The Issue The issue is whether Respondent’s request for a substantial interests hearing under section 120.57(1), Florida Statutes (2017),1/ should be dismissed as untimely.
Findings Of Fact The Department is the State agency charged with regulating the practice of marriage and family therapy interns pursuant to section 20.43 and chapters 456 and 491, Florida Statutes. Mr. Tito is a licensed registered marriage and family therapist intern in the state of Florida, having been issued license number IMT 1070, and practices in Pompano Beach, Florida. He is subject to regulation by the Department and the Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling. On or about September 27, 2017, the Department filed an Administrative Complaint against Mr. Tito’s license to practice as a registered marriage and family therapist intern. On October 23, 2017, Mr. Tito received the Administrative Complaint sent by the Department, which included a cover letter, a settlement agreement, and an Election of Rights form. Mr. Tito signed and mailed a certified mail receipt acknowledging his receipt of the Administrative Complaint and attachments, which the Department received on November 6, 2017. Both the cover letter and the Administrative Complaint that Mr. Tito received stated that he must return the Election of Rights form to the Department within 21 days of his receipt of the Administrative Complaint if he chose to request a formal hearing. The cover letter stated, in relevant part: You must sign the Election of Rights form, and return the completed form to my office within twenty-one (21) days of the date you received it. Failure to return this form within twenty-one (21) days may result in the entry of a default judgment against you without hearing your side of the case. In a portion denominated “Notice of Rights,” the Administrative Complaint included the following language in bold print: A request or petition for an administrative hearing must be in writing and must be received by the Department within 21 days from the day Respondent received the Administrative Complaint, pursuant to Rule 28-106.111(2), Florida Administrative Code. If Respondent fails to request a hearing within 21 days of receipt of this Administrative Complaint, Respondent waives the right to request a hearing on the facts alleged in this Administrative Complaint pursuant to Rule 28- 106.111(4), Florida Administrative Code. The Election of Rights form that Mr. Tito received stated in relevant part: In the event that you fail to make an election in this matter within twenty-one (21) days from receipt of the Administrative Complaint, your failure to do so may be considered a waiver of your right to elect a hearing in this matter, pursuant to Rule 28-106.111(4), Florida Administrative Code, and the Board may proceed to hear your case. At the bottom of the Election of Rights form was a notation that the form could be mailed or faxed and provided addresses and telephone numbers. Mr. Tito wrote a letter to the Department requesting a formal hearing and mailed that to the Department along with an executed Election of Rights form. The Department received Mr. Tito’s letter and Election of Rights form on November 20, 2017, 28 days after Mr. Tito received a copy of the Administrative Complaint. The cover letter, copy of the Administrative Complaint with Notice of Rights, and Election of Rights form together gave Mr. Tito sufficient written notice of intended agency action that affected his substantial interests. These documents informed him of his right to an administrative hearing, indicated the procedures he must follow to obtain the hearing, and stated the time limits that applied.
Recommendation In view of the foregoing Findings of Fact and Conclusions of Law, it is: RECOMMENDED that Respondent’s request for a substantial interests hearing under section 120.57(1), Florida Statutes, should be dismissed as untimely. DONE AND ENTERED this 9th day of November, 2018, in Tallahassee, Leon County, Florida. S F. SCOTT BOYD 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 9th day of November, 2018.
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 Complaints and Election of Rights forms to the Respondent. (Ex. 1 and Ex. 2) The Election of Rights form advised of the right to an administrative hearing. The Respondent returned the Election of Rights forms selecting “Option 3.” (Ex. 3 and Ex. 4) On October 17, 2011, the Administrative Law Judge entered an Order consolidating both cases (Ex. 5). On February 6, 2012, the Administrative Law Judge entered an Order granting the Agency’s Motion to Relinquish Jurisdiction and Closing Files. (Ex. 6). On April 2, 2012, Richard J. Saliba, the Informal Hearing Officer, entered an Order Relinquishing Jurisdiction and Closing File based on Briarwood’s decision that it was abandoning its request for a hearing (Ex. 7). Based upon the foregoing, it is ORDERED: 1. The findings of fact and conclusions of law set forth in the Administrative Complaints are adopted and incorporated by reference into this Final Order. 2. The assisted living facility license of Briarwood Manor is REVOKED. The Respondent shall pay the Agency $35,500.00. If full payment has been made, the cancelled check acts as receipt of payment and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. A check made payable to the “Agency for Health Care Administration” and containing the AHCA ten-digit case number should be sent to: Filed June 26, 2012 11:00 AM Division of Administrative Hearings Office of Finance and Accounting Revenue Management Unit Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 14 Tallahassee, Florida 32308 ORDERED at Tallahassee, Florida, on this_A*e*-day of C Ste AL , 2012.
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 cpey otis Final Order was served on the below-named persons by the method designated on this 7S “day of , 2012. Agency for Health Care Administration 2727 Mahan Drive, 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) Lourdes A. Naranjo, Senior Attorney Cindy Dookeran Office of the General Counsel Administrator Agency for Health Care Administration Briarwood Manor (Electronic Mail) 5721-5631 N. W. 28" Street Lauderhill, Florida 33313 (U.S. Mail) Katrina Derico-Harris Arlene Mayo-Davis Medicaid Accounts Receivable Field Office Manager Agency for Health Care Administration Agency for Health Care Administration (Electronic Mail) (Electronic Mail) Shawn McCauley Errol H Powell Medicaid Contract Management Agency for Health Care Administration (Electronic Mail) Administrative Law Judge Division of Administration Hearings (Electronic Mail) Richard Saliba, Esq. Informal! Hearing Officer Agency for Health Care Administration (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2011005869 Return Receipt Requested: v. 7009 0080 0000 0586 1985 DDJJ LLC d/b/a BRIARWOOD MANOR, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”’), by and through the undersigned counsel, and files this administrative complaint against DDJJ LLC d/b/a Briarwood Manor (hereinafter “Briarwood Manor”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2010), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the assisted living facility license of Respondent [License No.: 7478], pursuant to Section 408.815(1) (c) &(d), Florida Statutes, and Section 429.14(1) (e), Florida Statutes, and to impose an administrative fine of $14,500.00, pursuant to Sections 429.14 and 429.19, Florida Statutes (2010), for the protection of public health, EXHIBIT 1 safety and welfare. Section 429.14(1)(e), Florida Statutes, provides that the Agency may revoke an assisted living facility license if the facility is cited with three or more Class II deficiencies. The Agency has considered the factors outlined in Section 419.19(3), Florida Statutes, in imposing the penalty and in fixing the amount of the fine. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2010), and Chapter 28-106, Florida Administrative Code (2010). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2010). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2010), and Chapter 58A-5 Florida Administrative Code (2010). 