The Issue The issue in the case is whether the allegations of the Administrative Complaint (as limited by the Notice of Limitation of Issues dated June 15, 2004) are correct, and if so, what penalty should be imposed.
Findings Of Fact At all times material to this case, the Respondent was a licensed mental health counselor, holding Florida license number ME 5853. In approximately July 2001, the Respondent began to counsel a five-year-old female, allegedly the victim of sexual abuse by an uncle, the brother of the child's mother. The Respondent believed, based on information provided by the father, that the uncle resided with the child's mother. The child's father had custody of the child, and the mother had some type of visitation rights. In approximately November of 2001, the Respondent began counseling the child's father and his girlfriend for various family-related issues. Towards the end of 2001 or early 2002, the father and his girlfriend married. Although the Respondent testified at the hearing that the couple "seemed to have plenty of money to do certain things," including personal care and entertainment expenses, she apparently believed, based on what she was told by the couple, that they had financial difficulties. The couple resided in a home owned by the child's father. Apparently based solely on the couple's representations, the Respondent believed that the father was in arrears on house payments. One of the issues addressed in counseling was the father's concern that, were he to lose his house, the child would be returned to the mother's custody, where the uncle resided. Also apparently based solely on the couple's representations, the Respondent believed that the couple wanted to purchase a new house and that they needed $7,000 to buy the house. In March of 2002, the Respondent loaned the couple $7,000. The couple repaid within a few weeks a total of $9,000 to the Respondent. At the time of the $7,000 loan, the clients owed to the Respondent a balance of approximately $3,200 in unpaid professional fees related to therapeutic services provided to them by the Respondent. The Petitioner asserts that the $9,000 repaid to the Respondent included interest charges of $2,000. Petitioner's Exhibit number one is a copy of a document dated March 20, 2002, and apparently notarized on March 21, 2002. The document appears to require that the couple repay to the Respondent by not later than May 16, 2002, a principal amount of $7,000 plus $2,000 in "interest" for a total of $9,000. The genesis of the document is unclear. At the hearing, the wife testified that the document memorialized the agreement between the Respondent and the couple. The Respondent testified that she did not require preparation or execution of any loan documentation. The Respondent testified that the funds received from the couple included repayment of the loan plus payment of $2,000 towards the unpaid professional fees. Based on the candor and demeanor of the witnesses at the hearing, the Respondent's testimony as to the basis for the payment of the $2,000 is credited. Subsequent to the loan and repayment transactions, the therapeutic situation deteriorated between the Respondent and the couple, particularly as to the wife, who began to believe that the Respondent was romantically involved with the husband. The therapeutic relationship between the couple and the Respondent dissolved acrimoniously within a few months after the loan. At the hearing, the Petitioner presented the expert testimony of Dr. Owen Wunderman, a Florida-licensed mental health counselor, and Dr. Andrew Wenger, a Florida-licensed psychologist. Both testified as to the Florida Statutes and as to ethical standards adopted by the American Counseling Association (ACA) applicable to the fact situation at issue in this proceeding. The Respondent presented the expert testimony Dr. Barbara Herlihy, a professor at the University of New Orleans and a licensed professional counselor in Louisiana and Texas. Dr. Herlihy has been involved with the adoption of the existing ACA standards and has written texts related to the issue of dual relationships in counseling situations. As identified during the hearing, the ACA standards address the issue of dual relationships as follows: Avoid when possible. Counselors are aware of their influential positions with respect to clients and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. (Examples of such relationships include, but are not limited to, familial, social, financial, business, or other close personal relationships with clients.) When a dual relationship cannot be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. Both Dr. Wunderman and Dr. Wenger testified that by making the $7,000 loan to her clients, the Respondent entered into a dual relationship (counselor and creditor) with the couple, and that in doing so, the Respondent failed to meet minimum standards of performance in professional activities when measured against generally prevailing peer performance, as well as violated the ACA standards. Dr. Wunderman testified that there was a meaningful risk of non-repayment of the $7,000 loan, given that the clients were several thousand dollars in arrears in paying professional fees, thereby increasing the likelihood that the therapist/creditor would have to take legal action against the clients for repayment, an action likely to impair professional judgment or increase the potential risk of harm to the clients, whether or not legal action was actually initiated. Dr. Herlihy testified that she did not regard the fact situation at issue in this case as a dual relationship because she viewed it as a "one-time" short-term loan and that there was no evidence that the counseling relationship between the parties was harmed. Dr. Herlihy testified that she viewed the situation as a "boundary crossing." Dr. Herlihy acknowledged that short of loaning a client a small sum for cab fare, she was unaware of any mental health counselor making a loan to a client such as occurred in this case. She also acknowledged that she was not familiar with professional performance standards as specifically applied to Florida practitioners. The weight of the evidence establishes that Drs. Wunderman and Wenger are more familiar with the minimum standards of professional performance as measured against generally prevailing peer performance within the State of Florida. The testimony of Dr. Wunderman and Dr. Wenger is credited.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health enter a final order finding the Respondent has violated Subsection 491.009(1)(r), Florida Statutes (2002), and imposing a fine of $1,000, a reprimand, and a one-year period of probation. DONE AND ENTERED this 13th day of January, 2005, in Tallahassee, Leon County, Florida. S WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 13th day of January, 2005. COPIES FURNISHED: Ellen M. Simon, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 William N. Swift, Esquire William N. Swift, Attorney at Law 901 Southwest Martin Downs Boulevard Suite 208 Palm City, Florida 34990 Susan Foster, Executive Director Board of Clinical Social Work, Marriage and Family Therapy & Mental Health Counseling Department of Health 4052 Bald Cypress Way, Bin C-08 Tallahassee, Florida 32399-1701 R.S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A-02 Tallahassee, Florida 32399-1701 Quincy Page, Acting General Counsel Department of Health 4052 Bald Cypress Way, Bin A-02 Tallahassee, Florida 32399-1701
The Issue The issue for determination is whether Respondent committed the offenses set forth in the Amended Administrative Complaint and, if so, what action should be taken.
Findings Of Fact At all times material hereto, Harmony Health Center was a skilled nursing facility operating at 9820 North Kendall Drive, Miami, Florida, and was licensed under Chapter 400, Florida Statutes. On December 5, 2003, AHCA conducted a survey of Harmony Health Center during which three deficiencies were found, one Class I deficiency and two Class II deficiencies. As a result of the deficiencies being found, AHCA filed an Administrative Complaint against Harmony Health Center. Subsequently, AHCA filed an Amended Administrative Complaint, citing two Class II deficiencies. Count I: Failure To Ensure That A Resident Entering The Facility Without A Pressure Sore Does Not Develop One Resident No. 31 was admitted to Harmony Health Center on May 9, 2003. Her records at Harmony Health Center indicate that she had suffered a stroke, paralyzing her on the left side, and that she had a swallowing problem, abnormally high blood pressure, and a feeding tube. Resident No. 31's records did not indicate that she had a pressure sore upon admission. An initial nursing assessment was performed on Resident No. 31 at the time of admission. Relating to pressure sores, the nursing assessment indicates that a Braden Scale for Predicting Pressure Sore Risk (Braden Scale) was performed. The Braden Scale is scored, with the lowest being 6 and the highest being 23, and has six categories, which are Sensory Perception-- ability to respond meaningfully to pressure-related discomfort; Moisture--degree to which skin is exposed to moisture; Activity- -degree of physical activity; Mobility--ability to change and control body position; Nutrition--usual food intake pattern; and Friction and Shear. As to Friction and Shear, Resident No. 31 received a score of one, which designates a "Problem" and states as follows: "Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction." Resident No. 31 received a total score of 12 on the Braden Scale. As to scoring, the Braden Scale provides, among other things, that a total score of 18 or below indicates that a resident is considered a risk and that "CAN Daily Skin Checks FFWP008 must be initiated." Recognizing the risk of Resident No. 31 developing pressure sores, Harmony Health Center ordered a heel protector for her right foot to prevent pressure sores. Resident No. 31's wound treatment and progress records for May 11, June 18, and July 1, 2003 do not reflect the presence of a pressure sore. The first mention of any pressure sore in Resident No. 31's medical records was on August 8, 2003, when a family member, not a staff person, observed a wound on Resident No. 31's right inner heel and pointed it out to a member of the nursing staff. The wound was described in the progress notes as a "blister like area." Resident No. 31's medical records refer to this wound as "in-house acquired." Harmony Health Center admits that Resident No. 31 developed a pressure sore while a resident but characterizes the pressure sore as "unavoidable." On August 8, 2003, Resident No. 31's physician ordered a podiatric consult. A progress note on August 12, 2003, indicates that the pressure sore was at Stage II. The podiatrist, Ann Marie Millar, DPM (Dr. Millar),who was at Harmony Health Center at least twice a week, usually performs consults within 24 hours. However, the consult did not occur until October 10, 2003, approximately two months after the consult was ordered. Dr. Millar was not contacted for the consult when the physician ordered the consult. The wound care nurse requested and the treating physician authorized the consult by Dr. Millar. No evidence was presented to explain why approximately two months elapsed before the consult was performed. When the consult was performed on October 10, 2003, the pressure sore had progressed to Stage IV, which is the most serious classification for a pressure sore. On October 15, 2003, Resident No. 31 was sent to the hospital for debridement of the wound to promote healing. The process of debridement involved either the chemical or surgical removal of necrotic (dead) tissue of the wound. In December 2003, the pressure sore was eventually resolved. Resident No. 31's medical records do not show that another pressure sore presented itself. Dr. Millar testified1 that Harmony Health Center did all that it could to prevent the pressure sore. Resident No. 31 had a heel protector and a Geo mat. Dr. Millar also testified that she was certain that the staff turned or rotated Resident No. 31; however, no documented evidence or any other testimony was presented which showed that the staff turned or rotated Resident No. 31 or which showed the actual care provided to Resident No. 31 by Harmony Health Center prior to the discovery of the pressure sore. According Dr. Millar, Resident No. 31's clinical condition causes contractures, which in turn causes more pressure to the affected heel and, unless the patient can be suspended, causes a heel ulcer. As a result, according to Dr. Millar, a heel ulcer, as experienced by Resident No. 31, is unavoidable. Dr. Millar further testified that Harmony Health Center had additional interventions, other than those used by it, to prevent a pressure sore. However, according to Dr. Millar, the other interventions were "not covered," as to being cost-covered, and, therefore, were not ordered or used. A registered nurse of 25 years, Eleanore Kennedy (RN Kennedy), performed the survey of Harmony Health