Conclusions Having reviewed the Amended Notice of Intent to Deny, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows: 1. The Agency has jurisdiction over the above-named Petitioner pursuant to Chapter 408, Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions. 2. The Agency issued the attached Amended Notice of Intent to Deny and Election of Rights form to the Petitioner. (Ex. 1) The Election of Rights form advised of the right to an administrative hearing. 3. The parties have since entered into the attached Settlement Agreement. (Ex. 2) Based upon the foregoing, it is ORDERED: 4. The Settlement Agreement is adopted and incorporated by reference into this Final Order. The parties shall comply with the terms of the Settlement Agreement, which set forth requirements of continued licensure imposed upon the Petitioner. The failure to comply with these requirements may result in licensure revocation or application denial as set forth in the Settlement Agreement. ORDERED at Tallahassee, Florida, on this 24 day of _Dece bey~ , 2012. Filed December 26, 2012 3:20 PM Division of Administrative Hearings
Other Judicial Opinions A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I CERTIFY that a true and correct pry of this Final Order was served on the below-named persons by the method designated on this 7/ lay of [ech , 2012. Richard Shoop, Agency Ch Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone: (850) 412-3630 Jan Mills Shaddrick Haston, Unit Manager Facilities Intake Unit Assisted Living Unit (Electronic Mail) Agency for Health Care Administration (Electronic Mail) Suzanne S. Hurley Rafael Gaitan, Esq. Office of the General Counsel Gus Suarez, Esq. Agency for Health Care Administration Counsel for Southern Parks, Inc. (Electronic Mail) 1110 Brickell Avenue, Suite 407. Miami, Florida 33131-3135 (U.S. Mail) | Pat Caufman, Field Office Manager R. Bruce McKibben Area 5/6 Administrative Law Judge Agency for Health Care Administration Division of Administrative Hearings (Electronic Mail) (Electronic Mail) Paul Brown, Health Facility Evaluator Supervisor Area 5/6 Agency for Health Care Administration (Electronic Mail) RICK SCOTT FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, ELIZABETH DUDEK GOVERNOR Better Health Care for all Floridians INTERIM SECRETARY August 8, 2012 Sanny P. Panningbatan, Administrator Southern Parks, Inc. d/b/a/ Southern Oaks ALF P.O. Box 789 Wauchula, FL 33873 re: Case No.: 2012005197 AMENDED NOTICE OF INTENT TO DENY Dear Ms. Panningbatan: The Agency for Health Care Administration hereby DENIES the application by Southern Parks, Inc. d/b/a Southern Oaks ALF for renewal of its Assisted Living Facility license. The Specific Basis for this determination is a failure by the facility to pay outstanding fines and assessed fees from 2008 in the amount of $154; a failure by the facility to pay an outstanding Medicaid fine in the amount of $6000 in Case #121947000; a failure by the facility to obtain a satisfactory Level 2 background screen for its Chief Financial Officer; and the facility has shown a pattern of deficient practice as indicated in detail below. The applicant failed to meet minimum licensure standards pursuant to Sections 408.809, 408.815(1)(d), 408.831, 429.14(1)(e), 429.14(3), and 429.174, Florida Statutes.’ On June 22, 2010, a complaint investigation was conducted. A widespread Class I deficiency was cited because the facility was found out of compliance with local authorities that oversee building construction codes and water and fire safety standards. The county fire jurisdiction had to issue a cease and desist order to suspend the use of the facility as related to multiple electrical violations; a “boil water” alert had also been put in place and all of the facility’s 49 residents had to be relocated on an emergency basis. A widespread Class II deficiency was also cited for the facility’s failure to maintain a safe and decent living environment and physical plant. The place was filthy throughout, including mattresses in the rooms, dirty floors & walls, bathrooms had mold, toilets were filled with feces and cigarette butts, blinds were broken, cockroaches were everywhere. The facility agreed to an immediate moratorium on admissions until corrections were made and approved by the Agency. On May 18, 2011, a complaint investigation was conducted. Four Class Il deficiencies were cited because the facility had failed to assure that its staff had received training in basic CPR and ' For each citation subsequently noted, the relevant section(s) of the Florida Statutes or Administrative Rule(s) violated, as was provided contemporaneously to the facility in writing, is incorporated herein by reference. SIN Headquarters 2727 Mahan Drive Tallahassee, FL 32308 http:/fahca.myflorida.com Area Office 525 Mirror Lake Drive, N. Sebring Building, #330H St. Peter wr 33701 EXHIBIT 4 First Aid, failed to assure proper training for its staff who worked with mental health residents, failed to assure sufficient staff to provide the necessary supervision, safety and care to the residents, and failed to obtain and keep the required medical examination reports for the residents. A patterned Class II deficiency was also cited for the facility’s failure to assure the required criminal background clearance for employees who were providing personal services. On June 28, 2011, a revisit to the complaint investigation was conducted and the facility had failed to correct the cited deficiencies. The Agency cited four uncorrected Class III deficiencies as it still lacked sufficient staff to provide