5. Briarwood Manor operates a 34-bed assisted living facility located at 5621-5631 N. W. 28" Street, Lauderhill, Florida 33313. Briarwood Manor is licensed as an assisted living facility under license number 7478. Briarwood Manor was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I BRIARWOOD MANOR FAILED TO KEEP RESIDENTS’ MEDICATIONS LOCKED IN THE REFRIGERATOR. RULE 58A-5.0185(6) (b)1, FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Briarwood Manor was cited with five (5) Class II deficiencies as a result of an Operation Spot Check Appraisal visit that was conducted on May 20, 2011. 8. An Operation Spot check appraisal visit was conducted on May 20, 2011. Based on observation and interview, it was determined that the facility did not keep residents' #1 and #4's medications locked within the refrigerator in the kitchen to ensure residents did not ingest potentially harmful medications. The findings include the following. 9. In an observation on 5-20-11 at 9:30 AM in the main kitchen, inside a non-lockable refrigerator and not in a lockable container, there were 2 boxes containing Risperdal 5O0mcg suspension, each marked for intramuscular administration for residents #1 and resident #4. 10. During this observation, it was determined the area where this refrigerator was located could not be locked and it was accessible by the general facility population of residents without encumbrances. ll. Based on the foregoing facts, Briarwood Manor violated Rule 58A-5.0185(6)(b)1, Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00 and gives rise to the revocation of the assisted living facility license. COUNT II BRIARWOOD MANOR FAILED TO MAINTAIN A SAFE AND SANITARY FOOD SERVICE AND KITCHEN AREA. RULE 58A-5.020(1) (b), FLORIDA ADMINISTRATIVE CODE (NUTRITION AND DIETARY STANDARDS) CLASS II VIOLATION 12. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 13. An Operation Spot check appraisal visit was conducted on May 20, 2011. Based on observations, it was determined the facility failed to maintain a safe and sanitary food service and kitchen area. The findings include the following. 14. Observations on 5/20/11 at approximately 9:15 AM revealed the following concerns in the kitchen area: a. The kitchen floor was dirty throughout, with a heavy layer of soil built up behind the three compartment sink area, equipment, and food storage area. b. The kitchen stovetop, cabinet under sink, food equipment shelving, potholders, utensil drawers, switch plates, walls and window sills were dirty. c. Cutting boards were blackened and deeply scored. d. Several kitchen refrigerators were missing thermometers. The microwave oven door was rust laden and the microwave was soiled in the interior. e. The deep chest freezer, which was full of frozen food, had a large build-up of ice, needed defrosting, and had no thermometer in the interior. f. The dirty window sill directly about the 3 compartment sink continued uncovered single serve plastic utensils, dirty scrub pads, brushes, measuring cups and a ladle. g. The kitchen back door was not vermin-proof as the door did not fit in the frame tightly. Live roaches were observed in the kitchen. h. There were paints and chemicals stored within the food storage room. i. Approximately 10 lbs. of ground beef was left in a sheet pan defrosting on a kitchen table. 15. There was a bucket of dirty dishes on the table alongside the ground meat. Various clean cooking vessels were stored on a shelf underneath this table. 16. Note: A representative from the Department of Health was on the premises on 5/20/11 and issued an unsatisfactory food service inspection report to the facility. 17. Based on the foregoing facts, Briarwood Manor violated Rule 58A-5.020(1) (b), Florida Administrative Code, herein classified as a Class II violation, widespread, which warrants an assessed fine of $5,000.00 and gives rise to the revocation of the assisted living facility license. COUNT III BRIARWOOD MANOR FAILED TO MAINTAIN A RESIDENTIAL AREA WHICH PROMOTED A RESIDENTIAL, HOMELIKE, AND SAFE CARING ENVIRONMENT FOR RESIDENTS; FAILED TO PROVIDE A SAFE AND DECENT ENVIRONMENT WITH RESPECT TO PERSONAL DIGNITY AND PRIVACY; AND FAILED TO ENSURE THAT FURNITURE AND FURNISHINGS WERE CLEAN AND IN GOOD REPAIR SECTION 429.28(1) (a), FLORIDA STATUTES RULE 58A-5.023(3) (a)1. & 2., FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS II VIOLATION 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. An Operation Spot check appraisal visit was conducted on May 20, 2011. Based on observations and interviews, it was determined that the facility failed to maintain a residential area which promoted a residential, homelike, and safe care environment for the census of 27 residents, and failed to provide a safe an decent environment with respect to dignity and privacy as required by the Residents’ Bill of Rights. The facility also failed to ensure that furniture and furnishings were clean, functional, and in good repair. The findings include the following. 20. During the tour of the facility on 05/21/11 at 9:30 a.m. in the resident bathroom located in Building A adjacent to room 5, the bathroom door was observed to be open. There were residents observed in the vicinity. Inside the bathroom was a large hole in the tile wall where the sink used to be. There was a pipe coming out of the hole in the wall and a large bucket positioned under the pipe as the pipe was leaking water. The bucket was observed to be full of dirty water. The hole in the wall had jagged edges, was approximately two to three feet wide, about two feet high and at least a foot or more deep, exposing bare blackened dirt and debris. 21. The area also was moisture laden from the leaking pipe. There were broken tiles littering the area, exposed metal piping and water valves from the missing sink. The floor under the bucket was also missing several tiles (a square area of approximately two feet by two feet) and exposing the brown sub floor. The brown sub floor was noted to be blackened with biogrowth. The bathroom door was observed open with no barrier or signage to alert residents, staff and visitors to the hazard. 22. Adjacent to the bathroom in Building A by room 5 was a storage closet that was easily opened, and not locked. Inside the closet there were construction materials, a green garden hose, buckets, and 2 containers of pesticides. 23. The maintenance staff member was interviewed on 05/20/11 at 9:45 a.m. He said that he is in the process of working on the sink and confirmed that the bathroom door was open. In addition, he confirmed that there was no lock on the storage closet adjacent to the bathroom and said he would find a way to lock it. The facility has a Limited Mental Health license and the census on the day of the survey was 27. 24. During observations on 05/20/11 at 10:30 a.m. in the laundry room in Building B there was a ladder and construction materials observed stored behind the door. There was a silver air conditioning (a/c) duct running along the wall just below the ceiling that was noted to have a large hole, exposing the insulation. The edges were blackened. There was a large shelving unit with folded blankets and comforters stored right below the a/c duct and next to the ladder and construction materials. In addition, the a/c vent just above the clean linens was observed to be dirty, and blowing directly onto the folded linens. The laundry room floor was filthy. This was brought to the attention of the maintenance staff member. 25. During observations on 05/20/11 at approximately 10:45 a.m. in the resident bathroom in Building A on the North side of the building the tub was observed to have no faucet. Instead there was just a bare metal thin spout with a sharp metal end coming out of the tub. In addition, the tub was very dirty. This was brought to the attention of the maintenance staff member. 26. On 05/20/11 at approximately 10:00 a.m. in Building B the bathroom outside room 11 was observed to be very dirty with a dried brownish substance smeared in places on the floor. On 05/20/11 at 11:00 a.m., about an hour later, the substance was noted to still be there. 27. Observations of Room 3 and 4 at approximately 10:30 AM on 5/20/11 revealed the rooms were adjoined together through the closet opening of room 3. A torn plastic shower curtain was hung at the opening in room 3 and the resident's bed in room 3 was placed in front of the shower curtain blocking access between rooms 3 and 4. 