The Issue The issues in this case are set forth in 11 separate counts within the four consolidated cases: Case No. 09-5360 Count I--Whether Respondent failed to properly monitor and care for a patient in restraints. Count II--Whether Respondent failed to ensure the physician's plan of care for patient was implemented. Case No. 09-5363 Count I--Whether Respondent failed to properly implement the physician's plan of care for patient. Case No. 09-5364 Count I--Whether Respondent failed to ensure a patients' right to privacy. Count II--Whether Respondent failed to ensure that food was served in the prescribed safe temperature zone. Count III--Whether Respondent failed to ensure that only authorized personnel had access to locked areas where medications were stored. Count IV--Whether Respondent failed to perform proper nursing assessments of a patient. Count V--Dismissed. Count VI--Whether Respondent failed to maintain patient care equipment in a safe operating condition. Case No. 09-5365 Count I--Whether Respondent failed to triage a patient with stroke-like symptoms in a timely fashion. Count II--Whether Respondent's nursing staff failed to assess and intervene for patients or ensure implementation of the physician's plan of care.
Findings Of Fact Petitioner is the state agency responsible for, inter alia, monitoring health care facilities in the state to ensure compliance with all governing statutes, rules and regulations. It is the responsibility of AHCA to regularly inspect facilities upon unannounced visits. Often AHCA will inspect facilities for the purpose of licensure renewal, certification, or in conjunction with federal surveys. AHCA will also inspect facilities on the basis of complaints filed by members of the general public. Respondent, Gulf Coast Medical Center ("Gulf Coast" or "GCH") is a hospital within the Lee Memorial Health System. South West Florida Regional Medical Center ("SWF") was another hospital within the Lee Memorial Health System. SWF closed in March 2009, when it was consolidated with Gulf Coast. On October 15, 2008, the Agency conducted a complaint investigation at SWF; a follow-up complaint investigation was done on November 13, 2008. SWF filed and implemented a plan of correction for the issues raised in each of the investigations. The November investigation resulted in an Administrative Complaint containing two counts. On December 16, 2008, AHCA performed another complaint investigation at Gulf Coast. Gulf Coast filed and implemented a plan of correction for the issues raised in the investigation. The investigation resulted in an Administrative Complaint containing one count. On January 5 through 9, 2009, AHCA conducted a routine licensure survey at Gulf Coast. The hospital filed and implemented a plan of correction for the issues raised in the survey. The survey resulted in an Administrative Complaint containing six counts (although Count V was dismissed during the course of the final hearing). On February 18, 2009, AHCA did its follow-up survey to the previous licensure survey. Gulf Coast filed and implemented a plan of correction for the issues raised in the survey. The survey resulted in an Administrative Complaint containing two counts. Case 09-5360 The complaint investigation at SWF on November 13, 2008, was conducted under the supervision of Charlene Fisher. Count I in this case addresses findings by the Agency concerning a patient who was placed in restraints at the hospital on August 28, 2008. The patient, A.D., came into the hospital emergency department under the Baker Act seeking medical clearance to a facility. The patient presented at approximately 4:00 p.m., with back pain. He had a history of drug abuse, so there was concern by the hospital regarding the use of narcotics or certain other medications to treat the patient. The patient engaged in some scuffling with police. A physician signed and dated a four-point restraint (one on each limb) order, resulting in the patient being physically restrained. The restraint was deemed a medical/surgical restraint, rather than a behavioral restraint. AHCA had concerns about the restraint, specifically whether there was a notation for Q 15 (or every 15 minutes) monitoring of the restrained patient. However, medical/surgical restraints only require monitoring every two hours. The restraint worksheet for the patient confirms monitoring every two hours. The patient was ultimately admitted to the hospital at 9:37 p.m., and, thereafter, began complaining of left shoulder pain. The hospital responded to the patient's complaints about back pain and began treating the pain with analgesics. However, the patient continued to complain about the pain. An X-ray of the patient's shoulder was finally done the next morning. Shoulder dislocation was confirmed by the X-ray, and the hospital (four hours later) began a more substantive regimen of treatment for pain. Surgery occurred the following morning, and the shoulder problem was resolved. It is clear the patient had a shoulder injury, but it is unclear as to when that injury became more painful than the back injury with which the patient had initially presented. The evidence is unclear whether or when the shoulder injury became obvious to hospital staff. During its course of treating this patient, the hospital provided Motrin, Tylenol, Morphine, Percocet and other medications to treat the patient's pain. Count II in this case also involved a restrained patient, M.D., who had presented to the emergency department under the Baker Act. The patient was released from handcuffs upon arrival at the hospital. After subsequently fighting with a deputy, this patient was also placed in a medical/surgical restraint pursuant to a physician's order. The doctor signed and dated, but did not put a time on, the restraint order. A time is important because there are monitoring requirements for patients in restraints. However, the time of 0050 (12:50 a.m.) appears on the patient's chart and is the approximate time the restraints were initiated. The proper procedure is to monitor a restrained patient every two hours. This patient, however, was removed from his restraints prior to the end of the first two-hour period. Thus, there are no records of monitoring for the patient (nor would any be necessary). The evidence presented by AHCA was insufficient to establish definitively whether the hospital nursing staff failed to properly respond to the aforementioned patients' needs. It is clear the patients could have received more care, but there is not enough evidence to prove the care provided was inadequate. Case No. 09-5363 On December 16, 2008, AHCA conducted a complaint investigation at SWF. The Agency had received a complaint that the hospital did not properly implement a physician's plan of care. Count I in this complaint addresses alleged errors relating to two of four patients reviewed by the surveyors. Both of the patients came to the hospital from a nursing home. One patient, I.A., had presented to the emergency department complaining of chest pains. The medication list sent to the hospital by the nursing home for I.A. actually belonged to someone other than I.A. I.A.'s name was not on the medication list. The drugs listed on the patient chart were different than the drugs I.A. had been taking at the skilled nursing facility from which she came. The skilled nursing facility actually sent I.A.'s roommate's medication list. The erroneous medications were then ordered by the admitting physician and administered to the patient. The hospital is supposed to review the medication list it receives and then enter the medications into the hospital system. The person reviewing the medication list does not necessarily have to be a nurse, and there is no evidence that the person making the error in this case was a nurse or was some other employee. It is clear, however, that the person reviewing the medication list did not properly ascertain that the list belonged to patient I.A. The other patient from the nursing home had been admitted for surgery at SWF. Again, the nursing home from whence she came sent a medication list that was incorrect. The medications on the incorrect list were entered into the system by a SWF employee. The erroneous medications were ultimately ordered by the attending physician for the patient, but there is no evidence the patient was ever administered those medications. Neither of the residents was harmed by the incorrect medications as far as could be determined. Case 09-5364 From January 5 through 8, 2009, AHCA conducted a licensure survey at Gulf Coast and SWF in conjunction with a federal certification survey. Count I of the complaint resulting from this survey addressed the right of privacy for two residents. In one instance, a patient was observed in her bed with her breasts exposed to plain view. In the other instance, a patient's personal records were found in a "public" place, i.e., hanging on the rail of a hallway in the hospital. AHCA's surveyor, Nancy Furdell, saw a female patient who was apparently asleep lying in her bed. The patient's breasts were exposed as she slept. Furdell observed this fact at approximately 1:15 p.m., on January 7, 2009. Furdell did not see a Posey vest on the patient. She did not know if anyone else saw the exposed breasts. Furdell continued with her survey duties, and at approximately 5:00 p.m., notified a staff member as to what she had seen. Furdell did not attempt to cover the patient or wake the patient to tell her to cover up. The female patient with exposed breasts was in the intensive care unit (ICU) of the hospital. Visiting hours in ICU at that time were 10:00 to 10:30 a.m., and again from 2:00 till 2:30 p.m. Thus, at the time Furdell was present, no outside visitors would have been in the ICU. ICU patients are checked on by nursing staff every half-hour to an hour, depending on their needs. This particular patient would be visited more frequently due to her medical condition. On the day in question, the patient was supposed to be wearing a Posey vest in an effort to stop the patient from removing her tubing. The patient had been agitated and very restless earlier, necessitating the Posey vest. Also on January 7, 2009, a surveyor observed some "papers" rolled up and stuffed inside a hand-rail in the hospital corridor. This occurred at 1:15 p.m., on the fourth floor of the south wing of the hospital. A review of the papers revealed them to be patient records for a patient on that floor. The surveyor could not state at final hearing whether there were hospital personnel in the vicinity of the handrail where she found the patient records, nor could she say how long the patient records had been in the handrail. Rather, the evidence is simply that the records were seen in the handrail and were not in anyone's possession at that moment in time. Count II of the complaint was concerned with the temperature of certain foods being prepared for distribution to patients. Foods for patients are supposed to be kept at certain required temperatures. There is a "danger zone" for foods which starts at 40 degrees Fahrenheit and ends at 141 degrees Fahrenheit. Temperature, along with time, food and environment, is an important factor in preventing contamination of food and the development of bacteria. Surveyor Mary Ruth Pinto took part in the survey. As part of her duties, she asked hospital staff to measure the temperature of foods on the serving line. She found some peaches at 44 degrees, yogurt at 50 degrees, and cranberry juice at 66 degrees Fahrenheit. According to Pinto, the hospital's refrigerator temperatures were appropriate, so it was only food out on the line that was at issue. Pinto remembers talking to the hospital dietary manager and remembers the dietary manager agreeing to destroy the aforementioned food items. The hospital policies and procedures in place on the date of the survey were consistent with the U.S. Food and Drug Administration Food Code concerning the storage, handling and serving of food. The policies acknowledge the danger zone for foods, but allow foods to stay within the danger zone for up to four hours. In the case of the peaches and yogurt, neither had been in the danger zone for very long (not more than two hours). The cranberry juice was "shelf stable," meaning that it could be stored at room temperature. The food services director for the hospital remembers the peaches and yogurt being re-chilled in a chill blaster. She does not believe any of the food was destroyed. Count III of the complaint addressed whether an unauthorized person had access to a room where medications were being stored. A state surveyor, Gary Furdell, was part of the survey team on January 5, 2009. Furdell was touring the second floor of the hospital when he noticed a locked door. Furdell asked a hospital medical technician who was standing nearby about the door. The medical technician gave Furdell the code to unlock the door. Furdell peeked inside and noticed bottles that he presumed were medications. It would be a violation for a medical technician to have access to medications, because medical technicians cannot distribute drugs. The room Furdell looked into is a "mixed use" room located behind a nursing station. A mixed use room is used to store medical supplies, including medications, as long as there is a locked cabinet in the room for that purpose. This particular mixed use room had a locked cabinet. The room is used for the preparation of medications and for other purposes. No narcotics were stored in this particular mixed use room. The room contained locked cabinets used to store other medications. The evidence presented was insufficient to determine what "medications" Furdell may have seen in the room. Count IV of the complaint concerned the nursing assessment of a patient, and whether the assessment was properly and timely performed. A patient, M.S., had been admitted to the hospital on June 18, 2008, for lung surgery. Following the surgery, Amiodarone (a very toxic drug which can cause clots and other complications) was administered to treat M.S. for heart arrhythmia. The Amiodarone was administered intravenously and M.S. developed blisters and irritation at the intravenous site. That is not an uncommon complication with Amiodarone. M.S.'s attending physician was notified about the irritation and prescribed a treatment. He also ordered a consult with an infectious disease specialist who ultimately changed M.S.'s antibiotics. Although M.S. was seen daily by her physicians, the nursing notes do not reflect the assessment and treatment of her blisters. It appears that proper care was rendered, but the care was not documented properly. Another patient was admitted to the hospital on December 15, 2008, with End Stage Renal Disease and diabetes mellitus for which she began dialysis treatment. The patient was not weighed before and after a particular dialysis treatment on January 5, 2009. However, the patient had been moved to an air mattress bed on that date for comfort. The air mattress bed did not allow for a weight to be taken as it could be on a regular bed. There is an allegation in the Administrative Complaint concerning the discontinuation of the calorie count for a patient. This issue was not discussed in AHCA's Proposed Recommended Order, nor was sufficient evidence of any wrong- doing concerning this matter presented at final hearing. During the survey, the hospital was found to be storing the medication Mannitol in blanket warmers, rather than in warmers specifically designed for the drug. The blanket warmers maintained the Mannitol at 100-to-110 degrees Fahrenheit. The manufacturer's label on the drug calls for it to be dispensed (injected) at between 86 and 98.5 degrees Fahrenheit. In order to meet this requirement, the hospital takes the drug out of the blanket warmer in time for it to cool sufficiently before it is injected. There is nothing inherently wrong with using a