The Issue Whether either or both of the certificate of need applications of North Shore Medical Center, Inc., and Victoria Hospital Partnership should be approved.
Findings Of Fact Victoria Hospital's Proposal Victoria Hospital ("Victoria") is an acute care hospital licensed for 300 beds. It is located close to downtown Miami in an area called "Little Havana." It has been in existence as a private hospital in Miami since 1924. Over ninety percent (90 percent) of Victoria's patients and medical staff are Hispanic. One hundred percent (100 percent) of its psychiatrists are Hispanic. The hospital is owned and operated by Victoria Hospital partnership, which is a partnership of a group of one hundred physicians and Columbia Hospital Corporation formed in 1988. Of its three hundred (300) beds, two hundred sixty (260) are acute-care beds, twenty (20) are psychiatric, and twenty (20) are substance abuse beds. In its CON application, Victoria proposes to convert ten (10) acute care beds (which were 47 percent occupied in 1990-91) to ten (10) additional adult psychiatric beds for a capital expenditure of $142,586.30. The existing 20-bed adult psychiatric unit was 88 percent occupied in 1990-91. Victoria Hospital is accredited by the Joint Commission on Accreditation of Health Organizations. North Shore's Proposal North Shore Medical Center, Inc. ("North Shore"), is a private, not- for-profit corporation which owns and operates North Shore Medical Center, a three hundred fifty seven (357) bed acute care facility, which has operated a psychiatric unit since 1985. North Shore is located in an area of Dade County, which is north of Northwest 20th Street and east of the Palmetto Expressway. The total service area population is over 800,000, and ninety percent (90 percent) of North Shore's patients reside in the service area. North Shore's existing twenty (20) bed adult psychiatric unit is a locked or closed unit, which is a designated Baker Act receiving facility. As such, North Shore admits court ordered involuntary patients for examination to determine whether hospitalization is needed. Some Baker Act patients are among the most seriously ill psychiatric patients, therefore, a locked or closed unit is required by the state to prevent involuntary patients from leaving. North Shore meets code requirements for safety in locked units, including break-away shower and curtain rods, protective features on all windows, secure areas, and policies for removing sharp and glass objects from patients. North Shore proposes to convert up to twenty (20) medical/surgical beds (utilized in 1990 at less than 40 percent) to up to twenty (20) additional adult general psychiatric beds for a project cost not to exceed $300,000. The existing twenty (20) adult psychiatric beds were 87 percent occupied in 1990. North Shore proposes to accept a condition to provide 5 percent of its total psychiatric unit patient days to Medicaid patients and 5 percent to indigent care. To serve more physically frail patients, North Shore proposes to use new beds approved as a medical/psychiatric unit to treat psychiatric patients who also need medical care. Currently, psychiatric patients in need of medical care are treated in the psychiatric unit when they do not require intravenous or oxygen therapy, treated on the medical floors of North Shore, or sent to nursing homes. AHCA Review The Agency for Health Care Administration (AHCA) is the single state agency authorized by statute to issue, deny or revoke CONs in Florida. See, Subsection 408.034(1), Florida Statutes (Supp. 1992). The parties have stipulated to the following facts: The applicants' letters of intent, public notices, application fees, applications and omissions responses, were timely received and in proper form The applicants' projections for project completion costs and project completion fore- casts are reasonable. The architectural drawings and floor plan layouts and costs of construction presented by the two applicants are reasonable and adequate. The projects proposed by both applicants are financially feasible in the short and long term, provided that the applicants' projected utilization is proven to be reasonable and attained. The projections concerning the proposed staffing of the project are reasonable and adequate. Each applicant has a history of providing quality of care and has demonstrated an ability to provide such care. Prehearing Stipulation, paragraph 8. On February 7, 1992, the Agency published a fixed need pool for inpatient adult psychiatric beds in its District 11. The published pool reflected a zero net need for additional adult psychiatric beds in the district. The Agency calculation of numeric need for additional adult psychiatric beds was performed in accordance with methodology requirements found in the inpatient psychiatric services rule ("psych rule"), Rule 59C-1.040(4)(c), Florida Administrative Code. The July 1997 planning horizon projection for District 11 showed a need for two beds without adjustment for occupancy. However, since the District 11 occupancy for the applicable period was 73.57 percent, or below the 75 percent occupancy threshold requirement, numeric need defaulted to zero. Subsection (4)(a) of the psych rule provides that additional adult psychiatric beds are not normally approved by the Agency in the absence of a need shown pursuant to the rule methodology. Subsection (4)(d) of the psych rule specifies one example of a condition in which an existing provider of adult psychiatric services may be approved for additional beds without a determination of numeric need and in the absence of district average occupancy requirements. That exception applies to providers with occupancy rates equal to or in excess of 85 percent for the 12 month period ending 6 months prior to the quarter in which the fixed need pool is published. This rule provision is one, but not the sole, factor in considering whether a provider should be granted additional beds. Other factors are those in Section 381.705, Florida Statutes (1991), and in other subsections of the psych rule. AHCA agrees that, for the July 1990 to June 1991 utilization period, both Victoria and North Shore had an average occupancy in their adult psychiatric units which equaled or exceeded eighty-eight percent (88 percent) and eighty-seven percent (87 percent) respectively. Review criteria as applied to the Victoria Hospital Proposal Subsection 381.705(1)(a)--District 11 Plan The 1990 District 11 health plan includes preferences for the review of CON proposals for inpatient psychiatric services which apply to the review of the Victoria application. The first preference is given when a conversion from acute care beds to psychiatric beds is proposed by an applicant which has provided the highest proportion of charity care and Medicaid days, as indicated by reimbursement as a disproportionate share provider. AHCA agrees that for 1990-1991, Victoria was a disproportionate share hospital. Secondly, publicly funded facilities receive a preference when applying for psychiatric beds. Victoria is not a publicly funded facility, and is not entitled to the preference. The third district preference is given to applicants for adult psychiatric beds who have a history of using, or who propose to use, treatment modalities resulting in an average length of stay of twenty days or less, with individualized follow-up care. Victoria is entitled to this preference, having established that its average length of stay is 12.8 days. See, also Finding