28. Room 4 had no window to the outside and was occupied Observations of room 4 on 5/20/11 revealed the by resident #4. room was dark, dreary, dimly lit, musty, warm, and difficult to maneuver around in. There was no closet either in room 3 and 4. 29. A referral was made to the City of Lauderhill Code Enforcement officer, who was present during the survey. The Code Enforcement Unit issued the facility a "Notice of Violation" on 5/20/11 with numerous violations. 30. A referral was made to the Broward County Health Department. Their representative arrived at the facility during the survey and issued an unsatisfactory inspection report to the facility. 31. During the tour of the facility on 05/20/11 at 9:30 a.m. the following was observed with the maintenance staff 32. In Building A room 4, there was a lamp with no shade and the bare bulb was exposed. 33. In Building A's day room, the window curtains were observed to be soiled and not hanging properly as many of the curtain hooks were not attached to the rod and hanging loosely. In the bathroom on the North side of Building A the vanity cabinet was observed to be in disrepair as it was separating from the wall. 34. In Building B, the bathroom off the day room was observed to have window blinds that were in disrepair. The sink vanity was in disrepair as the veneer was peeling off and worn. The toilet tank lid had a large crack in the middle. The shower 10 curtain was torn and the floor was very dirty with black scuff marks and a large puddle of water. 35. In Building B, the bathroom adjacent to room 11 was very dirty including old feces on the floor. 36. A leather sofa in the common area in Building B had a large tear in the cushion. 37. The bathroom outside room 13 was observed to have a very dirty floor, a hole behind the toilet, and a rusty opened can of food was found stored inside the mirrored vanity door. 38. The administrator was interviewed on 05/20/11 at 11:30 a.m. and no additional information was provided. 39. Based on the foregoing facts, Briarwood Manor violated Rule 58A-5.023(3)(a)l. & 2., Florida Administrative Code, and Section 429.28(1) (a), Florida Statutes, herein classified as a Class II violation, widespread, which warrants an assessed fine of $5,000.00 and gives rise to the revocation of the assisted living facility license. 11 COUNT IV BRIARWOOD MANOR FAILED TO ENSURE THAT THE DOORS WERE FUNCTIONAL AND IN GOOD WORKING ORDER, AND THAT PEELING PAINT WAS REPAIRED OR REPLACED. RULE 58A-5.023(3) (a)3, FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS II VIOLATION 40. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 41. An Operation Spot check appraisal visit was conducted on May 20, 2011. Based on observations and interviews, it was determined that the facility failed to ensure that doors were functional and in good working order, and that peeling paint was repaired or replaced. The findings include the following. 42. During the tour of the facility on 05/20/11 at 9:30 a.m. the following was observed: a. In Building A room 4, observations revealed the room had a door to the outside of the facility. The door was observed to be ill fitting, so that a large gap was between the door and the door jamb. b. In Building B room 10, there was a door to the outside that had a large gap between the door and the door jamb, allowing the potential for insect infestations. 12 c. In Building B room 14, there was a door to the outside that did not fit the door jamb so that there was a large gap. d. In Building B, the bathroom by the large paint storage closet was labeled with a sign that said the bathroom was out of order due to the bathtub leaking. 43. During the tour of the facility on 05/20/11 at 09:30 a.m. in Building A room 4, there was peeling paint on the walls. In addition, throughout Building B the walls were observed to be patched and not painted over in several places throughout the building. The maintenance staff member was present and confirmed the findings. 44, The maintenance staff person was present during the observations on 05/20/11 and confirmed the findings. 45. Based on the foregoing facts, Briarwood Manor violated Rule 58A~5.023(3) (a)3, Florida Administrative Code, herein classified as a Class II violation, patterned, which warrants an assessed fine of $2,500.00 and gives rise to the revocation of the assisted living facility license. 13 COUNT V BRIARWOOD MANOR FAILED TO HAVE A SATISFACTORY HEALTH DEPARTMENT INSPECTION. RULE 58A-5.016(6), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0161(1), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS II VIOLATION 46. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 47. An Operation Spot check appraisal visit was conducted on May 20, 2011. Based on record reviews and interviews, it was determined that the facility failed to have a satisfactory health department inspection. The findings include the following. 48. During observations of multiple physical plant issues at the facility, a referral was made to the Broward County on 05/20/11 at approximately 9:45 a.m. The Health Department representative arrived at the facility and was apprised of all of the findings of the survey team. At the conclusion of their visit the facility was issued an unsatisfactory Group Care and Food Service inspection on 05/20/11. 49. Based on the foregoing facts, Briarwood Manor violated Rule 58A-5.016(6), Florida Administrative Code, and Rule 58A- 5.0161(1), Florida Administrative Code herein classified as a Class II violation, which warrants an assessed fine of $1,000.00 14 and gives rise to the revocation of the assisted living facility license. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Briarwood Manor on Counts I through vi. 2. Revoke the assisted living facility license [License No.: 7478] of Briarwood Manor on Counts I through V for the violations cited above. 3. Assess an administrative fine of $14,500.00 against Briarwood Manor on Counts I through V for the violations cited above. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2010). Specific options for administrative action are set out in the attached Election of Rights. All 15 requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER Komen @ koe an td Lourdes A. Naranjo, Esq. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 537? Street Suite 300 Miami, Florida 33166 305-718-5906 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) 16 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Cindy Dookeran, Administrator, Briarwood Manor, 5621-5631 N. W. 28th Street, Lauderhill, Florida 33313 on a \ this2Z@ "day of , 2011. Dr lie, Glew orf Ourdes A. Naranjo, Esq. 17 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: DDJJ LLC d/b/a Briarwood Manor AHCA No.: 2011005869 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)____—sid dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) 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 licensee referred to above. Signed: 0 Dates Print Name: Title: Late fee/fine/AC STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2011009335 Return Receipt Requested: v. 7009 0080 0000 0586 2180 DDJJ LLC d/b/a BRIARWOOD MANOR, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”’), by and through the undersigned counsel, and files this administrative complaint against DDJJ d/b/a Briarwood (hereinafter “Briarwood Manor”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2010), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the assisted living facility license of Respondent [License No.: 7478], pursuant to Section 408.815(1) (c)&(d), Florida Statutes, and Section 429.14(1) (e), Florida Statutes, and to impose an administrative fine of $21,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2010), for the protection of public health, EXHIBIT 2 safety and welfare. Section 429.14(1)(e), Florida Statutes, provides that the Agency may revoke an assisted living facility license if the facility is cited with one or more Class I deficiencies. Section 408.815(1) (c)&(d), Florida Statutes, provides that the Agency may revoke a license for a violation of “this part, authorizing statues, or applicable rules” or “for a demonstrated pattern of deficient practice”. The Agency has considered the factors outlined in Section 419.19(3), Florida Statues, in imposing the penalty and fixing the amount of the fine. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2010), and Chapter 28-106, Florida Administrative Code (2010). 3. Venue lies pursuant to Rule = 28-106.207, Florida Administrative Code (2010). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2010), and Chapter 58A-5 Florida Administrative Code (2010). 5. Briarwood Manor operates a 34-bed assisted living facility located at 5621-5631 N. WwW. 28° Street, Lauderhill, Florida 33313. Briarwood Manor is licensed as an assisted living facility under license number 7478. Briarwood Manor was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. 6. On August 17, 2011, the Agency entered an Immediate Moratorium on Admissions (AHCA No.: 20110090890) on the basis that the Agency determined that the current practices and conditions at Briarwood Manor present a threat to the health, safety, or welfare of the residents of the facility; present an immediate serious danger to the public, health, safety, or welfare; and present an immediate or direct threat to the health, safety, or welfare of the Residents who reside at Briarwood Manor. COUNT I BRIARWOOD MANOR FAILED TO PROVIDE APPROPRIATE SUPERVISION FOR EACH RESIDENT INCLUDING GENERAL AWARENESS OF THE RESIDENT’S WHEREABOUTS, AND A WRITTEN RECORD AFTER A MAJOR INCIDENT. RULE 58A-5.0182(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE - SUPERVISION STANDARDS) CLASS I VIOLATION 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. Briarwood Manor was cited with two (2) Class I deficiencies and one (1) Class II deficiency as a result of a survey conducted on August 11, 2011. On August 17, 2011, an Immediate Moratorium on Admissions was served on Briarwood Manor 9. A survey was conducted on August 11, 2011. Based on Based on interview and record review, it was determined that the facility failed to provide appropriate supervision for each resident including: General awareness of the resident's whereabouts and a written record, updated after a major incident for 1 of 3 sampled residents reviewed (Resident #1). The findings include the following: 10. Record review on 8/11/11 revealed Resident #1 was admitted to the facility on 1/22/09 with a diagnosis to include schizophrenia and renal cell cancer. A facility note on 7/20/11 documented the resident did not return to the facility until 2:00 AM. Note on 7/23/11 documented the resident did not return to the facility until 11:30 PM. On 7/28/11 the resident left the facility. A Resident Elopement Prevention Drill Form dated 7/29/11 at 7:00AM did not identify the employees who noticed the resident missing, the time she was last seen, employees who assisted in the search or a description of the resident. Further review of the record did not contain an incident report. 11. During an interview with the administrator on 8/11/11 at 10:45 AM, she stated the facility has not identified any residents who may be at risk for elopement. She also stated the residents are not required to sign in or out when they leave the property as it is all done verbally. The surveyor was unable to determine the last time Resident #1 was seen at the facility. 12. A review with the administrator of the facility staffing schedule identifies one staff member working the 11:00 PM-7:00 AM shift. Two days a week the staff member working the overnight shift works a 16 hour double shift. During the review the administrator stated this is the facility's permanent schedule. 13. A review with the administrator of the policy and procedure manual did not identify a policy regarding resident supervision. A review of the elopement policy revealed the facility will: "conduct elopement drills with all the staff twice a year to protect our residents from elopement." "Any elopement will be documented in the resident file along with a copy of the adverse incident report. “A review of the elopement drills did not identify a drill in 2011 and only one drill in 2010. 14. During an interview on 8/11/11 at 11:46 AM with several unsampled residents, they were asked if they had to notify anyone when they leave the facility's property. All the residents interviewed stated they did not need to notify anyone, and they just needed to be back by 11:00 PM. As of 8/11/11 at 3:00 PM Resident #1 has not been found. 15. Based on the foregoing facts, Briarwood Manor violated Rule 58A-5.0182(1), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $10,000.00. COUNT IT BRIARWOOD MANOR FAILED TO HAVE MEDICATIONS AVAILABLE TO ADMINISTER IN ACCORDANCE WITH HEALTH CARE PROVIDER’S ORDER OR PRESCRIPTION LABEL. RULE 58A-5.0185(4)&(5), FLORIDA ADMINISTRATIVE CODE (MEDICATION ADMINISTRATION STANDARDS) CLASS II VIOLATION 16. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 17. A survey was conducted on August 11, 2011. Based on record review and interview, it was determined that the facility failed to have medications available to administer in accordance with a health care provider's order or prescription label, for 1 of 3 sampled residents reviewed (Resident #3). The findings include the following. 18. Resident #3 was admitted to the facility on 6/3/11 with a diagnosis to include Psychosis and COPD. An 1823 health assessment form completed by the physician on 6/14/11 identified the residents medications to include Simvastin 40 mg 1 tab daily and Risperidone 4 mg 1 tablet HS. A review of the medication observation record (MOR) did not list the medications. 19. During an interview on 8/11/11 at 2:30 PM with the med tech, it was confirmed the MOR did not include Simvastin 40 mg 1 tab daily or Risperidone 4 mg 1 tablet HS. She acknowledged the facility did not have the medications and stated they were probably discontinued. The facility was not able to provide evidence the physician discontinued any of the resident's medications. The facility must maintain a daily medication evaluation record (MOR) for each resident who receives assistance with self-administration of medication or medication administration. The MOR must include a chart recording each time the medication is taken, any missed dosages, refusals to take medication, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. 20. Based on the foregoing facts, Briarwood Manor violated Rule 58A-5.0185(4)&(5}, Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00. COUNT III BRIARWOOD MANOR FAILED TO ESTABLISH A RISK MANAGEMENT AND QUALITY ASSURANCE PROGRAM. SECTION 429.23, FLORIDA STATUTES RULE 58A-5.0241, FLORIDA ADMINISTRATIVE CODE (RISK MANAGEMENT AND QUALITY ASSURANCE STANDARDS) CLASS I VIOLATION 21. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 22. A survey was conducted on August 11, 2011. Based on record review and interview, it was determined that the facility failed to establish a risk management and quality assurance program, the purpose of “which is to assess resident care practices, facility incident reports, and adverse incident reports, for 2 of 3 records reviewed (Resident #1 and #2). The findings include the following. 23. Record review on 8/11/11 revealed Resident #1 was admitted to the facility on 1/22/09 with a diagnosis to include schizophrenia and renal cell cancer. A facility note on 7/20/11 documented the resident did not return to the facility until 2:00 AM. Note on 7/23/11 documented the resident did not return to the facility until 11:30 PM. On 7/28/11 the resident left the facility. A Resident Elopement Prevention Drill Form dated 7/29/11 at 7:00 AM did not identify the employees who noticed the resident missing, the time she was last seen, employees who assisted in the search or a description of the resident. Further review of the record did not contain an incident report. 24. During an interview with the administrator on 8/11/11 at 10:45AM, she stated the facility has not identified any residents who may be at risk for elopement. She also stated she faxed an adverse incident report to the agency on 7/29/11 but could not provide confirmation. At 10:55 AM the AHCA complaint unit was contacted and confirmed the agency had not received the required notification regarding the elopement. 