proper care and supervision; it lacked sufficient qualified staff to care for the mental health residents; it failed to provide minimum staffing hours and it had still not required proper training in CPR and First Aid for the staff providing services. On July 22, 2011, a follow up survey was conducted in regard to the above and three Class III deficiencies were cited. The deficiencies included that the facility was failing to provide care and services appropriate to the needs of the residents, medications were being mishandled, and the physical plant was still filthy with evidence of pest and/or insect droppings. On September 15, 2011, a second revisit to the June 28 complaint investigation was conducted and two uncorrected Class III deficiencies were cited. The facility had still not required the proper training in CPR and First Aid for staff providing personal services and had failed to assure that one staff member trained in CPR and First Aid were available on all shifts. Corrections were not completed until October 27, 2010. On August 4, 2011, a monitoring visit was conducted with “operation spot check.” Twelve Class III deficiencies were cited, including: a) residents’ health assessments indicated that they were inappropriate for assisted living; b) some residents lacked the required health assessments; c) documentation was lacking to show that the residents were receiving proper activities; d) the facility had no elopement policy and had failed to conduct elopement drills as required; e) the facility was assisting a resident with medication when there was no signed physician order for same; f) the facility had failed to put in place the required Do Not Resuscitate (“DNR”) policy; g) staff members were lacking the required training in abuse, neglect, resident rights, emergency procedures and reporting adverse incidents; h) the facility administrator lacked the required nutrition and food service training; i) the facility staff lacked the required training for DNR; j) the facility had failed to obtain the required surety bond before acting as representative payee for residents; j) the facility had failed to maintain a safe living environment with regard to sanitation; and k) the facility had failed to assure that it had contracts with all of its residents. On November 17, 2011, another complaint survey was conducted along with a revisit. Two Class III deficiencies were cited. The medication observation record was found not to match the medication orders for residents on healthcare forms signed by their physicians. The residents had been receiving medications which were not ordered and had been missing medications that their physicians had ordered for them. The deficiencies appeared to be corrected on January 31, 2012, when the Agency conducted three complaint surveys. On March 5, 2012, a complaint survey was conducted in conjunction with a revisit survey and two Class III deficiencies were cited. The facility was failing to fill out the medication observation record appropriately and it was using an outdated form for the heaithcare assessments for the residents. Corrections had been made when the Agency returned on April 26, 2012. The Class I and Class II deficiencies along with an extraordinarily-large number of Class III deficiencies supports the Agency’s denial. EXPLANATION OF RIGHTS Pursuant to Section 120.569 Florida Statutes, you have the right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes, your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code and must state the material facts you dispute. SEE ATTACHED ELECTION OF RIGHTS FORM Sincerely, Shh Z— Shaddrick A. Haston, Manager Assisted Living Unit Bureau of Long Term Care Services Copy to: Jan Mills, Office of the General Counsel STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: SOUTHERN PARKS, INC. d/b/a CASE NO.: 2012005197 SOUTHERN OAKS ALF ELECTION OF RIGHTS’ This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Deny, Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Deny, Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2012) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS: OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. ' Here filed in response to the Agency’s Amended Notice of Intent to Deny OPTION THREE (3)___—s-.s dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) [hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Deny/Late fee/fine/AC STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION SOUTHERN PARKS, INC. d/b/a SOUTHERN OAKS ALF, Petitioner, vs. DOAH Case No. 12-2274 AHCA Case No. 2012005197 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / SETTLEMENT AGREEMENT Respondent, the State of Florida, Agency for Health Care Administration (the “Agency”), through its undersigned representatives, and Petitioner, Southern Parks, Inc. d/b/a Southem Oaks ALF (“Petitioner”), pursuant to Section 120.57(4), Florida Statutes, each individually, a “party,” collectively as “parties,” hereby enter into this Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Petitioner is an assisted living facility licensed pursuant to Chapters 429, Part I and 408, Part II, Florida Statutes, and Chapter 58A-5, Florida Administrative Code; and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Petitioner, pursuant to Chapters 429, Part I and 408, Part II, Florida Statutes; and WHEREAS, the Agency served Petitioner with a Notice of Intent to Deny dated May 10, 2012, and an Amended Notice of Intent to Deny dated August 8, 2012, notifying the Petitioner of the Agency’s intent to deny Petitioner’s renewal application