of Fact 21. The fourth district preference is given to applicants for inpatient psychiatric programs accredited by the Joint Commission on Accreditation of Health Care Organizations ("JCAHO"). Victoria Hospital and its psychiatric programs are accredited by the JCAHO. The fifth district preference applies to applicants who include discharge planning and follow-up case management proposals. Victoria has an extensive discharge planning and follow-up program. Finally, the district plan has a preference for an applicant who will meet a demonstrated need for services for an identified ethnic group. With a showing that its therapies are provided in Spanish and that its psychiatric program takes into consideration cultural differences of some Hispanic persons, Victoria has demonstrated a commitment to serve an identified ethnic group. Subsection 381.705 (1)(a)--State Health Plan The preferences related to inpatient psychiatric services in the 1989 Florida State Health Plan also apply as review criteria in this case. A preference for applicants proposing the conversion of excess acute care hospital beds to establish a separate and distinct psychiatric unit, is supportive of Victoria's CON application. See, Finding of Fact 4. Preference is also given to an applicant who includes among its patients, the most seriously mentally ill people. Even though it does not have a locked unit, Victoria has proposed to treat a wide range of serious mental illnesses, particularly those combined with substance abuse problems. Preference is also given to an applicant who proposes to serve indigent and Baker Act patients. As a for-profit hospital without a locked unit, Victoria is not eligible for Baker Act designation. Victoria also proposed to make no commitment, as a condition for the approval of the CON, to serve indigents. However, Victoria's status as a disproportionate share provider outweighs its failure to commit to charity or medicaid patient days in a 10-bed psych unit. The state health plan also includes a preference for proposals which include a continuum of care, with follow-up outpatient programs. Victoria's proposal meets the preference. By its past participation in Medicaid and its projection of 50.5 percent Medicaid patient days in the psychiatric unit, Victoria meets the preference for providers serving Medicaid patients. Victoria Hospital also qualifies for a separate state preference as a disproportionate share hospital for fiscal year 1990-1991, although the testimony about its subsequent status was inconclusive. The percentage of psychiatric beds located in acute care hospitals in District 11 is .28 per 1,000 population, which exceeds the minimum of .15 per 1,000 favored in the state health plan. Therefore, the preference cannot be met by Victoria. Two other state health plan preferences (1) for the construction of separate structures for children and adolescents, and (2) for services to substance abusing pregnant and postpartum women are not applicable to or included in the programs proposed by Victoria. Subsection 381.705(1)(b), (c) and (d)--increasing access, availability, efficiency, history of quality care, alternatives and need. AHCA preliminarily denied Victoria's application based, in large part, on Victoria's failure to adequately explain why access to the proposed services is not available in other underutilized facilities in the district. At hearing, although it disputed the applicability of the requirement, Victoria showed that most of the underutilized facilities have a mix of patients by payer categories which differs significantly from the norm for the district. In the case of specialty hospitals, for example Medicaid reimbursement is not available, although 22 percent of the psychiatric patients in District 11 are Medicaid patients. In three of five underutilized general acute care hospitals, the Medicaid percentage as compared to the district norm was also low. In another hospital, the payer mix was composed of more than double the district norm for commercially insured patients. The parties, by Prehearing Stipulation, agreed that Victoria has historically provided quality care, and has been appropriately staffed and managed. See, also Subsections 381.705(1)(c) and (h). Victoria's proposal also meets other psych rule requirements which positively impact the quality of care, including minimum unit size, outpatient services, screening procedures, and ancillary therapies. Victoria has demonstrated a need for its service to Hispanic patients and to Medicaid patients. The alternative of having psychiatrists refer patients to other facilities is currently being used by Victoria within the constraints of financial accessibility. See, Finding of Fact 32. Subsection 381.705(1)(i)--Utilization and Financial Feasibility AHCA questioned, in Victoria's financial pro forma, its projected increase in utilization. With a psychiatric unit waiting list averaging 11 patients per week and an increase in admitting staff psychiatrists from 33 in 1991 to 37 in 1992, Victoria's projections of an increase of 2 to 4 additional admissions per week is reasonable. As a result of the finding that Victoria's projected utilization is reasonable, as stipulated, Victoria's proposal is, financially feasible in the immediate and long term. In addition, as stipulated, Victoria's construction plans are reasonable and adequate. Balancing Criteria Of the inpatient psychiatric services preferences in the state health plan, Victoria's application is not supported by the preferences for health maintenance organizations and for facilities serving Baker Act patients. Of the local health plan preferences, Victoria's application is not consistent with the preference for publicly funded facilities. On balance, Victoria's proposal complies with applicable review criteria, and will have a positive institutional effect of shifting beds to a needed, profitable service, thereby increasing cost effectiveness. In addition, there was no evidence of any adverse impact on other providers of inpatient psychiatric services. Review criteria as applied to North Shore's Proposal, Subsection 381.705(1)(a)--District 11 plan The 1990 District 11 plan also applies to the review of the North Shore CON application, which is also the subject of review in this case. North Shore is not a disproportionate share provider and is not a publicly funded facility. See, Findings of Fact 17 and 18. North Shore has an average length of stay of 18.1 days in its psychiatric unit, and is entitled to preference as a provider with an average length of stay below 20 days with appropriate discharge and after care planning. See, Findings of Fact 19 and 21. North Shore's hospital and psychiatric program are JCAHO accredited. See, Finding of Fact 20. North Shore proposes to serve identified ethnic groups, particularly Haitians and Hispanics. All signs and directions in the hospital are in English, Spanish and Creole. Its staff of 291 bilingual employees is able to communicate in 21 languages. See, Finding of Fact 22. Subsection 381.705(1)(a)--State Health Plan North Shore's application meets the preference for conversion of 20 excess acute care beds, with 45.83 percent utilization in 1990-1991, to a 12 or 20 bed adult psychiatric unit. From 1990-1991, the existing 20 psychiatric beds were utilized in excess of 85 percent. See, Finding of Fact 8. North Shore is a non-for-profit hospital, which qualifies for the preferences for serving Baker Act and other seriously mental ill adults. See, Findings