disease is a progressive, organic brain disease which causes brain cells to die at a rate much more rapid than in the normal aging process. As the brain slowly dies and degenerates, other functions of the body dependent upon the brain's messages begin to deteriorate. The initial effects of the disease, such as forgetfulness and disorientation, are subtle, but the disease progresses through several stages where, increasingly, the disease victim is unable to perform normal daily functions or care for himself and, ultimately, loses the ability to control basic bodily functions and becomes bedridden. Alzheimer's disease is a disease of the elderly victims at two levels of the disease require inpatient care. Some victims develop psychiatric manifestations of the disease and short-term hospitalization or stabilization to enable the family caregiver to manage the patient still in the home setting. As victims reach the later stages of the disease, caregivers must consider institutional placement in a setting where there is a 24-hour-a-day care, seven days a week. In these later stages, the patients require total care which usually cannot be managed on a full-time basis at home, particularly by persons without significant resources. The primary caregiver of Alzheimer's disease patients is an older spouse, but in some instances it may. be an adult child. Ideally, inpatient programs for Alzheimer's disease victims would be designed with a continuum of care to minimize frequent changes in the victim's environment. In other words, the Alzheimer's care program would offer a range of care for patients who move through the various stages of Alzheimer's disease, from ambulatory to bed bound. Day care is an important component of the continuum development of Alzheimer's components for day-care programs in of care in an Alzheimer's program, because it offers rest to the family by placing the victim in a special care facility for a full day. The State of Florida allocated resources for the 1985 legislative session. Sophisticated, high-tech nursing care is required for patients in the later stages of the disease who have lost the ability to swallow, feed themselves, and perform other necessary/ bodily functions. Providing care from day care through high-tech care in the same facility minimizes frequent relocation of the Alzheimer's patient and facilitates the family coming to terms with the final outcome of the disease, where the family must relinquish total care to an institution. Alzheimer's disease victims in the middle and late stages of the disease who are still ambulatory exhibit the tendency to wander aimlessly. Nursing home care for such victims must provide a safe and secure environment in which the Alzheimer's patients may wander without endangering themselves or others. Otherwise, these patients will wander away from the facility and get lost or wander into dangerous traffic situations. Alzheimer's victims often disrupt the routine of non- Alzheimer's patients and the staff of the facilities by their constant wandering and by entering other patients' rooms and going through other patients' belongings. Special Alzheimer's units expect this behavior and make provisions to control it without physical or chemical constraint. In state-of-the-art Alzheimer's care, the physical nature of the decor and design of a nursing home appropriate for Alzheimer's care ideally would provide a safe and secure environment for the wandering, unstable Alzheimer's victim and provide a pleasant, therapeutic environment which copes with the patient's lost ability to synthesize data. Fixtures in the nursing home would be appropriately designed to enable the Alzheimer's patient to distinguish between significant fixtures, such as commodes, sinks, and wastebaskets. Ideally, activity areas for Alzheimer's patients would be separate from other nursing home patients, because of the Alzheimer's patient's disruptive wandering, absence of inhibitions and short attention spans which require a variety of activities and programs to accommodate. The staff of an Alzheimer's care program must be able to deal with the Alzheimer's patient. The staff will seldom see any improvement in the condition of the patient and will seldom get any positive feedback from the patient. Staffing patterns in Alzheimer's programs need to be more intense than average because the staff must deal with patients who have lost the ability to care for themselves. There is a need for closer supervision than is needed by the typical nursing home patient. Such a program also requires a social worker to develop the individual treatment plan for the patient and an occupational therapist to teach the patients those functions which the patients are continually losing. An Alzheimer's program within an adult congregate living facility is within the continuum of care required for some patients. The care provided here is less intense than that provided in a nursing home. However, once the victim loses basic bodily functions and begins wandering, the adult congregate living facility is no longer able to deal with these patients. Adult congregate living facilities and boarding homes in Hillsborough which accept Alzheimer's victims are frequently required to discharge such victims when the care becomes too difficult. In Hillsborough County, there are no nursing homes which provide state-of-the-art inpatient care designed for the care and treatment of Alzheimer's disease patients. Although there are two adult congregate living facilities in Hillsborough County which accept Alzheimer's disease patients, these facilities do not have safeguards for the wandering patient. Nursing homes traditionally deal with wandering Alzheimer's patients by physically restraining the patients or by chemically restraining the patients through the use of drugs. A state-of-the-art program designed to meet the special needs of Alzheimer's disease victims eliminates or reduces the need for physical and chemical restraints. HCR intends to offer a service, from day care through inpatient nursing care, that is designed for the needs of the typical Alzheimer's patient. In addition to the Alzheimer's patient, many patients not diagnosed as Alzheimer's disease victims but who are cognitively impaired (suffering from dementia) would also benefit from the service designed for the Alzheimer's patient. The adult day-care portion of the facility will allow the Alzheimer's victim to remain at home much of the day but allow the family and the well spouse to have time to provide for their own personal needs. The assisted living (adult congregate living) portion of the facility would be available for Alzheimer's victims not requiring advanced nursing care and would be available as a facility where the well spouse and the Alzheimer's victim could live together and both benefit from support services. The nursing home portion of the facility would offer special designs and programs to meet the needs of a maximum of 15 Alzheimer's patient in the middle stages, where wandering is a particular problem, as well as the needs of patients in the latter stages and death. The care