Center for AHCA. RN Kennedy testified that for a family member, and not staff, to observe and report a pressure sore is unusual; and that, with protective equipment and proper turning, no reason existed for Resident No. 31 to develop a pressure sore. Consequently, according to RN Kennedy, Resident No. 31's pressure sore was avoidable. A registered nurse of 16 years, Jennifer Mata (RN Mata) testified, as an expert in nursing home care, on behalf of Harmony Health Center. RN Mata was also Harmony Health Center's director of nursing. RN Mata opined that Resident No. 31's pressure sore was unavoidable because, in essence, a resident in a nursing home with Resident No. 31's clinical condition develops pressure sores. The undersigned finds the testimony of RN Kennedy to be more credible than RN Mata. The evidence is irrefutable that the pressure sore developed after the admission of Resident No. 31 to Harmony Health Center. The evidence presented was insufficient to satisfactorily explain why a staff person had not observed the skin area at Resident No. 31's heel if Resident No. 31 had a heel protector, was being rotated or turned, and was having daily skin checks, as required by the Braden Scale. Furthermore, a lack of documented evidence exists showing that Resident No. 31 was turned or rotated and that her skin was checked daily although the evidence showed that her skin was checked weekly. This lack of sufficient evidence and lack of evidence causes the undersigned to find the testimony of RN Kennedy more credible. Further, RN Kennedy's testimony is found to be more credible than Dr. Millard’s as to whether the pressure sore was avoidable. The evidence was insufficient to satisfactorily explain why approximately two months elapsed before Dr. Millar was called to perform a consult on Resident No. 31. Furthermore, a lack of documented evidence exists to show that Resident No. 31 was turned or rotated and that her skin was checked daily although the evidence shows that her skin was checked weekly. This lack of sufficient evidence and lack of evidence causes the undersigned to find the testimony of RN Kennedy more credible. Hence, a finding is made that Harmony Health Center failed to prevent Resident No. 31's pressure sore and that, therefore, the pressure sore was avoidable. Count II: Failure To Implement Measures To Protect A Resident From Ongoing Falls, Resulting In Actual Harm To The Resident Resident No. 18 was admitted to Harmony Health Center on April 5, 2002. Resident No. 18's nursing assessment upon admission indicated that she had several conditions and needs. She had Alzheimer's Disease and right-side weakness. Her decision- making was severely impaired, with her never or rarely making any decisions. Resident No. 18 was a wanderer, moving with no rational purpose, seemingly oblivious to needs or safety. She required the assistance of two persons in her daily living activities (ADLs)--ambulation, transfer, bed mobility, eating, toileting, personal hygiene, and bathing. Resident No. 18 also used a wheelchair. Upon admission, Harmony Health Center identified Resident No. 18 as being at risk for falls and injury and prepared an Interdisciplinary Resident Care Plan (Care Plan) for her regarding falls. On April 5, 2002, the Care Plan indicated that she was at risk for falls and injury and indicated nine interventions to lessen her risk for falls, which were implemented. The interventions were as follows: (1) access/record full risk factors; (2) report to M.D. incidence of fall; (3) monitor possible causes of fall; (4) bed in low position; (5)items within easy reach; (6) maintain environment clutter-free; (7) call bell within reach; (8) provide PT/OT therapy evaluation and treatment as prescribed; and (9) orient to surroundings as needed. In spite of the interventions, Resident No. 18 fell six times at Harmony Health Center. Falls were documented on the Care Plan for April 15, 2002 (ten days after admission), June 5, 2002, August 28, 2002, May 22, 2003, June 25, 2003, and August 11, 2003. At the time of each fall, the documentation indicates that Resident No. 18 was found on the floor in her room. The Care Plan for Resident No. 18 indicates that another intervention was added on June 5, 2002, after the fall on the same day; on August 28, 2002, after the fall on the same day; on May 22, 2003, after the fall on the same day; on June 26, 2003, after the fall on June 25, 2003; and on August 11, 2003, after the fall on the same day. The intervention on June 5, 2002, was to use one-half side rails, to instruct her to use call light when needed, and to assist with ADLs; on August 28, 2002, was to place in well-supervised area; on May 22, 2003, was to instruct her to use call light when needing help; on June 26, 2003, was to have close supervision; and on August 11, 2003, was to monitor closely and frequently. As to the intervention added on June 5, 2002, the staff at Harmony Health Center was aware that Resident No. 18 would, on her own, get out of bed and go to the bathroom. One- half side rails make it easier for and assist a resident to get out of bed. Consequently, the one-half side rails made it easier for Resident No. 18 to get out of bed, which would contribute to her falling. Based on the evidence presented, this intervention to reduce the risk of falls was unreasonable for Resident No. 18, who was a high risk for falls. As to instructing Resident No. 18 to use the call light when needed, this intervention was essentially contained in the original Care Plan before her falls. As a result, this intervention on June 5, 2002, was not a new or different intervention. Further, Harmony Health Center was aware that Resident No. 18 was cognitively confused and suffered from sundowner's syndrome, which meant that she became more confused at night. An example of Resident No. 18's confusion and sundowner's syndrome occurred during the fall of August 11, 2003, when she was questioned, after the fall, as to where she was going; she responded that she was going to visit her sister. Based on the evidence presented, to instruct Resident No. 18 to use a call light, as an intervention to lessen the risk of falls, was unreasonable. A nursing assessment for Resident No. 18 was performed on July 17, 2003, a little over 15 months after her admission and after five falls. The nursing assessment indicates that, as to bed mobility (moving to and from lying position, turning side to side, and positioning body while in bed), Resident No. 18 required limited assistance, with one person assistance; and that, as to transfer (moving between surfaces to and from the bed, chair, wheelchair, and standing position), she required extensive assistance, with one person assistance. Further, the nursing assessment indicates that, as to cognitive skills for daily decision making (making decisions regarding tasks of daily life), Resident No. 18’s cognitive skills were independent (decisions were consistent and reasonable). The restorative nurse for Harmony Health Center, Adrienne Underwood, LPN, provided a service to Resident No. 18. Nurse Underwood's role was to maintain or increase Resident No. 18's level of care after Resident No. 18 completed rehabilitation. Nurse Underwood testified that Resident No. 18 could ambulate independently but could not recall when Resident No. 18 became independent. No medical records or assessments or Care Plan entered into evidence supports Nurse Underwood's testimony as to Resident No. 18's independence in mobility and/or transfer. Nurse Underwood's testimony, as to Resident No. 18's ability to ambulate independently, is found not to be credible. Regarding the falls on June 26, 2003 and August 11, 2003, for which the interventions of close supervision and to monitor closely and frequently, respectively, were added, Harmony Health Center's expert, RN Mata opined that the two interventions were appropriate. However, RN Mata also testified that Harmony Health Center was already performing these interventions, before the falls. A finding is made that the interventions added on June 26, 2003, and August 11, 2003, were not new or different interventions. Related to close supervision is the intervention on August 28, 2002, which was placing Resident No. 18 in a well- supervised area. As aforementioned, Harmony Health Center was already closely supervising and monitoring Resident No. 18 before the falls. Consequently, a finding is made that this intervention was not a new or different intervention. Restraining Resident No. 18 to lessen her risk of falls was not an option available to Harmony Health Center. She had no physician order for restraints. Without a physician order, Harmony Health Center could not and would not restrain Resident No. 18. No determination, as to the cause of Resident No. 18's falls, was made by either AHCA or Harmony Health Center. AHCA made no determination in its survey. Neither Resident No. 18's records presented into evidence nor testimony presented showed that Harmony Health Center determined the cause of the falls. AHCA did not contact the physician for Resident No. 18 regarding her falls as to whether the interventions were adequate or the cause of the falls. Whether to contact a physician is a judgment call for AHCA's consultants. AHCA's consultant made a judgment call not to contact Resident No. 18's physician. As an intervention, AHCA suggests that Harmony Health Center could have used bed alarms. Harmony Health Center does have bed alarms for some residents. RN Mata testified that bed alarms are used for residents who have a history of falling out of bed, i.e., from the bed to the floor. Furthermore, according to RN Mata, the purpose of bed alarms is to alert the staff to assist a resident before the resident falls. Resident No. 18's records indicate that she was found on the floor in her room. No evidence was presented that Resident No. 18 was found on the floor next to her bed, which would be an indication that she fell moving from the bed to the floor. However, the evidence does show that Resident No. 18 needed assistance to ambulate. An inference is drawn and a finding is made that, based on Resident No. 18's fall history, her cognitive ability, her need for assistance to ambulate, and the failure of prior interventions, a bed alarm would have been a reasonable intervention.2 Regarding Resident No. 18's fall on August 12, 2003, which was at 3:00 a.m., she sustained an injury, i.e., a hematoma to the right frontal area of her head. After the fall on August 12, 2003, Resident No. 18 was a total care resident. According to Harmony Health Center, the interventions were added after Harmony Health Center investigated each fall, the treating physician was contacted, and a team of Harmony Health Center's personnel reviewed each investigation and reached a consensus as to how to address the falls. To Harmony Health Center, the interventions were appropriate and adequate. No evidence was presented to indicate that an investigation of a resident's fall would not produce the cause of the fall. Based on the evidence presented, an inference is drawn and a finding is made that the investigations were inadequate and not thorough and failed to produce sufficient information to assist Harmony Health Center in determining the cause of Resident No. 18's falls. AHCA has no expectation that a facility will prevent all falls. AHCA has no rule or requirement that a new or different intervention must be developed and implemented for every fall by a resident at a nursing home. Based on the evidence presented, a finding is made that all the interventions added in Resident No. 18's Care Plan after her falls, except for the interventions on June 5, 2002, found to be new and different, were not new or different from the interventions developed by Harmony Health Center, before the falls. Based on the evidence presented, a finding is made that the interventions added after Resident No. 18's falls failed to lessen the risk of her falls and were, therefore, inadequate and inappropriate.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order: Finding Ayintove Associates, LLC, d/b/a Harmony Health Center, f/k/a Integrated Health Services at Greenbriar in violation of Counts I and II for two Class II deficiencies. Imposing a fine of $5,000. Upholding the issuance of a conditional license. DONE AND ENTERED this 22nd day of March 2005, in Tallahassee, Leon County, Florida. S ERROL H. POWELL Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 22nd day of March, 2005.
The Issue In this case, the Petitioners challenge the determination by the Respondent that Anastasia Rush, Ph.D. is an employee of the Baker County School Board based upon the Division of Retirement's determination that Dr. Rush is not an independent contractor. The issue is whether Dr. Rush should be a member of the Florida retirement system. This determination which turns upon whether she is an employee of the school district. Which turns upon whether or not she is, and was, an independent contractor providing professional services to the school board pursuant to contract.