of Fact 7, 25 and 26. North Shore is willing to accept a CON conditioned on its providing 5 percent of total patient days in the additional psychiatric beds to indigents. See, Finding of Fact 26. North Shore's proposed medical/psychiatric services will include follow-up and outpatient services. See, Finding of Fact 27. In 1990, HCCB data showed that North Shore provided 6.8 percent total Medicaid patient days, and 2 percent in its existing psychiatric unit, but North Shore does not qualify as a disproportionate share Medicaid provider. The special preference for applicants in districts with fewer than .15 psychiatric beds per 1000 population in acute care hospitals does not apply to this case. See, Findings of Fact 30. North Shore is proposing to coordinate its psychiatric, substance abuse and prenatal programs to pregnant or postpartum women. There is no proposal to serve children and, therefore, no proposal to construct a separate facility for children. See, Finding of Fact 31. Subsection 381.705(1)(b), (c) and (d)--Increasing Access, Availability, Quality of Care; Alternatives and Need Although AHCA conceded that the North Shore proposal will partially improve availability and access without any adverse impact, AHCA preliminarily denied the CON application of North Shore, in large part based on North Shore's failure to explain why facilities operating at 75 percent occupancy or below do not provide adequate alternatives. In March 1990, North Miami Medical Center closed and six of its psychiatrists moved their practices to North Shore. As a result, North Shore's admissions increased 48 percent and occupancy reached 95 percent. North Shore has a policy of delaying patient admissions for 24 hours so that a bed is always available for emergency, suicidal or Baker Act patients. More specifically, in evaluating the availability of alternatives, North Shore noted that the district occupancy is 73.57 percent but is in excess of 75 percent in the five facilities nearest to North Shore. In the district, the psychiatric services at Jackson Memorial Hospital and Palmetto are most like those at North Shore, provided in general acute care hospitals which can accept Medicaid and Baker Act patients. In 1990- 91, Jackson Memorial's occupancy was 77.76 percent and Palmetto's was 80.3 percent. The general acute care hospitals under 75 percent occupancy without Baker Act certification, were considered as possible alternatives for North Shore's voluntary adult patients. They are Deering, Humana-Biscayne, Larkin, Mercy and Mt. Sinai. Deering and Larkin are 45 minutes to 1 hour south of North Shore. Humana-Biscayne and Mt. Sinai are Medicare providers at 78 percent and 94 percent respectively, indicating service to geriatric patients in greater numbers than the norm for the district. Mercy, with a payer mix most comparable to the overall district, had an occupancy rate in excess of the district average threshold of 75 percent (78.87 percent) for the approval of new beds in 1990- 1991. Another alternative considered by North Shore at hearing is Charter Hospital. Charter's occupancy is only 59.66 percent, but its location is approximately an hour west of North Shore. In addition, Charter, Southern Winds, Harbor View and Grant Center are specialty hospitals which cannot accept Medicaid. North Shore has established the need for some medical/psychiatric beds in the district, because there are no beds in the district to meet these combined needs. In addition, alternative providers of adult psychiatric services for comparable payer groups, which are geographically accessible to North Shore's area, exceed 75 percent occupancy. Subsection 381.705(1)(i)--Utilization and Financial Feasibility AHCA contends that North Shore's reliance on its waiting list to support projected admissions is in error, because the waiting list is, in reality, a "reservations" system. In support, AHCA notes that 22 percent of wait listed patients cancel and refuse treatment. AHCA also questioned North Shore's projections of the number of admissions which will result from the waiting list and from the emergency room. North Shore asserted that voluntary mental patients sometimes refuse treatment in locked units. In addition, medically ill patients cannot be accommodated in a locked unit. These were considerations given in planning an "unlocked" medical/psychiatric unit. Between January 1991 and December 1991, 209 patients were placed on the waiting list. As mentioned by AHCA, 22 percent of those reservations were cancelled. The expectation of fewer cancellations for an unlocked unit is reasonable. North Shore was able to establish that fourteen patients on the waiting list were admitted elsewhere, and three to North Shore in a subsequent month. Of the fourteen admitted elsewhere, five had conditions which could be served in medical/psychiatric units, but were admitted to medical/surgical units. North Shore's projection that it could have admitted two to four patients from its waiting list to a medical/psychiatric unit is supported by its analysis of the ultimate placement of patients on the 1991 waiting list. North Shore quantified and reasonably projected these admissions based on the following: one patient a week from the emergency room, approximately two patients a week from the medical floor, additional admissions based on patient referrals by new staff psychiatrists, fewer refusals of voluntary treatment in an unlocked unit, and the ability to serve patients in an unlocked unit who are referred to the existing psychiatric unit but do not meet the current admissions criteria. North Shore will achieve a forty percent (40 percent) occupancy in the first year, if one patient per week is admitted to the unit. North Shore's projected utilization is reasonable and, by stipulation, the project is financially feasible in the immediate and long term. AHCA's Application of Other Rules Comparable to the Eighty-five Percent (85 percent) Occupancy Rules Comparable occupancy exceptions are also included in the substance abuse rule [Rule 59C-1.041(4), Florida Administrative Code], acute care rule [Rule 59C-1.038(7), Florida Administrative Code], the neonatal intensive care rule [Rule 59C-1.042(3), Florida Administrative Code], and the comprehensive medical rehabilitation rule [Rule 59C-1.039(5), Florida Administrative Code]. According to AHCA witness Elizabeth Dudek, there have been several circumstances, probably under five, where the Department has awarded beds when there was no need and the minimum district occupancy standard was not met, but an institution's occupancy exceed the threshold in the rule.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that, alhough Vicotria has otherwise demonstrated its entitlement to Certificate of Need Application No. 6955 to convert ten (10) acute case beds to general adult psychiatric beds, the Agency for Health Care Administration issue a Final Order denying such application due to a change in the identity of the applicant, in violation of Rule 59C-1.008(1)(c), Florida Administrative Code, and granting Certificate of Need Application 6956 to convert up to twenty (20) acute care beds to general adult psychiatric beds at North Shore with the condition that 5 percent of the patient days for the additional 20 beds be dedicated to each Medicaid and indigent care. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 9th day of September 1993. ELEANOR HUNTER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 10th day of September, 1993.