available for the Alzheimer's disease victim in the latter stages of the disease (high-tech care) will also be available and appropriate for patients discharged from acute care hospitals who still need nursing care prior to returning home. The level of staffing provided in the HCR facility is higher than one would expect to find in the typical nursing home. The staffing proposed assumes that 15 of the patients will be Alzheimer's wanderers. HCR proposes a staffing higher than the typical nursing home because of the personal attention required for state-of-the-art Alzheimer's patient care and HCR's intent to reduce the amount of medication and physical restraint imposed upon the Alzheimer's patient. Increased staffing will encourage the Alzheimer's patient to retain whatever cognitive capabilities they have for as long as possible and will reduce the disruption experienced in a normal nursing home when the Alzheimer's disease patients wander, disrupt other patients, and generally disrupt the nursing home. The HCR facility will provide an area for wandering patients and a fenced courtyard which will allow wandering patients to have outside activity without danger of leaving the facility. The facility includes a therapeutic kitchen important to the Alzheimer's patient who retains some cognitive recognition of kitchen activities. A separate dining room for the Alzheimer's patient will be provided in order to accommodate the increased spillage experienced by Alzheimer's patient and the risk of incontinence, which is very disruptive and disturbing to non-Alzheimer's patients. wandering patients will be continuously monitored through the use of an electronic wristband which will prevent the patient from wandering outside of the facility and those areas where the wandering patient could cause problems. Dementia patients are now being cared for and treated in existing nursing homes in Hillsborough County. There was no persuasive evidence that patients have been denied access to nursing home beds in Hillsborough County. The features proposed in HCR's supplemental application would allow HCR to provide better quality care and treatment for those patients. However, HCR has only committed to treat up to 15 Alzheimer's patients in the "wandering" stage. That degree of commitment and the extent to which those special features for the care and treatment of dementia patients are needed would not themselves justify the proposed project absent an overall need for additional nursing home beds. HCR is in the process of purchasing four existing. nursing homes from Care Corporation. HCR did not prove that it has studied whether renovation of those facilities to accommodate special features for the care and treatment of Alzheimer's patients would not be less costly, more efficient or more appropriate alternatives to this proposed project or that they are not practicable. The project proposed in HCR's supplemental application is immediately and long-term financially feasible. HCR is a subsidiary of Owens-Illinois. On December 31, 1985, Owens- Illinois had total assets of approximately $3.3 billion, total current assets of approximately $903 million, and cash of approximately $47 million. Meanwhile, current liabilities were approximately $723 million and total shareholders' equity was approximately $1,559,000,000. In addition, HCR proved that it would be able to finance the approximately $2.2 million total project costs by borrowing 75% at favorable interest rates and funding the remaining 25% out of HCR's equity. Making reasonable, conservative assumptions--including an 11.5% interest rate, a January 1989 opening of the facility, and 40% Medicaid utilization on a patient day basis--the project can be anticipated to break even during year two of operation and earn approximately $158,000 during year two of operations. The nursing home portion of the facility and the day- care element adjacent to the nursing home portion will comprise 25,000 square feet; the nursing home portion alone will contain 23,000 gross square feet, or 383 gross square feet per bed. The construction costs for the nursing home and day-care portion of the facility will be $1,458,000, or $58.32 per square foot for the 25,000 square foot area; the cost of construction for the 23,000 gross square foot for the nursing home portion is $1,341,360. The cost per bed for construction of the nursing home portion of the facility is $22,356. The total project costs for the facility estimated by HCR and the cost per bed of the facility includes both the nursing home and adult day-care portion of the facility; when the adult day-care portion of the facility (8 percent of the construction costs) is taken into consideration, the total project cost becomes $2,083.360, at a cost per bed of $34,722. The estimated project cost for the nursing home portion of HCR's proposed facility is as follows: Feasibility studies $15,000; legal and accounting fees $32,000; plan review $8,000; subtotal of project development costs (the foregoing three items) $55,000; costs for financing $120,000; architectural and engineering fees $15,000; site survey and soil investigation $5,000; subtotal of the foregoing professional services $20,000; construction costs $1,458,000 (which includes the day-care portion of the facility but would be reduced to $1,341,360 for the nursing home portion alone); equipment costs $222,000; land acquisition costs $200,000; interest during construction $125,000; total project costs $2,200,000 ($2,083,360 when the adult day-care portion of the facility is excluded). All 60 of the nursing home beds in HCR's proposed facility will be certified both for Medicare and Medicaid utilization. However, in its supplemental application, HCR limits its commitment to serve Medicaid patients to 40% of its patient days. The increased cost of special features for Alzheimer's patients influenced HCR's financial decision not to commit to a higher percentage of Medicaid utilization. HCR has received approximately 13 certificates of need to develop nursing homes in Florida. HCR has completed three nursing homes, and HCR has seven projects under construction. Various difficulties prevented HCR from initiating construction of three projects for which it received certificates of need in 1981 and 1982. HCR has experienced no problems in initiating construction of its certificates of need obtained since that time, and its experience in Florida renders it unlikely that its previous failure to commence construction of facilities will reoccur. HCR acknowledges that it has previously sold and does not now operate nursing homes for which it had obtained certificates of need in Florida. However, these sales were facilities in the same building as the nursing home. A dietician and central kitchen and central laundry will serve all three levels. Housekeeping, building supervision, building plant, and other building maintenance operations will be centralized, saving some expenses. The Forum Proposal. Forum Group, Inc., sponsor of Retirement Living of Hillsborough County (Forum), Petitioner in Case No. 85-3376, is a general partner in a Florida