blanket warmer to store Mannitol. On January 5, 2009, a surveyor found two vials of Thrombin, one vial of half-percent Lidocaine and Epi, and one vial of Bacitracin in operating room No. 4. The operating room is within the secured and locked suite of surgical rooms on the second floor. Two of the vials had syringes stuck in them and one of them was spiked. Whoever had mixed the medications was not attending to them at the time the surveyor made her observation. There were two unlicensed technicians in the room preparing for the next surgery. A registered nurse anesthetist was present as well. There was no identifying patient information on the medications. The hospital's policies and procedures do not require the patient's name to be on the label of medications prepared for impending surgery. That is because the procedures for the operating room include a process for ensuring that only the correct patient can be in the designated operating room. There is a fail-safe process for ensuring that only the proper patient can receive the medications that are set out. At around 2:45 p.m. on January 5, 2009, there were patient records in the emergency department showing that several drugs had been administered to a patient. The surveyor did not see a written order signed by a physician authorizing the drugs. When the surveyor returned the next morning, the order had been signed by the physician. The hospital policy is that such orders may be carried out in the emergency department without a doctor's signature, but that a physician must sign the order before the end of their shift. AHCA cannot say whether the physician signed the order at the end of his shift or early the next day. Count V of the complaint was voluntarily dismissed by the Agency. Count VI of the complaint concerned the status of certain patient care equipment, and whether such equipment was being maintained in a safe operating condition. A patient was weighed at the hospital upon admission on December 27, 2008, and found to weigh 130 pounds using a bed scale. Six days later, on January 2, 2009, the patient's weight was recorded as 134 pounds. Two days later, in the same unit, the patient weighed 147 pounds and the next day was recorded as weighing 166 pounds. During the survey process, the patient was weighed and recorded at 123 pounds on a chair scale. The hospital does not dispute the weights which were recorded, but suggests there are many factors other than calibration of the equipment that could explain the discrepant weights. For example, the AHCA surveyor could not say whether the patient sometimes had necessary medical equipment on his bed while being weighed, whether different beds were involved, or whether any other factors existed. AHCA relies solely on the weight records of this single patient to conclude that the hospital scales were inaccurate. Case No. 09-5365 On February 18, 2009, AHCA conducted a licensure survey at Gulf Coast. Count I of the complaint from this survey concerned the timeliness of triage for a patient who presented at the hospital emergency department with stroke-like symptoms. AHCA surveyors witnessed two patients on stretchers in the ambulance entrance hallway leading to the emergency department. Each of the two patients had been brought in by a separate emergency medical service (EMS) team and was awaiting triage. One patient was taken to an emergency department room (ER room) 50 minutes after his/her arrival at the hospital. The other patient waited 45 minutes after arrival before being admitted to an ER room. Meanwhile, a third patient arrived at 2:20 p.m., and was awaiting triage 25 minutes later. During their observation, the surveyors saw several nursing staff in the desk area of the emergency department, i.e., they did not appear to be performing triage duties. The emergency department on that date was quite busy. That is not unusual during February, as census tends to rise during the winter months due to the influx of seasonal residents. A summary of the action within the emergency department from 1:00 p.m. to 3:00 p.m., on the day of the survey shows the following: Patient L.G., 74 years old with stable vital signs, was radioed in by her EMS team at 1:08; L.G. was processed into the ER at 1:21 (which is not an unreasonable time; EMS teams call in when they arrive at or near the hospital. By the time they gain access, wait their turn if multiple ambulances are present, and get the patient inside, several minutes may lapse). L.G. was stabilized and quickly reviewed by ER staff, then officially triaged at 2:04. Patient H.M., an 89-year-old male residing in a nursing home, arrived at 1:20 and was processed in at 1:59. He was triaged at 2:01, but ultimately signed out of the hospital against medical advice. Patient E.M. arrived at 2:18 and was processed at 2:25. Triage occurred one minute later. This patient presented as a stroke alert, and hospital protocol for that type patient was followed. Patient C.J. arrived at 1:08 and was processed at 2:38. Triage occurred immediately after C.J. was processed. This patient was not stroke alert, but had some stroke-like symptoms.1 C.J. had not been transported to the hospital as emergent, because the symptoms had been going on for 24 hours. Patient W.M., an auto accident victim, arrived at 1:40 and was processed at 1:49. Triage occurred within six minutes. Patient M.M., W.M.'s wife (who had been with M.M. in the automobile accident, but was placed in a separate ambulance), arrived at 2:06 and was triaged at 2:34. There is no record of when M.M. was processed. Patient L.M. came to the hospital from a nursing home. She arrived at 1:43 and was processed at 2:35. L.M. was triaged at 2:37. Patient K.M. arrived at 2:45 and was processed within three minutes. Triage occurred at 2:52. Her triage was done very quickly due to the condition in which she arrived, i.e., shortness of breath and low oxygen saturation. Patient R.S. arrived at 1:00 and was triaged at 1:15. The aforementioned patients represent the patients presenting to the emergency department by ambulance during a two-hour period on a very busy day. It is the customary procedure for ER staff to make a quick visual review (rapid triage) of patients as they come into the hospital. Those with obvious distress or life-threatening conditions are officially triaged first. Others, as long as they are stable, are allowed to wait until staff is available for them. As part of their duties, nurses necessarily have to be in the desk area (nursing station) in order to field phone calls from physicians concerning treatment of the patients who present. It is not unusual or improper for nurses to be in the nursing station while residents are waiting in the processing area. It is clear that some patients waited a much longer time for triage than others. However, without a complete record of all patients who presented that day and a complete review of each of their conditions, it is impossible to say whether the hospital was dilatory in triaging any of them. Count II of the complaint addressed the nursing staff and whether it failed to assess and intervene in the care of a patient or failed to implement a physician's plan of care for the patient. Patient D.W. was a 67-year-old female who was morbidly obese, diabetic, debilitated, had end stage renal disease, and was receiving dialysis. Upon admission, D.W. had a Stage 3 pressure ulcer to her sacrum and a Stage 4 ulcer on her left calf. A wound care protocol was initiated immediately, and a Clinitron bed was obtained for her on the day of admission. Due to the seriousness of her condition, the wound care physician declined to accept her case at first. He later ordered Panafil, and it became part of the protocol for treating the patient. The nursing documentation for D.W. was only minimally sufficient, but it does indicate that care was provided. Patient R.H. was an 83-year-old male who presented on February 10, 2009, in critical condition. R.H. was suffering from congestive heart failure, pneumonia, and respiratory failure. Due to the critical nature of his respiratory problems, R.H. was placed on a ventilator. As a ventilator patient, he did not fit the profile for obtaining wound care. Nonetheless, the hospital implemented various other measures to deal with R.H.'s pressure wounds.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by Petitioner, Agency for Health Care Administration, imposing a fine in the amount of $500.00 in DOAH Case No. 09-5363 and a fine in the amount of $500.00 in DOAH Case No. 09-5364, Count VI. DONE AND ENTERED this 30th day of April, 2010, in Tallahassee, Leon County, Florida. R. BRUCE MCKIBBEN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of April, 2010.
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 $14,500. 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 January 28, 2014 3:22 PM Division of Admitlistrative Hearings 3. Conditional licensure status is imposed on the Respondent beginning on August 30, 2012 and ending on September 4, 2012. 4. The references in the Statement of Deficiencies for the August 28-30, 2012 survey of Springwood Care and Rehabilitation Center relating to Resident #2 being on thickened liquids is deleted. ORDERED at Tallahassee, Florida, on this 2-4 day of eee , 2014. i Le ek, Secretary y for Nealfh Care 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 opt this Final Order was served on the below-named persons by the method designated on this ZY. ay of eauary , 2014. 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) Andrea M. Lang Thomas W. Caufman, Esq. Office of the General Counsel Quitairos, Prieto, Wood & Boyer, P.A. Agency for Health Care Administration Attorney for Respondent (Electronic Mail) 4905 West Laurel Street, 2"! Floor Tampa, Florida 33607 (U.S. Mail) Lynne A. Quimby-Pennock Administrative Law Judge Division of Administrative Hearings (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2012009469 4602 NORTHGATE COURT, LLC d/b/a SPRINGWOOD CARE AND REHABILITATION CENTER, Respondent. / ADMINISTRATIVE COMPLAINT. COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against 4602 NORTHGATE COURT, LLC d/b/a SPRINGWOOD CARE AND REHABILITATION CENTER (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action against a nursing home to impose an administrative fine of TEN THOUSAND DOLLARS ($10,000.00) pursuant to Section 400.23(8)(a), Florida Statutes (2012), based upon one (1) Class I deficiency; to assess a survey fee in the amount of SIX THOUSAND DOLLARS ($6,000.00) based upon Respondent being cited for one (1) Class I deficiency pursuant to Section 400.19(3), Florida Statutes (2012), and to assign conditional licensure status beginning on August 30, 2012, pursuant to Section 400.23(7)(b), Florida Statutes (2012). The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. EXHIBIT 1 JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2012). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Part II, Florida Statutes (2012). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the regulatory authority responsible for the licensure of nursing homes and the enforcement of all applicable federal and state statutes, regulations and rules governing nursing homes pursuant to Chapter 400, Part Il, Florida Statutes (2012) and Chapter 59A-4, Florida Administrative Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121 and 400.23, Florida Statutes (2012); assign a conditional license pursuant to Section 400.23(7), Florida Statutes (2012); and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Florida Statutes (2012). 5. Respondent operates a 120-bed nursing home, located at 4602 Northgate Court, Sarasota, Florida 34234, and is licensed as a nursing home, license number 15130962. Respondent was at all times material hereto, a licensed nursing home under the licensing authority of the Agency, and was required to comply with all applicable state rules, regulations and statutes. COUNTI The Respondent Failed To Ensure Residents The Right To Receive Adequate And Appropriate Protective And Support Services In Violation Of Section 400.022(1)(), Florida Statutes (2012) 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the Agency. Section 400.022(1)(1), Florida Statutes (2012). 8. On or about August 28, 2012 through August 30, 2012, the Agency conducted a Complaint Investigation (CCR# 2012009348 and CCR# 2012008938) of the Respondent’s facility. 9. Based on record review, interview and observation, the facility failed to prevent the abuse, neglect and mistreatment of one (1) of three (3) sampled residents, specifically Resident number two (2). This resulted from the willful spraying of water in the facial area of Resident number two (2), who had an order to receive only thickened liquids, palliative care and was known to be resistive to activities of daily living, including showering. The facility's failure with Resident number two (2) and their failure to identify the need to retrain staff on procedures to appropriately shower residents with similar conditions placed all residents with those conditions at risk for serious injury, harm, impairment, or death. 10. On August 28, 2012, a review of Resident number two’s (2) record containing a Nursing Progress note dated August 25, 2012 at 5:30 a.m. which documented, “Resident number two (2) moaning loudly (and) then screaming... Visible signs of pain on Resident’s face (fear and grimacing)." Morphine 5 mg/0.25 cc SL (11:00 p.m. and 5 a.m.) and back rubbing, both had positive calming effect. 11. The progress note also documented, "Took 80 cc of water during the night shift. Pulse 78, respirations 16; unlabored while awake, dyspnea noticed while sleeping. Resting with cycs closed. Will monitor." 12. A nursing note at 12:20 p.m. documented MS04 (Morphine Sulfate) 0.25 cc was administered "with minimal effect" to Resident number two (2), who was "very anxious and moaning loudly." The note states at approximately 11:50 a.m., Certified Nursing Assistants called the nurse into the shower room where Resident number two (2) was found unresponsive with a faint pulse. Resident number two (2) was returned to bed immediately with a board under him/her. Cardio Pulmonary Resuscitation was administered and oxygen was placed over Resident number two’s (2) face. No pulse was felt. The paramedics arrived and continued Cardio Pulmonary Resuscitation. At 12:10 p.m., paramedics stated Resident number two (2) had passed away. The nursing note documented, the "Director of Nursing notified and family was being contacted by Director of Nursing. Westside funeral home called." 13. On August 29, 2012 at 12:45 p.m. during an interview regarding the event on August 25, 2012, Employee F stated, "I asked another Certified Nursing Assistant (Employee G) to help me give Resident number two (2) a shower." During the shower, when Employee G sprayed water in the resident's face, Employee F said, "Do not do that, he/she is on thickened liquids." Employee G said, “Resident number two (2) had soap in his/her eyes." After that, Employee F got the nurse because Resident number two (2)"was not acting normal." 14. During this interview, Employee F stated, "I am CPR certified, (but) did not assist with it." When asked when the last training on abuse was received, Employee F said, “I do the modules on the computer; | believe last month." Regarding the facility staff to notify in a case of abuse, Employee F stated, "You notify the Abuse Coordinator, the Director of Nursing, her name is on my badge." The incident was reported via phone call to Employee M, the Unit Manager, who was at home on August 25, 2012, by Employees J and F. 15. Inn interview on August 29, 2012, at 10:30 a.m., Employee M reported receiving a call at home on August 25, 2012 at approximately 1:10 p.m. regarding Resident number two (2). Employees I and F reported that while giving Resident number two (2) a shower, Employee G sprayed Resident number two (2) in the face and the mouth. Employee I did not see the action, but Employee F witnessed Employee G spray Resident number two (2). 16. During interviews on August 29, 2012, Employees B, D, N and H stated they received training about abuse after August 25, 2012. Employee H stated the instruction provided during training regarding getting shampoo out of a resident’s hair included "have them hold their head back and rinse it out." When asked if a resident had mucous coming out of their nose and going into their mouth, can you spray it off with the shower head, Employee H answered, “It is okay to spray it (face) to get it (mucous) out." 17. On August 28, 2012, a record review of Resident number two’s (2) Minimum Data Set Kardex Report for 2880 noted the resident as "Moderately Impaired" to make Activities of Daily Living, but made no mention of bathing or behavior issues. Also, there was no indication Resident number two (2) was receiving thickened liquids. The Kardex report is used by staff as a quick review of resident information. 18. On August 28, 2012, a review of the shower schedule used by the Certified Nursing Assistants, last updated on June 14, 2012 for Resident number two (2), revealed the resident due "Saturday" by the "11:00 p.m. to 7:00 a.m. shift." The shower schedule notes no change can be made without the Unit Manager’s approval. Resident number two (2) was given a shower on August 25, 2012 during the 7:00 a.m. to 3:00 p.m. shift. 19. On August 28, 2012, a review of Resident number two’s (2) Medication Administration Record dated August 25, 2012 revealed a physician order for palliative care to start on August 23, 2012. There was no indication the nursing staff knew to provide the palliative care on August 23, 2012, August 24, 2012 and August 25, 2012 as no nurse initialed those dates. 20. A record review on August 28, 2012 revealed Resident number two (2) was admitted to the facility on July 20, 2012. On August 23, 2012, Resident number two (2) was documented with a "Medical Diagnosis of Dysphasia," and was to receive "Palliative Care Only." 21. During an interview on August 29, 2012 at 2:25p.m., the administrator stated, "We are pretty much concluding with the investigation. We are unable to substantiate abuse.” 22. Regarding training provided since August 25, 2012, the administrator said, "We have done education on the Abuse and Neglect policy; what it means, how it is reported, with examples specifically of the scenario of Resident number two (2). If staff has an understanding of what abuse is, they are more aware of how they are interacting with residents. I am comfortable with what has taken place so far." During the interview, the administrator did not report any training was provided regarding the appropriateness of residents receiving showers, who are on palliative care, do not like showers, and have behavior issues." 23. \ The facility had failed to prevent abuse, neglect or the mistreatment of Resident number two (2) and other similarly-effected residents. Interviews and record reviews revealed staff failed to implement current standard of practice showering procedures with a resident that was on palliative care; had identified issues with exhibiting difficult behaviors, including while being showered and was on thickened liquids. On August 28, 2012, August 29, 2012 and August 30, 2012, the facility administrative staff failed to retrain and monitor adequately direct care staff administering showers to residents. 24. The facility has failed to ensure the critical incident will not be repeated. 25. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility. The Agency cited Respondent for an isolated Class I deficiency as set forth in Section 400.23(8)(a), Florida Statutes (2012). WHEREFORE, the Agency intends to impose an administrative fine in the amount of TEN THOUSAND DOLLARS ($10,000.00) against Respondent, a nursing home in the State of Florida, pursuant to Sections 400.23(8)(a), Florida Statutes (2012). COUNT I Assignment Of Conditional Licensure Status Pursuant To Section 400.23(7)(b), Florida Statutes (2012) 26. The Agency re-alleges and incorporates by reference the allegations in Count I. 27. The Agency is authorized to assign a conditional licensure status to nursing homes pursuant to Section 400.23(7), Florida Statutes (2012). 28. Due to the presence of one (1) Class I deficiency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes (2012), or the rules adopted by the Agency. 29. The Agency assigned the Respondent conditional licensure status with an action effective date of August 30, 2012. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the Respondent conditional licensure status for the period beginning on August 30, 2012, pursuant to Section 400.23(7)(b), Florida Statutes (2012). COUNT OI Assessment Of Fine Pursuant To Section 400.19(3), Florida Statutes (2012) 30. The Agency re-alleges and incorporates by reference the allegations in Count I and Count II. 31. The Respondent has been cited for one (1) Class I deficiency and therefore is subject to a six (6) month survey cycle for a period of two (2) years and a fine of SIX THOUSAND DOLLARS ($6,000.00) pursuant to Section 400.19(3), Florida Statutes (2012). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two (2) years and assess a fine in the amount of SIX THOUSAND DOLLARS ($6,000.00) against Respondent, a nursing home in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2012). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency on Count I through Count III. 2. Impose an administrative fine against the Respondent in the amount of TEN THOUSAND DOLLARS ($10,000.00) pursuant to Section 400.23(8)(a), Florida Statutes (2012), and assess a survey fee in the amount of SIX THOUSAND DOLLARS ($6,000.00), pursuant to Section 400.19(3), Florida Statutes (2012), for a total of SIXTEEN THOUSAND DOLLARS ($16,000.00). 3. Assign a conditional license to the Respondent beginning on August 30, 2012. 4. Assess costs related to the investigation and prosecution of this case. 5. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this i144 day of Sewer , 2012. tug a ae Co oN, YJ wane Andrea M. Lang, Assistant General Cournsel Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 335-1253 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 412-3630. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to: Corporation Service Company, Registered Agent for 4602 Northgate Court, LLC d/b/a Springwood Care and Rehabilitation Center, 1201 Hays Street, Tallahassee, Florida 32301, by United States Certified Mail, Return Receipt No. 7011 2000 0001 4884 9195 and to Susan Ritchie, Administrator, 4602 Northgate Court, LLC d/b/a Springwood Care and Rehabilitation Center, 4602 Northgate Court, Sarasota, Florida 34234, by United States Certified Mail, Return Receipt No. 7011 2000 0001 4884 9195 on this is Onis day of Segoe mbec . 2012. Qt 1M, Nowe Andrea M. Lang, Assistant General Counsel Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 335-1253 Copies furnished to: Susan Ritchie, Administrator 4602 Northgate Court , LLC d/b/a Springwood Care and Rehabilitation Center 4602 Northgate Court Sarasota, Florida 34234 (U.S. Certified Mail) Andrea M. Lang, Assistant General Counsel Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Electronic Mail) Corporation Service Company Registered Agent for 4602 Northgate Court, LLC d/b/a Springwood Care and Rehabilitation Center 1201 Hays Street Tallahassee, Florida 32301 (U.S. Certified Mail) Bernard Hudson, Health Services and Facilities Consultant Supervisor Bureau of Long Term Care Services Long Term Care Unit Agency for Health Care Administration 2727 Mahan Drive, Building #3, Room 1213B Tallahassee, Florida 32308 (Electronic Mail) Harold Williams Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2012009469 4602 NORTHGATE COURT, LLC d/b/a SPRINGWOOD CARE AND REHABILITATION CENTER, Respondents. 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 an Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. Your Election of Rights must be returned by mail or by fax within twenty-one (21) days of the date you receive the attached Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. If your Election of Rights with your elected 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 in accordance with Chapter 120, 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 the allegations of fact 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 the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, 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. OPTION THREE (3)__ I dispute the allegations of fact and law 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, 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: (Assisted Living Facility, Nursing Home, Medical Equipment, Other) Licensee Name: License Number: Contact Person: Name Title Address: Street and Number City State Zip Code Telephone No. Fax No. E-Mail (optional) I 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 above licensee. Signature: Date: Title: Print Name: FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT ELIZABETH DUDEK GOVERNOR SECRETARY September 11, 2012 SPRINGWOOD CARE AND REHABILITATION CENTER 4602 NORTHGATE COURT SARASOTA, FL 34234 Dear Administrator: The attached license with Certificate #17737 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for a Status Change to Conditional Sincerely, Pp bbe O aco Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Visit AHCA online at 2727 Mahan Drive, MS#33 ahca.myflorida.com Tallahassee, Florida 32308 Exhibit A Original Certificate of Conditional License 4602 Northgate Court, LLC d/b/a Springwood Care and Rehabilitation Center Certificate No. 17737 License No. SNF15130962 CLOC/TE/OT ‘-ALVG NOLLVaId Xd CLOC/0E/80 “HLVd AALLOSAda HONVHD SN.LV.LS Sddd Oct “IVLOL vETvE Td ‘VLOSVUVS Land ALVOHLYON 709P YALNYO NOLLVITTEVHAY GNV FAVOD GOOMONIadS :3UIMOTI[OJ oy} oyeIado 0} PEZHOYINE ST sosudo!] BY] SB puB ‘saynyels epLOLy ‘[] Weg ‘OOp JeideyD ur paezuoyjne ‘uoneNsTUTUpY sed Wop 10,4 Aouesy ‘epuopy Jo areig am Aq paidope suone[ngar pur sani oy) ym porto sey OTT ‘LUNOD ALVOHLYON 7209p Jeu} WEFUOD 0} St SY, TVNOILIGNOD HINOH ONISHON FONVANSSV ALITWNO HLTWIH AO NOISIAIC NOLLVULSININGYV FaVO HLTVAaH YOd AONADV BPLIOLy JO 93e)S STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No(s): 2012009469 13-1617 4602 NORTHGATE COURT, LLC d/b/a SPRINGWOOD CARE AND REHABILITATION CENTER, Respondent. SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “A gency”), through its undersigned representatives, and Respondent, 4602 Northgate Court, LLC d/b/a Springwood Care and Rehabilitation Center (hereinafter “Respondent”), 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, Respondent is a Nursing Home licensed pursuant to Chapters 400, Part II, and 408, Part II, Florida Statutes, Section 20.42, Florida Statutes and Chapter 59A-4, Florida Administrative Code; and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Respondent, pursuant to Chapter 400, Florida Statutes; and WHEREAS, the Agency served Respondent with an administrative complaint on or about September 17, 2012, notifying the Respondent of its intent to impose administrative fines EXHIBIT 2 in the amount of $10,000 and a survey fee of $6,000 and assign a conditional licensure status commencing August 30, 2012 and ending September 4, 2012; and WHEREAS, Respondent requested a formal administrative proceeding by filing a Petition for Formal Administrative Hearing; and 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, Respondent agrees to waive any and all appeals and proceedings to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), Florida Statutes, a formal proceeding under Subsection 120.57(1), Florida Statutes, appeals under Section 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, however, 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, Respondent agrees to pay $8,500 in administrative fines and a survey fee in the amount of $6,000 in accord with law. Respondent accepts the assignment of conditional licensure status commencing August 30, 2012 and ending September 4, 2012. In addition, the references in the Statement of Deficiencies relating to Resident #2 being on thickened liquids will be deleted. 5. 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, Respondent neither admits nor denies, and the Agency asserts the validity of the allegations raised in the administrative complaint referenced herein. No agreement made herein shall preclude the Agency from imposing a penalty against Respondent for any deficiency/violation of statute or rule identified in a future survey of Respondent, which constitutes a “repeat” or “uncorrected” deficiency from surveys identified in the administrative complaint. The parties agree that in such a “repeat” or “uncorrected” case, the deficiencies from the surveys identified in the administrative complaint shall be deemed found without further proof. 7. No agreement made herein shall preclude the Agency from using the deficiencies from the surveys identified in the administrative complaint in any decision regarding licensure of Respondent, including, but not limited to, licensure for limited mental health, limited nursing services, extended congregate care, or a demonstrated pattern of deficient performance. The Agency is not precluded from using the subject events for any purpose within the jurisdiction of the Agency. Further, Respondent acknowledges and agrees 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 Respondent’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. Respondent 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 Respondent or related facilities. 12. This Agreement is binding upon all parties herein and those identified in paragraph eleven (11) of this Agreement. 13. ‘In the event that Respondent was a Medicaid provider at the subject time of the occurrences alleged in the complaint herein, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 59G-9.070, Florida Administrative Code. 14. Respondent 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 Respondent in the Final Order, or any portion thereof, owed by Respondent to the Agency from any present or future funds owed to Respondent by the Agency, and that the Agency shall hold a lien against present and future funds owed to Respondent 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. 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. / | ia Susan Ritchie, Administrator 4602 Northgate Court, LLC Agency for Health Care Administration d/b/a Springwood Care and 2727 Mahan Drive, Bldg #1 Rehabilitation Center Tallahassee, Florida 32308 4602 Northgate Court Sarasota, Florida 34234 DATED: { | DANY DATED: _/2-6-73 Stuért F.“Williafns, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 DATED: /; al/ [7 Andrea M. Lang, Senior Attorney Agency for Health Care Administration 2295 Victoria Avenue Fort Myers, Florida 33901 DATED: 1 [4/1 Loh: Thomas W. Caufinar, Esq. Quitairos, Prieto, Wood & Boyer, P.A. 4905 West Laurel Street, 2™ floor Tampa, Florida 33607 Attorney for Respondent patep:_/2 - #-/3