Findings Of Fact At all times material to the Administrative Complaint, the Respondent was licensed as a Registered Nurse in the State of Florida, holding License No. RN 1471852. (Admission #2). From May 19, 1980 until April 6, 1988, the Respondent was employed at HCA North Florida Regional Medical Center, Gainesville, Florida. (Admission #4). The Respondent made charting errors or failed to chart as alleged in the Administrative Complaint regarding patients at North Florida Regional Medical Center. This constitutes unprofessional conduct proscribed by Chapter 464, Florida Statutes. See the Respondent's admissions through counsel at hearing. The Respondent saw a counselor at Charter Springs Hospital for an evaluation. Whether the Respondent was a participant in the Impaired Practitioner's program is unclear, and whether this evaluation was part of that program is also unclear. In the preparation for that interview, the Respondent executed two release forms, Michel's Exhibits 1 and 2. These release forms bear the following direction: PROHIBITION ON REDISCLOSURE: THIS INFORMA- TION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THIS INFORMATION. Michel's Exhibit 3, an information sheet on the intervention program for nurses, states in pertinent part regarding potential release of information as follows quoting from Section 464.0185(6)(b), Florida Statutes: If, in the opinion of such a consultant after consultation with the provider, an impaired nurse who is enrolled in an approved program has not progressed satisfactorily, then the consultant shall disclose to the department all information in his possession regarding such nurse.... The Petitioner offered no evidence that the Respondent was ever accepted into the program. Respondent's Exhibit 4, a screening form for the impaired nurse program, contains the following question and language: "Immediate reason for applying to the IPN program?" and, "I understand participation in the IPN program will be for at least 2 years from the date of acceptance or beginning of treat- ment." The Petitioner offered no evidence that a consultant ever determined that the Respondent was not "progressing satisfactorily." The Respondent's admission that she was dismissed from the program falls short of proving lack of progress. There was no predicate established for the release of the information, notwithstanding the prohibition against redisclosure. While evidence was presented concerning the failure to chart, there was no evidence of failure to file out those forms required to be annotated when control substances are administered. No evidence was received regarding Respondent's alleged possession of drugs, sale of drugs, and falsification of records.
Recommendation Based upon the foregoing findings of fact and conclusions of law, and considering the length of time since the events and the lack of proof of the other charges, it is RECOMMENDED that the Respondent receive a letter of reprimand. RECOMMENDED this 25th day of July, 1991, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this day of July, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 91-2087 Petitioner's Proposed Findings of Fact Duplicates paragraph 2. Adopted, as amended. 3-4. Adopted and combined. 5-19. Unnecessary in light of the Respondent's admission that she did not chart professionally in violation of Chapter 464, Florida Statutes. Rejected as contrary to the facts. There was no evidence that the Respondent was accepted into the IPN project for nurses. There is an admission tht she was dismissed from it. However, the grounds and status for dismissal were not established by evidence or admissions. Rejected as not being based upon the evidence presented. 22-24. Unnecessary in light of the Respondent's admission that she did not chart professionally in violation of Chapter 646, Florida Statutes. 25-26. Admitted for the purpose of establishing the reason for the Charter Springs evaluation. Exhibit 5 was excluded upon objection by the Respondent because of the confidential nature of the examination and information developed in it and the limits on the release of this information. In addition, the exact source of the information is uncertain. The information in the report not only came from the Respondent but from other persons at the hospital. Exhibit 5 was excluded upon objection by the Respondent because of the confidential nature of the examination and information developed in it and the limits on the release of this information. In addition, the exact source of the information is uncertain. The information in the report not only came from the Respondent but from other persons at the hospital. Source is "Deposition, page 5"; however, no deposition was ever introduced into the record. See attached copy of the docket sheet and transcript. Exhibit 5 was excluded upon objection by the Respondent because of the confidential nature of the examination and information developed in it and the limits on the release of this information. In addition, the exact source of the information is uncertain. The information in the report not only came from the Respondent but from other persons at the hospital. Adopted as paragraph 2 of this Recommended Order. Irrelevant. 33-35. Unnecessary in light of the Respondent's admission that she did not chart professionally in violation of Chapter 464, Florida Statutes. 36-37. Exhibit 5 and testimony surrounding it was excluded. Admission does not support the proposed factual statement. The testimony does not support the proposed factual statement. The Respondent signed out for drugs for patients at approximately the same time the doctor changed the orders. It is possible that the Respondent had no knowledge of the doctor's orders had changed. 34. (SIC) Appears to duplicate paragraph 34. See comments for paragraph 34 above. COPIES FURNISHED: Judie Ritter, Executive Director Board of Nursing Department of Professional Regulation 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202 Jack McRay, Esquire General Counsel Department of Professional Regulation Northwood Centre, Suite 60 1940 North Monroe Street Tallahassee, FL 32399-0792 Tracey S. Hartman, Esquire Department of Professional Regulation Northwood Centre, Suite 60 1940 North Monroe Street Tallahassee, FL 32399-0792 Rodney Smith, Esquire P.O. Box 628 Alachua, FL 32615