for licensure to operate an assisted living facility in the State of Florida; and WHEREAS, Petitioner requested a formal administrative proceeding by selecting Option “3” on the Election of Rights form or by the filing of a Petition; and EXHIBIT 2 WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals herein are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, Petitioner agrees to waive any and all appeals and proceedings to which it may be entitled including, but not limited to, an informal proceeding under § 120.57(2), Florida Statutes, a formal proceeding under § 120.57(1), Florida Statutes, appeals under § 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court of competent jurisdiction; and agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled provided that the form of the Final Order remains consistent with the recitals, “whereas” clauses, and terms of this Settlement Agreement; and, further that no agreement herein shall be deemed a waiver by either party of its right to judicial enforcement of this Agreement. 4. Upon full execution of this Agreement, the parties stipulate and agree as follows: a. Petitioner shall contract with and maintain as a consultant Ms. Marlene Hunter, MS CHCRM, commencing September 1, 2012, and extending for two (2) years thereafter. Petitioner shall cause its consultant to review and complete a written quarterly report on a monthly basis regarding the facility’s operations and regulatory compliance. Said quarterly report shall include, but not be limited to: assessments of and actions taken related to medication administration and records, quality of care, risk management activities, staff training activities, and the adoption or amendment of facility policy and procedures. The quarterly report shall be maintained by Petitioner and provided to the Agency upon request. b. The provisions of subparagraph (a) above and the affirmative duties therein, shall continue in full force and effect throughout any renewal of the Petitioner’s license as necessary during the two (2) year period referenced herein. c. Petitioner places itself under a Voluntary Limitation on Admissions effective (retroactive to) August 17, 2012. The Voluntary Limitation on Admissions prohibits Petitioner from admitting any resident which would result in the Facility’s census exceeding forty (40) residents. d. A violation of the Voluntary Limitation on Admissions shall result in administrative sanctions by the Agency just as if for violation of a duly-entered Emergency Immediate Moratorium on Admissions. e. On or after February 17, 2013, the Petitioner may request the Agency’s authorization to discontinue its Voluntary Limitation on Admissions. Any such request shall be supported by documentation, including but not limited to, reports or records of Petitioner’s consultant referenced in subparagraph (a) above, which demonstrate actions undertaken by Petitioner to assure current and future compliance with the regulatory mandates. Upon receipt of any such request, the Agency may take such action as is appropriate and prudent, including but not limited to: a survey of the Facility, a request for further information or direct communication with Petitioner’s consultant. The Agency agrees to review any request in good faith, in a timely manner and not to unreasonably withhold consent. Said review shall be conducted as soon as possible and/or practical for the Agency. Should consent be denied, the Agency shall state in writing the reasons for 5. denial and will provide, if applicable, corrective measures to be taken by Petitioner to receive consent. Petitioner may seek further consent at any time. f. Upon adoption of this Agreement as a Final Order of the Agency, the Agency for Health Care Administration shall issue to Petitioner a renewal license for a facility capacity of sixty (60) residents, valid for a period of two calendar years commencing on May 5, 2012. g. On or after September 1, 2013, the Petitioner may apply to increase its licensed capacity at the Facility as provided by law. Any application to increase the licensed capacity of the Petitioner’s facility filed prior to September 1, 2013, shall be summarily denied based upon the terms of this Agreement and that the Petitioner waives any right to challenge said summarily denied application in any judicial or quasi-judicial forum. The Agency further agrees to review any application, received on or after September 1, 2013, to increase Petitioner’s licensed capacity in good faith and not to unreasonably deny the same other than as provided by law. Should Petitioner’s application be denied, the reasons for the denial shall be set forth in writing or as provided by law. h. Should Petitioner be cited for one Class I, one Class II, or three or more uncorrected Class III deficient practices at any survey over a two-year period from the date of the issuance of the renewal license (i.e., May 5, 2012), Petitioner stipulates that the deficient practice(s) will, if proven, constitute grounds for revocation of the Petitioner’s license (if provided for by law) in addition to additional Agency action pursuant to applicable provisions of law. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in Circuit Court in Leon County, Florida. 6. By executing this Agreement, Petitioner denies the allegations set forth in the Notice of Intent to Deny and the Amended Notice of Intent to Deny, and the Agency asserts the validity of the allegations raised in these Notices of Intent to Deny. No agreement made herein shall preclude the Agency from imposing a penalty against Petitioner for any deficiency/ violation of statute or rule identified in a future survey of Petitioner, which constitutes a “repeat” or “uncorrected” deficiency from surveys identified in the administrative complaint. 