25. The surveyor was unable to determine the last time Resident #1 was seen at the facility. As of 8/11/11 at 3:00 PM Resident #1 has not been found. 26. Resident #2 was admitted to the facility on 11/16/93 with a diagnosis to include Diabetes, COPD, and Neuropathy. A note dated 3/27/11 documents the resident was dizzy and fell. The resident was transferred to the hospital and returned to the facility on 3/30/11. During an interview on 8/8/11 at 1:45 PM with the administrator and med tech, it was revealed the med tech stated 911 was contacted and the resident was transported by ambulance to the local hospital. She could not remember what happened to the resident and did not complete an incident report. 27. Based on the foregoing facts, Briarwood Manor violated Section 429.23, Florida Statutes, and Rule 58A-5.0241, Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $10,000.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Briarwood Manor on Counts I through IIl. 2. Revoke the assisted living facility license [License No.: 7478] of Briarwood Manor for the citations cited in counts I through III. 3. Assess an administrative fine of $21,000.00 against Briarwood Manor on Counts I through III for the violations cited above. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2010). Specific options for administrative action are set out in the attached Election of Rights. All 10 requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS ~= 4#3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER vo Ve vile, blwraus.) Lourdes A. Naranjo, Esq. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53°? Street Suite 300 Miami, Florida 33166 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) 11 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Cindy Dookeran, Administrator, Briarwood Manor, 5621-5631 N. W. 28° Street, Lauderhill, Florida 33313 on this [7 aay of ih. , 2011. Lourdes A. Naranjo, Esq. 12 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: DDJJ LLC d/b/a Briarwood Manor AHCA No.: 2011009335 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) _ I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued.that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) I hereby certify that ] am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC 000 p.1 Jan170106:28p STATE OF FLORIDA ; to. AGENCY FOR HEALTH CARE ADMINISTRATION Fr | 1 rE D RE: DDJJ LLC d/bfa Briarwood Manor AHCA No.: 2011005869 _ AGE eva, ERK ; 20H AUG Te ECTION OF RIGHTS BPI) This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice jof Entent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Cd maplaint. pour Election of Rights must be returned by mgit or by fax within 22 days of the dav you receive the attached Notice of Intent to Impose a Lite /Fes. Notice of Intent to Impose a Late Fin Administrative Complat Hf your Election of Rights with your selected optjon is not received by AHCA within twenty- one (21) days from the date you received this noticd of proposed action by AHCA, you will have given up your right to contest the Agency's proposed < and a fial order will be issued. (Please use this form unless you, your attomey or yo feprescntative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Fk rida Administrative Code.) PLEASE RETURN YOUR CTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration j Attention: Agency Clerk ; 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT Q GF THESE 3 OPTIONS OPTION ONE (1). I admit to the allegatipns of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and | waive my right to object and to have a hearing, | understand that by}giving up my right to a hearing, a final order will be issued that adopts the proposed agency actionjand imposes the penalty, fine or action. OPTION TWO (2) L adunit to the allegati$ns of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent td Impose a Late Fine, or Administrative Complaint, but J wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Flocida Statutes) where I may submit testimony and written evidence to the Agoncy to show that -the proposed admuinistrative action is too severe or that the fine should be reduced. ; OPTION THREE (3)_X 1 dispute the allegatiqas of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent td Impose a Late Fine, or Administrative Complaint, and 1 request a formal hearing (pursupnt to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by thd Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (4), by itself, is NOT sufficient te obtain a forma! hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Se¢tion 120.57(1), Florida Statutes. It must be + 1 srg CeLbt Le ezine EXHIBIT 3 000 p2 Jan 1704 06:28» 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 tbe requirements of Rule 28- 106.2015, Florida Administrative Code, which requifes that it contain: 1. Your name, address, and telephone number, ang 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 fapt. If there are none, you soust state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: ALF (ALF? nursing hoche? medical equipment? Other type?) Licensee Name: BATARWoAD MANOR | License number: Contact person: SNE DookFA AN ‘DUN Name Title Address; °°71 maw? 2aty S71 name pL 33313 Street and number City Zip Code Telephone No. 784-135: #179 Pax No, 44 -486-30}) |Email(optional) [hereby certify that I am duly authorized to submit tliis Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licengee referred to above. Sign od: Cu ws, Date: “At ‘ PrintName:_ Cand) —_Dot/tep.An/ Title:_Abran Late fee/fine/AC 6rd Bebb bE BZ ine 99/22/2011 3:26PM FAX 905919 PHARHCO {21000170008 - Ye \. . STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: DDIJ LLC d/b/a Briarwood Manor AHCA No.: 2011009436 ae wa) ty _ ELECTION OF RIGHTS 2 By, ee Co ceeeecee ee OP, This form is attached to a proposed action ‘by the “Agency for Health Care Administration en, ‘The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint, vecelve ve attached Notice of inte ‘ent ty Impose 2 Late 2 Fee, Notice of ‘Tatent ‘0 Impose a Late Fine or Adminisirative Complaint, jf tf If your Election of Rights with your selected option Is not received od By AHCA within twenty. _ one ys trom the date you received this notice of propos lion Dy , you will have given up your right to contest the Agency's proposed action and a final order will be issued. - (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for ilealth 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 ONF (i) T admit to the allegations of factsjand law contained in the Notice of Intent to Ympose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing, T 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 nally, fine or action. OPTION TWO (2) _ lL admit to the allegations of facts contained i in the Notice of Intent to, Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an Informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)_ 46 J dispute the allegations of fact contained in the Notice of Intent to. Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaini, 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. : Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain » formal hearing. You also must file a written petition in order to obtain a formal hearing bofore the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be EXHIBIT 4 VOefeVll S.cOrM FAA suOMIET PHARMUU (g0902/0008 received by the Agency Clerk at the address above within 21 days of your recoipt of this proposed + administrative action, The request for formal hearing must conform to the roquirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: L. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if arty. : - ; Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, a Ligense type: ALE (ALF? nursing home? medical equipment? Other type?) ? Contact person: cxeupy DoockErans ADAENE SRA TDR. . Name - Title Address S62! NW gerd Sr Lauber aril AL 333) Street and number : City Zip Code Telephone No, 98V - 735" Pax No. 8Y~ ¥95_ Rmail(optional) FPF BEY) : I hereby certify that [ am duly authorized to submit this Notice of Election of Rights to the Agency for Health Cure Administration on behalf of the licensee referred to above. Signed: Grip). Date; ahs) : i Print Name:_G2N0 nokeRan rite Abu, Late fee/fine/AC STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS AGENCY FOR HEALTH CARE ) ADMINISTRATION, ) ) Petitioner, ) ) vs. ) Case Nos. 11-4432 ) 11-5103 DDJJ, LLC d/b/a BRIARWOOD ) MANOR, ) ) Respondent. ) ) ORDER OF CONSOLIDATION These cases having come before the undersigned on the Agreed Motion to Consolidate, filed October 14 and 17, 2011, and the undersigned having reviewed the records in these cases, it is, therefore, ORDERED that: 1. DOAH Case Nos. 11-4432 and 11-5103 are consolidated pursuant to Florida Administrative Code Rule 28-106.108. 