Conclusions THE PARTIES resolved all disputed issues and executed a Settlement Agreement. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. DONE and ORDERED on this the @ day of Z, Vuctrae. , 2015, in Leon County, Tallahassee, Florida. Filed March 10, 2015 3:08 PM Division of Administrative Hearings A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A 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 PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: William M. Blocker, II Medicaid Finance & Health Systems Chief Counsel Agency for Health Care Administration William.Blocker@ahca.myflorida.com (Electronic Mail) Joanne B. Erde, P.A. DUANE MORRIS, LLP 200 South Biscayne Blvd., Suite 3400 Miami, Florida 33131-2318 JErde@duanemorris.com (Electronic Mail) Thomas J. Wallace, Bureau Chief, Medicaid Program Finance Finance and Accounting Health Quality Assurance CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to _ the above named addressees by electronic mail or inter-office mail on this the re day of L Le ehy , 2015. Richard J. Shoop, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308-5403 (850) 412-3630/FAX (850) 921-0158
The Issue Whether the Respondent committed the violation alleged in the Amended Administrative Complaint and, if so, what penalty should be imposed.
Findings Of Fact The Department is the state agency charged with the responsibility of regulating the practice of nursing in the State of Florida. At all times material the allegations of this case, the Respondent was a licensed registered nurse, license number RN 3254372. At all times material to the allegations of this case the Respondent was employed at the North Shore Medical Center located in Miami, Florida. The Respondent was assigned to the pediatric floor and was to provide nursing services to patients on that floor during her duty hours. Tamy Ziaukas was also employed at North Shore and had been there prior to the Respondent's employment. Ms. Ziaukas was designated the senior nurse for the pediatric floor from 11:00 p.m. until 7:00 a.m. As such, she helped coordinate the work for the nurses assigned to the floor. Although technically not a supervisor, Ms. Ziaukas did perform duties as a charge nurse for the floor. The Respondent did not appreciate the manner in which Ms. Ziaukas assumed and performed the duties of charge nurse for the floor. Although their disagreement was little more than a personality conflict, the Respondent maintains that such disagreement fueled the allegations of the instant case. Such contention is not supported by the persuasive evidence in this case. To the contrary, the weight of the credible evidence supports the finding that the Respondent inappropriately handled a pediatric patient on or about September 29, 1998. The Respondent responded to a pediatric patient whose I-V had come out. The patient was agitated and did not want the line to be reinserted. Three nurses were present for the procedure. Respondent was to insert the I-V while Ms. Ziaukas and another nurse, Ms. Mezadieu, assisted. The patient continued to be difficult. When the patient refused to cooperate, the Respondent either slapped or pushed the patient on his face to get him to submit to the procedure. The force of the slap was not sufficient to leave a mark on the patient's face. Nevertheless, Ms. Ziaukas reported the incident to her supervisor; moreover, the Respondent reported the incident to the patient's physician. When the nurses were questioned about the incident Ms. Ziaukas characterized the touch as a "slap." The Respondent did not deny touching the child but said it was a "push" to get the child to calm down. The third witness to the incident has no current recollection of the event. Statements taken from the witnesses at or near the time of the incident confirmed that the Respondent touched the child's face. The use of a forceful push or slap to a pediatric patient's face would not be medically necessary. A difficult patient may be held down or subdued without inappropriately touching the face. Prior to this incident, the Respondent had performed all aspects of her job in a satisfactory manner. The Respondent was given the opportunity to attend an anger management class but declined the employer's offer. Subsequently, the Respondent left employment at North Shore Medical Center.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Nursing enter a Final Order imposing an administrative fine in the amount of $250, requiring the Respondent to remit the agency's costs in prosecuting this case, requiring the Respondent to complete an anger management course, and placing the Respondent on probation for a period of three years. DONE AND ENTERED this 3rd day of October, 2001, in Tallahassee, Leon County, Florida. J. D. PARRISH 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 3rd day of October, 2001. COPIES FURNISHED: Reginald D. Dixon, Esquire Agency for Health Care Administration Post Office Box 14229, Mail Stop 39 Tallahassee, Florida 32317-4229 Peter Loblack, Esquire Law Office of Peter Loblack, P.A. Office Parks at California Club 1030 Ives Dairy Road, Suite 132 Miami, Florida 33179 Lawrence Allen Schwartz, Esquire 8005 Northwest 155th Street Miami, Florida 33016 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way Bin A00 Tallahassee, Florida 32399-1701 Ruth R. Stiehl, Ph.D., R.N., Executive Director Board of Nursing 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714
Conclusions THIS CAUSE came on for consideration before the Agency for Health Care Administration (“the Agency”), which finds and concludes as follows: 1. The Agency issued the Petitioner a letter denying her application for exemption from disqualification from employment. (Exhibit 1) 2. The Petitioner requested a formal administrative hearing and the case was referred to the Division of Administrative Hearings (DOAH). 3. Subsequently, the Petitioner and the Agency filed a Stipulation of Dismissal without Prejudice. The Administrative Law Judge issued an order closing file with leave to re-open the matter and relinquishing jurisdiction to the Agency. (Exhibit 2) 4. The denial of the Petitioner’s application for exemption from disqualification from employment is UPHELD without prejudice to the Petitioner reapplying for an exemption from disqualification from employment in the future. ORDERED in Tallahassee, Florida, on this £75 day wo Phawh 2015. CBee Agency for Health Care Administration Filed March 19, 2015 9:19 AM Division of Administrative Hearings