7. No agreement made herein shall preclude the Agency ftom using the deficiencies from the surveys identified in the Notice of Intent to Deny in any decision regarding licensure of Petitioner, including, but not limited to, licensure for limited mental health, limited nursing services, extended congregate care, or a demonstrated pattern of deficient performance, as provided for by then existing law. The Agency is not precluded from using the subject events for any purpose within the jurisdiction of the Agency as provided for by law. Further, Petitioner acknowledges that this Agreement shall not preclude or estop any other federal, state, or local agency or office from pursuing any cause of action or taking any action, even if based on or arising from, in whole or in part, the facts raised in the administrative complaint. This agreement does not prohibit the Agency from taking action regarding Petitioner’s Medicaid provider status, conditions, requirements or contract. 8. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and closing the above-styled case. 9. Each party shall bear its own costs and attorney’s fees. 10. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 11. Petitioner for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Petitioner or related facilities; provided and limited, however, that Petitioner’s rights to any costs, expenses or attorneys fees arising from or relating to enforcement of this Settlement Agreement shall survive. 12. This Agreement is binding upon all parties herein and those identified in paragraph eleven (11) of this Agreement. 13. In the event that Petitioner was a Medicaid provider at the subject time of the occurrences alleged in the complaint herein, this settlement does not prevent the Agency from secking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 59G-9.070, Florida Administrative Code. 14, Petitioner agrees that if any funds to be paid under this agreement to the Agency are not paid within thirty-one (31) days of entry of the Final Order in this matter, the Agency may deduct the amounts assessed against Petitioner in the Final Order, or any portion thereof, owed by Petitioner to the Agency from any present or future funds owed to Petitioner by the Agency, and that the Agency shall hold a lien against present and future funds owed to Petitioner by the Agency for said amounts until paid. 15. The undersigned have read and understand this Agreement and have the authority to bind their respective principals to it. Petitioner has the capacity to execute this Agreement. 16. This Agreement contains and incorporates the entire understandings and agreements of the parties. 17. This Agreement supersedes any prior oral or written agreements between the parties. 18. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. 19. All parties agree that a facsimile signature suffices for an original signature. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. epi Agency for Health Care Administration _2727 Mahan Drive Tallahassee, Florida 32308 DATED: _\ vi Stuart F. Williams General Counsel Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5407 : ie urley, Seni ’ Florida Bar No. 0985775 r Lake Drive, Suite 330H St. Petersburg, Florida 33701 Of G (20) 32. DATED: Florida Bar No. 17987 Gus Suarez, Esq. Florida Bar No. 616613 Counsel for Southern Parks, Inc. ~ 1110 Brickell Avenue? Suite 407 ~~ Miami, Florida 33131-3135 paTep: /°/ 9 /20/2_ Name (printed): Sherry Qanleo Position: i Southern Parks, Inc. DATED: 9-/4-ja@
Conclusions Having reviewed the Administrative Complaint, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows: 1. The Agency has jurisdiction over the above-named Respondent pursuant to Chapter 408, Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions. 2. The Agency issued the attached Administrative Complaint and Election of Rights form to the Respondent. (Ex. 1) The Election of Rights form advised of the right to an administrative hearing. 3. The parties have since entered into the attached Settlement Agreement. (Ex. 2) Based upon the foregoing, it is ORDERED: 1. The Settlement Agreement is adopted and incorporated by reference into this Final Order. The parties shall comply with the terms of the Settlement Agreement. 2. The Respondent shall pay the Agency $5,500.00. If full payment has been made, the cancelled check acts as receipt of payment and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. A check made payable to the “Agency for Health Care Administration” and containing the AHCA ten-digit case number should be sent to: Office of Finance and Accounting Revenue Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS 14 Tallahassee, Florida 32308 Filed November 7, 2012 1:32 PM Dipision of Administrative Hearings ORDERED at Tallahassee, Florida, on this b day of /V 6 Va be , 2012. ‘, - Sy At, * q Elizabeyh Dudek, ae Agency for Healt! e Administration