Findings Of Fact The Board, in compliance with the statutory mandate requiring special education programs for emotionally-handicapped students, contracted with the Child Guidance Center, Inc., (CGC) to provide assessment and counseling of qualified students. See, Ex. A-B and Tr. 215-217. The Board obtained additional funding from grants to provide its students with these mandated special educational programs relating to mental health. See, Ex. E, F, G, H, and M. The Board contracts with neighboring school boards which are unable to afford their own programs and pay the Baker County Board to provide services to severely emotionally disturbed children in their counties as required by the statute. The Board's contracts with mental health specialists are dependent upon funding for special students from state monies allocated based upon the total number of students and upon grant money. See, Tr. 38 and 215-216. The Board has not established a permanent position for a health care professional to render clinical mental health services. See, Tr. 72 and 217. The Board has contracted for these professional services to severely emotionally handicapped students, as well as for the professional services of occupational therapists and physical therapists. See, Tr. 79. CGC, the first provider of services to emotionally-handicapped students, is a corporation whose business is providing mental health care. See, Tr. 29. The Board contracted annually with CGC beginning in 1982 to provide a specified number of hours of counseling for its qualifying students. See, Tr. 31-33. The number of hours stated in the contract with CGC varied according to the availability of funding and established a financial liability limit on the contract. Each contract between the Board and CGC was for the term of the school year and could be terminated by either party upon 30 days notice. See, Ex. B. The contracts between the Board and CGC provided that the services would be rendered in the Baker County public schools. See, Ex. B. CGC billed the Board for each hour of counseling provided by its employees. See, Ex. B. CGC did its billing and accounting on a quarterly basis and arranged with the Board to be paid on a quarterly basis for its convenience. See, Ex. B; Tr. 145-146. Dr. Rush was an employee of CGC and first began providing mental health services to the students of Baker County in the early 1980's. See, Tr. 142. Dr. Rush is a licensed psychologist specializing in child psychology. Dr. Rush received a graduate degree in psychiatric social work from the University of Athens, Greece, and received a Ph.D. in clinical psychology from the University of Florida. See, Tr. 140-141. Dr. Rush has worked in the field of mental health for approximately 20 years. Dr. Rush began her own practice while still working for CGC through Dr. Freeman under the name of Salisbury Counseling Clinic. See, Tr. 168-169 and 183. In 1990, Dr. Rush no longer wanted to be an employee of CGC and became an independent contractor with CGC. See, Tr. 146-147. Dr. Rush's private practice grew gradually and prior to 1991, she had resigned her employment with CGC, concentrating on her private practice. See, Tr. 146. In 1991, the Board cancelled its contract with CGC. See, Tr. 37-38. Wanda Walker, administrator of the special education programs, approached Dr. Rush and asked her if she would provide the mental health care as an independent contractor, as previously provided by CGC. See, Tr. 37-38. On August 16, 1991, the Board entered into two contracts with Dr. Rush to provide different types of mental health counseling to its students. See, Ex. A One contract between Dr. Rush and the Board provided that Dr. Rush would provide mental health services to the Board for at least nine hours per week, from which two hours would be committed to the special needs of the students in the Opportunity Program at Baker County High School. The contract services were for 37 weeks of the 1991-1992 school year. The cost of the service was $40.00 per hour, and Baker County agreed to pay Dr. Rush an amount not to exceed $14,460.00 for the service. The agreement required Dr. Rush to perform the services at Baker County public school sites, and provided that the mental health services should include psychological evaluations, classroom observations, participation as a member of the crisis intervention team, and consultations with teachers, guidance counselors and other appropriate school personnel. Dr. Rush submitted a statement of hours worked every two weeks, and was paid the contractual rate for each hour of professional services rendered. The contract provided that either party could terminate upon 30 days written notice. The other contract between the Board and Dr. Rush provided that Dr. Rush would provide mental health services to severely emotionally disturbed students in the Day Treatment Program at Southside Educational Center. This contract provided that Dr. Rush would provide case management, assessments and evaluations, consultation to school personnel, mental health services appropriate to the program, and direct the counseling services provided to Day Treatment Program students. The contract provided that Dr. Rush would provide for 10 hours of professional services per week for 37 weeks at a cost of $40.00 per hour not to exceed $14,550.00. The contract provided that Dr. Rush would submit a statement of hours worked every two weeks, and that the agreement could be terminated by either party upon 30 days written notice. On June 4, 1992, Dr. Rush entered into an agreement to provide professional services to the Board for the 1992-1993 school year. This contract duplicated the previous contract for nine hours per week of mental health services for 37 weeks in the 1992-1993 school year at a cost of $40.00 per hour not to exceed $14,460.00. The only significant change in this contract was that the contract covered the provision of services by Dr. Rush or her associate, Nancy Davie. On June 4, 1992, Dr. Rush entered into a contract with the Board to provide mental health services to severely emotionally disturbed students similar to the previous contract for the 1991-1992 school year. The contract for mental health services to severely emotionally disturbed students did not provide for the provision of these services by Nancy Davie. When the June 1992 contracts were executed, Dr. Rush had incorporated her professional practice; however, she entered into the contracts with the Board in her individual name. The Board was unaware of Dr. Rush's incorporation. Dr. Rush did not believe that there was a difference between contracting in her name or the name of her corporation; however, this contract was subsequently amended to indicate that her corporation was the contracting entity. See, Tr. 152-153, 189 and 190. Dr. Rush contracted with the Board in the name of her corporation, Protepon Counseling Center, in 1993. Dr. Rush maintained two offices, one in Jacksonville and one in Macclenny, where she held herself out to the public as a individual providing psychological counseling and where she conducted her professional business. Generally, Dr. Rush and her associates provided their services at the schools within the district; however, Dr. Rush maintained a professional office in Macclenny, Florida, and met with students and their parents at her professional office as necessary. See, Tr. 71. Both Dr. Rush and CGC provided services at the various schools within the district to alleviate the need to transport children and disrupt their schedules. Dr. Rush and her associates used the offices of guidance counsellors when at the various schools. See, Tr. 14 and 85. During the time that Dr. Rush has provided mental health services to the Board, Dr. Rush has provided her own tools for counseling and assessing students. She provides all of her own supplies. See, Tr. 88 and 297-298. Dr. Rush is not reimbursed for the use of her supplies or standardized tests. See, Tr. 211 Dr. Rush provides mental health counseling to private individuals and agencies, to include St. Johns River Hospital, the Center for Life Enrichment, Capp Care, Flamedco, Inc., and the Florida Medical Association Alternative Insurance Program. See, Tr. 160-165. Dr. Rush provides a profit sharing plan to her associates and maintains workers compensation insurance for her employees. See, Tr. 174 and 208. The contracts with the Board make up only a fraction of Dr. Rush's gross income from her professional practice. See, Ex. J(2); Tr. 169-170. Dr. Rush maintains her own retirement fund and has done so since she left CGC in 1991. See, Ex. J(3); Tr. 172-173. Neither the Board or Dr. Rush consider their relationship to be an employment relationship. See, Tr. 149 and 217. It was never the intent of Dr. Rush to be an employee of the Board or the Board's intent for Dr. Rush to be its employee. See, Tr. 149 and 181. Both Dr. Rush and the Board anticipated the continuation of the independent contractor relationship. The Board paid Dr. Rush for the services rendered by her and her associates from the special fund and not from a salary or payroll account. See, Ex. I. Every two weeks, Dr. Rush submitted statements of professional services rendered by her or her associates and charged the Board per hour for these services. See, Tr. 180-182. Dr. Rush was paid for each hour of service which she or her associates provided, and was not paid a salary or reimbursed or compensated for travel costs or supplies. See, Ex. I; Tr. 297 The statements do not indicate whether Dr. Rush or one of her associates provided the service to the Board. The Board never paid any of Dr. Rush's associates. See, Tr. 43-44, 106 and 107. Dr. Rush's associates have always been paid by Dr. Rush. See, Tr. 151-152. The Board never deducted withholding taxes from its payments to Dr. Rush. See, Ex. I. Dr. Rush paid her own social security tax. See, Tr. 207. Dr. Rush was paid by the Board as she is paid by all of her clients at the agreed-upon hourly rate for her professional counseling services. See, Ex. I; Tr. 182. In making its determination, the Division of Retirement relied upon the answers provided by Dr. Rush and Wanda Walker to a questionnaire sent out by the Division of Retirement. See, Ex. O. Both Dr. Rush and Ms. Walker answered the questionnaire without help from legal counsel and without understanding its purpose or legal implications. See, Tr. 77-79, 82, and 176. Dr. Rush provided an annual orientation to new personnel and students; however, she did not take any training program required by the Board during the period of these contracts. The answers provided by Dr. Rush and Ms. Walker were ambiguous regarding the fact that the annual orientation in which Dr. Rush participated was provided by Dr. Rush to Board employees. See, Ex. O; Tr. 70, 88-89, and 178-179. Using the school calendar, Dr. Rush prepared a schedule calendar indicating the dates, times, and school locations at which she or her associates would provide professional services under the contract with the Board. See, Tr. 178. See, Tr. 45-48, and Ex. D. Pursuant to their contract, Dr. Rush provided professional services for the Board at the times and dates when students were attending school. See, Ex. C. Dr. Rush set her own schedule within the confines of the school day and the school year. The purpose of the calendar schedule was to alert teachers as to Dr. Rush's availability at particular schools. See, Tr. 85. Dr. Rush and her associates did not check in with a supervisor at the various schools. Dr. Rush called Ms. Walker, who notified the appropriate school when a new counsellor would be going to that school. See, Tr. 121-122. This practice was designed for security reasons to let the school know for security reasons that a new individual would be providing services. Dr. Rush was available if there was an emergency. When paged, Dr. Rush called the school and determined from the facts if it was necessary for her or one of her associates to respond. See, Tr. 131 and 297. Dr. Rush was not subject to being summoned by Board employees, but exercised her professional judgment about the by of response which was necessary. See, Tr. 131 and 297. Dr. Rush and her associates evaluated students and recorded the results of their testing and observations. They participated as part of the multidisciplinary team required by law to assess special education students and prepare their educational programs. In this regard, the reports of Dr. Rush and her associates were expressions of their professional expert opinion. See, Tr. 66. It was the experience and expertise of Dr. Rush and her associates which the Board sought in contracting with Dr. Rush. The Board did not direct Dr. Rush's counseling of students. See, Tr. 81-87. Dr. Rush and her associates conducted their counseling without any control from the Board. See, Tr. 83-84 and 227.