Other Judicial Opinions A party that is adversely affected by this Final Order is entitled to seek 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, 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 along with filing fee as prescribed by law, days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I] HEREBY CERTIFY that a true and correct copy named persons/entities by the method designated on this _/ ay of Lfare& is Final Order was served on the below- Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone (850) 412-3630 Jan Mills Facilities Intake Unit Agency for Health Care Administration (Electronic Mail) Taylor Haddock, Supervisor Background Screening Unit Bureau of Long Term Care Services Agency for Health Care Administration (Electronic Mail) Lindsay Granger, Assistant General Counsel Office of the General Counsel Agency for Health Care Administration (Electronic Mail) Lorenzo Palomares, Esquire Palomares-Starbuck and Associates 2333 Brickell Ave., Suite A-1 Miami, FL 33129 (U.S. Mail) John G. Van Laningham Administrative Law Judge The Division of Administrative Hearings (Electronic Mail)
Conclusions THE PARTIES resolved all disputed issues and executed a settlement agreement, which is attached and incorporated by reference. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. DONE AND ORDERED this /6 & day of May , 2014, in Tallahassee, Leon County, Florida. Secretary Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A Filed May 23, 2014 8:29 AM Division of Administrative Hearings 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 PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Theodore E Mack Powell & Mack 3700 Belwood Drive Tallahassee, Fl] 32303 tmack@talstar.com (Via Electronic Mail) Shena L. Grantham Assistant General Counsel Mercedes Bosque, Audit Administrator (Interoffice mail) Finance & Accounting (Interoffice mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served on the regan persons, by Electronic Mail/U.S. Mail or interoffice mail as indicated on this lay 0 the /7 a 2014. Richard Shoop, Agency Clef. State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403
Conclusions THE PARTIES resolved all disputed issues and executed a settlement agreement, which is attached and incorporated by reference. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. DONE AND ORDERED this /6 id day of May , 2014, in Tallahassee, Leon County, Florida. LML Elizabeth Dudek Secretary Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A Filed May 23, 2014 8:40 AM Division of Administrative Hearings 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 PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Theodore E Mack Powell & Mack 3700 Belwood Drive Tallahassee, Fl 32303 tmack@talstar.com (Via Electronic Mail) Shena L. Grantham Assistant General Counsel Mercedes Bosque, Audit Administrator (Interoffice mail) Finance & Accounting (Interoffice mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served on the ab ed persons by Electronic Mail/U.S. Mail or interoffice mail as indicated on this the £7*day of we State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403
The Issue Whether Respondent committed the violations alleged in the Administrative Complaints? If so, what disciplinary action should be taken against him?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: The Parties The Agency is a state government licensing and regulatory agency. Respondent is now, and has been since August 27, 1971, a physician licensed to practice medicine in the State of Florida. He holds license number ME 0018306. Respondent previously faced charges of professional misconduct in DPR Case No. 89-0925. In that case, Respondent was charged with practicing medicine with an inactive license from on or about January 1, 1984, until on or about November 22, 1989. The matter was resolved by the parties entering into a settlement stipulation, which was approved by the Board of Medicine in a final order entered August 13, 1990. Under the terms of the agreement, Respondent, without admitting his guilt, agreed to pay a $500.00 administrative fine and not to "in the future violate Chapters 455, 458 and 893, Florida Statutes, or the rules promulgated pursuant thereto." Facts Relating to Case No. 93-2640/Administrative Complaint #1 From on or about February 8, 1991, to March 24, 1991, patient R.D., a 43 year old male who had tested positive for the Human Immunodeficiency Virus (HIV), was hospitalized at North Florida Reception Medical Center Hospital (hereinafter referred to as "MCH"). During his hospitalization, R.D. received treatment for advanced Acquired Immunodeficiency Syndrome (AIDS) and related complications. Elizabeth Mutch, M.D., was R.D.'s attending physician at MCH. R.D. was experiencing difficulty in swallowing oral medications due to multiple ulcerations in his mouth secondary to an uncontrolled Herpes Virus. On or about March 16, 1991, Dr. Mutch determined that R.D. would benefit from intravenous medications through a central venous line. She therefore wrote an order for "central venous line placement Monday 3/18." In another written order, she directed that "IV fluids [be held] until central venous line in place." Both orders were dated March 16, 1991. In her progress notes for March 16, 1991, Dr. Mutch indicated "Central line ASAP." In the middle of March of 1991, Respondent was the acting medical director of MCH. In addition to his duties as acting medical director, he was on the staff of the hospital's internal medicine department. Respondent was the only internist on staff at the hospital with any significant experience in central line placements of the type ordered by Dr. Mutch, although there was a surgeon affiliated with the hospital, a Dr. Capliwski, who had such experience and in fact performed most of the placements needed by patients at the hospital. Sometime after she wrote the order for central venous line placement for R.D., Dr. Mutch verbally requested Respondent to attempt such placement at his earliest possible convenience. On March 18, 1991, Respondent made approximately five unsuccessful attempts to place a subclavian venous line in R.D., the first of which yielded air, indicating that R.D.'s lung had been punctured. Following these unsuccessful placement attempts, Respondent ordered a chest x-ray for R.D. The x-ray taken revealed no evidence of pulmonary distress. Respondent's progress notes for March 18, 1991, do not reflect that he ordered a surgical consultation that day after his placement attempts failed. The next two or three days Respondent was out of town on hospital business in his capacity as the hospital's acting medical director. Respondent reasonably assumed that, in his absence from the hospital, Dr. Mutch would ask Dr. Capliwski to try to perform the central venous line placement that she had initially requested Respondent to attempt. Upon his return to the hospital, Respondent learned that no such attempt had been made. Respondent therefore again made several attempts at central venous line placement. Placement was attempted via R.D.'s jugular vein. While the approach was different, the results were the same. Respondent was unable to accomplish his objective. Following this second series of unsuccessful placement attempts, Respondent ordered another chest x-ray for R.D. On March 24, 1991, at approximately 1:00 a.m., R.D. began to have difficulty breathing. He also had a rapid heart rate, a pulse rate of 140, a respiratory rate of 30, and a temperature of 103.3. degrees. Respondent was the "on call" physician. He was at home, approximately 35 miles away from the hospital. The duty nurse telephoned Respondent and spoke with him about R.D. 3/ Respondent instructed the nurse to give R.D. Tylenol and to make sure that he was receiving oxygen. He did not suggest that R.D. be seen by Dr. Chandler, the physician manning MCH's emergency room. By 9:15 p.m. that same day, R.D.'s condition had further deteriorated. His respiratory rate had increased to 40. The duty nurse again telephoned Respondent at home and informed him of R.D.'s deteriorating condition. This time Respondent directed that R.D. be immediately evaluated by Dr. Chandler. In accordance with Respondent's directive, Dr. Chandler was contacted. He ordered a chest x-ray for R.D. The x-ray revealed a 50 percent pneumothorax with right mediastinal shift. Dr. Chandler therefore performed an emergency thoracotomy. Arrangements were then made to transfer R.D. to Lake Shore Hospital. At approximately 10:10 p.m. on March 24, 1991, shortly after he was placed in the ambulance that was to transport him to Lake Shore Hospital, R.D. experienced respiratory arrest and expired. An autopsy was performed by Carolyn Hopkins, M.D., of the local Medical Examiner's Office. The autopsy report prepared by Dr. Hopkins lists "complications of acquire[d] immunodeficiency syndrome" as the cause of death. More specifically, Respondent died as a result of a tension pneumothorax. Facts Relating to Case No. 93-2683/Administrative Complaint #2 Counts 1 and 2 Respondent's license to practice medicine in the State of Florida was inactive due to non-renewal from on or about December 31, 1983, until approximately November of 1989. Respondent engaged in the practice of medicine at Cypress Medical and Professional Centre (hereinafter referred to as the "Centre") in Winter Haven, Florida, during a portion of the period that his medical license was inactive. On or about September 12, 1989, Respondent entered a plea of nolo contendere to the criminal offense of referring a patient to a business entity without disclosure of financial interest, in violation of Section 458.327(2)(c), Florida Statutes (1989). It was stipulated by Respondent and the prosecutor at the time of the entry of the plea that the crime to which Respondent pled was a lesser included offense of the crime of practicing medicine without a license. On or about October 25, 1989, adjudication of guilt was withheld and Respondent was ordered to pay a $500.00 fine. Counts 3, 4 and 5 On January 20, 1989, patient M.L. went to the Centre complaining, among other things, of chronic headaches. M.L. was first seen by a chiropractor at the Centre, who referred her "to M.D. for complete detailed neurologic-orthopedic exam." On January 24, 1989, M.L. was examined by Respondent at the Centre. The records maintained at the Centre reflect that, during this initial examination, Respondent explored the history and possible etiology of M.L.'s chronic headaches. The entries made on the Progress Notes and Patient Control Sheet maintained at the Centre (11 of which apparently were made by, or at the direction of, Respondent) reflect that M.L. visited the Centre on 21 different occasions. Bills from the Centre for 20 of these 21 visits were signed by Respondent. 4/ The Progress Notes and Patient Control Sheet do not reflect that Respondent saw M.L. on all 20 visits covered by these bills. Facts Relating to Case No. 94-0234/Administrative Complaint #3 On November 22, 1989, patient A.M.D., a 40-year old female, presented to the emergency room at Polk General Hospital (hereinafter referred to as "PGH") in Bartow, Florida, with complaints of a high fever, abdominal pain, vomiting and coughing. An examination revealed that she had rapid pulse and respiration rates. It was further observed that she had a flushed face and epigastric tenderness. A.M.D. was treated in the PGH emergency room with, among other things, an antibiotic, vibramyacin, for which she was also given a prescription. She was then discharged. A.M.D. returned to the PGH emergency room on November 23, 1989, with symptoms similar to those with which she had presented the previous day. She was again treated and discharged. Records of these two emergency room visits were made and kept by the hospital. A.M.D. paid a third visit to the PGH emergency room on November 24, 1989, with symptoms similar to those she had exhibited during her first two visits. On this occasion, she was admitted to PGH in the care of Respondent. She remained in Respondent's care throughout her entire stay at the hospital. As her attending physician, it was incumbent upon Respondent to review the records of A.M.D.'s prior two emergency room visits. Upon A.M.D.'s admission to the hospital, Respondent failed to order multiple blood cultures, notwithstanding that, as Respondent should have known, Respondent was already on an antibiotic. A single blood culture is insufficient to properly diagnose the condition of such a patient. Respondent's initial diagnosis of A.M.D., made without the benefit of results of multiple blood cultures, was undetermined gastrointestinal problems. A.M.D. was treated with, among other things, antibiotics. Although A.M.D. still had a high fever following the first several days of her hospitalization and the diagnosis of her condition remained obscure, Respondent did not attempt to obtain a consultation with an infectious disease specialist, 5/ nor did he order that A.M.D.'s treatment plan be modified to include intravenous administration of high dosages of at least two different broad spectrum, latest generation antibiotics. A.M.D. continued to run a fever until December 4, 1989, after which her condition slightly improved. Even though a blood culture had indicated that A.M.D. had a staphylococcal infection, Respondent nonetheless ordered that the intravenous administration of antibiotics be discontinued because A.M.B. had been afebrile for a few days. Thereafter, A.M.D.'s condition quickly deteriorated. She suffered congestive hear failure, but Respondent did not seek to obtain a consultation with a cardiologist. On December 11, 1989, 17 days after she had been admitted to the hospital, A.M.D. expired. At the time of her death she was not on antibiotics. This was a factor which contributed to her demise. Respondent's final primary diagnosis of A.M.D. was toxemic shock, protracted. His secondary diagnoses included: staphylococcal septicemia, acute; cholelithiasis, chronic; and pneumonitis, subacute, staphylococcal. In not doing the following while A.M.D. was hospitalized at PGH and under his care, Respondent failed to practice medicine with that level of care, skill and treatment that, in light of the surrounding circumstances, a reasonably prudent internist would have recognized as being acceptable and appropriate at the time: ordering multiple blood cultures upon A.M.D.'s admission to the hospital in order to properly assess her condition; attempting to seek a consultation with an infectious disease specialist and ordering that A.M.D.'s treatment plan be modified to include intravenous administration of high dosages of at least two different broad spectrum, latest generation antibiotics when A.M.D. still had a high fever following the first several days of her hospitalization and the diagnosis of her condition remained obscure; seeking to obtain a consultation with a cardiologist when A.M.D. suffered congestive heart failure; and appropriately treating A.M.D. with antibiotics throughout the time she was under his care, including the period following the brief improvement in her condition and reduction of her temperature to normal. Facts Relating to Case No. 94-0235/Administrative Complaint #4 On or about August 17, 1992, patient A.A., a 69 year old male, presented to Respondent at Preferred Quality Medical Care in Plantation, Florida with complaints of shortness of breath and nocturia (two to three times a night). A.A. provided Respondent with a written medical history, which revealed, among other things, that he was a heavy smoker. During his physical examination of A.A., Respondent observed and noted in his written record of the examination, among other things, inspiratory wheezes, prolonged expiration, shortness of breath and that A.A. gave the appearance of being chronically ill. Respondent diagnosed A.A.'s condition as C.O.P.D. (chronic obstructive pulmonary disease) and what Respondent termed "tobaccism," which is a nonstandard diagnosis. Respondent ordered an EKG, spirometry, urinalysis and blood tests. He failed to order a chest x-ray, notwithstanding that A.A. had indicated he was a heavy smoker and that Respondent's examination had revealed that A.A. had shortness of breath and that he had the appearance of someone who was chronically ill. Under such circumstances, it was quite possible that A.A. was suffering from C.O.P.D., as Respondent had opined. There were other possibilities, however, such as cancer, 6/ tuberculosis, pneumonia and congestive heart failure. In order to fully investigate these other possibilities, it was necessary for Respondent to order a chest x-ray. On or about September 11, 1992, A.A. returned to Respondent complaining of intermittent coughing spells. Respondent examined A.A. and observed prolonged wheezing. Respondent diagnosed A.A.'s condition as C.O.P.D. and hypertensive disease and treated him with bronchodilators. Although a diagnosis of hypertensive disease requires a baseline chest x-ray as part of the initial evaluation, Respondent made his diagnosis without the benefit of such an x-ray. A.A. next visited Respondent on October 19, 1992, complaining of extreme nervousness and inability to sleep. Respondent found that A.A. was expectorating large amounts of mucus. Respondent treated A.A. with Sinequan, which is an antidepressant that helps with sleep. Once again Respondent failed to order a chest x-ray. A.A. returned to Respondent on November 23, 1992, complaining of shortness of breath and nocturia. Respondent examined A.A. and discovered a soft mass in the supraclavicular area. He also noted that A.A. had a heart murmur. Respondent finally ordered a chest x-ray. The x-ray revealed pleural effusion. Subsequent testing detected inoperable cancer, which led to A.A.'s death on May 9, 1993. In waiting until A.A.'s fourth visit before ordering a chest x-ray and, as a result, not making an earlier diagnosis of A.A.'s cancer, Respondent failed to practice medicine with that level of care, skill and treatment that, in light of the surrounding circumstances, a reasonably prudent internist would have recognized as being acceptable and appropriate at the time.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby recommended that the Board enter a final order finding Respondent guilty of the violations of subsection (1) of Section 458.331, Florida Statutes, noted above, dismissing the remaining allegations against him and disciplining him for the violations he committed by suspending his license for a period of eighteen months, placing him on probation for the following five years, and imposing an administrative fine in the amount of $4,000.00. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 15th day of November, 1994. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 15th day of November, 1994.