The Issue Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Jay's Medical Center Jay's Medical Center (hereinafter referred to as "JMC") is a medical clinic located in a low income area in Miami. It is staffed by three physicians, including Shelley Wolland, D.O., the clinic's Medical Director, 6/ and several support staff. In general, the community JMC serves is poorly educated and has a relatively high incidence of medical problems. Approximately 7,000 members of the community receive medical services at JMC, with anywhere from 40 to 80 patients receiving services in a single day. Many of the clinic's patients are Medicaid recipients. The Provider Agreement JMC is now, and has been since May of 1990, when it entered into a Non- Institutional Professional and Technical Medicaid Provider Agreement with the Department, authorized to provide physician services, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) services, and family planning services to its Medicaid patients eligible to receive such services. The provider agreement between JMC and the Department provided as follows: The provider agrees that services will be provided to recipients of the Florida Medicaid Program without regard to race, color, religion, national origin, or handicap. The provider agrees to keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billing made under the Medicaid program and agrees to furnish the State Agency and Medicaid Fraud Control unit upon request such information regarding any payments claimed for providing these services. Access to the pertinent patient records and facilities by authorized Medicaid program representatives will be permitted upon reasonable request. All records relating to Medicaid recipients are to be held confidential as provided under 42 CFR 431.305 and 306. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, Medicaid compensable and of quality comparable to those furnished by the provider's peers, and the services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting a claim. The provider agrees to submit Medicaid claims in accordance with program policies and that payment by the program for services rendered will be based on the payment methodology in the applicable Florida Administrative Rule. The provider in executing this agreement acknowledges that he understands that payment of Florida Medicaid claims is made from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. The providers of Independent Laboratory, Portable X-Ray Services, Home Health Services, Hospice and Rural Health Clinic Services agree to furnish the Office of Licensure and Certifi- cation a completed copy of Form HCFA-1513 (Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104. The providers of Prescribed Drug Services agree to bill the Medicaid program no more than usual and customary charges and on request, to provide access to usual and customary pricing information. The Department agrees to notify the provider of any major changes in Federal or State rules and regulations relating to Medicaid. Payment made by the State Agency shall constitute full payment for services rendered to recipients under the Medicaid program. This includes situations when no payment is made to physicians when Medicare coinsurance claims are adjudicated due to Medicaid's payment methodology. The only exception is in specific programs when Medicaid coinsurance is required from the recipient. The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Department may terminate this agreement in accordance with Chapter 120, F.S. This agreement becomes effective the date the signature of the authorized agent of the Office of Medicaid is affixed. The provider eligibility will be established at the latter of the date of licensure of the provider, if applicable, or ninety (90) days prior to receipt of the application. The provider shall be responsible for assuring that the signature on the claim form is appropriate for authorization. Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's employees or authorized agent. Handbook Provisions Among the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement was the Medicaid Physician Provider Handbook (hereinafter referred to as the "MPP Handbook"). Chapter 10 of the MPP Handbook addressed the subject of "provider participation." Section 10.9 of this chapter provided as follows: RECORD KEEPING You must retain physician records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, treatment plans, prior authorization information, any third party claim information, x-rays, fiscal records, and copies of sterilization and hysterectomy consents. Medical records must contain the extent of services provided. The following is a list of minimum requirements: history, physical examination, chief complaint on each visit, diagnostic tests and results, diagnosis, a dated, signed physician order for each service rendered, treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services, signature of physician on each visit, date of service, anesthesia records, surgery records, copies of hospital and/or emergency records that fully disclose services, and referrals to other services. If time is a part of the procedure code prescription being billed, then duration of visit shown by begin time and end time must be included in the record. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the MPP Handbook addressed the subject of "covered services and limitations." Section 11.1 of this chapter provided as follows: INTRODUCTION The physician services program pays for services performed by a licensed physician or osteopath within the scope of the practice of medicine or osteopathy as defined by state law. The services of this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient. Delivery of the services in this manual must be done by or under the personal supervision of a physician or osteopath at any place of service. Personal supervision is defined as the physician being in the building when the service was rendered. The physician must sign and date the medical record either on the date of service or within 24 hours. Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment. HCPCS CODES and ICD-9-CM CODES Procedure codes listed in Chapter 12 are HCPCS (Health Care Financing Administration Common Procedure Coding System) codes. These are based on the Physician's Current Procedural Terminology, Fourth Edition. Determine which procedure describes the service rendered and enter that code and description on your claim form. HCPCS codes described as "unlisted" are used when there is no procedure among those listed that describes the service rendered. Physician's Current Procedural Terminology, Fourth Edition, Copyright 1977, 1980, 1981, 1982, 1983, 1984, 1985, 1986, 1987 by the American Medical Association (CPT-4) is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes CPT-4 descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in CPT-4 which are copyrighted by the American Medical Association. The Diagnosis Codes to be used are found in the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM). A diagnosis code is required on all physician claims. Use the most specific code available. Fourth and fifth digits are required when available. There are six levels of service associated with the visit procedure codes. They require varying skills, effort, responsibility, and medical knowledge to complete the examination, evaluation, diagnosis, treatment and conference with the recipient about his illness or promotion of optimal health. These levels are: . Minimal is a level of service supervised by a physician. . Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exam. . Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate a problem including a history and examination, review of effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustments of therapeutic management as indicated and discus- sion of findings. . Intermediate level of service pertains to the evaluation of a new or existing condition compli- cated with a new diagnostic or management problem, not necessarily related to the primary diagnosis, that necessitates the obtaining of pertinent history and physical or mental status findings, diagnostic tests and procedures, and ordering appropriate therapeutic management; or a formal patient, family or a hospital staff conference regarding the patient's medical management and progress. . Extended level of service requires an unusual amount of effort or judgment including a detailed history, review of medical records, examination, and a formal conference with the patient, family, or staff; or a comparable medical diagnostic and/or therapeutic service. . Comprehensive level of service provides for an in-depth evaluation of a patient with a new or existing problem requiring the development or complete reevaluation of medical data. This service includes the recording of a chief complaint, present illness, family history, past medical history, personal review, system review, complete physical examination, and ordering appropriate tests and procedures. 7/ Section 11.2 of Chapter 11 of the MPP Handbook provided in part, that "[t]reatment of an illness found by a physician during an EPSDT screening that requires considerable office time (30 minutes or more) to treat, may also be billed as an office visit on the appropriate claim form." Another of the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement between JMC and the Department was the Medicaid EPSDT Provider Handbook (hereinafter referred to as the "EPSDT Handbook"). Chapter 10 of the EPSDT Handbook addressed the subject of "provider participation." Section 10.8 of this chapter provided as follows: RECORD KEEPING You must retain EPSDT records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, Treatment plans, Prior authorization information, Any third party claim information, X-rays, Fiscal records, and Copies of sterilization and hysterectomy consents. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the EPSDT Handbook addressed the subject of "covered services and limitations." Sections 11.3 and 11.5 of this chapter provided that the components of an EPSDT preventive health screening examination were: a health and developmental history; unclothed physical assessment or examination; nutritional assessment; updating of routine immunizations, "as indicated by the recipient's age, health history, or population group;" laboratory tests, "as indicated by the recipient's age, health history, or population group;" development assessment, vision, hearing and dental screening; and health education. Section 11.7 of Chapter 11 provided, in part, as follows: Under federal regulations the state must provide for medically necessary treatment services diagnosed as a result of screening. Once the EPSDT recipient is screened and referred for treatment, any further diagnosis and/or treatment is then provided through the individual treatment service program. For example, if an EPSDT recipient is found to have an abnormal laboratory test result, such as tuber- culin (TB) skin test, any further referral, diagnosis and treatment is considered diagnostic treatment under physician services. Billing for a treatment visit at the time of a screening visit is only allowed when the illness is discovered during the screening examination. This treatment visit must be at least 30 minutes or more. Treatment visits completed in conjunction with a screening visit must be billed on the HFCA-1500 and the fact that the visit is screening related must be noted on the claim form. Treatment procedure codes should be related to screening results as noted on the EPSDT 221 claim form. An EPSDT screening should not routinely be completed on an obviously ill child, as the illness may distort the screening results. Sound professional judgment should be exercised in determining the appropriate- ness of screening an ill child. If screening results are questionable, treatment should be provided and the screening appointment rescheduled. If, however, an illness is detected during a screening examination, the screening may be completed and treatment provided on the same date, billing the treatment on the appropriate Medicaid claim form. Billing for treat- ment on the same day as the screening evaluation should be done only when a detected illness or condition requires significant time and procedures in addition to the time usually spent for a screening evaluation. The Audit Commencing in 1992, the Department conducted an audit of Medicaid claims submitted by JMC for services rendered from July 1, 1990, through December 31, 1991. During the course of the audit, the Department examined the files of 40 patients (Patients 1 through 19 and 21 through 41, hereinafter also referred to by their initials) who had received services during the audit period. Patient 1 (S.M.) January 16, 1991, Visit On January 16, 1991, S.M. presented at the clinic complaining of a sore throat and fever. The attending physician determined that S.M. had an upper respiratory tract infection, as well as vaginitis. Treatment was provided. JMC billed this as a "comprehensive" visit (procedure code 90020) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one (procedure code 90060), as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 29, 1991, Visit S.M. next visited the clinic on January 29, 1991. JMC billed this visit as a "limited" one (procedure code 90050) and payment was made accordingly. Respondent does not dispute the appropriateness of such billing and payment. 8/ April 23, 1991, Visit On April 23, 1991, S.M. presented at the clinic complaining of blood in her urine. She further indicated that she had recently had a Pap smear test, the results of which reflected a possible precancerous condition. A pregnancy test revealed that S.M. was pregnant. She was also diagnosed as having an upper respiratory tract infection, for which she was treated. A gynecological referral was made. JMC billed this visit as a "extended" one (procedure code 90070) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 9, 1991, Visit and Streptococcal Test S.M. visited the clinic again on October 9, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. It also sought and obtained separate payment for a streptococcal (hereinafter referred to as "strep") test (procedure code 86317) given during the visit. Both parties are now in agreement that the billing and payment for the strep test was appropriate 9/ and that the office visit should have been billed and paid, not as an "extended" visit, but as an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. November 6, 1991, Visit Cerumen Removal and Strep Test On November 6, 1991, S.M. presented at the clinic complaining of sinus problems and pustules on her nose. She was diagnosed as having folliculitis, pharyngitis and sinusitis. Treatment was provided. JMC billed this visit as a "extended" one and payment was made accordingly. It also sought and obtained separate payment for impacted cerumen removal (procedure code 69210) and a strep test. The parties are in agreement that the billings and payments for the impacted cerumen removal and strep test were appropriate. 10/ A dispute still exists, however, as to the appropriateness of JMC billing and receiving payment for an "extended" visit. JMC's medical records pertaining to the visit, to the extent that they are legible, document that the visit was not an "extended" visit, but was merely an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. Moreover, these records were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. 11/ Accordingly, JMC should not have received any payment for this office visit. Patient 2 (O.R.) October 7, 1991, Billings JMC billed and was paid for a "comprehensive" visit and other services (procedure codes 86317, 94010 and 94664) it claimed it rendered Patient 2, O.R., on October 7, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that, on that date, O.R. was seen at the clinic by a physician or that she received the other billed for services. Accordingly, payment should not have been made to Petitioner for an office visit of any type or for any of the other services Petitioner claimed it rendered O.R. on October 7, 1991. October 22, 1991, Visit On October 22, 1991, O.R. presented at the clinic with a fever, sore throat and high blood pressure. In addition, she complained that she was wheezing, suffering from headaches and had a runny nose. At the time of the visit, O.R. was five feet, two inches tall and weighed 206 pounds. The attending physician determined that O.R. was suffering from asthma. Using a nebulizer, he treated her with Ventolin. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit, Routine Venipuncture and Therapeutic Injection O.R. returned to the clinic two days later, on October 24, 1991, with respiratory problems. She was coughing and wheezing severely. Her throat was red. The attending physician determined that O.R. had pharyngitis, pneumonia and severe asthma. Treatment was provided. Medications were prescribed and oral instructions regarding medication administration and compliance were given. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC also sought and obtained separate payment for a routine venipuncture (procedure code 36415) and a therapeutic injection for asthma (procedure code 90782). The parties are in agreement that the routine venipuncture was appropriately billed and paid. The appropriateness of the billing and payment for a therapeutic injection, however, is still in dispute. JMC's medical records, to the extent that they are legible, do not document that O.R. was given the billed and paid-for therapeutic injection on October 24, 1991. Accordingly, it should not have been paid for this service. Patient 3 (T.F.) January 31, 1991, Visit On January 31, 1991, Patient 3, T.F., a ten-year old girl who had already begun menstruating, presented at the clinic with complaints of vomiting for the past two days, as well as cramps and abdominal pain. She further indicated that she had had her last menstrual period two weeks previous. A physical examination, which included the genital and rectal areas, was conducted, a history was taken and a strep test was given. The results of the strep test were positive. The attending physician determined that T.F. had strep throat, for which she received treatment. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 19, 1991, Visit On September 19, 1991, T.F. presented at the clinic complaining of a high fever and a sore throat. She further indicated that she had vomited earlier in the morning. A physical examination, which did not include the genital area, was conducted, an updated history was taken and a strep test was given. The attending physician determined that T.F. had tonsillitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 4 (K.W.) October 3, 1991, Visit On October 3, 1991, Patient 4, K.W., presented at the clinic. He had lower back pain, an upper respiratory tract infection, trauma to his right ankle and folliculitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 4, 1991, Billings JMC billed and was paid for an "extended" visit and another service (procedure code 86317) it claimed it rendered K.W. on November 4, 1991, but the medical records maintained by JMC do not contain legible, physician-signed and dated documentation substantiating that, on that date, K.W. was seen at the clinic by a physician or that he received the other billed-for service. Accordingly, payment should not have been made to Petitioner for any type of office visit or for the other service Petitioner claimed it rendered K.W. on November 4, 1991. Patient 5 (S.W.) October 19, 1990, Visit JMC billed and was paid for a "comprehensive" office visit, in addition to an EPSDT screen (procedure code W9881), for services rendered to Patient 5, S.W., on October 19, 1990. The parties are in agreement that the EPSDT screen was appropriately billed and paid. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. The medical records maintained by JMC do not contain legible, physician-signed and dated documentation justifying JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. October 29, 1990, Visit S.W. again visited the clinic on October 29, 1990. This was a follow- up visit. She had been to the clinic four days previous with a high fever and complaining of a headache, stuffiness and a cough. JMC billed S.W.'s October 29, 1990, visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 14, 1991, Visit On May 14, 1991, S.W. presented at the clinic complaining of a cough. She was diagnosed as having an upper respiratory tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit Two weeks later, on May 29, 1991, S.W. returned to the clinic for a follow-up visit. She was still coughing. Tests taken before the visit revealed that, in addition to her respiratory problems, S.W. was suffering from iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 12, 1991, Visit On June 12, 1991, S.W. paid another follow-up visit to the clinic. During the visit, she admitted that she had not taken her medication "properly." A spirometry test taken before the visit revealed "severe obstruction." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 6 (B.F.) July 12, 1990, Visit On July 12, 1990, Patient 6, B.F., a 32-year old woman, presented at the clinic complaining of chest palpitations and abdominal pain. A physical examination, which included an examination of the vaginal and pelvic areas, was conducted, a history was taken, tests were ordered and treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, a "comprehensive" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. January 14, 1991, Visit B.F. visited the clinic on January 14, 1991, complaining of lower abdominal discomfort, which, she claimed, she had been experiencing for the past two weeks. The attending physician determined that, in addition to the abdominal discomfort B.F. was experiencing, she also had vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 28, 1991, Visit On January 28, 1991, B.F. presented at the clinic complaining of general malaise and a cough that she claimed she had had for four or five days. The attending physician determined that B.F. was suffering from acute bronchitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 24, 1991, Visit On April 24, 1991, B.F. presented at the clinic complaining of chest pain, headaches and dizziness she had been experiencing for several days. She also had shortness of breath. A physical examination, which included an examination of the genital and rectal areas, was conducted, an updated history was taken and tests were ordered. The chest pain was determined to be non-cardiac in nature. It was thought to be caused by a tender rib. Medication was prescribed to combat B.F.'s headaches and dizziness. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, B.F. paid a followup visit to the clinic. She reported that she was still experiencing dizziness, but no longer had any chest pain or headaches. She further advised that she was unable to tolerate the medication that had been prescribed on the previous visit. A rhythm strip test was administered. A new medication was prescribed to combat B.F.'s dizziness. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 7 (C.C.) July 23, 1991, Visit On July 23, 1991, Patient 7, C.C., visited the clinic for the removal of a lesion from her nose by electrodesiccation. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 8 (L.F.) October 21, 1991, Visit On October 21, 1991, Patient 8, L.F., presented at the clinic complaining of a skin rash. The attending physician determined that L.F. was suffering from impetigo, as well as bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 9 (L.A.) November 26, 1990, Visit On November 26, 1990, Patient 9, L.A., presented at the clinic complaining of chest pain. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that such billing and payment was appropriate and thus JMC was not overpaid for this visit. March 28, 1991, Visit On March 28, 1991, L.A. presented at the clinic complaining of chest and abdominal pain. 152. The attending physician determined that the chest pain was non- cardiac in nature and that L.A. was suffering from gastritis. 153. Medication was prescribed. 154. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 6, 1991, Visit On May 6, 1991, L.A. visited the clinic to obtain birth control pills. JMC billed this visit as an "extended" one. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 17, 1991, Visit On June 17, 1991, L.A. presented to the clinic complaining of a sore throat and back pain. The latter ailment was the result of her having been hit in the back with a chair that was thrown at her at work. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 8, 1991, Debridement On August 8, 1991, L.A. presented to the clinic complaining of a gash on her left leg that she had received the night before, as well as a headache and continuing back pain. The leg wound was cleaned. Necrotic tissue around the edge of the wound was removed. JMC billed for a debridement (procedure code 11042) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC. JMC was therefore appropriately paid for this procedure. September 27, 1991, Visit On September 27, 1991, L.A. presented at the clinic complaining of diarrhea, a cold and postnasal drip. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 28, 1991, Visit On October 28, 1991, L.A. presented to the clinic complaining of a sore throat. She further indicated that she had been exposed to the flu. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 10 (B.W.) February 26, 1991, Visit and EPSDT Screen On February 26, 1991, Patient 10, B.W., who was then twelve years old, presented at the clinic for an EPSDT screen. complaining of an abscess behind her ear and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 12/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. March 1, 1991, Billing JMC billed and was paid for services rendered B.W. during an "intermediate" office visit it claimed took place on March 1, 1991, but the physician signed-medical records maintained by JMC, to the extent that they are legible, do not document that B.W. was seen that day at the clinic by a physician. Payment for such an office visit therefore should not have been made. March 13, 1991, Visit On March 13, 1991, B.W. presented at the clinic with multiple, yet relatively uncomplicated, medical problems, including iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. June 24, 1991, Visit On June 24, 1991, B.W. presented at the clinic complaining of a skin rash. She also had a slightly elevated temperature. The attending physician determined that B.W had dermatitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 27, 1991 Visit Three days later, on June 27, 1991, B.W. again visited the clinic. This time she had an abscess in the area of her left armpit. The abscess was drained. JMC billed this visit as an "extended" one and payment was made accordingly. 13/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit and EPSDT Screen On October 18, 1991, B.W. presented at the clinic for an EPSDT screen complaining of an abscess in the area of her right armpit and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 14/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 11 (T.M.) October 30, 1990, Visit On October 30, 1990, Patient 11, T.M., who was then six years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, a wart was discovered on T.M.'s left wrist. The wart was removed. The procedure took approximately 15 minutes. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 15/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. May 9, 1991, Visit T.M. presented at the clinic on May 9, 1991, with an elevated temperature. The attending physician determined that he had an upper respiratory tract infection. Medication was prescribed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 12 (D.W.) November 30, 1990, Visit On November 30, 1990, Patient 11, D.W., who was then three months old, presented at the clinic for an EPSDT screen. He had a stuffy nose. The screen was performed. The physician performing the screen determined that D.W. was suffering from an upper respiratory tract infection and otitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 14, 1990, Visit On December 14, 1990, D.W. presented at the clinic. His mother reported that D.W. had a persistent cough. D.W. was given a strep test, the results of which were negative. The attending physician determined that D.W. still had an upper respiratory tract infection and otitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 17 and 27, 1990, Visits D.W. visited the clinic on December 17, 1990, and again on December 27, 1990. JMC billed these visits as "intermediate" ones and payments were made accordingly. The parties agree that these billings and payments were appropriate. January 21, 1991, Visit On January 21, 1991, D.W. returned to the clinic with his mother. He had a fever of 102 degrees Fahrenheit, which, his mother reported, he had had for the past four days. Following an examination and a strep test, the attending physician determined that D.W. had a strep throat and an ear infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 7, 1991, Visit On June 7, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was discovered that D.W had an ear problem, for which he received treatment. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office on this date. June 21, 1991, Visit 254. D.W. returned to the clinic on June 21, 1991, with an ear infection and a rash behind his right ear. 255. Treatment was provided. 256. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. July 23, 1991, Visit On July 23, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that D.W. was suffering from diaper rash. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 13 (J.H.) December 29, 1990, Visit and EPSDT Screen On December 29, 1990, J.H., who was then three years of age, presented at the clinic for an EPSDT screen. She was suffering from constipation. During the screen, the attending physician determined that J.H. also had vaginitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, there is no indication that J.H.'s teeth and gums were examined during the visit. Accordingly, JMC was not entitled to receive any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 4, 1991, Visit On January 4, 1991, J.H. presented at the clinic. She looked ill and had glassy eyes. It was reported that her temperature (taken with a rectal thermometer) had reached 104 degrees Fahrenheit at home. When her temperature was taken (again rectally) at the clinic, however, it was only 99.2 degrees Fahrenheit. The attending physician determined that J.H. had a urinary tract infection and pharyngitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 14 (J.Y.) April 20, 1991, Visit On April 20, 1991, Patient 14, J.Y., a 25-year old woman suffering from obesity and hypertension, presented at the clinic to obtain a refill of medication that she had been given on a previous visit. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 15 (K.C.) September 20, 1991, Visit On September 20, 1991, Patient 15, K.C., who was then four years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that K.C. was suffering from an upper respiratory ailment. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "intermediate" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "intermediate" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 16 (D.W.) December 17, 1991, Visit On December 17, 1991, Patient 16, D.W., who was then eight years of age, presented to the clinic for an EPSDT screen. During the screen, the attending physician determined that D.W. was suffering from dermatitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks adequate supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 17 (R.G.) There are no issues in dispute concerning any billings and payments made in connection with services JMC rendered to Patient 17, R.G. Patient 18 (C.F.) February 12, 1991, Visit On February 12, 1991, C.F., a 25-year old woman, presented at the clinic complaining of profuse menstrual bleeding. The attending physician determined that C.F. was simply having irregular menstrual periods and that medical intervention was not warranted. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 18, 1991, Visit On November 18, 1991, C.F. returned to the clinic. She still had irregular menstrual periods and, in addition, she complained of a heavy discharge of breast milk from both of her breasts. Tests were ordered. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991, Visit On December 9, 1991, C.F. again visited the clinic. This time she had an upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 19 (J.R.) September 17, 1990, Visit On September 17, 1990, Patient 19, J.R., who was then six months old, visited the clinic. 16/ He had, what his mother described as, a "bad cold." The attending physician determined that J.R. had an upper respiratory tract infection and bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 31, 1991, Visit On January 31, 1991, J.R. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that J.R. was suffering from a rash, a mild upper respiratory ailment, and a sore throat. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "extended" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. February 26, 1991, Visit On February 26, 1991, J.R. again visited the clinic. He had an ear infection and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, J.R. paid another visit to the clinic. Diaper rash was still a problem. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit J.R. returned to the clinic on May 29, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that any of JMC's staff physicians provided medically necessary services to J.R. on this date. While these records do reflect that J.R. received an abbreviated physical examination during his visit to the clinic, they do not reveal why the examination was conducted or what conclusions the attending physician reached as a result of the examination. Accordingly, JMC should not have received any payment for an office visit on this date. Patient 21 (T.M.) April 26, 1991, Visit On April 26, 1991, Patient 21, T.M., who was then five years of age, presented at the clinic for an EPSDT screen. He had sickle cell anemia, but was doing well. The screen was performed. Following the screen, the attending physician recommended that T.R. continue taking folic acid and vitamins. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 22 ( K.C.) August 28, 1990, Visit On August 28, 1990, Patient 22, K.C., who was then six months old and had recently been exposed to hepatitis B, presented at the clinic for an EPSDT screen. The screen was performed. The attending physician did not believe that K.C. had contracted hepatitis B. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 23 ( K.G.) July 10, 1990, Visit On July 10, 1990, Patient 23, K.G., presented at the clinic complaining of a vaginal discharge. The attending physician determined that K.G. was suffering from vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 15, 1990, Visit On October 15, 1990, K.G. presented at the clinic complaining of a rash in the area of her groin. The attending physician determined that K.G. had folliculitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. February 15, 1991, Visit On February 15, 1991, K.G. presented at the clinic complaining of swelling in her legs. 17/ The attending physician determined that she had pinworms. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. March 8, 1991, Visit On March 8, 1991, K.G. presented at the clinic complaining of rectal pain and a persistent cough. The attending physician determined that K.G. had pharyngitis, pneumonia and an anal fissure. Treatment, which included the use of an aerosol spray, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 18/ 372. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. June 6, 1991, Visit On June 6, 1991, K.G. visited the clinic complaining of weight gain and pain in her left side. The attending physician determined that the pain was caused by gas and prescribed medication to combat the problem. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 28, 1991, Visit On June 28, 1991, K.G. presented at the clinic complaining of a sore throat and a cough producing yellowish sputum. She claimed that she had had the sore throat for three to four days. A strep test was given, the results of which were negative. The attending physician determined that K.G. had bronchitis and pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 1, 1991, Visit On August 1, 1991, K.G. presented at the clinic. 19/ She had a pararectal abscess and a urinary tract infection. The abscess was drained. In addition, treatment was provided for the urinary tract infection. JMC billed this visit as an "extended" one and payment was made accordingly. 20/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 5, 1991, Visit On September 5, 1991, K.G. presented at the clinic. She had a cough and sore throat. A strep test was given, the results of which were negative. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 24 (L.W.) December 10, 1990, Visit On December 10, 1990, Patient 24, L.W., who was then five years of age, presented at the clinic for an EPSDT screen. The screen was performed. As part of the screen, her weight was taken. She weighed only 30 pounds. 401. Because she had a persistent cough and a runny nose, a strep test was given, the results of which were positive. 402. JMC billed for an EPSDT screen and a "comprehensive" visit. 403. The parties agree that the billing and payment for an EPSDT screen was appropriate. The billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. July 2, 1991, Visit On July 2, 1991, L.W. presented at the clinic. 21/ Her right breast was enlarged. In addition, she had pharyngitis and impacted cerumen in her ears. A strep test was given, the results of which were negative. Treatment, which included the removal of the impacted cerumen, was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 22/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 25 (R.W.) October 3, 1991, Visit On October 3, 1991, Patient 25, R.W., who was then four months old, presented at the clinic for an EPSDT screen. 23/ He had an asthmatic condition and bronchitis. The screen was performed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 24/ JMC therefore should not have received any payment for an office visit on this date. October 10, 1991, Visit On October 10, 1991, R.W. presented at the clinic for another EPSDT screen. His asthma and bronchitis were much improved. The screen was performed. No new problems were discovered. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 25/ JMC therefore should not have received any payment for an office visit on this date. October 16, 1991, Visit On October 16, 1991, R.W. returned to the clinic. His condition had worsened and he was crying in his mother's arms. In addition to the problems he had had previously, he now also had an ear infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit R.W. paid a follow-up visit to the clinic on October 24, 1991. His condition had improved since his last visit to the clinic on October 16, 1991. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that this visit, like R.W.'s prior visit to the clinic, was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 26 (E.W.) September 16, 1991, Visit On September 16, 1991, Patient 26, E.W., who was then four months old, presented at the clinic with a cold and cough. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks sufficient supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 27 (C.S.) 26/ November 4, 1991, Visit and EPSDT Screen On November 4, 1991, Patient 27, C.S., who was then seven months old, presented at the clinic. She was suffering from a cold. Treatment was provided. JMC billed for an EPSDT screen and an "extended" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, these records contain no nutritional or developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not an "extended" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 28 (S.S.) 27/ May 15, 1991, Visit On May 15, 1991, Patient 28, S.S., presented at the clinic complaining of keloid skin masses on both of her ears which, she indicated, she wanted removed. JMC billed this visit as a "comprehensive" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as an "intermediate" one and that therefore JMC was overpaid for this visit. May 29, 1991, Visit On May 29, 1991, S.S. returned to the clinic for evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on May 29, 1991. June 12, 1991, Visit On June 12, 1991, S.S. paid another visit to the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on June 12, 1991. July 10, 1991, Visit On July 10, 1991, S.S. again visited the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on July 10, 1991. August 7, 1991, Visit S.S. went back to the clinic on August 7, 1991, for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 12, 1991, Visit On September 12, 1991, S.S. presented at the clinic for additional evaluation and treatment of her keloids, which were scheduled to be removed the following day. She also had a sore throat. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 19, 1991, Visit Only one of the keloids, the one on her left ear, was removed on September 13, 1991. Six days later, on September 19, 1991, S.S. visited the clinic for a postsurgical examination and to discuss the removal of the keloid on her right ear. She presented at the clinic with a sore throat and earache. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 26, 1991, Visit S.S. returned to the clinic on September 26, 1991. She had an abscess on her ear. The abscess was incised and drained. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 28/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Debridement On October 7, 1991, S.S. presented at the clinic complaining of continuing skin problems on and behind her ears. An abscess and "raggedy" skin were discovered. The abscess was incised and drained and the "raggedy" skin was removed. JMC billed and was paid for a debridement. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC, and that therefore JMC was entitled to the payment it received for the debridement. Patient 29 (T.J.) January 28, 1991, Visit On January 28, 1991, Patient 29, T.J., who was then one month old, was seen at the clinic. She had congenitally deformed ("toe[d] in") feet, multiple insect bites and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 30, 1991, Visit T.J. returned to the clinic two days later. She had been vomiting for the past two days. In addition, she had a sore throat and an earache. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 22, 1991, Visit On April 22, 1991, T.J. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was determined that T.J. had dermatitis caused by insect bites. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 24, 1991, Visit On April 24, 1991, T.J. again visited the clinic. Her dermatitis was still causing her some discomfort. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 30 (G.D.) March 11, 1991, Visit On March 11, 1991, Patient 30, G.D., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed that G.D. had upper respiratory problems, as well as an umbilical hernia. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 22, 1991, Visit G.D. was next seen at the clinic on April 22, 1991. He had pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 3, 1991, Visit G.D. next visited the clinic on June 3, 1991. He had a mild upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 31 (H.C.) October 15, 1990, Visit On October 15, 1990, H.C., who was then 18 years old, presented at the clinic complaining of delayed menstruation. She was given a pregnancy test, the results of which revealed that she was pregnant. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 32 (R.M.) February 12, 1991, Visit On February 12, 1991, Patient 32, R.M., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in R.M.'s ears. The impacted cerumen was removed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 29/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 33 (C.W.) December 3, 1990, Visit On December 3, 1990, Patient 33, C.W., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in C.W.'s ears and that R.M. had pharyngitis. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 30/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. August 22, 1991, Visit 534. On August 22, 1991, C.W. presented at the clinic complaining of a headache. 535. The attending physician determined that C.W. had pharyngitis. 536. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Visit On October 7, 1991, C.W. again visited the clinic. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed and paid for as a "limited" one, as described in Chapter 11 of the MPP Handbook. October 10, 1991, Visit Three days later, on October 10, 1991, C.W. returned to the clinic. She had tonsillitis, pharyngitis and an upper respiratory infection. Her temperature was 103.4 degrees Fahrenheit. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 34 (K.K.) September 19, 1990, Visit On September 19, 1990, Patient 34, K.K., who was then three years old, presented at the clinic for an EPSDT screen. He had a runny nose and a cough. His mother also complained that he was hyperactive. 549. The screen was performed. 550. The screen revealed that K.K. had impacted cerumen in his ears. 551. provided. Treatment, including the removal of the impacted cerumen, was 552. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 31/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 17, 1990, Visit On or about December 17, 1990, K.K. returned to the clinic. He had dermatitis, as well as impacted cerumen in his ears. In addition, his mother was concerned about his behavior. Treatment, including the removal of the impacted cerumen, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 32/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 3, 1991, Visit On January 3, 1991, K.K. returned to the clinic for a physical examination for school. During the visit, his mother complained that K.K.'s appetite for food had decreased. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 35 (T.B.) November 15, 1990, Visit On November 15, 1990, Patient 35, T.B., presented at the clinic for a physical examination for work. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 20, 1990, Visit T.B. returned to the clinic on December 20, 1990, complaining that she was not feeling well. During the visit, impacted cerumen was removed from her ears. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 33/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. July 18, 1991, Visit On July 18, 1991, T.B. went to the clinic to obtain "medical certificates." A routine physical examination was performed, but no history was taken. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 4, 1991, Visit On December 4, 1991, T.B. presented at the clinic with "pink eye." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 36 (D.W.) January 2, 1991, Visit On January 2, 1991, Patient 36, D.W., who was then 19 years of age, visited the clinic for a checkup. The attending physician determined that D.W. had an iron deficiency and anemia, for which treatment was provided. During the visit, family planning issues were also addressed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit On April 17, 1991, D.W. presented at the clinic complaining that she had been feeling ill for two days. 34/ 592. A strep test was given, the results of which were negative. The attending physician determined that D.W had tonsillitis and was still suffering from anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 16, 1991, Visit On September 16, 1991, D.W. presented at the clinic. She had a sore throat and vaginitis. 35/ In addition, she was now pregnant and still anemic. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. 601. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 17, 1991, Visit On October 17, 1991, D.W., who was still pregnant at the time, made a follow-up visit to the clinic. She complained of shortness of breath and tightness in her chest, as well as a sore throat. A fetal examination was conducted. A strep test was given, the results of which were negative. The attending physician determined that D.W. had a urinary tract infection, sinusitis, pharyngitis and anemia. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 14, 1991, Visit and Echography D.W. returned to the clinic on November 14, 1991. She was in approximately the thirty-second week of her pregnancy and she was still suffering from a urinary tract infection and anemia. Her sinus condition was improving. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. It also sought and received separate payment for an echography (procedure code 76855). The parties now agree that JMC should not have been paid for an echography. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 3, 1991, Visit A still-pregnant D.W. visited the clinic again on December 3, 1991, complaining of shortness of breath. The attending physician determined that she was still suffering from a urinary tract infection and anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 10, 1991, Visit A week later, on December 10, 1991, with her anticipated date of delivery approaching, D.W. returned to the clinic complaining of vaginal irritation and pain in her left wrist. Her urinary tract infection was improving. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 37 (E.A.) September 27, 1991, Visit On September 27, 1991, Patient 37, E.A., who was then seven weeks old, presented at the clinic with an upper respiratory infection, pharyngitis and thrush. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit E.A. returned to the clinic on October 18, 1991, for an EPSDT screen. 633. The screen was performed. The screen revealed that he still had an upper respiratory infection and thrush. Treatment was provided. JMC billed for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. November 20, 1991, Visit E.A. visited the clinic again on November 20, 1991. He had a bad cough and a green discharge from his eyes and nose. The attending physician determined that E.A. had an upper respiratory infection and pharyngitis, as well as a "foreign body" in his nose. Treatment, including the removal of the "foreign body," was provided. 36/ JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore entitled to the payment it received for this visit. November 21, 1991, Incision and Removal JMC billed and was paid for an incision and removal of a "foreign body" (procedure code 10120) it claimed had been performed on E.A. at the clinic on November 21, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that E.A. received an incision and removal at the clinic on this date. Accordingly, payment should not have been made to JMC for this billed-for service. Patient 38 (O.S.) December 2, 1991, Visit and EPSDT Screen On December 2, 1991, Patient 38, O.S., who was then three months old, presented at the clinic for an EPSDT screen. She had a cold and blotches all over her body and her hair was falling out. The screen revealed that O.S. had tinea capitis, otodynia, and pharyngitis, as well as impacted cerumen in her ears. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 37/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete EPSDT screen was performed. For example, these records contain no developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991 O.S. returned to the clinic a week later on December 9, 1991. She had a new rash on her left arm. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 39 (T.G.) September 5, 1991, Visit On September 5, 1991, Patient 39, T.G., who was then three months old, presented at the clinic for an EPSDT screen. She had a stuffy nose and was crying. According to his mother, he had been crying for the past 12 hours. The screen was performed. A strep test was given, the results of which were negative. The attending physician determined that T.G. had an ear infection, an upper respiratory tract infection and phayrngitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, justify JMC billing and receiving payment for, in addition to an EPSDT screen, only an "intermediate" office visit and not a "comprehensive" one. JMC was therefore overpaid for this visit. September 19, 1991, Visit T.G. returned to the clinic for a follow-up visit on September 19, 1991. He had diaper rash. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 40 (T.B.) November 26, 1991, Visit On November 26, 1991, T.B., a 62-year old man with a history of heart disease, hypertension and stroke, presented at the clinic with a periorbital abscess. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. 38/ JMC was therefore overpaid for this visit. November 29, 1991, Visit Three days later, on November 29, 1991, T.B. returned to the clinic again complaining about the abscess. The attending physician reevaluated the problem and referred T.B. to Jackson Memorial Hospital for treatment. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 41 (L.B.) January 25, 1991, Visit On January 25, 1991, Patient 41, L.B., who was then 19 years of age and had history of mental illness, presented at the clinic stating that she was pregnant and complaining, among other things, of abdominal pain. She appeared to be confused and it was difficult to obtain an accurate history from her. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit L.B. returned to the clinic on April 17, 1991, complaining of continuing abdominal pain, vaginal discharge, breast tenderness and nausea. The attending physician determined that L.B. had vaginitis and a urinary tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 25, 1991, Visit L.B. visited the clinic again on November 25, 1991. On this visit she complained of a rash. The attending physician determined that L.B. had dermatitis. 694. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 6, 1991, Visit On December 6, 1991, L.B. presented at the clinic claiming that there were things crawling on her scalp. The attending physician determined that L.B. was demented. He filled out a Social Security Administration form indicating that it was his opinion that L.B. was "not medically competent." JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration adopt the findings made by the Hearing Officer regarding the sampled claims remaining in dispute in the instant case and use these findings to redetermine the total amount of Medicaid overpayments made to Petitioner during the audit period and the amount of the fine Petitioner should be required to pay for its erroneous billings during this period of time. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd of May, 1995. 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 22nd day of May, 1995.
The Issue Whether the Respondent committed the violations alleged in the Administrative Complaint dated March 27, 2009, and, if so, the penalty that should be imposed.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made:1 At the times material to this proceeding, the Department was the state agency responsible for the investigation and prosecution of complaints involving physicians licensed to practice medicine in Florida. See § 456.072, Fla. Stat. (2004-2005). At the times material to this proceeding, the Board of Medicine ("Board") was the entity responsible for regulating the practice of medicine and for imposing penalties on physicians found to have violated the provisions of Section 458.331(1), Florida Statutes (2004-2005). See § 458.331(2), Fla. Stat. (2004-2005). At the times material to this proceeding, Dr. Genao was a physician licensed to practice medicine in Florida, having been issued license number ME 58604. Dr. Genao practiced in the field of pediatric medicine, and he was board-certified in pediatrics. His practice was located at 13059 Southwest 112th Street, Miami, Florida. In or about 2005, Dr. Genao became aware that so-called "infusion centers" were opening in Miami-Dade and Broward Counties, Florida, to treat patients who had been diagnosed with HIV/AIDS and who required injections and infusion treatments for HIV/AIDS-related conditions. Dr. Genao visited one such center and observed a physician, a Dr. Fauler, as he provided infusion treatments to HIV/AIDS patients. Dr. Genao believed that Dr. Fauler's treatment of the HIV/AIDS patients was appropriate. Dr. Genao had training in intravenous treatments, and, after observing Dr. Fauler and working for a time under Dr. Fauler's supervision, Dr. Genao considered himself ready to begin treating HIV/AIDS patients in an "infusion center" that he intended to operate out of the office housing his pediatric practice. By his own admission, Dr. Genao had no formal training or experience treating patients with HIV/AIDS. Dr. Genao's first patient was G.M., whom Dr. Genao treated for HIV/AIDS-related conditions between May 25, 2005, and June 20, 2005. At the end of July, Dr. Genao was approached by two men who offered to bring him HIV/AIDS patients for injections and infusion treatment for HIV/AIDS-related conditions. Dr. Genao felt he was competent to treat HIV/AIDS patients with infusion therapy, and he signed a contract with the two men in which he agreed to see HIV/AIDS patients in exchange for a salary. Dr. Genao assumed that the patients he would see also had primary care physicians who were treating the patients for HIV/AIDS. In mid-August, 2005, Dr. Genao began to see HIV/AIDS patients regularly at his office in the mornings, before his pediatric patients arrived. Between August 15, 2005, and October 14, 2005, Dr. Genao treated 11 HIV/AIDS patients. Dr. Genao diagnosed these patients as suffering from conditions associated with HIV/AIDS, such as neuropathy; neutropenia; thrombocytopenia; and diarrhea. Dr. Genao ordered various treatments for these patients, including intramuscular injections of drugs such as Sandostatin and infusion of such drugs as Rituxan, Neupogen, and Neumega. Shortly after he began treating these HIV/AIDS patients, Dr. Genao began to question the appropriateness of the modes of treatment he had observed at Dr. Fauler's infusion center and to feel uncomfortable about treating the HIV/AIDS patients. He sought training at Jackson Memorial Hospital in Miami, Florida, and attended training sessions during which he observed a physician who specialized in the treatment of HIV/AIDS patients and who ran the HIV/AIDS clinic at Jackson Memorial Hospital. Dr. Genao attended these training sessions three days per week for two weeks. Dr. Genao realized that the treatment given by the physician at Jackson Memorial Hospital was completely different from the treatment he was providing the HIV/AIDS patients in his office. Dr. Genao also realized that the patients he was treating for HIV/AIDS-related conditions were not being treated for the underlying HIV/AIDS by primary care doctors. Dr. Genao decided to stop treating the HIV/AIDS patients that he was seeing pursuant to the contract with the two men, who were not physicians. When he told the men that he wanted to renege on the agreement, they told Dr. Genao that he had to continue treating the HIV/AIDS patients until they could find another physician to provide them treatment. Dr. Genao felt threatened by the men, and he continued to treat the patients until on or about October 14, 2005. During the time that Dr. Genao treated the HIV/AIDS patients brought to him by the two men, the men prepared all of the bills to be submitted to Medicare and/or Medicaid. Dr. Genao signed each bill in the large stacks of bills presented to him without reviewing any of them. The Department's expert testified at length about the treatment that Dr. Genao provided to the 12 HIV/AIDS patients he had treated, and the expert enumerated the ways in which Dr. Genao had violated the standard of care in their diagnosis and treatment. In his responses to the Department's request for admissions, Dr. Genao admitted that he failed to diagnose and treat these patients properly.2 Furthermore, in his testimony at the final hearing, Dr. Genao admitted that his treatment of these patients fell below the standard of care, and he agreed with the Department's expert that he misused some of the drugs he prescribed for the patients, failed to follow through with necessary treatment for these patients, and neglected their care.3 Based on the patients' medical records, on testimony of the Department's expert, and on Dr. Genao's admissions and testimony, the ways in which Dr. Genao failed to meet the applicable standard of care in treating the 12 HIV/AIDS patients may be grouped into categories and summarized as follows: Dr. Genao treated patients S.B. and J.S. for diarrhea with intramuscular injections of Sandostatin; Sandostatin is a medication that is not appropriate for the treatment diarrhea but is used to treat the very rare disease, acromegaly. Dr. Genao treated patients S.B. and G.M. for thrombocytopenia with multiple intravenous infusions of Rituxan, a drug that is not appropriate for the treatment of thrombocytopenia, which is a bleeding disorder caused by an abnormally low level of platelets. Rituxan is used to treat lymphoma and rheumatoid arthritis, and it is a very expensive and dangerous drug that can sometimes cause death. Dr. Genao failed to follow-up with diagnoses and treatment for seriously abnormal values that showed up in the results of blood work ordered by Dr. Genao for patients S.B., S.E., L.G., G.M., J.S., and J.T. Dr. Genao failed to refer patients S.B., S.E., M.E., L.G., J.T., E.T., and J.T. 2 to specialists for evaluation when such evaluation was indicted by the patients' complaints and symptoms. Dr. Genao failed to notify patient M.E., whom Dr. Genao saw only once, of abnormal blood test results that should have been evaluated and treated. Dr. Genao failed to revise his treatment of patients S.E., L.G., J.T., and E.T. when it became clear that there had been no improvement in the conditions of the patients after Dr. Genao had treated them for a month or more. Dr. Genao administered Neupogen to patients E.T. and J.T. 2 when treatment with this drug, which is used primarily to treat patients with a critically low white blood cell count resulting from chemotherapy, was not indicated by the results of blood tests. Dr. Genao failed to diagnose accurately and/or timely conditions that were indicated by the complaints, symptoms, and results of blood tests for patients S.B., S.E., M.E., L.G., G.M. J.S., J.T., E.T. and J.T. 2. By his own admission, Dr. Genao failed to keep appropriate medical records of the treatment of these 12 patients. Dr. Genao's medical records were often illegible4; there were no medical records for patients M.C. and R.M., just billing records; and the medical records were incomplete and generally failed to justify the course of treatment for patients S.B., S.E., M.E., L.G., G.M., J.S., M.S., J.T., E.T., and J.T. 2. Summary and findings of ultimate fact The evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao committed medical malpractice because he did not provide to the 12 HIV/AIDS patients he treated the level of treatment, skill, and care that would be found acceptable by a reasonable prudent similar physician under similar circumstances. Even though the evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao prescribed and administered Rituxan, Sandostatin, and Neupogen inappropriately and in excessive quantities for some of his HIV/AIDS patients, the evidence is not sufficient to establish that this conduct occurred outside Dr. Genao's professional practice. The evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao failed to keep medical records that were legible and complete and that justified the treatment that he provided his HIV/AIDS patients.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Medicine enter a final order finding that Estaban Antonio Genao, M.D., violated Section 458.331(1)(m) and (t), Florida Statutes (2004 and 2005), and revoking the license of Estaban Antonio Genao, M.D., to practice medicine in the State of Florida. DONE AND ENTERED this 30th day of November, 2010, in Tallahassee, Leon County, Florida. S Patricia M. Hart 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 30th day of November, 2010.
The Issue The issues in this case are whether Petitioner committed the alleged violations and, if so, should her paramedic license be revoked.
Findings Of Fact At all times relevant to this proceeding, Petitioner was employed as a paramedic by the City of Gulfport and worked as a paramedic for the Gulfport Fire Department. In this capacity, Petitioner worked under the auspices of the medical director for Pinellas County Emergency Medical Services (Pinellas County EMS). Petitioner was a paramedic from 1997 until March 2003. Prior to that time, from 1991 until 1997, she worked as an emergency medical technician (EMT). On February 20, 2003, Petitioner, along with Lt. Brian Campbell and Firefighter/EMT Dennis Jackson, were called to respond to the scene of a shooting. Petitioner was the only paramedic on the scene and, therefore, the only person on the scene certified by the Office of the Medical Director (OMD) to provide advanced cardiac life-saving treatment. Petitioner received the call at 12:22 a.m., and arrived at the patient's side at 12:30 a.m. When Petitioner arrived at the patient's side, she observed a white male, approximately 20 years old, lying on his back in the street. His skin color was ashen, his mouth and eyes were wide open, and his pupils were fixed and dilated. Upon physical examination, Petitioner could not detect a pulse and observed two small holes in the patient's trunk. At that point, Petitioner did not know whether the two holes represented two separate entry wounds or one entry and one exit wound. Petitioner observed a trail of blood, at least a block long, leading to the patient, but there was not a lot of blood around the patient. Petitioner attached an electrocardiogram (ECG) monitor to the patient to monitor the electrical activity of his heart. When Petitioner first turned on the ECG monitor, she observed four ticks of electrical activity within a 14-second span. Petitioner testified that based on her observation and physical examination of the patient, she believed that the electrical activity exhibited on the ECG monitor was not pulseless electrical activity (PEA), but rather "artifact" caused by her manipulation of the patient. Petitioner further testified that, thereupon, she stopped touching the patient and observed that the ECG read-out went mostly flat, showing only occasional ticks. Petitioner testified that these occasional ticks, as observed on the ECG monitor, indicated to her that the patient was in asystole. Shortly thereafter, Petitioner declared the patient dead. After Petitioner declared the patient dead, she prepared a Patient Care Report (Report or Patient Care Report) while still on the scene. In the Report, Petitioner wrote that she found a white male laying on the ground with an apparent small entrance wound in his upper chest and a possible small exit wound near his back rib. She further noted that the patient's temperature was normal, that his eyes were fixed and dilated, that he was not breathing (apneic), and that he had no discernible pulse. Petitioner also noted in the Report that the patient was in asystole within one minute after the ECG pads were attached, but she failed to note the initial four ticks she observed, which may have represented PEA. In the Report, Petitioner noted that at 12:30 p.m., the patient was hooked up to the monitor; at 12:31 p.m., he was asystolic; and at 12:32, she confirmed the patient dead. Upon completing the Report at the fire station, Petitioner attached to the Report the last of several ECG strips she had intermittently printed while at the patient's side. The ECG printout that Petitioner attached to the Report depicted a classic "flat line" indicative of asystole or no electrical activity. Petitioner discarded each of the ECG strips that contained some indicia of electrical activity. A Patient Care Report is a legal document that Petitioner is required to complete by law. By signing the Report, Petitioner acknowledged that the information contained in the Report was true and accurate. Later, on the morning of February 20, 2003, when the employees' shifts at the fire station were changing, Petitioner and Toni Lanahan (Lanahan), a firefighter/paramedic coming on duty, talked about the shooting incident. That such conversation occurred is undisputed. However, there was conflicting testimony as to what Petitioner told Lanahan during that conversation. According to Lanahan, Petitioner told her that when she (Petitioner) arrived at the scene, the patient looked dead but she hooked him up to the ECG monitor, that he had a rhythm but she did not work him, and that she turned off the monitor. Petitioner testified that she did not tell Lanahan that the patient had a heart rhythm, but only that the patient "was dead" and that she did not work him.1 About two hours after her conversation with Petitioner, Lanahan retrieved stored ECG code summary data of the patient described above.2 When Lanahan reviewed the ECG code summary, she saw that the patient had a presenting ECG rhythm showing approximately 40 beats per minute of PEA with gradually slowing PEA for the entire seven minutes depicted in intervals on the ECG summary. Based on her review of the ECG record of the gunshot wound patient, Lanahan believed that in this situation, the OMD protocols mandated that immediate resuscitative treatment be administered. Lanahan then reported these concerns to her emergency medical services (EMS) Coordinator, Lt. Marenkovic, who in turn, reported the incident to Gulfport Fire Chief Brian Brooks. Chief Brooks notified the OMD of the possible violations of its protocols by Petitioner. The OMD initiated an investigation, which included reviewing the written statements of Petitioner, Lt. Campbell, and EMT Jackson; the ECG code summary for the incident; Petitioner's Report; and the transcripts of the sworn interviews of Petitioner, Lt. Campbell, and EMT Jackson taken by the Gulfport Fire Department. After reviewing the above-referenced documents, Dr. Laurie Romig (Dr. Romig), the medical director of the Pinellas County EMS, decided to revoke Petitioner's certification. This decision was based on Dr. Romig's determination of the following: (1) Petitioner violated numerous protocols in the Medical Operations Manual, both administrative and direct patient care protocols; and (2) Petitioner attempted to make the situation appear differently from what it turned out to be, and that, apparently, she did that on purpose. Specifically, Dr. Romig charged Petitioner with violating Pinellas County Emergency Medical Services Protocol 2.3, Sections 5 and 6, and Protocol 10.8 and the following Pinellas County Emergency Medical Services Rules and Regulations: Sections XIII-3-b, related to falsification or inappropriate alteration of emergency medical services records; XIII-3-e, related to theft or dishonesty in performance of duty; XIII-3-i, related to demonstrated ability, failure or refusal to adhere to established protocols and standards as established by the authority; and XIII-3-k, related to just cause, including unbecoming behavior or unprofessional conduct reflecting a poor system image. The Pinellas County emergency protocols are written requirements that paramedics must follow when administering emergency treatment to patients. The protocols are published in a document entitled Pinellas County Medical Operations Manual, which is approved by the medical director and distributed to all Pinellas County EMS paramedics. Petitioner received a copy of the most recent medical operations manual in January 2003. EMS Protocol 5.10 prescribes treatment for patients presenting with PEA. As defined in Protocol 5.10, PEA is "any semi-organized electrical activity that can be seen on a monitor screen although the patient lacks a palpable, radial, brachial, or carotid pulse." When PEA is present in a patient, Protocol 5.10 mandates that immediate life-saving treatment be implemented. The patient initially had electrical activity. Nonetheless, Petitioner did not follow Protocol 5.10. According to Petitioner's testimony, she believed that the patient was asystolic and, thus, the protocol related to PEA was inapplicable to the shooting victim. Petitioner's belief was not supported by the ECG report. Protocol 5.4 delineates the procedures to be followed in the treatment of asystole. In the book utilized for Pinellas County EMS paramedic training, "asystole" is defined as a cardiac arrest rhythm associated with no discernible electrical activity on the ECG ("flat line"). Significantly, Protocol 5.4 and Protocol 5.10, discussed in paragraph 21, require that resuscitative efforts be started immediately and that such resuscitative efforts and treatment be terminated by the paramedic only "after 10 minutes of continuous asystolic arrest with appropriate interventions." Even if Petitioner's assertion that the patient was asystolic is accepted, she failed to provide the required resuscitative efforts and/or treatments prescribed by Protocol 5.4. Petitioner did not prematurely terminate resuscitative efforts, she never implemented them. Protocol 5.15 prescribes the treatment and transport considerations for "patients with cardiac arrest secondary to trauma, regardless of presenting cardiac rhythm." The protocol provides that such patients should be transported to the closest hospital emergency facility. Contrary to the requirements in Protocol 5.15, the patient was not transported to a hospital emergency facility. Protocol 2.3 requires paramedics, when possible, to contact and consult with On-line Medical Control (OLMC) in any case in "which a deviation from protocol has been made intentional or otherwise." The OLMC is a system which allows paramedics to contact the OMD and consult with a medical doctor regarding a situation in the field. Petitioner clearly deviated from Protocols 5.4 and/or 5.10, by failing to initiate and implement the resuscitation procedures required by both protocols, and Protocol 5.15, by failing to have the patient transported to a hospital emergency facility, yet she never contacted the OLMC as mandated by Protocol 2.3. Petitioner acknowledged that she did not follow either Protocols 5.4 or 5.10, both of which required immediate resuscitative efforts. Petitioner testified that instead, she followed Protocol 10.8, which provides an exception to the protocols that require initiation of resuscitative efforts. Petitioner contends that Protocol 10.8 provided the basis for her withholding resuscitation from the patient. Protocol 10.8 requires that cardiopulmonary cerebral resuscitation (CPCR) be initiated "in all cases when the patient is found in cardiopulmonary arrest unless one of the exclusion or special situation criteria applies." The exclusion criteria provides that CPCR may be withheld if the patient has, "in conjunction with apnea, pulselessness and asystole on the ECG," an "obviously unsurvivable trauma." If CPCR is withheld, Protocol 10.8 requires that exclusion criteria be fully documented and described. Protocol 10.8 does not define "obviously unsurvivable trauma." However, according to Dr. Romig, the term connotes catastrophic injuries observable by an untrained eye. Dr. Romig, an expert in emergency medicine and traumatic cardiac arrest, testified that nothing about this patient, based on her review of the records and documents, indicated that the patient had suffered an "obviously unsurvivable trauma." Also, Lt. Campbell, an EMT certified for 12 years, who was at the scene, testified that although the patient "looked dead," he could not say that the patient suffered an "obviously unsurvivable trauma" because the patient showed only a small bullet wound to the chest and a "little bit" of blood on his (the patient's) clothing. The weight of the evidence showed that the patient had not suffered an obviously unsurvivable trauma. However, even accepting Petitioner's testimony that she believed that the patient had suffered an obviously unsurvivable trauma, she failed to comply with Protocol 10.8. If Petitioner, in fact, relied on Protocol 10.8 in deciding to not administer CPCR, she was required to document and describe the exclusionary criteria, which was the basis of her decision to withhold CPCR. Petitioner failed to provide any such documentation and, thus, violated Protocol 10.8. In addition to violating the above-noted protocols, Petitioner was dishonest in the performance of her duties as a paramedic and also falsified EMS records. The ECG summary showed that despite the patient's having electrical cardiac activity of at least 40 beats, Petitioner turned off the ECG machine and pronounced the patient dead. After pronouncing the patient dead, she then turned the ECG machine on again, and intermittently printed activity on four separate occasions until reaching a reading showing no electrical cardiac activity. By engaging in this conduct, Petitioner was dishonest in the performance of her duties. Paramedics are required to truthfully and accurately complete the Patient Care Records of patients for whom they provide emergency medical services. Here, the ECG summary showed PEA of over 40 beats per minute initially and diminished electrical activity for over eight minutes total, six minutes of which were after Petitioner had already pronounced the patient dead. Petitioner initially saw a rhythm of four beats or ticks in a 14-second period, which was a beat rate of 40 and showed on the ECG strip as 42. Although the initial reading of approximately 40 beats and PEA was clearly visible during the entire nearly eight minutes depicted on the six-second intervals shown on the ECG code summary, this was omitted from Petitioner's Report. Petitioner omitted from the patient's Record the ECG readings that showed electrical activity. Instead, Petitioner reported that at the time she declared the patient dead, he was in "asystole" when, in fact, the ECG summary showed PEA. Moreover, Petitioner documented the Report with an asystole ECG strip reflecting a "flat line" reading printed some six or seven minutes after the reported time of death.3 Petitioner admitted during her sworn statement and at this proceeding that she deliberately did not attach to the Report any part of the ECG strip that reflected the interim electrical activity. Petitioner testified that the ECG strips showing interim electrical activity could raise doubts about the propriety of the treatment she gave this patient in a future criminal trial or other investigation.4 The medical director is required by law to ensure that Pinellas County EMS personnel provide quality care and are not a danger to the safety of the county's citizens, residents, or visitors. Here, Petitioner violated the protocols related to the standard of care for patients and completion of reports and rules and regulations related to dishonesty in the performance of duties and to falsification of records. These infractions are a possible threat to public health and safety of residents of and visitors to Pinellas County. As such, they constitute just cause to conditionally revoke Petitioner's Pinellas County Paramedic Certificate. The conditional revocation allows Petitioner to reapply for a paramedic certificate in two years. Such recertification may include a one-year probationary period, with monitoring by the medical director to include a review of all trauma-run reports. Petitioner's Pinellas County Emergency Medical Technician Certification was not revoked and she retains that certification.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that Respondent enter a final order finding Petitioner guilty of the violations alleged in the Notice of Revocation dated March 28, 2003, and upholding revocation of Petitioner's Pinellas County Paramedic Certificate. DONE AND ENTERED this 1st day of October, 2003, in Tallahassee, Leon County, Florida. S CAROLYN S. HOLIFIELD 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 1st day of October, 2003.