2. The style of this cause is amended as reflected above. DONE AND ORDERED this 17th day of October, 2011, in Tallahassee, Leon County, Florida. Erol A Verb ERROL H. POWELL 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 EXHIBIT 5_ Filed with the Clerk of the Division of Administrative Hearings this 17th day of October, 2011. COPIES FURNISHED: Lourdes A. Naranjo, Esquire Agency for Health Care Administration 8333 NW 53rd Street, Suite 300 Miami, Florida 33166 Cindy Dookeran Briarwood Manor 5631 Northwest 28th Street Lauderhill, Florida 33313 Cindy Dookeran DDJJ, LLC d/b/a Briarwood Manor 5621 Northwest 28th Street Lauderhill, Florida 33313 STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS AGENCY FOR HEALTH CARE ) ADMINISTRATION, ) ) Petitioner, ) ) vs. ) Case Nos. 11-4432 ) 11-5103 DDJJ, LLC d/b/a BRIARWOOD ) MANOR, ) ) Respondent. ) ) ORDER CLOSING FILES AND RELINQUISHING JURISDICTION These causes having come before the undersigned on Petitioner's Motion to Relinquish Jurisdiction, filed January 25, 2012, to which Respondent did not file a response, having been provided an opportunity to do so, and the undersigned being fully advised, it is, therefore, ORDERED that: 1. The final hearing scheduled for February 27 and 28, 2012, is canceled. 2. The files of the Division of Administrative Hearings are closed. Jurisdiction is relinquished to the agency. EXHIBIT G_ DONE AND ORDERED this 6th day of February, 2012, in Tallahassee, Leon County, Florida. COPIES FURNISHED: Lourdes A. Naranjo, Esquire Euol A Veurll ERROL H. POWELL 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 6th day of February, 2012. Agency for Health Care Administration 8333 NW 53rd Street, Suite 300 Miami, Florida 33166 Cindy Dookeran Briarwood Manor 5631 Northwest 28th Street Lauderhill, Florida 33313 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO.: 2011009335:2011005869 CASE NO.: 12-106PH vs. DDJJ LLC d/b/a BRIARWOOD MANOR, Respondent. / ORDER CLOSING FILE AND RELINQUISHING JURISDICTION This cause came before the undersigned upon receipt from the Respondent informing of the withdrawal of the request for a hearing. Based upon this notice from the Respondent informing that the facility is closed the Respondent specifically informs that the Respondent no longer requests a hearing. A copy of this writing from the Respondent is attached hereto as Exhibit ‘A’ and by reference made a part hereof. The undersigned being fully advised, it is, therefore, ORDERED that: 1. This informal hearing file is closed and jurisdiction is relinquished to the Agency for Health Care Administration for entry of final order. DONE AND ORDERED at Tallahassee, Leon County, Florida, this and day of April, 2012. Agency for Health Care Administration Rickard. Joseph. ‘Sahiba Richard Joseph Saliba Informa! Hearing Officer EXHIBIT 7_ Copies furnished to: Lourdes Naranjo, Esquire Agency for Health Care Administration (Electronic Mail) Ms. Cindy Dookeran DDJJ LLC d/b/a BRIARWOOD MANOR 5621 NW 28" Street Lauderdale Hill Fl 33313 rwood Manor Phone: 954-735-8989 Fax: 954-485-3641 Reference to case #: 12-106PH. AHCA Nos. 20110056869 & 2011009335. Formerly DOAH Nos. 41-4432 & 11-5103. ATTN: Mr. Saliba rm you that Briarwood Manor was officially closed and is as of 3/21/12. Briarwood Manor is no longer interested in This letter is to inf no longer in operatio defending this case. Thank you a dobg Cindy Dookeran
Conclusions Having reviewed the Administrative Complaints (Ex.1), 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. Filed June 11, 2013 8:42 AM Division of Administlative Hearings 2. The Agency issued the attached Administrative Complaints and Election of Rights forms to the Respondent. (Ex. 1) The Election of Rights forms 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’s assisted living facility license number 8345 for the operation of Apple House I is RELINQUISHED and deemed cancelled effective June 20, 2013.. The Respondent and Mary Ann B. Vinarta, Individually, or as one holding an ownership interest in any applicant, shall not seek initial licensure nor operate any facility licensed by the Agency, other than the currently licensed Apple House II facility, for a period of 5 years from the date of this Final Order. 3. An administrative fine and survey fee totaling $9,000.00, payable in Agency Case Numbers 2012007505, 2012009335, and 2013003691', and an administrative fine of $9,250.00 payable to Agency Case Numbers 2012005203, 2012007816, 2012009374, and 2012012761, is imposed. 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 180 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 4. An additional administrative fine of $18,250.00 is imposed against the Respondent in Agency Case Numbers 2012005203, 2012007816, 2012009374, and 2012012761, but is STAYED for purposes of collection as long a Respondent does not seek any new type of licensure from the Agency. In the event Respondent or Mary Ann B. Vinarta, Individually or as one holding an ownership interest in another entity, seeks licensure from the Agency after the period set forth above, the Respondent or Mary Ann B. Vinarta, Individually, or as one holding an ownership interest in another entity, will pay the sum of $18,250.00 as a condition precedent to consideration of any such application for licensure. ORDERED at Tallahassee, Florida, on this [2 day of Heine > 2013. Elizabeth Dudtk, Secretary Agency ealth Care Administration 1 The settlement agreement contains a scrivener’s error on page 4 in listing the case number as 2013009691. 2
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_capy of this Final Order was served on the below-named persons by the method designated on this _4 “day of Jee , 2013. Richard Shoop, Agency Cler Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone: (850) 412-3630 Jan Mills Thomas J. Walsh II, Senior Attorney Facilities Intake Unit Office of the General Counsel (Electronic Mail) Agency for Health Care Administration (Electronic Mail) Finance & Accounting Shaddrick Haston, Unit Manager Revenue Management Unit Assisted Living Unit (Electronic Mail) Agency for Health Care Administration (Electronic Mail) Katrina Derico-Harris Kriste Mennella, Field Office Manager Medicaid Accounts Receivable Area 3 Agency for Health Care Administration Agency for Health Care Administration (Electronic Mail) (Electronic Mail) Shawn McCauley John F. Gilroy, Esquire Medicaid Contract Management 1695 Metropolitan Circle Agency for Health Care Administration Tallahassee, Florida 32308 (Electronic Mail) (U.S. Mail) F. Scott Boyd Administrative Law Judge Division of Administrative Hearings (Electronic Mai!) NOTICE OF FLORIDA LAW 408.804 License required; display.-- (1) It is unlawful to provide services that require licensure, or operate or maintain a provider that offers or provides services that require licensure, without first obtaining from the agency a license authorizing the provision of such services or the operation or maintenance of such provider. (2) A license must be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued. 408.812 Unlicensed activity. -- (1) A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license. (2) The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency. (3) It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense. (4) Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance. (5) When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s. 408.814 and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation. (6) In addition to granting injunctive relief pursuant to subsection (2), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules. (7) Any person aware of the operation of an unlicensed provider must report that provider to the agency.