Recommendation Having considered the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Dr. Rush be treated as an independent contractor and denied participation in the Florida Retirement System. DONE AND ENTERED this 12th day of January, 1994, in Tallahassee, Florida. STEPHEN F. DEAN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 12th day of January, 1994. APPENDIX TO RECOMMENDED ORDER CASE NO. 93-3378 Both parties submitted proposed findings which were read and considered. Contrary to the Division's rules, Baker County did not number its findings and did not limit them to short statements of fact. Therefore, although most of its findings were adopted in the order originally presented, it is virtually impossible to identify which of the findings were adopted. In order to assist those attempting to determine which facts were adopted, and which were rejected and why, the numbers listed under the Recommended Order column below reference the paragraphs in the Recommended Order which contain the findings suggested by the Division, or the alternative findings suggested by Baker County which the Hearing Officer determined were based upon the more credible evidence. It is readily apparent when the reason is stated for rejecting the proposed findings. Retirement's Findings Recommended Order Paragraphs 1-3 1,2,3,6,7,13 Paragraph 4 14 Paragraph 5,6 19 Paragraph 7 Rejected as contrary to more detailed descriptions of the contracts at issue. Paragraph 8,9 20,21,22 Paragraph 10 Irrelevant. Paragraph 11 As indicated in the Conclusions, there is no issue concerning the fact that employees of school boards are qualified for membership in the retirement system. The issue is whether Dr. Rush was an employee. Paragraph 12,13,14 23,24,25,49,50 Paragraph 15 26,32,34 Paragraph 16 The differences in the terms of the board's contracts with CGC and Dr. Rush are not relevant. Paragraph 17 1,53,54 Paragraph 18 48,49 Paragraph 19 37-44 Paragraph 20-23 2-4,37-44. The manner in which some non-instructional staff are paid is irrelevant. Paragraph 24 26,28-31 Paragraph 25 45-47 Paragraph 26 51,52 Paragraph 27-28 53 paragraph 29 26,28 Paragraph 30,31 25 Paragraph 32,33 Irrelevant argument. COPIES FURNISHED: A.J. McMullian, III, Director Division of Retirement Cedars Executive Center, Bldg. C 2639 North Monroe Street Tallahassee, FL 32399-1560 Sylvan Strickland, General Counsel Department of Management Services Knight Building, Suite 309 2737 Centerview Drive Tallahassee, FL 32399-0950 John W. Caven, Jr., Esquire Claire M. Merrigan, Esquire CAVEN, CLARK, RAY & TUCKER, P.A. 3306 Independent Square Jacksonville, FL 32202 Jodi B. Jennings, Esquire Assistant General Counsel Florida Division of Retirement Cedars Executive Center, Bldg. C 2639 North Monroe Street Tallahassee, FL 32399-1560 William H. Linder, Secretary Department of Management Services 309 Knight Building 2737 Centerview Drive Tallahassee, FL 32399-0950
Findings Of Fact The application and project On October 15, 1986, Respondent, Florida Residential Treatment Centers, Inc. (FRTC), filed a timely application with the Respondent, Department of Health and Rehabilitative Services (Department), for a certificate of need to construct a 60-bed specialty hospital to be licensed as an intensive residential treatment program for children and adolescents in Broward County, Florida. On March 11, 1987, the Department proposed to grant FRTC's application, and petitioners, Florida Psychiatric Centers (FPC) and South Broward Hospital District (SBHD), timely petitioned for formal administrative review. FRTC is a wholly-owned subsidiary of Charter Medical Corporation (Charter). Currently, Charter owns, operates or has under construction 85 hospitals within its corporate network. Of these, 13 are general hospitals, and 72 are psychiatric hospitals. Notably, Charter now operates residential treatment programs in Newport News, Virginia, Provo, Utah, and Mobile, Alabama; and, is developing such a program in Memphis, Tennessee. Within the State of Florida, Charter operates psychiatric hospitals in Tampa, Jacksonville, Fort Myers, Miami, and Ocala. In connection with the operation of these facilities, Charter has established satellite counseling centers to screen patients prior to admission and to provide aftercare upon discharge. Of 20 such centers operated by Charter, one is located in Broward County and two are located in Dade County. The facility proposed by FRTC in Broward County (District X) will treat seriously emotionally disturbed children and adolescents under the age of 18. The patients admitted to the facility will have the full range of psychiatric diagnoses, with the probable exception of serious mental retardation and severe autism. FRTC will not treat patients who present themselves with a primary substance abuse diagnosis, nor will it admit patients who are actively dangerous. This distinguishes FRTC from an acute psychiatric hospital where actively dangerous patients requiring immediate medical intervention are often admitted. The anticipated length of stay at FRTC will vary depending upon the patient's responsiveness to treatment, but is reasonably expected to range between 6 months to 2 years, with an average of 1 year. The treatment programs to be offered at FRTC will be based upon a bio- psychosocial treatment model. This model assumes that the biological component of a patient's condition has been stabilized and that psychiatric medication will be administered solely to maintain this stabilized condition. The social component of the model is designed to resolve problems in interpersonal, family and peer relationships through educational groups, psychiatric co-therapeutic groups and family group therapy. The psychological component focuses primarily on developing personal understanding and insight to guide the patient toward self-directed behavior. Among the therapies to be offered at FRTC are individual, family, recreational, group and educational. Group therapy will be designed to resolve interpersonal problems and relationships, and focuses primarily on building trust among group members. Some group therapy sessions will also cover specific issues such as sex education, eating disorders, self-image and social skills. The goal of recreational therapy will be to teach patients to play appropriately, showing them how to give, take and share, and to follow and to lead. Recreational activities will be available both on and off campus. The goal of occupational therapy will be to develop skills used in work. For a child whose work is school, this often involves using special education techniques. For teenagers, occupational therapy also develops work skills, and prepares them for vocational training or employment. Family therapy is crucial because the family is she core of child development. Families will be invited to spend days with their children at FRTC where they will learn behavioral management techniques, and participate in parent education activities and multifamily groups. The school component of the program includes development of an individualized educational plan for each child. School will be conducted 4-5 hours a day. FRTC will utilize the level system as a behavioral management tool This system provides incentives for learning responsibility for one's own behavior and for functioning autonomously. The typical progress of a patient at FRTC will be as follows. First, a team which includes a psychiatrist, social worker, psychologist and teacher will decide, based upon available information, whether admission is appropriate. If admitted, a comprehensive assessment will be conducted within 10 days, a goal- oriented treatment program will be developed for each patient, designed to remedy specific problems. Discharge planning will begin immediately upon admission. A case manager will be involved to assure that the treatment modalities are well-coordinated. Finally, FRTC will provide aftercare upon discharge. Should any FRTC patients experience acute episodes, they will be referred to acute care psychiatric hospitals with which FRTC has entered into transfer agreements. Likewise, patients who require other medical attention will be referred to appropriate physicians Consistency with the district plan and state health plan. While the local health plan does not specifically address the need for intensive residential treatment programs (IRTPs) for children and adolescents, it does contain several policies and priorities that relate to the provision of psychiatric services within the district. Policy 2 contains the following relevant priorities when an applicant proposes to provide a new psychiatric service: ... Each psychiatric inpatient unit shall provide the following services: psychological testing/assessment, psychotherapy, chemotherapy, psychiatric consultation to other hospital departments, family therapy, crisis intervention, activity therapy, social services and structured education for school age patients, and have a minimum patient capacity of 20 and a relationship with the community mental health center. Facilities should be encouraged to provide for a separation of children, adolescents, adults, and geriatric patient' where possible. Greater priority should be given to psychiatric inpatient programs that propose to offer a broad spectrum of continuous care. ... Applicants should be encouraged to propose innovative treatment techniques such as, complementing outpatient and inpatient services or cluster campuses, that are designed to ultimately reduce dependency upon short term psychiatric hospital beds. New facilities should be structurally designed for conducive recovery, provide a least restrictive setting, provide areas for privacy, and offer a wide range of psychiatric therapies. Applicants should be encouraged to offer intermediate and follow-up care to reduce recidivism, encourage specialty services by population and age, engage in research, and offer a full range of complete assessment (biological and psychological). Additionally, the local plan contains the following policies and priorities which warrant consideration in this case: POLICY #3 Services provided by all proposed and existing facilities should be made available to all segments of the resident population regardless of the ability to pay. Priority #1 - Services and facilities should be designed to treat indigent patients to the greatest extend possible, with new project approval based in part on a documented history of provision of services to indigent patients. Priority #2 - Applicants should have documented a willingness to participate in appropriate community planning activities aimed at addressing the problem of financing for the medically indigent. POLICY #4 Providers of health services are expected to the extent possible to insure an improvement of the quality of health services within the district. Priority #1 - Applicants for certificate of need approval should document either their intention or experience in meeting or exceeding the standards promulgated for the provision of services by the appropriate national accreditation organization. Priority #2 - Each applicant for certificate of need approval should have an approved Patient Bill of Rights' `as part of the institution's internal policy. POLICY #5 Specialized inpatient psychiatric treatment services should be available by age, group and service type. For example, programs for dually diagnosed mentally ill substance abusers, the elderly, and children, should be accessible to those population groups. Priority #1 - Applicants should be encouraged to expand or initiate specialized psychiatric treatment services. The FRTC application is consistent with the local health plan. FRTC's program elements and facility design are consistent with those mandated by the local plan for mental health facilities, and its proposal offers a wide range of services, including follow-up care. FRTC intends to provide a minimum of 1.5 percent of its patient day allotment to indigent children and adolescents, and will seek JCAH accreditation and CHAMPUS approval. The state health plan addresses services similar to those being proposed by FRTC, and contains the following pertinent policies and statements: Mental health services are designed to provide diagnosis, treatment and support of individuals suffering from mental illness and substance abuse. Services encompass a wide range of programs which include: diagnosis and evaluation, prevention, outpatient treatment, day treatment, crisis stabilization and counseling, foster and group homes, hospital inpatient diagnosis and treatment, residential treatment, and long term inpatient care. These programs interact with other social and economic services, in addition to traditional medical care, to meet the specific needs of individual clients. STATE POLICIES As the designated mental health authority' for Florida, HRS has the responsibility for guiding the development of a coordinated system of mental health services in cooperation with local community efforts and input. Part of that responsibility is to develop and adopt policies which can be used to guide the development of services such that the needs of Florida residents are served in an appropriate and cost effective manner. Policies relating to the development of mental health services in Florida are contained in Chapter 394 and Chapter 230.2317, F.S. The goal of these services is: '... reduce the occurrence, severity, duration and disabling aspects of mental, emotional, and behavioral disorders.' (Chapter 394, F.S.) '... provide education; mental health treatment; and when needed, residential services for severely emotionally disturbed students.' (Chapter 230.2317, F.S.) Within the statutes, major emphasis has also been placed on patient rights and the use of the least restrictive setting for the provision of treatment. 'It is further the policy of the state that the least restrictive appropriate available treatment be utilized based on the individual needs and best interests of the patient and consistent with optimum improvement of the patient's condition.' (Chapter 394.459(2)(b), F.S.) 'The program goals for each component of the network are'... 'to provide programs and services as close as possible to the child's home in the least restrictive manner consistent with the child's needs.' (Chapter 230.2317(1)(b), F.S.) Additional policies have been developed in support of the concept of a 'least restrictive environment' and address the role of long and short term inpatient care in providing mental health services for severely emotionally disturbed (SED) children. These include: 'State mental hospitals are for those adolescents who are seriously mentally ill and who have not responded to other residential treatment programs and need a more restrictive setting.' (Alcohol, Drug Abuse and Mental Health Program Office, 1982) 'Combined exceptional student and mental health services should be provided in the least restrictive setting possible. This setting is preferably a school or a community building rather than a clinical or hospital environment.' (Office of Children Youth and Families, 1984) 'Alternative, therapeutic living arrangements must be available to SED students in the local areas, when family support is no longer possible, so that they may continue to receive services in the least restrictive way possible.' (Office of Children Youth and Families, 1984) 'SED students should not be placed in residential schools or hospitals because of lack of local treatment resources, either educational or residential.' (Office of Children Youth and Families, 1984). * * * Sufficient funding for the development of residential treatment and community support is necessary if the state is to fulfill its commitment to providing services for long term mentally ill persons. These services provide, in the long run, a more humane and cost effective means of meeting the mental health needs of Florida residents. Community services have been shown to be effective in rapidly returning the majority of individuals to their productive capacity and reducing the need for costly long term, institutional mental health services. There is, therefore, a need to proceed as rapidly as possible with the development of publicly funded services in those districts which are currently experiencing problems resulting from gaps in services. * * * Services for Adolescents and Children An additional issue which has been identified as a result of increased pressures for development of hospital based programs is the need to differentiate between services for adults and those for children and adolescents. Existing policy supports the separation of services for children and adolescents from those of adults and requires the development of a continuum of services for emotionally disturbed children. The actual need for both long and short term inpatient services for children and adolescents is relatively small compared to that of adults but is difficult to quantify. Providers, however, continue to request approval for long and short term adolescent and children services as a means of gaining access to the health care market. Continued development of long and short term inpatient hospital programs for the treatment of adolescents and children is contrary to current treatment practices for these groups and is, therefore, inappropriate without local data to support the need for these services. Such development can contribute to inappropriate placement, unnecessary costs of treatment, and divert scarce resources away from alternative uses. In addition, the following pertinent goals are contained in the state health plan: GOAL 1: ENSURE THE AVAILABILITY OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES TO ALL FLORIDA RESIDENTS IN A LEAST RESTRICTIVE SETTING. * * * GOAL 2: PROMOTE THE DEVELOPMENT OF A CONTINUUM OF HIGH QUALITY, COST EFFECTIVE PRIVATE SECTOR MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT AND PREVENTIVE SERVICES. * * * GOAL 3: DEVELOP A COMPLETE RANGE OF ESSENTIAL PUBLIC MENTAL HEALTH SERVICES IN EACH HRS DISTRICT. * * * OBJECTIVE 3.1.: Develop a range of essential mental health services in each HRS district by 1989. * * * OBJECTIVE 3.2.: Place all clients identified by HRS as inappropriately institutionalized in state hospitals in community treatment settings by July 1, 1989. RECOMMENDED ACTIONS: 3.2a.: Develop a complete range of community support services in each HRS district by July 1, 1989. * * * OBJECTIVE 3.3.: Develop a network of residential treatment settings for Florida's severely emotionally disturbed children by 1990. The FRTC application is consistent with the state health plan which emphasizes the trend toward deinstutionalization, and the importance of education, treatment and residential services for severely emotionally disturbed children and adolescents rather than the traditional approach of institutional placement. Deinstutionalization assures more appropriate placement and treatment of patients, and is less costly from a capital cost and staffing perspective. The FRTC application also promotes treatment within the state, and will assist in reducing out-of-state placements. Need for the proposed facility The Department has not adopted a rule for the review of applications for IRTPs, and has no numeric need methodology to assess their propriety. Rather, because of the paucity of such applications and available data, the Department reviews each application on a case by case basis and, if it is based on reasonable assumptions and is consistent with the criteria specified in Section 381.705, Florida Statutes, approves it. In evaluating the need for an IRTP, the Department does not consider other residential treatment facilities in the district, which are not licensed as IRTP's and which have not received a CON, as like and existing health care services because such facilities are subject to different licensure standards. Under the circumstances, the Department's approach is rational, and it is found that there are no like and existing health care services in the district. While there are no like and existing health care services in the district, there are other facilities which offer services which bear some similarity to those being proposed by FRTC. These facilities include short-term and long-term residential treatment facilities, therapeutic foster homes and therapeutic group homes. These facilities are, however, operating at capacity, have waiting lists, and do not in general offer the breath or term of service proposed by FRTC. There are also short-term and long-term psychiatric hospitals within the district that include within their treatment modalities services similar to those proposed by the applicant. The short-term facilities are not, however, an appropriate substitute for children and adolescents needing long-term intensive residential treatment and neither are the long-term facilities from either a treatment or cost perspective. Notably, there are only 15 long term psychiatric beds in Broward County dedicated to adolescents, and none dedicated to children. In addition to the evident need to fill the gap which exists in the continuum of care available to emotionally disturbed children and adolescents in Broward County, the record also contains other persuasive proof of the reasonableness of FRTC's proposal. This proof, offered through Dr. Ronald Luke, an expert in health planning whose opinions are credited, demonstrated the need for and the reasonableness of FRTC's proposed 60-bed facility. Dr. Luke used two persuasive methodologies which tested the reasonableness of FRTC's 60-bed proposal. The first was a ratio of beds per population methodology similar to the rule methodology the Department uses for short-term psychiatric beds. Under this methodology, approval of FRTC's proposal would result in 25.47 beds per 100,000 population under 18 in District X. This ratio was tested for reasonableness with other available data. Relevant national data demonstrates an average daily census of 16,000 patients in similar beds. This calculates into 24.01 beds per 100,000 at a 90 percent occupancy rate and 25.93 beds per 100,000 at an 85 percent occupancy rate. Additionally, Georgia has a category of beds similar to IRTP beds. The Georgia utilization data demonstrates a pertinent ratio of 27.05 beds per 100,000 population. The second methodology used by Dr. Luke to test the reasonableness of FRTC's proposal, was to assess national utilization data for "overnight care in conjunction with an intensive treatment program." The national census rate in such facility per 100,000 population for persons under 18 was 21.58. Multiplying such rate by the district population under 18, derives an average daily census of 52. Assuming an optimal occupancy rate of 85 percent, which is reasonable, this demonstrates a gross need for 61 IRTP beds in District X. Dr. Luke's conclusions not only demonstrate the reasonableness of FRTC's proposal, but corroborate the need for such beds within the district. This proof, together with an analysis of existing or similar services, existing waiting lists for beds at similar facilities, and the placement by the Department of 28 children from Broward County outside the county in 1986 for long-term residential treatment, demonstrates the need for, and reasonableness of, FRTC's proposal. Quality of care The parties have stipulated that Charter and its hospitals provide quality short and long term psychiatric care. All of Charter's psychiatric hospitals are JCAH accredited, and Charter will seek JCAH accreditation and CHAMPUS approval for the proposed facility. Based on Charter's provision of quality psychiatric care, its experience in providing intensive residential treatment, and the programs proposed for the Broward County facility, it is found that quality intensive residential treatment will be provided at the FRTC facility. The availability of resources, including health manpower, management personnel, and funds for capital and operating expenditures, for project accomplishment and operation. The parties have stipulated that FRTC has available resources, including management personnel and funds for capital and operating expenditures, for project accomplishment and operation. The proof further demonstrates that FRTC will be able to recruit any other administrative, clinical or other personnel needed for its facility. 1/ Accessibility to all residents FRTC projects the following utilization by class of pay: Insurance 66.5 percent, private pay 25 percent, indigent 1.5 percent, and bad debt 7 percent. While this is an insignificant indigent load, FRTC has committed to accept state-funded patients at current state rates. FRTC's projected utilization by class of pay is reasonable. The evident purpose of FRTC's application is to permit its licensure as a hospital under Section 395.002, Florida Statutes, and thereby permit it to be called a "hospital." If a residential treatment facility is licensed as a hospital it has a significant advantage over unlicensed facilities in receiving reimbursement from third party payors. Therefore, accessibility will be increased for those children and adolescents in need of such care whose families have insurance coverage since it is more likely that coverage will be afforded at an IRTP licensed as a "hospital" than otherwise. Design considerations The architectural design for the FRTC facility was adopted from a prototype short-term psychiatric hospital design which Charter has constructed in approximately 50 locations. This design contains the three essential components for psychiatric facilities: administration, support and nursing areas. The floor plan allows easy flow of circulation, and also allows for appropriate nursing control through visual access to activities on the floor. This design is appropriate for the purposes it will serve, and will promote quality residential care. As initially proposed, the facility had a gross square footage of 31,097 square feet. At hearing, an updated floor plan was presented that increased the gross square footage by 900 square feet to 32,045, an insignificant change. In the updated floor plan the recreational component was increased from a multipurpose room to a half-court gymnasium, an additional classroom was added, and the nursing unit was reduced in size to create an assessment unit. The updated floor plan is an enhancement of FRTC's initial proposal, and is a better design for the provision of long-term residential care to children and adolescents than the initial design. While either design is appropriate, acceptance of FRTC's updated floor plan is appropriate where, as here, the changes are not substantial. Financial feasibility As previously noted, the parties have stipulated that FRTC has the available funds for capital and operating expenses, and that the project is financially feasible in the immediate term. At issue is the long-term financial feasibility of the project. FRTC presented two pro forma calculations to demonstrate the financial feasibility of the project. The first pro forma was based on the application initially reviewed by the Department. The second was based on the proposal presented at hearing that included the changes in staffing pattern and construction previously discussed. Both pro formas were, however, based on the assumption than the 60-bed facility would achieve 50 percent occupancy in the first year of operation and 60 percent occupancy in the second year of operation, that the average length of stay would be 365 days, and that the daily patient charge in the first year of operation would be $300 and in the second year of operation would be $321. These are reasonable assumptions, and the proposed charges are reasonable. The projected charges are comparable to charges at other IRTP's in Florida, and are substantially less than those of acute psychiatric hospitals. For example, current daily charges at Charter Hospital of Miami are $481, and FPC anticipates that its average daily charge will be $500. FRTC projects its utilization by class of pay for its first year of operation to be as follows: Insurance (commercial insurance and CHAMPUS) 65.5 percent, private pay 25 percent, indigent 1.5 percent, and bad debt 8 percent. The projection by class of pay for the second year of operation changes slightly based on the assumption that, through experience, the bad debt allowance should decrease. Consequently, for its second year of operation FRTC projects its utilization by class of pay to be as follows: Insurance (commercial insurance and CHAMPUS) 66.5 percent, private pay 25 percent, indigent 1.5 percent, and bad debt 7 percent. These projections of utilization are reasonable. FRTC's pro forma for the application initially reviewed by the Department demonstrates an estimated net income for the first year of operation of $97,000, and for the second year of operation $229,000. The updated pro forma to accommodate the changes in staffing level and construction, demonstrates a $102,000 loss in the first year of operation and a net income in the second year of operation of $244,000. The assumptions upon which FRTC predicated its pro formas were reasonable. Accordingly, the proof demonstrates that the proposed project will be financially feasible in the long-term. Costs and methods of construction The estimated project cost of the FRTC facility, as initially reviewed by the Department, was $4,389,533. The estimated cost of the project, as modified at hearing, was $4,728,000. This increase was nominally attributable to the change in architectural design of the facility which increased the cost of professional services by approximately $7,500 and construction costs by $139,322. Of more significance to the increased cost of the project was the increase in land acquisition costs which raised, because of appreciation factors, from $750,000 to $1,000,000. The parties stipulated to the reasonableness of the majority of the development costs and most of the other items were not actively contested. Petitioners did, however, dispute the reasonableness of FRTC's cost estimate for land acquisition and construction supervision. The proof supports, however the reasonableness of FRTC's estimates. FRTC has committed to construct its facility south of State Road 84 or east of Interstate 95 in Broward County, but has not, as yet, secured a site. It has, however, allocated $1,000,000 for land acquisition, $200,281 for site preparation exclusive of landscaping, and $126,000 for construction contingencies. The parties have stipulated to the reasonableness of the contingency fund, which is designed as a safety factor to cover unknown conditions such as unusually high utility fees and unusual site conditions. Totalling the aforementioned sums, which may be reasonably attributable to land acquisition costs, yields a figure of $1,326,281. Since a minimum of 6 acres is needed for project accomplishment, FRTC's estimate of project costs contemplates a potential cost of $221,047 per acre. In light of the parties' stipulation, and the proof regarding land costs in the area, FRTC's estimate for land acquisition costs is a reasonable planning figure for this project. FRTC budgeted in its estimate of project costs $6,000 for the line item denoted as "construction supervision (Scheduling)." Petitioners contend that construction supervision will far exceed this figure, and accordingly doubt the reliability of FRTC's estimate of project costs. Petitioners' contention is not persuasive. The line item for "Construction supervision (Scheduling)" was simply a fee paid to a consultant to schedule Charter's projects. Actual on site supervision will be provided by the construction contractor selected, Charter's architect and Charter's in-house construction supervision component. These costs are all subsumed in FRTC's estimate of project cost. FRTC's costs and methods of proposed construction, including the costs and methods of energy efficiency and conservation, are reasonable for the facility initially reviewed by the Department and the facility as modified at hearing. The petitioners FPC, a Florida partnership, received a certificate of need on May 9, 1986, to construct a 100-bed short term psychiatric and substance abuse hospital in Broward County. At the time of hearing, the FPC facility was under construction, with an anticipated opening in May 1988. Under the terms of its certificate of need, the FPC facility will consist of 80 short-term psychiatric beds (40 geriatric, 25 adult, and 15 adolescent) and 20 short-term substance abuse beds. Whether any of the substance abuse beds will be dedicated to adolescent care is, at best, speculative. The principals of FPC have opined at various times, depending on the interest they sought to advance, that 0, 5, or 20 of such beds would be dedicated to adolescent care. Their testimony is not, therefore, credible, and I conclude that FPC has failed to demonstrate than any of its substance abuse beds will be dedicated to adolescent care and that none of its treatment programs will include children. As a short term psychiatric hospital, FPC is licensed to provide acute inpatient psychiatric care for a period not exceeding 3 months and an average length of stay of 30 days or less for adults and a stay of 60 days or less for children and adolescents under 18 years. Rule 10-5.011(1)(o), Florida Administrative Code. While its treatment modalities and programs may be similar to those which may be employed by FRTC, FPC does not provide long-term residential treatment for children and adolescents and its services are not similar to those being proposed by FRTC. Notably, FPC conceded that if the patients admitted by FRTC require treatment lasting from 6 months to 2 years, there will be no overlap between the types of patients treated at the two facilities. As previously noted, the proof demonstrates that the length of stay at the FRTC facility was reasonably estimated to be 6 months to 2 years, with an average length of stay of 1 year. Under the circumstances, FPC and FRTC will not compete for the same patients. As importantly, there is no competent proof that FRTC could capture any patient that would have been referred to FPC or that any such capture, if it occurred, would have a substantial impact on FPC. Accordingly, the proof fails to demonstrate that FPC will suffer any injury in fact as a consequence of the proposed facility. SBHD is an independent taxing authority created by the legislature. Pertinent to this case, SBHD owns and operates the following facilities in Broward County: Memorial Hospital of Hollywood, 1011 North 35th Avenue, Hollywood, Florida, and Memorial Hospital Share Program, 801 S.W. Douglas Road, Pembroke Pines, Florida. Memorial Hospital of Hollywood is a general acute care hospital, with 74 beds dedicated to short-term psychiatric care. These beds are divided between three units: two closed units for acute care (42 beds) and one open unit (32 beds). There is no unit specifically dedicated to the treatment of adolescents, and Memorial does not admit any psychiatric patient under the age of 14. When admitted, adolescents are mixed with the adult population. From May 1987 through January 1988, Memorial admitted only 5-10 adolescents (ages 14-18). Their average length of stay was 12-14 days. Memorial Hospital Share Program is a 14-bed inpatient residential treatment program for individuals suffering from chemical dependency. No patient under the age of 18 is admitted to this program, which has an average length of stay of 27 days. SBHD contends that its substantial interests are affected by this proceeding because approval of FRTC's facility would result in the loss of paying psychiatric and residential treatment patients that would erode SBHD's ability to provide services to the indigent, and would, due to a shortage of nursing, recreational therapy and occupational therapists who are skilled and trained in the care of psychiatric patients, affect the quality of care at its facility and increase costs for recruiting and training staff. Due to the paucity of competent proof, SBHD's concerns are not credited, and it has failed to demonstrate that its interests are substantially affected by these proceedings. Succinctly, SBHD offered no proof concerning any staffing problems it was encountering and no proof of any disparity that might exist between wages and benefits it offers its employees and those to be offered at the FRTC facility. In sum, it undertook no study from which it could be reasonably concluded that the FRTC facility would adversely impact its staffing or otherwise increase the cost of recruiting and training staff. Likewise, SBHD undertook no study and offered no credible proof that the FRTC facility would adversely impact it financially. In fact, the FRTC facility will not treat the same patient base that is cared for by SBHD.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that FRTC's application for certificate of need, as updated, be granted, subject to the special condition set forth in conclusions of law number 12. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 7th day of September, 1988. WILLIAM J. KENDRICK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 7th day of September, 1988.
The Issue The issue in this case is whether the allegations of the Administrative Complaints are correct and, if so, what penalty should be imposed.
Findings Of Fact At all times material to this matter, Respondent Robert S. Colen was a licensed mental health counselor, holding Florida license MH 0001546. The Respondent’s business address is 800 Belcher Road, North, Suite 1, Clearwater, Florida 34625. The Respondent was trained in a form of mental health counseling identified as “Gestalt” or “humanistic” therapy. Such therapy includes physical, non-sexual, touching, such as hugs. There is no credible evidence that therapeutic touching within a counseling relationship is inappropriate. A number of the Respondent’s clients testified that he almost always hugged them at the end of the counseling session. The only witness who testified that the Respondent did not hug was a male patient who indicated that he was not inclined to permit the Respondent to hug him. Other than the three patients identified herein, none of the witnesses regarded the hugging as sexual, and none seemed at all offended by the physical contact. Patient M. C. Patient M. C. was referred to the Respondent by Dr. Michael Gemino, the patient’s psychiatrist. At the time of the referral, M. C. was diagnosed with bipolar disorder, alcohol abuse, and passive aggressive disorder. She was referred to the Respondent for counseling related to alcohol addiction and co-dependency issues. During the course of therapy, the Respondent began to hug M. C. as he did many of his other patients. At some point during the therapy, a discussion of different types of “love” occurred. Based on that discussion, M. C. apparently became convinced that the Respondent was in love with her and she with him. At some point during the counseling, the Respondent and M. C. began to experience some type of emotional involvement which exceeded the typical counselor-client situation. There were extended periods when the Respondent held M. C. in his arms as she recounted painful experiences she had suffered. M. C. asserts that the Respondent told her that he loved her and that beginning in February 1994, she engaged in sexual activity with the Respondent. She asserts that the two would lie on pillows on the floor of his office, that the Respondent would touch her unclothed genital area with his hands and mouth, and that she would perform fellatio on the Respondent. In about July 1994, M. C. reported the alleged sexual activity to Dr. Gemino, who referred her to Kerry Kushmick, an unlicensed individual apparently working with Dr. Gemino. Mr. Kushmick met with the Respondent and M. C. to discuss the matter. Although M. C. repeated her allegations, the Respondent denied any sexual contact, but acknowledged that the two were in a "psychological cocoon,” that he was "in over his head," that he should have terminated therapy earlier, and that there were some “boundary” issues which needed resolution. The evidence fails to establish that the Respondent engaged in sexual activity with M. C. The recollection of M. C. as to times and circumstances under which the sexual activity occurred lacks credibility. The Respondent’s office was located immediately adjacent to a public waiting area which served a number of professional offices. The receptionist’s desk in the waiting area was located next to the Respondent’s office. The walls in the office suite were poorly insulated and sound traveled from the offices into the waiting area; however the receptionist testified that she heard nothing indicating any sexual activity ever took place in the Respondent’s office. She also testified that the door to the Respondent’s office closed improperly and would not lock. The evidence establishes that the Respondent did not maintain an appropriate therapeutic relationship with M. C. The Respondent did not recognize that transference and counter- transference were occurring, and did not timely seek assistance to resolve the situation. The Respondent's failure to recognize the developing situation with M. C. was detrimental to her mental condition and constitutes a failure to meet minimum standards of performance as his professional activity. At some point after M. C. spoke to Dr. Gemino, he provided to her the names of other patients whom he had referred to the Respondent for counseling. M. C. met separately with J. M. and R. P. They discussed the interactions with the Respondent. The former patients continued to maintain contact for a period of time after the initial meeting. At the hearing, J. M. and R. P. expressed concern regarding the emotional condition of M. C. Patient J. M. In about October 1993, J. M. was referred to the Respondent by Dr. Gemino, the patient’s psychiatrist. At the time of the referral, J. M. was diagnosed with bipolar disorder. She was referred to the Respondent for marital therapy, after having been involved in sexual relations outside her marriage. J. M. attended initial counseling session with her husband. She attended subsequent sessions without her husband. She also participated in group therapy at the Respondent’s office. J. M. dressed in a “seductive” manner for counseling sessions, frequently wearing very short shorts. At one time, after a group therapy session, the Respondent received a complaint from another patient regarding J. M.’s attire during counseling, stating that she was sitting on a pillow on the floor, was not wearing underwear, and was exposing herself. J. M. testified that she did not wear underwear during the group therapy and further acknowledged that she was not wearing underwear at the time of her testimony. J. M. asserts that during the initial counseling session, while her husband was out of the room, the Respondent told her she was attractive. J. M. asserts that during subsequent session, which she attended alone, the Respondent would lie on the pillows with her, touch her, tell her she was beautiful and call her his “soul mate.” She asserts that the Respondent was always touching her and kissing her. The evidence fails to support the assertions J. M. asserts that the Respondent purchased gifts for her. The Respondent acknowledged that he may have purchased some type of tape for her, but there were not multiple gifts. J. M. asserts that he did not charge for all sessions. The Respondent acknowledged that he did not charge for all her sessions and said that is frequently the case when a patient is undergoing financial difficulty. J. M. testified that the Respondent told her she should take a test for the AIDS virus. She believed that the Respondent made the suggestion for the purpose of determining her health status prior to engaging in sexual relations with her. The Respondent testified that he made the suggestion based on her sexual activity outside her marriage and the fact that she was referred to him for marital counseling. Despite having been interviewed by an investigator for the Department, J. M. testified for the first time at the hearing that the Respondent told her he was going to “lick her pussy like you’ve never had it before.” There is no credible evidence that the Respondent made the statement. J. M. terminated her therapy with the Respondent because he indicated she needed to pay him some of the money she owed from the counseling. The evidence fails to establish that the Respondent acted inappropriately in his interaction with J. M. Patient R. P. The Respondent provided therapeutic counseling to R. P. from January to March of 1988. At the time of the 1988 counseling, R. P. was being treated for an inability to accept affection. From August to October 1991, the Respondent engaged in a second round of therapy with R. P. She was depressed, lacked a social support system, and was dependent on prescription pain medication. She was also involved in a difficult relationship with her mother. There were only four sessions during the 1991 round of therapy. During the second round of therapy, the Respondent encouraged her to bring her mother to counseling (her mother declined.) The Respondent hugged and touched R. P during the sessions, told her she was special and a valuable person. R. P. had expressed concern about being able to be physically affectionate with a man. Part of the Respondent’s plan of therapy was physically hugging or holding R. P. in a manner intended to permit her to become comfortable with such attention in a non-threatening environment. Some of the hugs lasted for up to 15 minutes. Depending on the mental status of the patient, a 15 minute hug, while unusual, is not necessarily inappropriate. R. P. asserts that the Respondent told her she was his “soul mate” and discussed sexual relations with her. She asserts that he told her he had feelings about her which he had not experienced with other patients. The evidence fails to support the assertion. After R. P. stopped attending the sessions, she received two letters from the Respondent, the second of which made her feel “threatened.” He also called R. P. several times. R. P. believed he was trying to make her feel guilty. The Respondent asserts that he was concerned about her discontinuation of therapy and the fact that she owed him money. The evidence fails to establish that the Respondent acted inappropriately in his interaction with R. P.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department of Health, Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, enter a Final Order imposing a fine of $1,000 on, and issuing a public reprimand to, Robert S. Colen. DONE AND ENTERED this 30th day of March, 1998, in Tallahassee, Leon County, Florida. WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32301-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 30th day of March, 1998. COPIES FURNISHED: William C. Childers, Esquire Thomas Wright, Esquire Anne Cox, Esquire Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32317-4229 Louis Kwall, Esquire Kwall & Showers, P.A. 133 North Fort Harrison Avenue Clearwater, Florida 33755 Lucy C. Gee, Executive Director Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0792 Angela T. Hall, Agency Clerk Department of Health 1317 Winewood Boulevard, Building 6 Tallahassee, Florida 32399-0700
The Issue Whether or not, on or about January 13, 1977, the Respondent, while undergoing an employment physical at the request of her employer, at St. Vincent's Medical Center of Jacksonville, Florida ,was observed by the examining physician to have between 50 and 75 puncture wounds in her arms overlying her veins, which puncture wounds were consistent with those made by a hypodermic needle. Whether or not the Respondent was obtaining oral Codeine, Dilaudid and Demerol tablets, controlled substances, by prescription, and subsequently dissolving the drugs and injecting them into her veins. Whether or not, on or about January, 1977, the Respondent was counseled by a member of St. Vincent's Medical Center Community Mental Health Department, and was offered the services of the Department which offer was declined by the licensee. Further, whether or not the Respondent informed Shirley Trawick, Assistant Administrator of the Mental Health Department, that she had been using controlled drugs in her younger years, stopped using them for a while and was once again using controlled drugs, including Demerol. Whether or not, on or about February 18, 1977, the Respondent uttered a forged prescription at Soutel Pharmacy, Jacksonville, Florida for a controlled drug to wit: Demerol, and was arrested by an officer of the Jacksonville Sheriff's Office for the felony of uttering or making a forged prescription. Further, whether or not at the time of the arrest a search of the licensee's purse revealed 20 more prescription blanks contained therein. Whether or not, on or about February 10, 1977, while confined to the Duval County Jail, licensee admitted to the jail nurse, L. Harris, that she had been abusing drugs (Demerol). Whether or not, on or about January 18, 1977, the Respondent uttered a forged prescription for a narcotic to wit: Demerol at Walgreen's Regency Pharmacy, 9501 Arlington Expressway. Whether or not, on or about January 27, 1977, the Respondent uttered a forged prescription at Revco Pharmacy, 5220 Firestone Road, for a narcotic drug, to wit: Demerol. Whether or not, on or about February 4, 1977, the Respondent forged a prescription for a narcotic drug, to wit: Demerol, which was passed at Revco Pharmacy, 5220 Firestone Road, Jacksonville, Florida by an individual, Lewis William Bergman. Whether or not the above allegations, if proven, would establish that the Respondent is guilty of unprofessional conduct and in violation of 464.21(1)(b), F.S., 464.21(c), F.S., 464.21(d), F.S., 464.21(f), F.S., and 464.21(g) F.S.
Findings Of Fact The Respondent, Rebecca Lee Brunson, is a Registered Nurse who holds license no. 89605-2, held with the Florida State Board of Nursing. This case is brought for consideration upon the amended administrative complaint of the Petitioner, Florida State Board of Nursing, which is dated for mailing on May 25, 1977. This complaint arises from the sworn complaint letter of April 25, 1977, propounded by Geraldine B. Johnson, R.N., Investigation and Licensing Coordinator for the Florida State Board of Nursing. This letter of complaint can be found as Petitioner's Exhibit #2 admitted into evidence. On January 13, 1977, the Respondent was seen by Dr. C. O. Plyler for purposes of an employment physical examination. At that time the Respondent was employed by St. Vincent's Medical Center of Jacksonville, Florida. The examination conducted by Dr. Plyler revealed many wounds on the arms of the Respondent, by Dr. Plyler's estimate, 50 to 75. These wounds appeared to be puncture wounds and followed a pattern on the visible blood vessels in the area between the wrists and elbows. These wounds were of a type, believed by Dr. Plyler to have possibly been caused by a hypodermic needle. When confronted with the need to make an explanation of these wounds, the Respondent replied by saying that the wounds had been inflicted by a cat. After further inquiry by Dr. Plyler, the Respondent stated that she was injecting her veins with narcotics. The specific method of this infection was to take oral narcotics, to wit: Codeine and Demerol, and dissolve these tablets and then inject them into herself. On this same occasion Kathleen Maher, the Director of the Nursing Service, St. Vincent's Medical Center, was called in to consult with the Respondent. Mrs. Maher knew Rebecca Brunson through Brunson's employment in the nursing staff at St. Vincent's Medical Center. A discussion was entered into between Mrs. Maher and the Respondent in which the Respondent was offered the opportunity to attend the St. Vincent's Medical Center Community Mental Health Program, but declined that opportunity. This opportunity was also offered by Shirley Trawick, the Assistant Director of the St. Vincent's Medical Center Community Mental Health Program. This conversation took place on the same date as the examination by Dr. Plyler. Mrs. Trawick also offered an alternative suggestion for treatment for the problem with narcotics. That alternative was placement in the Jacksonville Drug Abuse Program. The Respondent declined Mrs. Trawick's offer for assistance in any efforts to be detoxed. Another element of the conversation between Brunson and Trawick concerned the question of addiction. The Respondent told Trawick that she had been addicted to drugs as an adolescent and was currently taking the drug Demerol. On the same day as the discovery by Dr. Plyler and the admission by the Respondent, the St. Vincent's Medical Center suspended the Respondent because they felt that she was not physically capable of continuing as a registered nurse in their service. The Respondent was ultimately terminated from her position with St. Vincent's Medical Center. On February 18, 1977, the Respondent went to Soutel Pharmacy, Jacksonville, Florida and tendered a prescription to be filled. The contents of the face of the prescription may be found in Petitioner's Exhibit #1, admitted into evidence. (This exhibit is a copy of the original document which was tendered.) She presented the prescription by inquiring if the Soutel Pharmacy had the prescription, because, "Scotties on Lem Turner could not fill the prescription." There is no Scotties on Lem Turner in Duval County, Florida. Additionally, the signature on the prescription showed the signature of Dr. Millard F. Jones. Dr. Jones, when contacted by the pharmacist, Joel Bressler, indicated that he had not signed such a prescription. The Respondent exited the Soutel Pharmacy while Joel Bressler, the pharmacist was calling Dr. Jones. Bressler then called the Jacksonville Sheriff's Office and an officer was dispatched to investigate the case. Officer Robert E. Sanders, Jacksonville Sheriff's Office, arrived at the Soutel Pharmacy and placed the Respondent under arrest for uttering a forged prescription. In the course of the arrest an envelope with a number of other prescription forms was found in the Respondent's purse. Later, in an interview setting between the Respondent and Detective John Farmer, Jacksonville Sheriff's Office, held in the Detective Bureau, the Respondent, after being advised of her rights under the Miranda Case, admitted having written the prescriptions in her purse and having, on numerous other occasions, passed or attempted to pass forged prescriptions. She particularly made mention of three cases that were under investigation by Detective Farmer, two involving Revco Pharmacy on Firestone Road, and one involving Walgreens Pharmacy in Arlington. The Respondent also indicated that she was addicted to drugs. During the course of a routine crisis intervention interview by Ms. Lynn Harris, now Mrs. Lynn Timmons, which occurred on February 18, 1977 at the Duval County Jail, the Respondent admitted abusing drugs. She specifically referred to the drug Demerol. The Respondent, at that time, denied any addiction to the drug Demerol. The substances identified as Codeine and Demerol are controlled substances as set forth in 893, F.S. Based upon the facts as shown the Respondent is guilty of unprofessional conduct within the meaning of 464.21(1)(b), F.S., by reason of her abuse of and addiction to the substances Codeine and Demerol and by reason of forgeries and uttering and attempting to utter forged prescriptions. The Respondent is also guilty of habitual intemperance or addiction to the use of controlled substances as set forth in 893, F.S., in addition to engaging in the possession of controlled substances within the meaning of the aforementioned 893, F.S., causing a violation of 464.21(1)(c)(d), F.S. The response by the licensee, Rebecca Lee Brunson, to the offer for assistance for her problem with drug abuse and addiction and her general physical condition exhibits behavior which the Nursing Board has regarded and may regard as creating an undue risk that the licensee as a nursing practitioner could cause harm to other persons in violation of 464.21(1)(f), F.S. Finally the Respondent has wilfully and repeatedly violated the provisions of 464, F.S. and the provisions of 893, F.S., thereby violating 464.21(1)(g), F.S.
Recommendation It is recommended that the Florida State Board of Nursing, revoke the license of Rebecca Lee Brunson, R.N., license no. 89605-2. DONE AND ENTERED this 28th day of July, 1977, in Tallahassee, Florida. CHARLES C. ADAMS, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1005 Blackstone Building Jacksonville, Florida 32201 William J. Sheppard, Esquire 215 Washington Street Jacksonville, Florida 32202 Geraldine B. Johnson, R.N. Investigation and Licensing Coordinator Board of Nursing 6501 Arlington Expressway, Building "B" Jacksonville, Florida 32211 Rebecca Lee Brunson, R.N. 1529 McDuff Avenue South Apartment #2 Jacksonville, Florida
The Issue Does Petitioner, Nicholas A. Mancini, PhD (Dr. Mancini), satisfy the requirements for licensure as a mental health counselor as established in section 491.005(4), Florida Statutes (2010)?1
Findings Of Fact Based on the evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made: On December 30, 2010, the Board issued its Notice of Intent to Deny Dr. Mancini's application for licensure as a Mental Health Counselor. Dr. Mancini requested a hearing to challenge the decision. This proceeding followed. Dr. Mancini has been licensed to practice psychology in California and Pennsylvania. His Pennsylvania license expired November 30, 2003. His California license was canceled on May 31, 2006. Dr. Mancini earned a master's degree in psychology from Fairleigh Dickinson University. He completed 34 semester hours of coursework there. The Fairleigh Dickinson University master's in psychology program that Dr. Mancini completed was not a mental health counseling program accredited by the Council of Accreditation of Counseling and Related Educational Programs. The program is, however, related to the practice of mental health counseling. At the time Dr. Mancini attended Farleigh Dickinson, it was accredited by the Commission on Higher Education of the Middle States Association of Colleges and Schools. It was also accredited by the Council of Higher Education Accreditation. By completing Fairleigh Dickinson course 20PY624, Counseling and Interviewing, Dr. Mancini obtained three semester hours of graduate coursework in the content area of counseling theories and practice. By completing Fairleigh Dickinson course 30PY633, Abnormal Psychology, Dr. Mancini obtained three semester hours of graduate coursework in the content area of diagnosis and treatment of psychopathology. By completing Fairleigh Dickinson Course 30PY600, Tests and Measurements I, Dr. Mancini obtained three semester hours of graduate coursework in the content area of individual evaluation and assessment. By completing Fairleigh Dickinson courses 20PY603 and 20PY604, Statistics and Experimental Psychology, Dr. Mancini obtained three semester hours of graduate coursework in the content area of research and program evaluation. By completing Fairleigh Dickinson course 30PY710, Social Problems, Dr. Mancini obtained three semester hours of graduate coursework in the content area of substance abuse. Dr. Mancini attended, but did not receive a degree from, Hahneman University Medical College of Philadelphia (now Drexel University). He completed four semester hours of graduate coursework there. At the time, it was regionally accredited by the Council of Higher Education Accreditation. Dr. Mancini attended, but did not receive a degree from, Glassboro State College (now Rowan University). He completed six semester hours of graduate coursework there. At the time, it was regionally accredited by the Council of Higher Education Accreditation. Dr. Mancini earned a doctoral degree in counseling psychology from the Professional School of Psychological Studies. At the time, the school was not regionally accredited. Dr. Mancini has not obtained three semester hours of graduate-level coursework from a regionally accredited institution in each of the following content areas: human growth and development; human sexuality, group theories and practice; career and lifestyle assessment; social and cultural foundations; counseling in community settings; and legal, ethical, and professional standards issues in the practice of mental health counseling.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Clinical Social Work, Marriage, and Family Therapy and Mental Health Counseling issue a final order denying Dr. Mancini's licensure application. DONE AND ENTERED this 7th day of June, 2011, in Tallahassee, Leon County, Florida. S JOHN D. C. NEWTON, II Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 7th day of June, 2011.
Findings Of Fact Based upon the record evidence, the following Findings of Fact are made: Question 7 Question 7 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 1 as the answer to this question. The vendor who prepared the examination for the Department determined that No. 4 was the correct answer. Because she did not have No. 4 as her answer, Petitioner was not given any credit for Question 7. While No. 4 is a correct answer to Question 7, so is No. 1, the answer selected by Petitioner. Compared to preadolescents, the moral judgments of adolescents are more susceptible to "prestige suggestion," Petitioner should therefore receive credit for her answer to Question 7. Question 30 Question 30 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 4 as the answer to this question. The vendor determined that No. 3 was the correct answer. Because she did not have No. 3 as her answer, Petitioner was not given any credit for Question 30. Petitioner was properly denied credit for this answer. Of the symptoms/traits listed, the one she selected is not the one most characteristic of chronic drug abuse. Those described in No. 3, as well as in No. 2, are more common. Question 68 Question 68 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 2 as the answer to this question. The vendor determined that No. 1 was the correct answer. Because she did not have No. 1 as her answer, Petitioner was not given any credit for Question 68. Petitioner was properly denied credit for this answer. Of the choices given, the one selected by Petitioner does not represent the most useful way for a counselor to handle the prejudice referenced in the question stem. A counselor may encounter clients whose morals, customs, and/or behavior arouse prejudice in the counselor, notwithstanding that there are no cultural differences between these clients and the counselor. Accordingly, learning as much as possible about various cultures will not be helpful to the counselor in handling such prejudice. The correct answer to Question 68 is No. 1. Self-awareness on the part of the counselor is essential to effective counseling. It is imperative that a counselor remain objective and not respond to the client on the basis of bias or prejudice. Question 69 Question 69 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 4 as the answer to this question. The vendor determined that No. 3 was the correct answer. Because she did not have No. 3 as her answer, Petitioner was not given any credit for Question 69. While No. 3 is a correct answer to Question 69, so is No. 4, the answer selected by Petitioner in counseling drug abusers, limit setting, or what is commonly known as "tough love," is generally more effective than approaching the client with sympathy and gentleness. Petitioner should therefore receive credit for her answer to Question 69. Question 85 Question 85 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 2 as the answer to this question. The vendor determined that No. 3 was the correct answer. Because she did not have No. 3 as her answer, Petitioner was not given any credit for Question 85. Petitioner was properly denied credit for this answer. A counseling session may be effective even though the client is upset upon leaving. The correct answer to Question 85 is No. 3. The mark of a skillful counselor is the ability to recognize the significance of minor or subtle changes in the client's conduct during the counseling session. Question 94 Question 94 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 4 as the answer to this question. The vendor determined that No. 2 was, the correct answer. Because she did not have No. 2 as her answer, Petitioner was not given any credit for Question 94. While No. 2 is a correct answer to Question 94, so is No. 4, the answer selected by Petitioner. Indeed, No. 4 is essentially the same answer as No. 2. They are simply worded differently. Petitioner should therefore receive credit for her answer to Question Question 99 Question 99 was received into evidence as part of Joint Exhibit 4. Petitioner selected No. 1 as the answer to this question. The vendor determined that No. 3 was the correct answer. Because she did not have No. 3 as answer, Petitioner was not given any credit for Question 99. Petitioner was properly denied credit for this answer. A couple that has been referred to a counselor for sexual problems should not be referred to a physician for medical work-ups before the counselor has met with the couple to find out more about the nature of the couples's difficulties. Accordingly, the correct answer to Question 99 is not No. 1, but No. 3.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling sustain Petitioner's challenge to the grading of her answers to Questions 7, 69 and 94 on Part II of the April, 1990, Mental Health Counseling Examination, reject her challenge to the grading of the remaining questions at issue, and modify her score on the examination accordingly. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd day of November, 1991. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of November, 1991. APPENDIX TO RECOMMENDED ORDER IN CASE NO 91-0650 The following are the Hearing Officer's specific rulings on the findings of fact proposed by the parties: Petitioner's Proposed Findings of Fact To the extent that it states that Petitioner's answers to Questions 7, 69 and 94 are correct and that she therefore should receive credit for these answers, this proposed finding has been accepted and incorporated in substance in this Recommended Order. To the extent that it states that her answers to Questions 30, 68, 85 and 99 are correct and that she therefore should receive credit for these answers, this proposed finding has been rejected because it is contrary to the greater weight of the evidence. Rejected because it is not supported by persuasive competent substantial evidence. Respondent's Proposed Findings of Fact 1-17. Accepted and incorporated in substance. 18-19. Rejected because they would add only unnecessary detail to the factual findings made by the Hearing Officer. Accepted and incorporated in substance. Rejected because it constitutes, not a finding of fact, but a statement of the opposing party's position regarding Question 30. 22-24. Accepted and incorporated in substance. 25-26. Rejected because they are contrary to the greater weight of the evidence. The preponderance of the evidence establishes that the concept of "prestige suggestion" incorporates the notion of peer identity and influence. 27. Rejected because it is irrelevant and immaterial. It matters not why an applicant selected a answer, if that answer is correct. 28-29. Rejected because they are contrary to the greater weight of the evidence. 30-33. Accepted and incorporated in substance. COPIES FURNISHED: Diane M. Kirigin, Esquire 2428 Broadway P.O. Box 9936 Riviera Beach, Florida 33419 Roberta L. Fenner, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Diane Orcutt Executive Director Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling 1940 North Monroe Street Tallahassee, Florida 32399-0792 =================================================================
Findings Of Fact Based on the evidence offered at the formal hearing in this case, the following facts are found: The Petitioner, Elizabeth R. Hillegas, took the Mental Health Counselor licensure examination administered on April 21, 1989. The Petitioner's examination was given a failing grade. The Petitioner needs to receive credit for correct answers on at least two more questions in order to be entitled to a passing grade. The Petitioner's answers to questions 8, 17, and 33 on the subject examination were incorrect. 2/ All three of the challenged questions, namely questions 8, 17, and 33, inquire as to matters which are part of the basic training in the field of Mental Health Counseling or matters which are crucial to competent practice in the field of Mental Health Counseling. The challenged questions ask about matters which should be known by a competent Mental Health Counselor. Therefore, the challenged questions are within the appropriate subject matter domain for a licensure examination for the profession of Mental Health Counselor. 3/
Recommendation For all of the foregoing reasons, it is RECOMMENDED that the Board of Mental Health Counselors issue a final order in this case dismissing the Petition and assigning to the Petitioner a failing grade on the April 21, 1989, Mental Health Counselor licensure examination. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 25th day of May 1990. MICHAEL M. PARRISH Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 25th day of May 1990.
The Issue Whether the Respondent should be dismissed from employment as an instructional employee of the Respondent, School Board of Lake County, Florida ("School Board"), or, to otherwise determine the terms under which the Respondent may be reinstated as an instructional employee by the School Board. The charges are based upon the acts and violations alleged in the Superintendent's letter of August 21, 1989 and Amendment to Charges dated July 12, 1990. Case No. 90-4382 Whether the Respondent's teaching certificate should be revoked or otherwise disciplined for violation of Section 231.28(1)(c) and (f), Florida Statutes.
Findings Of Fact The School Board of Lake county, Florida pursuant to Sect. 120.57(1)(b)10, Fla. Stat., which precludes the agency from rejecting or modifying the Findings of Fact made by the Hearing officer, unless the agency finds that the Findings of Fact were not based upon competent substantial evidence or that the proceedings on which the findings were based did not comply with the essential requirements of law, adopts the findings of fact made by the Hearing Officer. The School Board of Lake County, Florida hereby rejects the Hearing Officer's Conclusions of Law that the petitioner was not guilty of immorality, was not incompetent by reason of incapacity and did not commit misconduct in office. The School Board of Lake County, Florida finds that although the Findings of Fact support a conclusion of drunkenness, the findings do not rise to the level of public drunkenness as is required for termination under Sect. 231.36, Fla. Stat. The School Board of Lake County, Florida therefore substitutes its conclusions of law as follows: That the respondent, Sarah I. Clark, giving con- sideration to Fla. Admin. Code Rule 6B-1.001(3) and Rule 6B-4.009(1)(b)(1) is incompetent due to incapacity, due to lack of emotional stability. That the respondent, Sarah I. Clark, has engaged im- morality in that respondent's conduct in urinating on her husband in the course of performance of a sexual act involves a sexual act which is deemed a violation of the law of Florida, notwithstanding the fact that the act was engaged in by the mutual consent of the parties thereto; and that the respondent's publication of that event to members of the Lake County Sheriff's Department and a resident in her home, Mr. William Rutland, and the resulting investigation by the Department of Health and Rehabilitative Services constitutes conduct sufficiently notorious to bring the individual concern or the education profession into public disgrace or disrespect to the end that the individual's service in the community is impaired. That the respondent, Sarah I. Clark, is guilty of misconduct in office for violation of the code of Ethics of the Education Profession as adopted in Fla. Admin. Code Rule 6B-1.001(3). For reference a copy of the Hearing Officer's Recommended Order is attached hereto. RULING ON EXCEPTIONS TO THE HEARING OFFICER'S RECOMMENDED ORDER Upon consideration of petitioner's exceptions to Hearing Officer's Recommended Order as served on March 1, 1991 and respondent's exceptions to the Recommended Order as served February 22, 1991, said exceptions be and the same are hereby denied.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is, therefore RECOMMENDED that: The Board take no action to discharge Respondent and condition her employment upon regular continued participation in Alcoholics Anonymous; and The EPC drop its charges against the Respondent and dismiss this case. DONE AND ENTERED this 6th day of February, 1991, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 6th day of February, 1991. APPENDIX TO RECOMMENDED ORDER IN CASE NOS. 89-5247 AND 90-4382 Petitioner, Betty Castor's Proposed Findings of Fact: 1-6. Adopted. 7. Irrelevant. 8-9. Adopted but restated. 10-23. Adopted. 24. Rejected. See paragraph 20(FA) of Respondent's Proposed Recommended Order. 25-32. Restated in Respondent's Proposed Recommended Order, paragraph 20(B)-40. 33-37. Rejected, credibility of Rutland. 38-40. Adopted but restated as in Respondent's Proposed Recommended Order, paragraphs 33-37. 41-48. Rejected, as contrary to the more credible testimony. 49-52. Irrelevant. 53-56. Rejected, as contrary to the more credible testimony. Adopted. Adopted in part, rejected in part, as irrelevant. 59-61. Deleted from Proposed Recommended Order. 62-67. Adopted and rewritten, see Respondent's Proposed Recommended Order, paragraphs 41-43. 68-70. Irrelevant. Petitioner, School Board's Proposed Findings of Fact: 1-3. Adopted. 4-18. Adopted, generally, but restated as proposed in Petitioner, Castor's Proposed Recommended Order, paragraphs 3-23. 19-23. Adopted, generally, but restated as proposed by Respondent in the two paragraphs 20 on page 8 of Respondent's Proposed Recommended Order and paragraph 25 of Petitioner, Castor's Proposed Recommended Order. 24-58. The facts based upon Rutland's testimony are rejected. The facts as restated in Respondent's proposed Recommended Order, paragraphs 21-40 are accepted as being a more accurate statement of the facts revealed in the record. 59-70. Rejected, as contrary to the more credible evidence in the record. Respondent's Proposed Findings of Fact: 1-2. Irrelevant. Irrelevant. Added to Conclusions of Law as last paragraph. 5-50. Adopted, generally, and summarized. Those findings which were deleted were deemed irrelevant. COPIES FURNISHED: Thomas E. Sanders, Superintendent Lake County School Board 201 W. Burleigh Boulevard Tavares, FL 32778 Martin B. Schapp, Administrator Professional Practices Services 352 Florida Education Center 325 W. Gaines Street Tallahassee, FL 32399-0400 Ms. Karen Barr Wilde Executive Director 301 Florida Education Center 325 W. Gaines Street Tallahassee, FL 32399-0400 Stephen W. Johnson, Esq. MCLIN, BUPNSED, ET AL. 1000 West Main Street P.O. Box 491357 Leesburg, FL 34749-1357 Stephen C. Willis, Esq. BROOKS & LEBOEUF 863 East Park Avenue Tallahassee, FL 32301 Sally C. Gertz, Esq. Florida Education Association/United 118 North Monroe Street Tallahassee, FL 32399-1700