partnership named Retirement Living of Hillsborough County. Forum originally applied for and continues to apply for a certificate of need to construct and operate a 60-bed nursing home. Like the project proposed in HCR's supplemental application, Forums proposal includes aspects in addition to the nursing home. Forum's proposed nursing home would be connected to a 15-bed wing of private rooms for patients who need assistance in their personal care and access to some of the capabilities of a nursing home on an intermittent basis but do not need nursing home care full-time. This is-bed wing would have separate dining facilities. This "personal care unit" will cost patients approximately $40 to $60 a day. In Forum's proposed nursing home, three wings, like the "personal care unit," would radiate from a hub where the nursing station would be located. Twenty of the sixty beds would be in private rooms occupied by private patients. Ten of those beds would be designated for skilled nursing care and ten for intermediate care. Of the 40 beds located in 20 semi-private rooms, 36 would be certified for Medicaid use, leaving 4 to be certified for Medicare use. Eighteen of the 40 beds would be for intermediate care, and 22 of the 40 beds would be for skilled nursing care. Forum's skilled nursing care would include "hi- tech" skilled nursing comparable to HCR's. A central corridor with central kitchen facilities and building maintenance facilities connects the three nursing home wings and the personal care unit wing with a retirement living center. The retirement living center will be able to accommodate 120 residents. Residents will be under a one year lease arrangement instead of an endowment-type arrangement. Monthly lease payments will probably fall between $950 and $1700 per month. The rental includes one meal a day in the retirement living center's dining room, weekly house cleaning, 24-hour security, transportation by automobile to appointments, banks, and doctor's offices and by mini-bus to shopping and theatres, availability of an on-call nurse, utilities, taxes, and the. services of a social director. The retirement living center will be marketed as a luxury facility to elderly persons approximately 75 years of age with an annual income of between $15,000 and $35,000. Forum projects initial utilization of all 36 Medicaid certified beds by Medicaid patients, resulting in 60% Medicaid utilization by patient day. However, that percentage would change with time. At first, residents of the retirement living apartments would not be expected to move immediately to the nursing home portion of the facility. The projected fill-up for the nursing home portion initially would not be derived from the initial fill-up of the retirement living apartments. Eventually, however, 10 to 15% of the residents of the retirement living apartments would require nursing home care, and approximately 50% of the patients in the nursing home will be, former residents of the retirement living section. In 10 to 12 years, the percentage of Medicaid utilization can be expected to drop, with a floor of approximately 45% Medicaid utilization by patient day. Like HCR's proposed project, Forum's proposal will benefit financially to some extent from the location of other facilities in the same building as the nursing home. A dietician and central kitchen and central laundry will serve all three levels. Housekeeping, building supervision, building plant, and other building maintenance operations will be centralized, saving some expenses. Like HCR, but probably not to the same extent, Forum would be able to benefit financially to some extent from the economies of scale of having a network of similar facilities (including approximately 11 facilities like the proposed project and approximately 20 free-standing nursing homes.) Location of the retirement center and the personal care unit in the same building with the nursing home will afford Forum some advantages in caring for its nursing home patients. First, some of the patients can be expected to use two or all three of the levels of care available in the complex as their medical condition worsens or, in some cases, improves. This would aid in the continuity of Forum's care and reduce the emotional strain of changing levels of care (since the patients do not have to move to a totally new location and environment.) Second, to the extent nursing home patients continue to have an independent means to pay to reside in the retirement living center or the personal care unit, those patients will have an incentive to improve their health so as to be able to move back to the retirement living center or personal care unit from the nursing home unit. (Obviously, these benefits would not apply to Medicaid patients in the nursing home.) Third, general education in health and hygiene of persons residing in the retirement living center and personal care unit will help to some degree in keeping them out of the nursing home or aiding their recovery if in the nursing home for short-term care. Like HCR, Forum also has the ability to provide quality nursing home care. However, Forum's proposal does not have the special features for care of Alzheimer's disease and other dementia patients proposed by HCR in its supplemental application. While some of those state-of-the-art special features could be incorporated by Forum during construction of its proposed nursing home, others could not, and Forum does not have the overall emphasis or commitment to provide those special features that HCR does. The total cost of Forum's nursing home proposal is approximately $2,200,000. This includes no interest cost during construction since Forum has decided to, and has the financial ability to, pay for the construction entirely out of its cash reserves. Forum has approximately $40,272,000 in cash assets. It has approximately $69,210,000 worth of current assets and only approximately $23,192,000 worth of current liabilities. Its total assets are approximately $290,747,000 and it has approximately $151,155,000 worth of common shareholders' equity. Its net income for the fiscal year ending March 31, 1986, was approximately $15,012,000. As a result, Forum's nursing home proposal is immediately financially feasible. Making reasonable, conservative assumptions including 13% interest on borrowed capital, late 1987 or early 1988 occupancy and 60% Medicaid utilization by patient day, Forum's nursing home proposal probably will break even in mid-year two and will earn approximately S69,000 net income in year two of operations. The following are Forum's final project development costs: feasibility studies $20,000, legal and accounting fees $30,000, development expenses $10,000, subtotal of the foregoing three categories $60,000; architectural and engineering fees $70,000, site survey and soil investigation $15,000, for a total cost for professional services total of $85,000; site preparation work $40,000, construction costs of $1,345,598, and contingency fees of $45,661, for a total construction cost of $1,390,258; fixed equipment cost of $65,998, moveable equipment cost of $128,850, tax-freight contingency and escalation provisions of $44,160 for a subtotal of equipment costs of $239,000; land acquisition of costs of $400,000, no interest costs during construction, pre-opening expenses' of $25,000, and, finally, a total project cost of $2,199,258. The expected construction cost per bed comes to approximately $23,171, and the total cost per bed comes-to approximately $36,165. HRS Rule Need Methodology. Rule 10-5.11(21)(b), Florida Administrative Code, provides the HRS bed need rule methodology for determining projected need for new or additional community nursing home beds. The methodology provided in Rule 10-5.11(21) is as follows: Departmental Goal. The Department will consider applications for community nursing home beds in context with applicable statutory and rule criteria. The Department will not normally approve applications for new or additional community nursing home beds in any departmental service district if approval of an application would cause the number of community nursing home beds in that departmental service district to exceed the number of community nursing home beds calculated by the methodology described in subsections (21)(b), (c), (d), (e), (f), (g), and (h) of this rule. Need Methodology. In addition to other relevant statutory and rule criteria to be used in considering the allocation of new or additional community nursing home beds, the Department will determine if there is a projected need for new or additional beds three years into the future according to the methodology specified under subparagraphs 1 through 10. This methodology provides for adjustments to current community nursing home bed rates based upon expected changes in the proportion of district residents age 75 + and the current utilization of community nursing home beds in the subdistricts designated by local health councils. In districts with a high proportion of elderly residents living in poverty, the methodology specifies a minimum bed rate. A = (POPA X BA) + (POPB X BB ): Where: A is the district's age-adjusted Number of community nursing home beds for the review cycle for which a projection is being made. POPA is the population age 65-74 years in relevant departmental district projected three years into the future. BA is the estimated current bed rate for the population age 65-74 years and over in the relevant district. BB is the estimated current bed rate for the population age 75 years and over in the relevant district. BA=LB/POPC + (6 X POPD): Where: LB is the number of licensed community nursing home beds in the relevant district. POPC is the current population age 65-74 years. POPD is the current population age 75 years and over. BB = 6 X BA SAA X (LBD/LB) X (OR/.90): Where: SA is the preliminary subdistrict allocation of community nursing home beds. LBD is the number of licensed community Nursing beds in the relevant subdistrict. Or is the average occupancy rate for all licensed community nursing homes within the subdistrict of the relevant district. Review of applications submitted for the July batching cycle shall be based upon occupancy rate data for the months of October through March preceding that cycle; applications submitted for the January batching cycle shall be based upon occupancy rate data for the months of April through September preceding that cycle. For the purposes of this rule, the occupancy data to be considered shall be that collected by the Department's Office of Healthcare Planning and Development or a contractor assigned to collect the data. In departmental districts where the percentage of persons age 65 and older living in poverty, according to the latest available U.S. census, exceeds the statewide average poverty rate for the 65 and older population and the sum of the currently licensed and certificate of need approved beds for community nursing homes within a district is less than 27 beds per thousand residents age 65 and older, the district shall be allocated a total of 27 community nursing home beds per thousand residents age 65 and older in the current year. This allocation is expressed as follows: If (Ls + AB ) /POPE is less than 27/1000 and PBD is greater than PBS, then: PA(27 X POPE)/1000 Where: AB is the number of certificate of need approved beds for community nursing homes in the relevant district. PBD is the percentage of persons age 65 and older below the poverty level within the district. PBS is the percent of persons age 65 and older below the poverty level within the state. PA is the poverty-adjusted number of beds in the relevant district. POPE is the sum of POPC and POPD. * * * 9. The net bed allocation for a sub-district which is the number of beds available for Certificate of Need approval, is determined by subtracting the total number of licensed and 90% of the approved beds within the relevant departmental subdistrict from the bed allocation determined under subparagraphs 1 through 9 unless the subdistrict's average estimated occupancy rate for the most recent six months is less than 80%, in which case the net bed allocation is zero. Prior to August 20, 1985, HRS had a long-standing policy interpreting the methodology as requiring use of population and occupancy rate at the time of the formal administrative hearing, if any, as the current population (POPC and POPD) and occupancy rate (OR) in the formula. HRS also subtracted the number of nursing home beds licensed and approved as of the date of the formal administrative hearing, if any, from the gross number of nursing home beds needed to determine the net need for nursing home beds proposed in a pending certificate of need application. Since the decision in Gulf Court Nursing Center vs. Department of Health and Rehabilitative Services, 483 So. 2d 700 (Fla. 1st DCA 1985), modified on rehearing (Fla. 1st DCA 1986), HRS adopted a new policy interpreting its rule methodology and the Gulf Court decision. HRS now interprets Gulf Court's reference to a "fixed pool of beds.' available in a given certificate of need application batching cycle to fix the health planning horizon in the rule methodology at three years into the future from the filing deadline for the certificate of need application batching cycle in question. Accordingly, POPA and POPB under the rule methodology represents the most current projection of population in the respective age cohorts on the fixed planning horizon. As before the Gulf Court decision, all other elements of the methodology including the figures for POPC, POPD, and OR are updated to the time of the formal administrative proceeding. Under its policy interpreting the rule methodology and the Gulf Court decision, HRS obtains the subdistrict occupancy rate (OR), by taking the average occupancy rate during the most recent six-month period for which data is available--in this case, from October 1, 1985 through March 31, 1986. However, the current population figures (POPC and POPD) HRS uses are the figures available closest to the date of the formal administrative hearing in this case on July 1, 1986. Under its policy, the occupancy rate (OR) does not relate to the figures for current population (POPC and POPD) to which it logically should relate. HRS did not satisfactorily explain the rationality of its policy. Meanwhile, there was ample evidence supporting the rationality of using as POPC and POPD the population at the midpoint of the time period used force determining occupancy rate (OR). In this case, since occupancy rate (OR) is determined by averaging the occupancy rates during the period from October 1, 1985 through March 31, 1986, the current population (POPC and POPD) should be the populations of the respective age cohorts on January 1, 1986. Otherwise, HRS' policy interpreting its rule methodology and the Gulf Court decision is a rational effort to reconcile the Gulf Court decision with the certificate of need statute, other conflicting court decisions and principles of sound health planning. It suffices here to say that, notwithstanding the Gulf Court decision, the evidence in this case does not establish the existence of a "fixed pool" of needed nursing home beds for which the applicants in this case applied. See Conclusions of Law 1 through 13 below. In addition, sound health planning not only dictates the use of the most recently available population projections (POPA and POPB) and the most current data (POPC, POPD, and OR) for determining current bed rates (BA and BB) under the rule methodology, but also would counsel against relying on state or district health plan determinations of a "fixed pool of beds" based upon inferior data and evidence. Departure from these sound health planning principles is likely to result in certificates of need for nursing home beds that are not needed or, in some cases, the denial of certificates of need for nursing home beds that are needed. See Appendix, paragraph B.4, below. For purposes of calculating need under the HRS rule need methodology, the appropriate health planning district is District VI, and the appropriate subdistrict is Hillsborough County. There currently are 5,617 licensed nursing home beds in District VI (LB). The District VI population for persons aged 65 to 74 on January 1, 1986 (POPC) is 131,501. The District VI population for persons aged over 75 for January 1, 1986 (POPD) is 91,433. The bed rate for the portion of the current population aged 65 to 74 (BA) is 0.008259. The bed rate for the portion of the current population aged over 75 (Bs) is 0.049554. The projected District VI population for persons aged 65 to 74 on January 1, 1988 (POPA) is 139,903. The projected District VI population for persons aged over 75 on January 1, 1988 (POPD) is 100,175. Using the bed rates for the two age cohorts (BA and BB) and the projected populations for those age cohorts on January 1, 1988 (POPA and POPB), the gross projected District VI nursing home bed need for January 1, 1988 (A) is 6,119.6. The occupancy rate for District VI nursing home beds between October 1, 1985 and March 31, 1986 (OR) was 93.3646%. This was the most current figure available at the time of the hearing. At the time of the formal administrative hearing, there were 2,512 licensed beds in Hillsborough County (LBD). At the time of the formal administrative hearing, there were 368 approved nursing home beds for the Hillsborough County subdistrict (AB). Using the figures for projected District VI bed need (A), licensed beds in District VI (LB), licensed beds for the Hillsborough County subdistrict (LBD) and the occupancy rate (OR), the allocation of nursing home beds for the Hillsborough County subdistrict (SA), is 2,839. The beds that will be available in Hillsborough County on January 1, 1988, is 2,843 (LBD plus .9 AB), leaving a surplus of 4 nursing home beds in Hillsborough County on January 1, 1988 under the HRS rule need methodology, as properly interpreted. In District VI, the percentage of persons aged 65 and older living in poverty, according to the latest available. U.S. census, exceeds the statewide average poverty rate for the 65 and older population, but the sum of the currently licensed and certificate of need approved beds for community nursing homes within District VI is approximately equal to 27 beds per thousand persons aged 65 and older, and no poverty adjustment is required under Rule 10-5.11(21)(b)5., Florida Administrative Code. State Health Plan. The State Health Plan endorses the concept of an integrated continuum of long-term care services. Forum's proposal integrates retirement living with minimal skilled nursing care needs, skilled and intermediate nursing care in a nursing home setting, and personal assistance care a middle ground between the two. Similarly, HCR's proposal integrates (1) adult congregate living with minimal requirement for skilled nursing care to limited nursing care provided to an Alzheimer's patient being primarily cared for by a spouse, and (2) skilled and intermediate nursing care in a nursing home setting, and (3) a range of specialized nursing services for the Alzheimer's patient in the second and third stages of the disease. The HCR proposal also integrates day care and respite services for Alzheimer's patients being cared for primarily for by relatives in their own homes. Addressing a related concern, the State Health Plan also endorses pre-admission screening to determine the level of care needed by a potential nursing home patient. This serves to foster a system of health care that seeks to promote "wellness" and independence of the patient. Both applicants will have some type of pre-admission screening process. Both applicants' proposals include on-site non-nursing home living facilities, and a decision would have to be made which of those two environments are appropriate for a particular patient. Forum also has personal assistance care which would require more precise screening, and Forum appeared more intent on establishing effective pre-admission screening procedures and cooperating with the state-sponsored CARES (Comprehensive Assessment and Review for Extended services) program aimed at diverting potential patients who do not truly need nursing home services. Both proposals also seek to promote "wellness" and independence of the patient. Both include less restrictive settings than nursing home care for patients who do not yet need full-time nursing services. For some patients, the less restrictive setting can serve as an incentive to recover from illnesses and shorten short-term nursing home stays. Again, Forum's proposal, with its three levels of care and more attractive retirement living setting, better fosters these objectives. Finally, the State Health Plan highlights the elderly's need for information on providers' charge structures and acceptance of Medicaid/Medicare assignment. It expresses a goal of availability of services to the medically indigent, and recommends adherence to the applicable local health plan's expectations. See Finding Of Fact 61 below. District VI Health Plan. As its second priority, the District VI Health Plan states that applicants for a certificate of need for nursing home services in the Northwest subdivision of the Hillsborough County subdistrict should commit, at minimum, 18.6% of its services to the care of Medicaid eligible patients. Forum's application commits 60% of its patient days to Medicaid during the first year of operation. HCR's commitment is only 40%. However, HCR's commitment is on a permanent basis, and Forum's actual Medicaid utilization can be expected to drop over the first ten years of operation with a floor of approximately 45%. The actual percentage of Medicaid days for the period January to March 1986, for Hillsborough County was 70%. The District VI Health Plan also ranks the Northwest subdivision of the Hillsborough County subdistrict as the first priority for location of new or additional nursing home services when needed in District VI. Both applicants propose to locate their projects in the Northwest subdivision of the Hillsborough County subdistrict. Another priority in the District VI Health Plan is to give preference to applicants with a documented history of implementing their certificates of need within the statutory time frames. Forum had no history in Florida but a good record of follow-through elsewhere. HCR has a history of mixed results in Florida but offered good explanations for the instances of delay in implementing certain certificates of need in earlier years, and the evidence was not persuasive that either Forum or HCR should be given a competitive advantage regarding this priority. The District VI Health Plan sets a 90% occupancy threshold for the continuous period of six months before additional beds are approved. This threshold has been met in Hillsborough County for at least three years. Current occupancy in Hillsborough County is 93.3646%. The District VI Health Plan states that applications for additional nursing home beds in a subdistrict should be considered against the availability of alternative forms and settings for long-term care. In this case, there was no evidence of alternatives to nursing home services other than the alternatives within the proposed projects. However, neither of the applicants will go forward with the retirement living or personal assistance care or adult congregate living alternatives without the attached nursing home. No specialized state-of-the- art Alzheimer's disease programs are now available in District VI. See Finding Of Fact 71 below. The District VI Health Plan states that applications should be reviewed with the goal that nursing home services be within 30 minutes travel time of 90% of urban residence and 45 minutes of 90% of rural residents. There was no evidence in this case regarding geographic access of the urban and rural populations or that the proposed projects would make Finally, the District VI Health Plan states that applicants should be evaluated as to their achievement of superior quality ratings by HRS and other indications of quality as available. Both applicants adequately establish that they will be able to provide quality nursing home services. It can be anticipated that both will seek and obtain a superior rating for its proposed facility. Other Pertinent Criteria. Both applicants propose projects which will be accessible to schools for health professions in Hillsborough County, such as colleges and trade schools for training and teaching purposes. In addition to its Medicaid utilization commitment previously discussed. Forum will establish a $10,000 fund, to be replenished annually, for indigent patients to draw upon as necessary for payment of nursing home services. This fund is intended to address, for example, the circumstance that could arise if a private pay nursing home patient runs out of money and all 36 Medicaid-certified nursing home beds are occupied. Unless the fund pays for the patient, the patient would have to be transferred to another nursing home. However, Forum does not yet nursing home services accessible to residents now outside the applicable travel time have any guidelines or criteria for the operation of the fund. Both Forum and HCR propose facilities to provide nursing home services. Neither applicant seeks to justify the need for its proposed nursing home on need for services that can be provided other than through a nursing home. No applicant in this batching cycle seeks to add beds as an alternative to new construction. Existing nursing home beds are alternatives to the proposals only if there is no need for additional nursing home beds. There is no existing alternative to the special Alzheimer's program proposed by HCR. Existing nursing homes serve Alzheimer's patients but not with state-of-the-art nursing home care. However, renovation of facilities HCR is in the process of purchasing from Care Corporation to accommodate special features for the treatment of Alzheimer's patients might be an alternative to the construction of a new nursing home for the purpose of providing those services. HCR did not prove that it has studied those alternatives and found either that they would not be less costly, more efficient or more appropriate or that they would not be practicable. Both HCR and Forum, through their network of retirement centers and nursing homes, generate economies of scale in centralized operations and management functions and in acquisition of equipment. As a larger nursing home company, HCR's economies of scale would be greater than Forum's. In addition, by combining different levels of care on one campus, both applicants can enjoy further economies in dietary, laundry, medical supply and bookkeeping operations. Both HCR and Forum can adequately meet manpower requirements for their proposed facilities with a combination of in-house transfers and recruiting from the local community. There was no evidence that approval of a new 60-bed nursing home facility in Hillsborough County would have a significant negative impact on the financial viability of existing nursing homes. Current occupancy rates are high, reducing patients' choice in the selection of a nursing home. The last 240 nursing home beds opened to patients in Hillsborough County quickly were absorbed by the demand for those services. Neither HCR nor Forum now own or operate a nursing home in the Tampa Bay area. However, HCR is in the process of acquiring four nursing homes from Care Corporation. As a result, HCR would have more control over the market than Forum and would have the potential eventually to use its market power to decrease competition. But at this time, it can be anticipated that either proposal would foster competition and promote quality assurance and effectiveness. Balanced Consideration of the Criteria. HCR and Forum are worthy applicants who have conceived and proposed nursing home projects worthy of consideration. However, balancing consideration of all of the criteria, and giving due weight to the HRS rule need methodology, it is found that there is no need at this time for a new 60-bed nursing home in Hillsborough County. There is no numeric need under the rule, and no special circumstances were proved by documentation of denied access to currently licensed but unoccupied beds or of need exceeding the number of licensed unoccupied and currently approved nursing home beds. Meanwhile, the special Alzheimer's program HCR proposes does not independently support construction of a new 60-bed nursing home. Renovation of the four nursing homes HCR is in the process of purchasing from Care Corporation might be a less costly, more efficient and more appropriate alternative to construction of a new 60-bed nursing home to provide special Alzheimer's programs in Hillsborough County. However, if there were a need for 60 additional nursing home beds, HCR's Alzheimer's program would be enough to give it a competitive advantage over Forum's proposal.
Recommendation Based upon the foregoing Findings Of Fact and Conclusions Of Law, it is recommended that Respondent, Department of Health and Rehabilitative Services, enter a final order denying the applications of both Health Care and Retirement Corporation of America, Petitioner in Case No. 85-3217, CON Action No. 3818, and Forum Group, Inc., Petitioner in Case No. 85-3376, CON Action No. 3817, for a certificate of need to construct and operate a new 60-bed nursing home in Hillsborough County. RECOMMENDED this 3rd day of November, 1986, in Tallahassee, Florida. J. LAWRENCE JOHNSTON, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 3rd day November, 1986.
The Issue Whether Petitioner was in violation of 42CFR 483.25(l)(1), 42CFR 483.60(d), Rules 59A-4.112(5) and 59A-4.1288, Florida Administrative Code, at the time of its annual survey in July 2000, and, if so, whether those violations were uncorrected at the time of resurvey in September 2000, in order to justify the issuance of a Conditional licensure rating.
Findings Of Fact Tampa Health Care Center (Petitioner) is a licensed nursing home in Tampa, Florida. Pursuant to Chapter 400, Florida Statutes, Respondent surveys Petitioner to determine whether it is in compliance with applicable laws and regulations. If there are deficiencies, it determines the level of deficiency. When Respondent conducts a survey of a nursing home, it issues a survey report, commonly called by its form number, a "2567." The particular regulation, and the allegedly deficient practices which constitute a violation of that regulation, are cited in a column on the left side of the paper. After receiving the 2567, the facility is required to develop a plan of correction which is put in the right hand column corresponding to the alleged deficiency. The facility is required to develop this plan regardless of whether it agrees that it is in violation of any regulations, and it is prohibited from being argumentative. Respondent conducted its annual survey of Petitioner, ending July 27, 2000, and issued a 2567 survey report noting certain deficiencies. The deficiencies are designated as tag numbers. Among those noted were Tag F329, which is the shorthand reference to 42 C.F.R. Subsection 483.25 (1)(1), and Tag F431, which incorporates 42 C.F.R. Subsection 483.60(d). Respondent rated these deficiencies as Class III deficiencies. Respondent conducted a follow-up survey on September 5, 2000, and determined that the deficiencies under tags F329 and F431 were uncorrected, and, as a result, issued a Conditional rating to the facility. On December 2000, Respondent conducted another follow- up survey and determined that all deficiencies had been corrected and therefore issued a Standard license to Petitioner effective that date. The 2567 constitutes the charging document for purposes of issuing a Conditional license. No other document was offered to describe the offenses, or deficiencies, which resulted in imposition of the Conditional license. The parties stipulated at the hearing that Tags F329 and F431 were the only ones at issue in this proceeding. In conducting its survey, Respondent uses a document developed by the Health Care Financing Administration (HCFA), called the State Operations Manual. It indicates guidance on how are to interpret regulations. TAG F 329 The 2567 from the July survey asserts, under Tag F 329, that the facility "failed to monitor psychotropic medications for 5 of 5 sampled residents." The regulation states that residents are to be "free from unnecessary drugs," and elaborates that a drug given without adequate monitoring is considered unnecessary. The guidelines establish that monitoring is expected only for residents on psychotropic medications. Therefore, for a violation to occur, there must first be a resident who is receiving psychotropic medications, and secondly, a lack of monitoring of the use of that drug. Respondent alleged and put on evidence that certain residents (numbers 1, 9, 19, and 21) identified in the July survey did not have "behavior monitoring records" in their files. Specific forms are not mandatory, and evidence of monitoring can be documented elsewhere in a resident's clinical record. Monitoring can be documented in nurses' notes, and those notes were not thoroughly reviewed, as Respondent's surveyors only had limited time for the survey. Respondent presented no evidence that Residents 9, 19, or 21 were receiving psychotropic medications. Petitioner presented evidence of numerous systems in place to monitor residents, including those receiving psychotropic medications. Residents are given a complete clinical assessment within 24 hours of admission; there is then a 14-day more thorough observation and assessment process, culminating in the development of care plans which address particular issues and direct staff to care for residents in particular ways. Nurses regularly document issues or concerns in nurses notes; a physician visits the residents at least once a month, which, as all drugs are ordered by the physician, includes review of the resident's medication. If necessary, a psychiatric evaluation is completed. Once a week a transdisciplinary team meets to discuss any residents "at risk," which includes those receiving psychotropic medications. Additionally, a consultant pharmacist reviews all residents' medications once a month. This review is to determine how well the resident is doing on the drug regimen. It includes reviewing nurses' notes, physicians' notes, the medication administration record, the record of dosages taken on an "as needed" basis, and discussions with nursing staff. The pharmacist reviews whether there are medications administered in excessive doses, in excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of adverse consequences. With regard to the September survey, Respondent alleged in the Form 2567 that "Residents numbers 3, 4, 9, 11, and 13 lacked Behavior Monitoring Forms in their records" and that all were on psychotropic medications which required monitoring. Respondent presented the testimony of Barbara Bearden who stated that Residents 3 and 4 were on psychotropic medications, and that there were no behavior monitoring forms. With regard to Resident 4, Respondent asserted that there was no assessment of behaviors in any records after August 14. Bearden acknowledged that both Residents 3 and 4 received reasonable doses, and that there was no reason to believe the level of medication was too high. Respondent's witness also asserted that there was no "AIMS" assessments, no initial assessment, and no indication of the reason for or effectiveness of the medications. These matters were not alleged in the charging document, which only asserted the lack of behavior monitoring forms. During her testimony, Respondent's witness acknowledged that there was no standard to determine how often there should be behavior monitoring. Marie Maisel testified for Respondent regarding Residents 9, 11, and 13. With regard to Resident 9, she testified that the resident received Restoril, a sleeping medication, and also Zoloft, an anti-depressant, and that there was no "systematic behavior monitoring." Sleeping medications do not require behavior monitoring, according to the State Operations Manual, and at deposition, the surveyor indicated that the only medication the resident received was Restoril. Petitioner therefore had no notice of the additional allegation regarding Zoloft and this fact cannot be considered. With regard to Resident 11, Maisel testified that the resident received Risperdal, a psychotropic medication, and that, in her opinion, the behavior monitoring was not adequate. At hearing the surveyor testified that Resident 13 was receiving Haldol and there was no systemic behavior monitoring. However, the witness acknowledged that when her deposition was taken, she did not know why Resident 13 had been cited. Petitioner therefore had no notice of these allegations regarding Resident 13. Petitioner presented evidence, including excerpts from the resident's clinical record, that Resident 3 had been assessed for drug use, and that behaviors were monitored. The resident had been admitted less than three weeks before the September survey, which means that an initial assessment had been performed, as well as the complete 14-day assessment, just prior to survey. Respondent admitted that it would be inappropriate to reduce medication soon after admission. There was a care plan which addressed the resident's use of Risperdal, and another which addressed the resident's ability to function with the activities of daily living. These care plans directed staff to monitor the resident's condition and behavior. Numerous nursing notes documented the resident's condition and behaviors. Resident 3 was not noted in the pharmacist's monthly report, meaning the review revealed no problems with medications. Furthermore, the resident's medications were significantly reduced while in Petitioner's care, and her condition improved dramatically, from being nearly comatose, to being alert and oriented, and needing only limited assistance with mobility. Resident 4 had been admitted just a month before the survey and had also just undergone an extensive assessment process. Her medications were also reduced from those she had been receiving on admission, and nurses notes clearly documented her condition and behaviors throughout the period up to the survey. These notes document not only the monitoring of behaviors, but the reason and need for the medication, as she exhibited combative behaviors. Resident 4 also did not appear on the pharmacist's report. With regard to Resident 9, Petitioner presented evidence that there was a care plan specifically addressing the resident's use of Zoloft, that there were other care plans which addressed behaviors and condition which required that the resident be monitored, and that there was periodic consideration of reductions. Resident 9 did appear on the pharmacist's report, suggesting consideration of a reduction in dosage; thus demonstrating the effectiveness of the system. Resident 11 had a care plan addressing her use of Risperdal, which required monitoring and other interventions. Monthly nursing summaries reflected that she was monitored, as did nursing notes. Generally, nurses notes indicate when there are problems or unusual occurrences, not when everything is routine. Petitioner also presented evidence with regard to Resident 13's use of Haldol, which showed the reason for its use (wandering, verbal abusiveness), numerous efforts to reduce the dosage, review by the pharmacist, a care plan to address its use, which required monitoring, and monthly summaries summarizing her condition and behaviors. Respondent presented sufficient evidence to show that Residents 3, 4, 9, 11, and 13, cited in the September survey, were appropriately monitored and were not receiving unnecessary drugs. TAG F431 Respondent charged in the September 2000 survey that several insulin vials in the medication room were not marked with the date they were opened. The regulation under Tag F431, 42 C.F.R. Subsection 483.60(d), requires that drugs be labeled "in accordance with currently accepted professional principles" and "the expiration date when applicable." The surveyor guidelines indicate that the critical elements of labeling are the name of the drug and its strength. Additionally, the guidelines advise that drugs approved by the Federal Drug Administration (F.D.A.) must have expiration dates on the manufacturer's container. Respondent's witness acknowledged that all insulin had the manufacturer's expiration date. Although there is a chance of contamination after opening a vial of insulin, it was acknowledged that it is customary to have a policy allowing use for six months after opening. Petitioner has a policy of discarding insulin 60 days after opening. While it is customary to write the opening date on the vial, a failure to do so will only reduce the amount of time it can be used, because of other systems in place. The pharmacy which dispenses the insulin puts a dispensing date on it, and the pharmacist reviews, monthly, stored medications. Within every three months, all medications are checked, and if there is no date of opening, the pharmacist looks to the dispensing date. If the vial was dispensed more than 60 days prior, it is given to the nurse for discarding. Instead of being able to be used for six months beyond the date opened, the medication is discarded sixty days, or at most ninety days, after it was dispensed. Writing the date opened on the vial is not an item encompassed by the regulation as explicated in the guidelines. Furthermore, there is no potential for harm, as there are redundant systems in place.
Recommendation Based of the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Director of the Agency for Health Care Administration enter a final order revising the July 27 and September 5, 2000, survey reports by deleting the deficiencies described under Tags F329 and F431, and issuing a Standard rating to Respondent to replace the previously issued Conditional rating. DONE AND ENTERED this 22nd day of August, 2001, in Tallahassee, Leon County, Florida. DANIEL M. KILBRIDE 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 August, 2001. COPIES FURNISHED: Patricia J. Hakes, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Room 310J St. Petersburg, Florida 33701 Donna H. Stinson, Esquire Broad and Cassel 215 South Monroe Street, Suite 400 Post Office Drawer 11300 Tallahassee, Florida 32302 Sam Power, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three Suite 3431 Tallahassee, Florida 32308 Julie Gallagher, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three Suite 3431 Tallahassee, Florida 32308