Other Judicial Opinions A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I CERTIFY that a true and correct_gopy of this Final Order was served on the below-named persons by the method designated on this Z lay of _ LY Loe , 2011. Richard Shoop, Agency Cler! Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone: (850) 412-3630 Jan Mills Finance & Accounting Facilities Intake Unit Revenue Management Unit (Electronic Mail) (Electronic Mail) David Selby, Esq. Haifa Harb, Administrator and Registered Agent Office of the General Counsel Bloomfield Manor Agency for Health Care Administration 2774 Wesleyan Dr., (Electronic Mail) Palm Harbor, FL 34684 (U.S. Mail) John D. C. Newton, II B. Kyle Morley, Esq. Administrative Law Judge Kelley, Kronenberg, et al Division of Administrative Hearings 8201 Peters Rd, Ste 4000 (Electronic Mail) Ft. Lauderdale, FL 33324 L (U.S. Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. Case No. 2012005357 BLOOMFIELD MANOR, INC. d/b/a BLOOMFIELD MANOR Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Bloomfield Manor, Inc. d/b/a Bloomfield Manor (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of $5,000.00 based upon one State Class II deficiency (Count I) and to assess a survey fee of five hundred dollars ($500.00) (Count Il). The total assessment is for $5,500.00. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and Chapters 408, Part Il, and 429, Part L Florida Statutes (2011). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted 1 EXHIBIT 1 living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Flonda Statutes, and Chapter 58A- 5, Florida Administrative Code (‘F.A.C.’), respectively. 4. Respondent operates a six bed assisted living facility (‘ALF’) located at 2774 Wesleyan Dr., Palm Harbor, FL 34684, and is licensed as an ALF, license number 9893. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I — CLASS TI FINE 5. The Agency re-alleges and incorporates paragraphs one through five as if fully set forth herein. 6. Florida regulatory law states the following concerning resident care and elopement standards at an ALF: 58A-5.0182 Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. (8) ELOPEMENT STANDARDS (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement shall be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility shall make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention shall be directed towards residents 2 assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease and related disorders assessed at high risk. Rule 58A-5.0182, FAC. 7. A-complaint survey, CCR # 2012000332, was performed on 9 February, 2012, in conjunction with a biennial state licensure survey of this ALF with extended congregate care. 8. The Agency’s surveyor reviewed facility records and interviewed facility staff and determined that the facility failed to provide adequate supervision to ensure the health and safety of a vulnerable 97 year old female resident, which resulted in her eloping from the facility in the early morning hours on 5 January, 2012, a very cold morning where the temperature dropped to as low as 39-42° F. She was found early that morning by law enforcement with a broken nose and bruised eyes. She had no identification on her and she was too confused to state her name. She was identified by law enforcement only after the caregiver called law enforcement at between 7:00 — 7:45 am to report the missing resident. 9. The following information was learned from the records review and staff interviews during the Agency’s survey: a. This resident was admitted to the facility as a respite (short stay) resident by her son on 1/1/12 to stay for a week while he was going to be away. b. A formal health assessment was not required for respite care for a stay of less than 30 days. The facility administrator/owner’s brief notes indicated that he had asked the son questions about his mother’s routine, behaviors, diet, and her general needs regarding her activities of daily living. The notes included no milk, no smoking, some confusion, no wandering, regular diet, no falling and supervision with dressing. He listed her age as 97. c. Additional unsigned handwritten notes on resident observation log sheets stated that she was confused, and she had stated that she was leaving and her son was going to come and get her. When the administrator came to the facility on 1/1/12, he and the live in caregiver (#1) (she stayed there five days a week) agreed to activate the front door alarm as a preventative step because of this particular resident's confusion. This was done the following day. There was no documentation of a plan to provide closer supervision. After the new door alarm was installed the next day, there was no documentation indicating that this resident had ever gone out the door and set off the alarm but it was documented that she continued to be confused and kept saying she was going to leave, that her son was coming for her. After a day of the alarm going off frequently due independent residents coming and going, the caregiver removed it the next day, 1/3/12, and contacted the administrator to let him know. The administrator acknowledged during his interview that he had been contacted as indicated by this caregiver. This caregiver said that she removed the door alarm because residents said it bothered them. Additionally, she did not see exit seeking behaviors from this respite resident, only confusion, and she stayed in the living room and kept a close eye on her. However, the caregiver did describe seeing the resident going from room to room, touching different doors and having difficulty finding the restroom. At one point during the night, the caregiver heard noise from the resident’s room and found her fooling with her travel bag which she had put on top of her bed. She described the inability of the resident to follow simple commands such as putting on clean clothes that had been selected for her to put on after she showered. Instead, she put on the same clothes she had worn previously. Her appetite was described as good. The caregiver further stated that she had verbally briefed the incoming replacement staff member (caregiver #2) on 1/4/12 before getting off at 9:00 am. She did not mention anything to her replacement about the door alarm being activated and then deactivated 4 i. but she did relate that the resident was confused. She did not say that this resident needed more supervision than the other residents. There were no written notes in the resident's file to describe for the benefit of the replacement the behaviors that had been observed that would have called for constant supervision or possible discharge to a higher level of care than could be provided at this facility. A confidential interview during the survey with a different resident revealed he had heard and felt someone touch his feet during the early hours of 1/5/12 and thought it was a burglar in his room but then realized it was the respite resident who immediately left his room. He recalled this happening between 3:00 - 3:30 am. He said he got up and rolled into the living room and found the caregiver (#2) asleep on the chair. Shortly after that he said he heard noises coming from behind his closet where the respite resident's closet backed up to his but the noises stopped and he did not think any more about it. He said the caregiver (#2) came into his room sometime around 5:00 am he thought and asked him if he had seen the respite resident. He told her that he had not seen her since earlier that morning when she had come into his room. He said the caregiver then began a full search. Review of the 1 day and 15 day Adverse Incident reports submitted on 1/15/12 and 2/5/12 (submitted late and cited as a separate deficiency) revealed the respite resident was discovered missing on 1/5/12 at approximately 7:30 am at which time the administrator was notified. By that time, the resident had already been picked up by law enforcement and taken to a nearby hospital with a fractured nose. Review of the facility's elopement drills revealed they were completed timely. Caregiver #1’s personnel file reflected all required training. 1. Caregiver #2’s personnel file was missing so it could not be reviewed. The administrator thought that that caregiver might have taken it from his office when she returned for the rest of her personal items on 1/20/12 after being terminated on 1/5/12. 10. The information set forth above reflects Respondent’s failure to ensure care and services appropriate to the needs of a resident accepted for admission to the facility including personal supervision where Respondent knew of or should have known of the resident’s confusion, risk of elopement, and possible injury, but nevertheless deactivated the alarm needed to ensure the continued safety of an obvious at-risk resident. 11. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 12. The same constitutes a State Class II offense, defined as follows: 408.813 Administrative fines; violations.—As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. (2) Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients. ... Violations shall be classified on the written notice as follows: (b) Class “II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an administrative fine as provided by law for a cited class II violation. A fine shall be levied notwithstanding the correction of the violation. Section 408.813, Florida Statutes (2011) 13. The fine for a Class II violation is set forth as follows: 429.19 Violations; imposition of administrative fines; grounds.— (1) In addition to the requirements of part I of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility, for the ... actions of a facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a 6 resident of the facility. (2) Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: (b) Class “If” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. (3) For purposes of this section, in determining if a penalty is to be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rules were violated. (b) Actions taken by the owner or administrator to correct violations. (c) Any previous violations. (d) The financial benefit to the facility of committing or continuing the violation. (e) The licensed capacity of the facility. (7) In addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 429.28(3) (c) to verify the correction of the violations. Florida Statute 429.19, Florida Statutes (2011). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an ALF in the State of Florida, pursuant to Section 429.19 (2) (b) and (3), Florida Statutes (2011). COUNT II- ASSESSMENT OF A SURVEY FEE 14. The Agency re-alleges and incorporates paragraphs 1 through 5 and Count | as if fully set forth herein. 15. Pursuant to Section 429.19 (7), Florida Statutes (2011) (paragraph 13 above), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28 (3) (c), Florida Statues, to verify the correction of the violations. 16. The citation of the Class II deficient practice based on the 9 February, 2012, survey was the subject of a complaint. 17. Respondent is therefore subject to a survey fee of $500.00, pursuant to Section 429.19 (7), Florida Statutes (2011). WHEREFORE, the Agency intends to impose a survey fee of $500.00 against Respondent, an ALF in the State of Florida, pursuant to Section 429.19 (7), Florida Statutes (2011). Submitted this 7 day of June, 2012. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building 525 Mirror Lake Dr. N., Suite 330H St. Petersburg, FL 33701 Ph: (727) 552-1942 Fax: 552-1440 L. 7 . CO ; py Cher O. /' Edwin D. Selby, Esq. Fla. Bar No. 262587 Attorney for Petitioner