Conclusions Having reviewed all matters of record, the Agency for Health Care Administration finds and concludes as follows: 4 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 two Notices of Intent (Case Nos. 2011004026 & 2011006078) and an Administrative Complaint (Case No. 2011004274), each with an Election of Rights form to the Respondent (Ex. 1, 2 & 3 respectively). The Election of Rights forms advised of the right to administrative hearings. 3. The parties herein entered into the attached Settlement Agreement (Ex. 4). Based upon the foregoing, it is ORDERED: 4 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’s application for relicensure to operate as a homemaker and companion service is hereby denied. 3. The Respondent’s application for a nurse registry license is hereby denied. 4. The Respondent shall pay the Agency $6,000.00. The first two thousand five hundred ($2,500.00) shall be due and payable within thirty (30) days of the date of the Final Order; the remainder shall be due on or before May 30, 2012. If full payment has been made, the cancelled checks act as 1 Filed December 21, 2011 4:46 PM Division of Administrative Hearings receipts of payment and no further payment is required. Overdue amounts are subject to statutory interest and may be referred to collections. All checks shall contain all three ten-digit AHCA case numbers, shall be made payable to the “Agency for Health Care Administration” and be shall be sent to: Office of Finance and Accounting Revenue Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS 14 Tallahassee, Florida 32308 5. The Respondent is responsible for any refunds that may be due to any clients. 6. The Respondent is responsible for retaining and appropriately distributing client records as prescribed by Florida law. The Respondent is advised of Section 408.810, Florida Statutes. The Respondent should also consult the applicable authorizing statutes and administrative code provisions as well as any other statute that may apply to health care practitioners regarding client records. 7. The Respondent is given notice of Florida law regarding unlicensed activity and advised of Section 408.804 and Section 408.812, Florida Statutes. The Respondent should also consult the applicable authorizing statutes and administrative code provisions. The Respondent is notified that the cancellation of an Agency license may have ramifications potentially affecting accrediting, third party billing including but not limited to the Florida Medicaid program, and private contracts. ORDERED at Tallahassee, Florida, on this 21 day of December , 2011. Elizabgth Dudek, Secre\ Agency for HealthCare 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 persons by the method designated on this Z day of <— y of this Final Order was served on the below-named » 2011. p . Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone: (850) 412-3630 Copies: Jan Mills Finance & Accounting Facilities Intake Unit Revenue Management Unit (Electronic Mail) (Electronic Mail) Nicole Stone Guardian Angel Adult Care Services, LLC 1899 Murrell Road, Ste. 100 Rockledge, FL 32955 (U.S. Mail) Bernadine Stone Guardian Angel Adult Care Services, LLC 1899 Murrell Road, Ste. 100 Rockledge, FL 32955 (U.S. Mail) — : | Suzanne Suarez Hurley, Attorney Office of the General Counsel Agency for Health Care Administration (Electronic Mail) George Indest, Esquire The Health Law Firm 1101 Douglas Avenue Altamonte Springs, FL 32714 (U.S. Mail) Shawn McCauley Medicaid Contract Management Agency for Health Care Administration (Electronic Mail) Katrina Derico-Harris Medicaid Accounts Receivable Agency for Health Care Administration (Electronic Mail) Anne Menard, Unit Manager Home Care Unit Agency for Health Care Administration J. D. C. Newton, II Administrative Law Judge Division of Administrative Hearings (Electronic Mail) (Electronic Mail) Theresa DeCanio, Field Office Manager J. D. Parrish Area 7 — Orlando Administrative Law Judge Agency for Health Care Administration Division of Administrative Hearings (Electronic Mail) (Electronic Mail) NOTICE OF FLORIDA LAW 408.804 License required; display.-- (1) It is unlawful to provide services that require licensure, or operate or maintain a provider that offers or provides services that require licensure, without first obtaining from the agency a license authorizing the provision of such services or the operation or maintenance of such provider. (2) A license must be displayed in a conspicuous place readily visible to clients who enter at the address that appears on the license and is valid only in the hands of the licensee to whom it is issued and may not be sold, assigned, or otherwise transferred, voluntarily or involuntarily. The license is valid only for the licensee, provider, and location for which the license is issued. 408.812 Unlicensed activity.-- (1) A person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that for which he or she actually holds the license. (2) The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency. (3) It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense. (4) Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance. (5) When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under s. 408.814 and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation. (6) In addition to granting injunctive relief pursuant to subsection (2), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules. (7) Any person aware of the operation of an unlicensed provider must report that provider to the agency. Certified Article: Number: wah TOS TULL OF 8447 “") SENDERS RECORD © FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: aN omen Better Health Care for all Floridians ELA B Eee EK April 18, 2011 20 APR 19 P 2 2u. CERTIFIED MAIL RECEIVED GUARDIAN ANGEL ADULT HOME CARh AHCA SERVICES LLC ERAL COUNSEL 550 LEE AVE SATELLITE BEACH, FL 32937 FILE #: 39963777 CASE #: 2011004026 NOTICE OF INTENT TO DENY The Agency for Health Care Administration intends to deny the application for a renewal registration for homemaker companion services for Guardian Angel Adult Home Care Services LLC, located at 1899 Murrell Road, Suite 100, Rockledge, Florida 32955. Guardian Angel Adult Home Care Services LLC was found to be providing services that require a nurse registry license on an April 6, 2011 complaint visit to Guardian Angel Adult Home Care Services by a surveyor from the Agency’s Orlando Field Office. 1. On this visit, three of three sampled clients were found to be receiving personal care services including bathing, toileting, dressing, physical transfers, and incontinence care, as described in the violations of state law that were cited in the survey report. 2. The office was found to be advertising and offering services beyond the scope of its homemaker companion registration as follows: Two poster boards advertised the services offered, including personal care assistance with bathing and dressing. The lettering on the poster boards was large enough to read while standing outside looking through the large picture window at the front entrance to the office. Brochures were located in visible locations inside the front door of the office and also visible through the window. The text of the brochure stated that Guardian Angel Adult Home Care Services provides “Out-patient Assistance/Post-op Care” for “Chemotherapy/Dialysis/Surgery”, “Physical Therapy/Cardiac Rehab” — “Whatever out-patient procedure you may undergo, Guardian Angel can assist you with transportation to and from your procedures, as well as provide before and after care...” This is the same brochure that was included in the previous Notice of Intent to Deny, case 2010012272. Nicole Stone, owner of Guardian Angel Adult Care 2727 Mahan Drive, MS#34 Tallahassee, Florida 32308 at ttp://ahca.myflorida.com GUARDIAN ANGEL AF “UT HOME CARE SERVICES LLC Page2 © April 18, 2011 Services, had submitted a statement on March 8, 2011 that she would refrain from using the brochure until legally licensed to perform personal care. The basis for this action is pursuant to 408.815(1)(c), Florida Statutes: “(1) In addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: ... (c) A violation of this part, authorizing statutes, or applicable rules.” The laws violated are 408.812(1) and (2); 400.462(7), (16), (12), (14), (15), (21), (24); and 400.509(1), Florida Statutes EXPLANATION OF RIGHTS Pursuant to Section 120.569, F.S., you have the right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS. Cle YWentid Anne Menard, Manager Home Care Unit Bureau of Health Facility Regulation Ce: Agency Clerk, Mail Stop 3 Legal Intake Unit, Mail Stop 3 AHCA Orlando Field Office Manager May O02 11 O2:10a Niccle Stone 321-773-"254 . p-.3 STATE OF FLORIDA FILED AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY ch ERK RE: GUARDIAN ANGEL ADULT HOME CARE SERVICES LLC 2 NAY -2 A & SQ) CASE NO: 2011004026 , ELECTION OF RIGHTS This Election of Rights form is attached to a proposed Notice of Intent to Deem Incomplete and Withdraw from Further Review of the Agency for Health Care Administration (AHCA). The fille may be Notice of Intent to Deem Incomplete and Withdraw from Further Review or some other notice of Intended action by AHCA. An Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Deem Incomplete and Withdraw from Further Review or any other proposed action by AHCA. It an Election of Rights with your selected option i is not received by AHCA within twenty-one (21) days from the.date you received this notice of proposed action, you will have given up your right fo contest the Agency's Ss proposed action and a final order will be issued. {Please reply using this Election of Rights form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) Please return your ELECTION OF RIGHTS to: 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 4 OF THESE 3 OPTIONS: OPTION ONE (1)____ | admit to the allegations of facts and law contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review, or other notice of intended action by AHCA and | waive my right to object and have a hearing. | understand that by giving up my right to a heating, a final order will be issued that adopts the proposed agency action and imposes the proposed penalty, fine or action. OPTION TWO (2) VA admit to the allegations of facts contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review, or other proposed action by AHCA, but | wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where | 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) ! dispute the allegations of fact contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review or other proposed action by AHCA, and | request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law dudge appointed by the Division of Administrative Hearings. May 02 11 02:10a Nicrle Stone 321-773-5254 p.4 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 fo obtain a format hearing before the Division of Administrative Hearings under Subsection 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, which requires that it contain: 1. The name and address of each agency affected and each agency's file or identification number, if known; 2, Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any; 3. An explanation of how your substantial Interests will be affected by the Agency's proposed action; : 4. Astatement of when and how you recaived notice of the Agoncy’ '$ proposed action; 5. A-statement of al disputed issues of material fact. If there are none, you must state that there are none; 6. A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency's proposed action; 7. A statement of the specific rules | or statutes you claim require reversal or modification of the » Agency's proposed action; and: - ; 8. A statement of the relief you are seeking, stating exactly what action you wish the Agenoy to to. take with respect to ils proposed action. (Mediation under Section 120.573, Florida Statut 108, may be avellable | in this matter if the Agency agrees.) License type: Homemaker Companion Service License number: 229370 Licensee Name: GUARDIAN ANGEL ADULT HOME CARE SERVICES LLC Contact person: Nicole fh. Stone. Danaging Empicyeo Name Tit pier Address: 1949 Maucrell Rd Sie. 10d Roe Kledge FL 32955 Street and number City Zip Code Ae 3al~ Telephone No (233-8130 Fax No le33-40btEmail (optional) Nicole. Stone © bellsouth. net I hereby certify that | am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behall of the licensee referred to above. Signed: Vn. PY. Pe Date: 4 “ag- He Print Name: Nicole (\. Stone. Title: Managing Employer FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: GovERNCR Better Health Care for all Floridians ELIZABETH DUDEK June 23, 2011 CERTIFIED MAIL BERNADINE STONE LICENSE NUMBER: GUARDIAN ANGEL ADULT CARE SERVICES, LLC CASE NUMBER: 2011006078 1899 MURRELL RD, STE 100 ROCKLEDGE, FL 32955 NOTICE OF INTENT TO DENY. ‘Your application for initial license as a Nurse Registry located at 1899 Murrell Rd., Ste 100, Rockledge, FI 32955 is DENIED. The issues resulting in the decision to deny the application are outlined below: 1, The applicant was delivering services without the appropriate license. Investigations into unlicensed activity were substantiated on April 6, 2011.The applicant holds a Homemaker/Companion registration that prohibits any hands on care, However, the applicant was advertising the provision of post- operative care in their brochure and delivering personal care to clients, The personal care services they were providing were outside the scope of a homemaker and companion agency and constituted unlicensed activity. They do not have a license to Provide hands on service to clients. The pertinent statutes and rules that apply include the following: . Chapter 408.812 (2), Florida Statutes Chapter 408.815 (1), (a)-(c) Florida Statutes 2. The applicant listed Bernadine Stone as the administrator and residing at 505 McGuire Blvd, Indian Harbour Beach, F! 32937.While Ms. Stone was represented in the application as living in Florida, all other supporting documentation on Ms. Stone indicated her residence is actually 4405 Summertime Dr., Nashville, Tennessee 37207. Her State of Florida RN license # RN270869 (Exhibit 1) listed her residence in Nashville, Tennessee. This same Tennessee address was the return address on the envelope transmitting the application to the agency; (See Exhibit 2) as well as the address given on the bank statements used to show proof of funding for the operation of the agency; regarding this application for licensure. (See exhibits 3-7), In a search for Ms. Stone’s Nashville Tennessee connections she was found under “LinkedIn” on the Internet as the current Manager of Operations at AmeriChoice in the Insurance Department located in the Greater Nashville Area. (See Exhibit 8). The position of administrator in a nurse registry must be full time. Ms. Stone could not be a full time administrator and reside in Nashville, Tennessee. The pertinent statutes and rules that apply include the following: Chapter 408.815 (1) (a) & (c), Florida Statutes Chapter 59A-18.006, (5) Florida Administrative Code Visit AHCA online at ahca.myflorida.com EXHIBIT 2 2727 Mahan Drive, MS#34 Tallahassee, Florida 32308 ov ana oe Page 2 © ‘Guardian Angel Adult Care$ Yes, LLC } June 24, 2011 3. The applicant listed Ms, Nicole Stone as the alternate administrator. Ms. Stone indicated on the application that she had one year of experience as a Medical Secretary at St. Thomas Hospital in Nashville, Tennessee. The Employes Service Center at the hospital was contacted to verify the experience. The response was that Ms, Stone was a Clerical Associate for just under 10 months from January 19, 2004 to October 10, 2004. (See Exhibit 9). The administrator of a nurse registry is required to name a qualified alternate administrator. The qualifications required for the alternate administrator are the same as the administrator: licensed physician, a registered nurse, or an individual with training and experience in health service administration and at least one year of supervisory or administrative experience in the health care field, Ms. Nicole Stone does not meet the required qualifications for the position. The pertinent statutes and rules that apply include the following: Chapter 59A-18,006 (1) &(6) Florida Administrative Code EXPLANATION OF RIGHTS Pursuant to Section 120.569, F.S., you have the right to request an administrative hearing. Jn order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F-.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS. CG : Anne Menard, Manager Home Care Unit ce; Agency Clerk, Mail Stop 3 Legal Intake Unit, Mail Stop 3 \ STATE OF FLORIDA ‘ AGENCY FOR HEALTH CARE ADMINISTRATION RE; Guardian Angel Adult Care Services, LLC CASE NO: 2011006078 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed Notice of Intent to Deem Incomplete and. Withdraw fiom Further Review of the Agency for Health Care Administration (AHCA). The title may be Notice of Intent fo Deem Incomplete and Withdraw from Further Review or some other notice of intended action by AHCA, An Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Deem Incomplete and Withdraw from Further Review or any other proposed action by AHCA. Ifan Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action, you will have given up your right fo contest the Agency’s proposed action and 2 final order will be issued. (Please reply using this Election of Rights form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) Please return your ELECTION OF RIGHTS to: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: (850) 412-3630 Fax: (850) 921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS: OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review, or other notice of intended action by AHCA and I waive my right to object and 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 proposed penalty, fine or action. OPTION TWO (2)__ I admit to the allegations of facts contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review, or other proposed action by AHCA, 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 6r that the fine should be reduced. OPTION THREE (3)_____—-E._ dispute the allegations of fact contained in the Notice of Intent to Deem Incomplete and Withdraw from Further Review or other proposed action by AHCA, and I request a formal hearing (pursuant to Section 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 Subsection 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.201, Florida Administrative Code, which requires that it contain: 1. The name and address of each agency affected and each agency’s file or identification number, if known; 2, Your name, address, and telephone number, and the name, address, and telephone ~ number of your representative or lawyer, if any; 3. An explanation of how your substantial interests will be affected by the Agency’s proposed action; 4. A statement of when and how you received notice of the Agency’s proposed action; 5. A statement of all disputed issues of material fact. If there are none, you must state that there are none; 6. A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency’s proposed action; 7. A statement of the specific rules or statutes you claim require reversal or modification of the Agency’s proposed action; and 8. A statement of the relief you are secking, stating exactly vihat action you wish the Agency to take with respect to its proposed action. (Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees.) License type: Nurse Registry License number: Licensee Name: Guardian Angel Adult Care Services, LLC Contact person: Name Title Address: : Street and number City Zip Code Telephone No. Fax No. Email (optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title:
