The Issue The issues to be resolved in this proceeding concern whether the application submitted by the Petitioner for a new one-year license for Small Fries Day Care, Inc., should be granted, or denied based upon violations of specified statutes and rules referenced below as alleged by the Respondent. It must also be resolved whether the application to operate a new facility known as the Growing Tree Learning Center and Nursery should be denied because of the same alleged instances of non- compliance with the relevant statutes and rules.
Findings Of Fact The Petitioner operates a child care facility known as Small Fries Day Care, Inc. She also has applied for a license to open a new facility known as the Learning Tree. The Department notified the Petitioner, by letter of July 23, 2004, that the application submitted for a new one-year license for Small Fries was denied. The letter of denial was based on violations of statutes and rules enforceable by the Department, which were purportedly discovered during the inspections of the facility in April, May, and July of 2004. Thereafter by letter of August 3, 2004, the Petitioner was notified that her application for a license to operate a second child care facility known as the Growing Tree Learning Center and Nursery was also denied, based upon the history of alleged violations and non-compliance with statutes and rules during the operation of the Small Fries. The Petitioner requested a formal administrative proceeding to contest both decisions and the matter was referred to the Division of Administrative Hearings. The two cases were later consolidated into the instant proceeding. The Department received a complaint regarding transportation of children. It therefore dispatched an investigator, Judy Cooley, to conduct an inspection of the Petitioner's facility on April 6, 2004. The precise nature of the complaint was never substantiated. Ms. Cooley, however, upon conducting her inspection, discovered a violation of Florida Administrative Code Rule 65C-22.001(6)(f). This is a rule which mandates that children transported in a van must be counted and that both the driver of the van and one staff member must both count the children and sign a transportation log verifying that all children had exited the van. This is required to be done each time children leave or board the van. The failure to document an inspection of the van by both the driver and another staff member to ensure that all children are accounted for and out of the van is considered to be a major violation of the Department's rules and policy. The purpose of that requirement is to prevent children from being accidentally left in a van in the hot sun (or left at some location away from their home or the Petitioner's facility when the van departs a location.) If a child is left in a van in the hot sun a serious injury can result, rendering this infraction a serious one. Ms. Cooley also determined that a violation had occurred concerning the "background screening" requirements upon her inspection on April 6, 2004. That is, the Petitioner's records did not show that screening had been done for all personnel employed by the Petitioner's facility. On May 11, 2004, another investigation or inspection of the facility was conducted by the Department. This was because the Department had received an anonymous abuse report concerning the Petitioner's facility. Upon investigation it was determined that the report was unfounded. It had been alleged that a child had sustained an eye injury while in the custody and care of the Petitioner, but that was determined not to be the case; rather, the eye problem was determined to have been "Sty" infectious process and not a result of any injury sustained while a child was in the care of the Petitioner or her staff members. The Petitioner was also charged with a violation regarding this eye injury issue for failing to file an "incident report" concerning it and failing to give a copy of the report to the child's parent the same day of the incident. This violation has not been proven by the Department because, in fact, no injury occurred. The child had to have appeared on the premises of the Petitioner's facility that day already suffering from the eye condition. Therefore, there was no "incident" occurring on the premises of the Petitioner, or while the child was in the Petitioner's care. Therefore, there could be no incident requiring reporting to the Department and the parent under the Department's rules and policies. Apparently, the owner of the facility, Ms. Carter, later provided a copy of an incident report in the belief that the Department required it. In any event, this purported violation was not shown to have legally or factually amounted to an incident or a violation. As to that May 11, 2004, inspection or investigation, however, the Department's evidence derived from that May 11, 2004, inspection which was not refuted establishes that the Child Protective Investigator (CPI) who conducted the investigation observed other violations. The investigator noted that the staff was failing to adequately supervise children and that the staff had not had required training. The CPI found that after observing the day care facility on three different occasions in a two-week period, there were always children "running around," not in their classroom and without staff providing supervision of them. The CPI noted prior reports for inadequate supervision and noted that some of the staff had not been trained in all of the required hours for teachers required by the Department's rules. These findings by the CPI were supported by unrefuted evidence adduced by the Department at hearing, and accepted as credible. Ms. Cooley returned to the facility to conduct a follow-up inspection on July 23, 2004. This inspection was specifically related to the pending application filed by the Petitioner for a renewed one-year license for the facility. Ms. Cooley prepared a list of activities, conditions, or records as to the facility, its operations, the children, and the staff personnel, for purposes of indicating whether those checklist items, based upon Department rules, had been complied with or had not been complied with. There were a total of 63 specific requirements under the Department's statutes and rules for Ms. Cooley to employ in inspecting the facility. Ultimately, she found that the facility was in non-compliance on 11 out of the 63 items. Ms. Cooley thus determined on this visit that the required staff-to-child ratio was improper. The facility was out of compliance on this issue by having only one staff member supervising the "infant room" with one child less than a year old, and five children aged one year. The number of staff needed is controlled by the age of the youngest child in a group. Two staff members were required in this instance instead of one. Ms. Cooley also found, as a minor violation, that the facility had an open door with no screen, with only a curtain covering the opening and that children were sleeping on the floor on only towels instead of the required individual sleeping mats (minimum one inch thick.) The owner of the facility, Ms. Carter, however, testified that indeed the mats were in use but were covered with towels and therefore they were not readily visible. It is thus difficult to determine whether all the children slept on required sleeping mats or some of them, or none of them. The testimony in this regard at least roughly amounts to an equipoise, and it is determined that this violation has not been established. Another violation Ms. Cooley found to have occurred was that there were no records which would establish that the facility had conducted required fire drills for one and one-half months. Child care facilities such as this mandatorily must conduct at least once a month fire drills. They mandatorily must document each fire drill in a record for ready inspection. Ms. Cooley also found that there was no record proof of enrollment by staff members in the required 40-hour training course which all employees must undergo within 90 days after they are hired. The facility also had been cited for this violation on the April 6, 2004, visit. It remained uncorrected during the interim and on the day of Ms. Cooley's second visit. Another violation was found on this occasion in that, for the number of children present in the facility, there must be at least two staff members who have the necessary child development associate credentials. There was only one staff member who had those necessary credentials. There are also no records to establish that the required in-service training for staff members had been conducted. The additional three violations found by Ms. Cooley involve the failure to maintain required records concerning child immunizations, staff personnel records, and background screening records establishing that background screening had been properly done. If that required information is not appropriately filed and available at the facility, that in itself is a violation. If the file record was required to document compliance with some requirements, such as staff training, the absence of the documentation results in a presumption that there was no compliance. The lack of adequate staff in the infant room necessary to meet the statutorily required staff-to-child ratio, as noted on the July 23, 2004, inspection, is a major violation under Department rules and policies. Direct supervision is mandated for children of that age at all times. The maintenance of this staff-to-child ratio is considered to be so important by the Department that its staff are not allowed to leave a facility if an improper staff-to-child ratio (inadequate) is found to exist until the problem is corrected. The failure to keep records establishing timely compliance with background screening requirements for staff of the facility, provided for in Chapter 435, Florida Statutes, was found on the April 6, 2004, inspection and found to still exist at the time of the July 23, 2004, visit. The same factor was true with regard to the requirement that new staff be enrolled in the mandatory 40 hours training program within 90 days of being hired. The failure to correct these problems concerning background screening and training and the documenting of it, between April 6, and July 23, 2004, becomes even more critical when one considers that Ms. Carter, the owner of the Petitioner, had been provided with technical assistance by Ms. Cooley designed to help her bring her facility into compliance in all respects at the April 6, 2004, inspection visits. These violations concerning the background screening, training requirements and then documentation are considered to be serious infractions by the Department in its interpretation of its rules, and in the carrying out of its policies. In summary, although one or two of the violations were not proven and at least one, such as the failure to have a screen on a door, was not established to be a serious violation, the established violations do show an overall pattern of disregard of statutes and rules adopted for the safety, health, and welfare of children entrusted to the care of such a child care facility owner and operator. That this was so, even the Petitioner was informed of and counseled regarding the violations. Some of them remained in non-compliance or at least again in non-compliance, upon the second inspection visit. It is not enough that the operator or owner of the facility provided the required documentation later after its absence is discovered or that she corrected the training, background screening, and other violations after they were discovered. The statutes and rules which apply require that such operations be done correctly at all times, and that performance be timely documented at all times. The keeping of documentation in the facility's records concerning the violative items referenced above is not required for mere hollow bureaucratic convenience, but rather, because the Department has a very high standard of public trust in ensuring that children in such facilities are maintained in a safe fashion. It must have available, for ready inspection, at all reasonable times, the documents which support that the duties imposed by the various relevant statutes and rules are being properly carried out, so that it can know, before severe harm occurs to a child or children, that they might be at risk. These established violations contribute to the overall pattern, shown by the Department, of an habitual disregard of the statutes and rules adopted and enforced for purposes of the safety of the children entrusted to the care of the Petitioner (or at least timely compliance). Indeed, prior to the denial of a new one-year license for Small Fries and the denial of initial licensure for the proposed Growing Tree Facility, the licensing supervisor, Ms. McKenzie, conducted a review of the licensing file of the Petitioner. Ms. McKenzie thus established in the evidence in this record, that the file reflected repeated past violations involving failing to adequately supervise children and concerning the background screening and training and timely training of employees. Upon completion of each inspection involved in this proceeding Ms. Carter, the operator, was given a copy of the report or checklist prepared by Ms. Cooley. She was given an opportunity at that point to respond to it or to write any comments thereon. On neither occasion, April 6, 2004, nor July 23, 2004, were there any written comments made by Ms. Carter that disputed the fact of the violations found by Ms. Cooley. There were some notes by way of explanation or of justification concerning the hiring of a teacher "for my toddlers" etc., but the notes or explanations provided by Ms. Carter in writing and in her testimony at hearing, do not refute the fact of the occurrence of the violations delineated in the above Findings of Fact. In summary, Ms. Carter's explanations in her testimony to justify or explain the failures or the violations found above are not credible, in terms of showing that the violations did not occur.
Recommendation That having considered the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, it is, therefore, RECOMMENDED that a final order be entered by the Department of Children and Family Services granting a provisional license to Small Fries Day Care, Inc., conditioned on the holder of that license undergoing additional training at the direction of the Department, designed to educate the operator under the license regarding the proper, safe care, and protection of children in her custody, operation of a child care facility, including the proper screening and training of staff, record keeping, and the other items of concern shown by the violations found in this case. Such provisional licensure shall be in effect for a period of one year when such training shall be completed, and shall be conditioned on monthly inspections being performed by relevant Department personnel to ensure compliance with the relevant statutes and rules. It is, further, RECOMMENDED that the application for licensure by the Growing Tree Learning Center and Nursery, Inc., be denied. DONE AND ENTERED this 12th day of September, 2005, in Tallahassee, Leon County, Florida. S COPIES FURNISHED: P. MICHAEL RUFF 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 Clerk of the Division of Administrative Hearings this 12th day of September, 2005. Gregory Venz, Agency Clerk Department of Children and Family Services Building 2, Room 204B 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Josie Tomayo, General Counsel Department of Children and Family Services Building 2, Room 204 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Robyn A. Hudson, Esquire 3900 Lake Center Drive, Suite A-2 Mount Dora, Florida 32757 T. Shane DeBoard, Esquire Department of Children and Family Services 1601 West Gulf Atlantic Highway Wildwood, Florida 34785
The Issue Whether the Petitioner's application for licensure as a Residential Foster Care Home should be granted.
Findings Of Fact Petitioner, Patricia Rovai, was first licensed by Respondent as a Developmental Services Residential Foster Care Home in 1989. Additionally, since 1975, Petitioner was and continues to be a Licensed Practical Nurse. Ms. Rovai specialized in providing foster care to children participating in the Medically Complex Children Foster Care Program. On January 18, 1996, a meeting was held between Donna Mims, head of foster care licensing for Developmental Services, and Petitioner and her husband. The meeting was held in regards to the conditional license which had been issued to Petitioner and was due to expire on January 31, 1996. During the meeting, Ms. Mims informed Petitioner that she was qualified to receive an ordinary foster care license and could receive such a license. However, Children’s Medical Services was not willing to designate, certify, or endorse Petitioner for participation in the medical foster care program. She therefore, would not be able to provide foster care to a medically complex child. At the conclusion of the meeting and in part due to the fact that Petitioner was exhausted after living through two successive hurricanes, Petitioner chose to allow her license to expire. Respondent admits that, other than the allegations set forth in its 1996 licensure denial letter, Petitioner is qualified to be licensed as a developmental services foster home. Around July 1996, Petitioner submitted an application for licensure as a developmental services foster home under Chapter 393, Florida Statutes, and Chapter 10F-6.009, Florida Administrative Code. On August 21, 1996, Respondent notified Petitioner by letter that her application had been denied. The letter denying a new license to Petitioner addresses several concerns of the Department based on Petitioner's past performance as a medical foster parent. The letter specifically referred to Petitioner's alleged problems with her foster child's school attendance, cooperation with Departmental staff or therapists assigned to her foster child, failure to utilize or inappropriate use of community resources and skilled nursing care, failure to encourage parental involvement or reunification, failure to encourage the child to achieve, and failure to share information regarding parental involvement with the Department. The letter cited Rule 10F-6.009, Florida Administrative Code, dealing with foster parent responsibility and training of the foster child. In general, foster care providers are subject to the promulgated rules applicable to foster care facilities and caregivers contained in Chapter 10F-6.009, Florida Administrative Code. These are the only rules applicable to foster care licenses for developmental services foster care or medically complex foster care. Whether a licensee provides medically complex foster care seems to depend on whether the licensee is designated, endorsed, or certified by Children's Medical Services. Children's Medical Services was part of Respondent, but is now part of a different agency. The evidence was unclear on the exact legal process for becoming a medical foster care parent. Even the various agencies involved seemed confused regarding the licensure status of a medical foster care parent. The licensure requirements set forth in Chapter 10F-6.009, Florida Administrative Code, are separate from the Statewide Operation Plan, which is not a rule. In fact, the Statewide Operation Plan specifically states at Chapter 7, page 4 that "failure to meet the requirements for Medical Foster Care does not necessarily affect their license as a 'traditional' foster parent." No administrative rules have been promulgated for the medical foster care designation. However, the effect of the medical designation upon a foster home license is to allow the foster home to become a Medicaid provider and be paid for their service from Florida's Medicaid program. The payment from Medicaid for the medical foster care designation is approximately $2,000.00 per month per child. The foster home also receives $440.00 per month per child from developmental services. The vast majority of children in the medically complex program live with their biological families. When a child needs to be placed in a medical foster home, the skills of the medical foster parent are matched to the child’s needs. The program looks at whether the medical foster parent is trained, licensed, and credentialed to meet the needs of a given child. If a medical foster care parent lacks a skill a potential placement might require, then the foster parent is given training to develop that skill. All the foster care parents assigned medically complex children have some background in the medical field. In February of 1989, at about two-years old, Adam Ingram was placed into Petitioner's care as a participant/patient in the Medical Complex Children Foster Care Program within the Developmental Services Program of Respondent. Dr. Rex Northup, the Medical Director for the Medical Foster Care Program, considered Adam Ingram to be one of the higher level of care children in the Medical Foster Care Program. Specifically, Adam Ingram was born with and continues to suffer from myotonic dystrophy. Myotonic dystrophy is a congenital disorder that affects neuromuscular formation and has an extensive impact on other bodily systems. Adam Ingram's mother, Karen Moncrief, permanently suffers from the related condition of muscular dystrophy. Adam Ingram's congenital disorder adversely affects his central nervous system functions, muscle functions, gastro- intestinal functions, cardiac functions, and respiratory functions. In short, Adam’s muscles, lungs, heart, stomach, legs, throat, bowels, and bladder, etc., do not work well. As a result of his medical condition, Adam Ingram has a respiratory insufficiency that required a tracheostomy. He is periodically ventilator-dependent when he is asleep or ill. When not ventilated, Adam’s respiratory system must be cleared of mucous through suctioning, coughing, or throat clearing. Because of his complex and often fragile medical condition, Adam Ingram receives treatment from a neurologist, ophthalmologist, otolaryngologist, pulmonologist, cardiologist, gastroenterologist, and orthopedist. He has been hospitalized on at least seven occasions between 1984 and 1995. Otherwise, Adam has frequently been below normal health. Adam Ingram has also needed and received surgical intervention relating to his trachea tube. Because of his tracheostomy, he is at a higher risk for contracting respiratory illnesses, such as colds. He has also had problems with controlling his bowels and with voiding his bladder, causing bladder distension. Adam is not potty trained and must wear diapers. Additionally, due to his medical problems, Adam Ingram has been delayed in development of speech, vocalization, and communication skills. However, he is of normal intelligence and emotion. He can to some degree operate a computer. In sum, Adam, as a medically complex patient, is one of the higher level of care children in that he requires a great deal of direct care to manage his medical problems. He is not as unstable as some of the other children in the program that require more technological assistance and medical care. These more unstable children tend to also lack mobility, activity, and awareness. Adam, on the other hand, is quite mobile, active, and aware. He requires and demands a great deal of attention, as any young child does. Adam is simply a handful to care for. As part of undertaking Adam’s care, Petitioner was specially trained to operate various ventilators required by Adam. Petitioner also served as a demonstrator for other foster parents who required training. Judith Benford was the medical foster care nurse who had substantial contact with Petitioner and who was primarily knowledgeable in the Department as to the conditions in Petitioner's home. She rated Petitioner as satisfactory in some areas and unsatisfactory in the areas noted in Respondent's letter of denial. However, Petitioner was recommended for re- licensing by Benford around October 6, 1995, after a complete evaluation of Petitioner's performance with Adam Ingram. In November of 1995, Petitioner's license was conditionally renewed. The only specific written conditions were that she recharge her fire extinguisher and renew her CPR certification. The capacity of the home was reduced to one bed. Although not listed specifically on the conditional license, other conditions on Petitioner's license, issued in November 1995, were to develop a list of people who were interested in licensure and would be willing to care for Adam, improve Adam’s school attendance, and other “concerns” expressed at Petitioner’s and Adam’s medically handicap assessment team (MHAT) staffings. It should be noted that these unspecified “conditions” or “concerns” probably were ineffective as limitations on Petitioner’s conditional license. What is relevant for this hearing is that these conditions had been ongoing issues throughout Petitioner’s time as a medical foster parent. One major concern was Petitioner's continual request for additional help or respite care from Respondent when the resources available are limited by budgetary concerns of the Department. Because funding for extra help is limited, medical foster parents are encouraged to try to provide cross-coverage for each other, in that one medical foster parent would take care of another's children to allow the other foster parent a break or respite for an evening, weekend, or whatever. This is a reciprocal arrangement between medical foster homes. However, in the absence of an available swap between foster parents for respite care, the Department has the ability and does occasionally provide extra help to the foster parent. The problem from the Department's point of view is whether Medicaid or other Departmental funds can be and are available to pay for the assignment of extra help to a foster parent. Medicaid pays for extra help only when the medical needs of the child require the extra service. Other Departmental funds, which are often not available, pay when the extra help is needed by the foster parents because they are exhausted or ill. Nursing care requested by Petitioner on some occasions was not provided. Additionally, the medical foster parent is the primary eyes and ears for the Department regarding the medical services required by any medical foster child. For that reason the communication and feedback between the licensee and the Department has to be good, trusted, and comfortable. In May 1993, Petitioner was urged to swap respite services with other medical foster parents. Petitioner was hesitant because not all medical foster parents were trained in ventilator usage and she had a low opinion of some of the care rendered by some of the medical foster parents. At the time, at least one other medical foster parent had ventilator training. However, the evidence did not show that the ventilator-trained foster parent was able to provide respite care to Petitioner when she needed it. The Department recognized the problem with the lack of ventilator training and on July 7, 1994, all medical foster parents were given training on ventilator usage. In the winter of 1994, the department was attempting to work out respite help for Petitioner. The Department provided some respite help for 12 hours per month at $7.50 per hour. For unknown reasons, the respite was not used. Petitioner was also encouraged to obtain services through developmental services. The evidence did not show what services were available, if any. In December, 1994, the Department offered to temporarily place Adam in another medical foster home so Petitioner could get some rest. Petitioner declined because of her opinion of the poor care rendered by that foster home and the fact that the preparation for moving Adam was just as taxing as his staying. On January 10, 1995, a private duty nurse was provided by the Department. Petitioner directed the nurse to take Adam outside to swing. The evidence did not show whether any medical care was rendered during this visit. In February 1995 a private duty nurse assigned to Adam found Adam in the living room watching TV with Petitioner. At the time, no medical symptoms of significance were noted by the nurse. On March 20, 1995, Petitioner reported that Adam was coughing incessantly and needed frequent suctioning every 15 minutes. Petitioner requested additional nursing help. That same day the Department’s supervising nurse visited the home for one and one-half hours. During that time, Adam’s condition was stable; he did not cough and did not need suctioning. The Department did not provide additional nursing help. Also, sometime in March 1995, a private duty nurse was utilized to cleanup Adam’s room, linens, and bed. She also emptied the suction machine and installed a new catheter. The evidence did not show whether private duty nursing care was needed. Around May, 1995, the department lost confidence in Petitioner’s ability to determine when Adam was sick. The loss in confidence was due in part to the high number of school absences, in part to the Petitioner’s frequent requests for respite help, and in part due to the department’s suspicion that Petitioner was overstating Adam’s illnesses in order to obtain more help. In May of 1995, the Respondent instituted close supervision, monitoring, and support in an effort to prevent disruption in the placement of Adam in the Petitioner's home. During this time, the Petitioner's daughter, Dana, was providing some of the extra nursing care to Adam. School attendance was basically non-existent. Petitioner increased her request for nursing services in July 1995 after becoming aware that another child who was medically more complex than Adam was receiving additional nursing services. Petitioner, correctly, felt it was her duty to seek the best care for Adam. Between July and the end of October 1995, Petitioner was averaging around 16 hours per week of private duty nursing. During that time period, Adam was experiencing chronic bronchitis and other illnesses, in part due to the fact that his trachea tube needed to be re-seated. Sixteen hours of private duty nursing care per week for a child such as Adam is unusual but not unreasonable. In August 1995, an extra private-duty nurse was provided to Petitioner. During that time, Adam put himself in his wheelchair and went outside to swing for 30 minutes. Adam then watched TV and played pretend games in the front room. The evidence did not show whether any medical care was rendered during the nurse's visit. To resolve some of the Petitioner’s problems with inadequate help, the Department in 1995 requested that Petitioner develop a “corrective action program” to maintain the placement of the child in her home. Petitioner continuously attempted to develop a respite system by involving and or recruiting other potential foster care providers into the program. However, Adam Ingram's complex medical condition and activity level limited the availability of such respite providers. Either the recruits lost interest in pursuing licensure or qualified caretakers would observe Adam and decide he was to much to deal with. As the foster care parent to Adam Ingram, Petitioner was considered to be the primary person to evaluate Adam's health to decide whether Adam was healthy enough to attend school. However, Adam's mother, Karen Moncrief, was expected to provide six to eight hours of care per week as well as provide some respite care. At some point during Adam’s placement at Petitioner’s home, Ms. Moncrief met Petitioner’s nephew. Ms. Moncrief and Petitioner’s nephew were eventually married. Karen Moncrief has always been involved in Adam’s care. However, her involvement was often sporadic due to complications from her medical condition and complications of her pregnancy. She often would not follow through on promises of caring for Adam or promises of helping Petitioner with Adam’s care. Her involvement was inconsistent. Therefore, the reports of Karen’s involvement with Adam reflected that inconsistency. The Department concluded that the problem of inconsistent reporting or refusal to share such parental information was because Petitioner was being inconsistent in her reports on parental involvement or not including such information in her reports. The Department’s conclusion was wrong and not based on the facts regarding Ms. Moncrief’s behavior. On September 29, 1995, Adam was scheduled to go on a weekend visit to the biological parent’s home. However, Petitioner refused to permit the visit because the home was in poor condition and not suitable or safe for Adam to visit. The evidence showed other parental visits were encouraged. Also, on September 29, 1995, after Adam’s mother had once again failed to keep her promise that she would help Ms. Rovai with Adam’s care, Ms. Rovai became very upset and called Respondent to come and get Adam. She was leaving. After some conversation, Petitioner calmed down and Adam was not picked up by the Department. On October 20, 1995, Petitioner submitted a letter of resignation as the foster parent of Adam. The resignation was to be effective in 30 days. Towards the end of Petitioner's licensure, on November 15, 1995, at 9:30 p.m., Petitioner called the Department’s supervising nurse and reported that Adam had labored respiration and retraction and was generally sicker than usual. The nurse advised Petitioner to take Adam to the emergency room. Petitioner reported she was too ill and exhausted to take Adam to the emergency room. Adam’s mother was called and she took Adam to the emergency room. The emergency room exam did not reveal anything unusual in Adam’s condition and Adam was well, for Adam. On November 16, 1995, Petitioner requested that the supervising nurse come to Petitioner's home to see Adam. Petitioner also indicated she was still ill and exhausted. The supervising nurse obtained Medicaid approval for 8 hours per day of extra private duty nursing care for four days based on Petitioner's exhaustion and for support of the continued placement of Adam in Petitioner’s home until he was moved to Hattie Grant’s home. Throughout 1995, the supervising nurse visited Adam on at least 8 occasions to double check his condition against any illness Petitioner had reported. Except for one visit when Adam was febrile, Adam appeared healthy enough to attend school. However, these visits were often several hours after Petitioner’s report and usually in the afternoon, enough time for fever, nausea, or congestion to reduce with medication. The Medical Director of the Medical Foster Care Program testified that Petitioner's request for nurses and or respite care were not unreasonable given that Adam was a high-level of care and medically needy person. Petitioner was simply expected by the Department to live with the lack of assistance, keep quiet about it, and not make requests for help, except when she needed help. The double-bind demands the Department was placing on Petitioner were simply unreasonable and cannot serve as a basis for denying her application for licensure. Around the end of November 1995, Hattie Grant, a medical foster care parent, agreed to take Adam Ingram into her home. The change in foster care parents was agreed to by Adam’s mother, Karen Moncrief. Ms. Moncrief agreed for reasons she described as manipulation of her by Petitioner. However, Adam along with his mother and Petitioner’s nephew continued to see Petitioner at church and visit her at her home. The medical condition of Adam improved once in Ms. Grant’s home. He did not need as much acute care. Additionally, his school attendance increased dramatically. His manners at office visits with the doctor improved. However, this improvement could not be attributed to the change in placement or to anything Petitioner did or did not do in caring for Adam. It is very likely that the improvement was due primarily to his physical maturation. It is also very likely that re-seating his tracheal tube caused Adam’s propensity to become ill to dissipate. Ms. Grant did not require the amount of additional skilled nursing help that Petitioner had. The lessening of the need for skilled nursing help may have been due, in part, to Adam’s improved health and better attendance at school, giving Ms. Grant a break from caring for Adam. Additionally, Ms. Grant expressed serious concerns about harassment and constant scrutiny by the parents of Adam. One such complaint arose when Adam’s mother, accompanied by Ms. Rovai, took Adam to the emergency room from school. The emergency room physician could not find anything wrong with Adam. Another complaint was that Adam was losing weight. Weight loss was not borne out by any medical examination. Ms. Grant felt that she could not do anything right in the opinion of Adam’s parents. Eventually, an abuse complaint was filed against Ms. Grant. The complaint was determined to be unfounded. She was concerned about her reputation, the constant scrutiny and second guessing of her care. The parents of Adam did not testify at the hearing. The testimony from Ms. Rovai and Ms. Grant was in conflict as to the legitimacy of various complaints regarding Ms. Grant’s care of Adam and who was behind those complaints. The evidence did show that some of the complaints came from Ms. Rovai. However, the evidence did not bear out the Department’s conclusion that Ms. Rovai was illegitimately interfering with Adam’s placement at Ms. Grant’s home. At the end of the school year, around June 1996, Adam was removed from Ms. Grant’s home at her request. He was taken back to Ms. Rovai’s house. The evidence that Adam’s health or behavior deteriorated during this second stay at Ms. Rovai’s home consists of doctor’s notes from one medical examination on July 15, 1996. The doctor did not testify at the hearing. Unexplained doctor’s notes related to one visit simply do not form a basis to conclude that Ms. Rovai’s care of Adam was inadequate. Adam was not a participant in the medical foster care program while at Ms. Rovai’s house. After a short period of time Adam was reunited with his mother and remains in her care to date. Since being in his mother’s care Adam has become a stronger individual. He has shown increased joint flexibility, more ability for independent movement with braces and crutches. He continues to have less need for acute care. Additionally, his school attendance has remained fairly good. Adam continues to demonstrate good manners. Again, the improvements in Adam’s condition are likely due to his continued maturation. The evidence clearly showed that Petitioner actively assisted and cooperated with Adam's physical therapist assistant and physical therapist. Apparently the Department failed to acquaint itself with the facts of Adam's case and based its allegation of failure to cooperate on very limited and uninformative notes contained in Adam's records. In July 1995 a behavior assessment by Lakeview Hospital Special Population was arranged for Adam. The first meeting with the assessor was postponed due to Adam’s ill health. Shortly after the postponement, the assessor met with Adam and viewed him at Petitioner's home. After one visit, the assessor determined that Adam did not need the help of a behavioral specialist. The assessor suggested some behavior modification techniques which Petitioner was already utilizing. Clearly, the evidence showed that Petitioner cooperated with the behavioral specialist assigned to review Adam Ingram's behavior. The evidence also showed that the Department again did not acquaint itself with the facts of Adam's case and based its conclusions about Adam's behavior on the Department's limited contacts with Adam and very limited and uninformative notes in Adam's record. Adam’s attendance at school while in the care of Petitioner was less than 50 percent. In the semester of school beginning January 1994, Adam was seen only 10 times by the occupational therapist at school. The other major complaint regarding Adam’s care by Petitioner centered on Adam’s poor school attendance. According to competent substantial evidence provided by Adam Ingram's teacher, Vernell R. Martin, Petitioner actively sought to encourage Adam in educational activities at the Oriole Beach Elementary School. There were no staff nurses working at Oriole Beach Elementary School. The school Adam attended while living at Ms. Grant's home provided more for children with special needs. It had staff nurses and could render better medical care to Adam. He therefore could attend more often when he was not feeling well. While at school, Adam would need some suctioning through the day. He also receives gastronomy feedings and various medicines through the day. Since Adam is not potty trained he requires his diapers to be changed when needed. He would receive general physical stimulation to develop his muscles and help with wearing ankle foot orthopedic supports. Physical therapy, occupational therapy and speech therapy were provided at school. However, the evidence also demonstrated that these various therapies were also provided at Petitioner’s home either by Petitioner or through other professionals. Home physical therapy would not continue once Adam reached a plateau or refused to participate. On the other hand, therapies received at school would continue daily or weekly as established in Adam’s Independent Educational Plan. Adam was seldom sent home for medical problems at school. However, given his poor attendance, it is speculation how much he would have been sent home had he been at school. On many occasions, Adam's complex medical condition prevented him from safely attending school. At the beginning of the 1994 school year, Petitioner, at the Department’s suggestion, was going to arrange for Adam to ride the school bus to school and be picked up from school by Petitioner. Petitioner scrapped the school bus ride when she discovered that no air-conditioned bus was available to transport Adam. Adam had apparently become overheated and ill when he rode the first time on a non-air conditioned bus. On the other hand, while at Ms. Grant’s home, Adam was able to ride in a non-air conditioned bus over about a six month period, some of which was in hot weather. Still, Petitioner was capable of transporting Adam to school in her air-conditioned car. The evidence did not demonstrate that Adam was harmed by his poor school attendance. From year to year, while in Petitioner's care, Adam achieved the educational, therapeutic, occupational, and social goals established in his Individual Educational Plan. On whole, Adam is a well-adjusted child. Ms. Rovai had legitimate reasons for his absences. Given this evidence, Adam's school attendance cannot form a basis for denying Petitioner's license application. Finally, another issue raised for the first time at the hearing was whether Petitioner was suctioning too deep or too often. One bronchoscope indicated that the catheter used for suctioning had touched the trachea by being inserted too far into the tracheostomy. The evidence did not show that Respondent had given corrective instructions to Petitioner on either of these two points. Moreover, suctioning too deep is a common problem and does not reflect poor care or a failure to follow Departmental instructions. Finally, the type of catheter used by Petitioner to suction Adam had a stop on it to prevent too deep insertion of the catheter into the trachea. In short, neither of these late raised issues were established by the evidence and neither of these issues can form a basis for disqualifying Petitioner from receiving a foster home license.
Recommendation Based upon the findings of fact and conclusions of law, it is RECOMMENDED: That the application of Petitioner be GRANTED. DONE AND ENTERED this 5th day of December, 1997, in Tallahassee, Leon County, Florida. DIANE CLEAVINGER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 5th day of December, 1997. COPIES FURNISHED: Matthew D. Bordelon, Esquire Bordelon and Bordelon, P.A. 2717 Gulf Breeze Parkway Gulf Breeze, Florida 32561 Rodney M. Johnson, Esquire Department of Health 1295 West Fairfield Drive Pensacola, Florida 32501 Katie George, Esquire Department of Children and Family Services Suite 601 160 Governmental Services Pensacola, Florida 32501 Gregory D. Venz, Agency Clerk Department of Children and Family Services Building 2, Room 204 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 Richard A. Doran, Esquire Department of Children and Family Services Building 2, Room 204 1317 Winewood Boulevard Tallahassee, Florida 32399-0700
The Issue Whether the after school child care program operated by the YMCA on the campus of Keeth Elementary School under a contract approved by the Seminole County School District, exclusively for children ages 5 Kindergarten and older, is required to be licensed as a child care facility, pursuant to the provisions of Sections 402.301-402.319, FLORIDA STATUTES(1988 SUPP.).
Findings Of Fact Respondent, Department of Health and Rehabilitative Services, is charged with the responsibility to enforce the statewide minimum standards for the care and protection of children in child care facilities, as set forth in Secticns 402.301-402.319, Florida Statutes (1987). Petitioner, YMCA of Central Florida, Inc. (YMCA), is a not-for-profit corporation licensed in Florida. The YMCA is a local membership organization affiliated with the national YMCA whose primary purpose is to provide activities that contribute to the development of good character and good sportsmanship of children and other family members in Seminole County. For several years, the YMCA has operated an after school child-care program for children five years old and older on the campus of Keeth Elementary School. The program is staffed by a YMCA counselor who participates in the program as the child-care counselor. The program was licensed as a child day care facility under the name YMCA/Keeth School Age Child Care by HRS, License Number 987-1. Their current license to operate this facility expired in 1988. Keeth Elementary School is a public elementary school owned and operated by the Seminole County School District. The YMCA operates the program under an oral year-to-year agreement with the School Board of the Seminole County School District. On August 22, 1988, an inspection of the facility (the buildings and grounds of the Keeth Elementary School) by an HRS inspector revealed that the facility failed to substantially comply with the requirements of Chapter 10M-12, Florida Administrative Code, which would be sufficient to sustain the denial of the license renewal. By letter dated September 12, 1988, Respondent advised the Petitioner that their application for relicensure was denied. Petitioner was directed to cease operation within 15 days of receipt of this letter unless the cited deficiencies were corrected and Petitioner re-applied for a license.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Petitioner's after school child-care program continue to operate without the requirement of a license from HRS, so long as they continue under contract with the School Board with the same terms and conditions as presently exist. DONE AND ENTERED this 18th day of May, 1989, in Tallahassee, Leon County, Florida. DANIEL M. KILBRIDE 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 18th day of May, 1989. APPENDIX The following constitutes my specific rulings, in accordance with section 120.59, Florida Statutes, on findings of fact submitted by the Petitioner. Petitioner's Proposed Recommended Order does not contain specific findings of fact but consists primarily of legal argument which has been adopted in substance. COPIES FURNISHED: William E. Ruffier, Esquire Sanders, McEwan, Mims and Martinez, P.A. Attorneys at Law 108 East Central Boulevard Post Office Box 753 Orlando, Florida 32802-0753 James A Sawyer, Jr., Esquire Department of Health and Rehabilitative Services District 7 Legal Office 400 West Robinson, Suite 911 Orlando, Florida 32801 Sam Power Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Gregory L. Coler Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 John Miller General Counsel Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 =================================================================
The Issue The issue in this case is whether Respondent's license to operate a child care facility should be revoked for alleged violations of Chapter 402, Florida Statutes (2002 through 2005),1 and Florida Administrative Code Chapter 65C-22 as set forth in the Administrative Complaint.
Findings Of Fact The Department is the state agency responsible for licensing and disciplining child care facilities. In carrying out its responsibilities, the Department conducts routine inspections of child care facilities, as well as inspections based on any complaints concerning a child care facility. Youth in Action is a child care facility located in Panama City, Florida. On February 5, 2003, Dia Green, who at that time was employed by the Department, conducted an inspection of Youth in Action based on a complaint. Ms. Green observed children in the two, three, and four-year-old age groups going to the restroom without direct supervision. A child at Youth in Action scratched his nose while going down the slide. Staff at Youth in Action did not document the incident on the day that it occurred. The facility did not have a staff person trained in first aid present during all operating hours. On March 10, 2003, Ms. Green made a routine inspection of Youth in Action. She found that Youth in Action had no documentation to show that monthly fire drills had been completed. On January 6, 2004, Ms. Green conducted a routine inspection of Youth in Action. Again, she found that Youth in Action lacked documentation to show that monthly fire drills had been completed. There were broken furniture and toys that needed to be removed from the facility. The immunization records for some of the children being cared for at the facility were incomplete. By letter dated January 22, 2004, the Department advised the owner/operator of Youth in Action, Sherlene McClary, that Youth in Action's license was being changed to provisional for failure to have a director meeting the credentialing requirements of Subsection 402.305(2)(f), Florida Statutes (2003). The provisional license was effective January 2, 2004, through June 1, 2004. On April 28, 2004, Lee Anne Case, a child licensing counselor employed by the Department, inspected Youth in Action. She found the staff-to-child ratio was not sufficient for different age groups. There was one staff person for seven children in the 0 to 12-month-old group. There was one staff person for seven children in the one-year-old group. There was one staff person for nine children in another one-year-old group. There was one staff person for 16 children in the two- year-old group. Ms. Case observed that, when the children were coming in from the playground, Youth in Action staff were leaving a child on the playground. The cook for the facility noticed the child and brought it to the attention of staff. Ms. Case found that areas in the facility were not in good repair. The carpet was dirty, had holes, and was fraying on the edges, creating tripping hazards. The thermostat was hanging by wires from the wall, and, when the thermostat was touched, the lights would flicker. There was a five-inch hole in the wall leading directly to the outside. The floor mats on which the children napped were torn. The bathrooms lacked supplies such as paper towels, soap, and toilet paper. During the April 28, 2004, inspection, Ms. Case found that diaper changing in the infant room was being done on a surface that was not impermeable. The container for soiled diapers was not covered and was accessible to children. Ms. Case also observed indoor and outdoor equipment which was not safe. Inside the facility, a changing table was broken, the power cord to a portable radio was accessible to children, and the air conditioning unit was not properly mounted, leaving sharp corners exposed. On the playground, there were exposed roots, which created a tripping hazard; broken toys were left in the area; and a picnic table was pushed up to the fence negating the required four-foot height requirement for the fence. Additionally, during the April 28, 2004, inspection, Ms. Case found that there was a lack of documentation to show that some of the staff members had completed the required 40-Hour Introductory Child Care Training. Personnel records for some of the staff were missing. The Department gave Youth in Action until May 5, 2004, to correct the deficiencies in the torn and dirty carpet, the thermostat, the hole in the wall, the debris and broken toys on the playground, the picnic table pushed against the fence, the air conditioning unit, the power cord to the radio, the personnel records, and the training requirements. On May 7, 2004, Youth in Action was re-inspected to determine if the deficiencies had been corrected. The carpet had not been repaired or cleaned. The hole in the wall had been filled loosely with paper towels. The playground still contained debris and leaves were piled next to the fence, eliminating the four-foot fence requirement. Sleeping mats were torn. The diaper changing in the infant room was being done on an impermeable surface. The deficiencies related to the changing table and the air conditioning unit had not been corrected. The deficiencies in the training documentation and the personnel records also remained uncorrected. Youth in Action was given until May 10, 2004, to make the necessary corrections. It was also noted during the May 7, 2004, inspection that the facility had a staff-to-children ratio deficiency. One staff person was observed with seven infants. One staff person was with seven children in the room for one-year-old children. In a second room with one and two-year-old children, there was one staff person for seven children. In one group of three and four-year-old children there were 17 children and one staff person. On May 13, 2004, another inspection was made of Youth in Action to determine if the deficiencies found on May 5, 2004, had been corrected. On May 13, 2004, sleeping mats in the one- year-old room were torn and needed to be replaced; the diaper changing pad was still torn; and the sharp corners of the air conditioner had not been eliminated. On August 11, 2004, Jason Kesterman, an employee of the Department, inspected Youth in Action. He found that the facility's plan of scheduled events was not posted in a place accessible to parents. Paper towels or air dryers were not available and within reach of the children in the bathroom next to the one-year-olds' room. Some of the staff of the facility had not completed the 40-hour mandatory training course within the allotted time frame, and some lacked the ten-hour training course. One of the staff did not have documentation of the initiation of training within the allotted time. The first aid kit for the facility lacked moist wipes and rubber gloves. On November 12, 2004, Ms. Case inspected Youth in Action. Numerous deficiencies were noted. There was an insufficient ratio of staff to children. There was one staff person for 16 children when there should have been two staff members. During nap time, there was insufficient staff accessible for the one-year-olds. Ms. Case observed a heavy- duty bathroom cleaner that was accessible to children. The floor mats for napping were torn. Staff did not clean and disinfect the diaper changing surface after each use. The pad on the diaper changing table was torn. The ground cover within the fall zone of the swings was not maintained. A rocking fish toy had sharp and jagged handles. One of the staff did not have documentation of one of the required ten-hour training courses. The director of the facility was not onsite a majority of the hours of operation. The first aid kit for the facility did not contain a thermometer, moistened wipes, and a guide on first aid. The facility did not have a staff member trained in current infant and child cardiopulmonary resuscitation present during all hours of operation. Diaper ointment was dispensed without written authorization from the parent. Some of the children did not have documentation of a student health examination. Personnel records for some of the staff were incomplete. On December 2, 2004, the Department issued an Administrative Complaint assessing a $500 fine against Youth in Action for failure to supervise a 19-month-old child who walked away from the facility. Youth in Action paid the $500 fine. On January 27, 2005, the Department notified Youth in Action that its license was being placed on provisional status effective December 1, 2004, for repeated violations of Florida Administrative Code Chapter 65C-22. The provisional license was to remain in effect until June 1, 2005. The Department advised the facility that inspections in addition to the routine inspections would be made of the facility to monitor the facility's compliance with Florida Statutes and the Florida Administrative Code. The facility was notified that "failure to immediately correct documented violations during your facility's inspections will leave the [D]epartment no alternative but to seek revocation of your license." Sherrie Gainer, an employee of the Department, inspected Youth in Action on January 19, 2005. She found cleaning supplies that were accessible to children as well as knives in a lower kitchen cabinet that was accessible to children. This deficiency was corrected at the time of the inspection. Ms. Gainer found that the director's file was not located at the facility. Some of the children's files were incomplete. Some of the personnel files for staff were incomplete. Youth in Action was given until January 31, 2005, to correct the deficiencies. On March 2, 2005, Ms. Gainer inspected Youth in Action. She found that there was a deficiency in the staff-to- child ratio. One group of children had seven three and four- year-old children and one one-year-old child. Such a mix required the supervision of two staff and only one staff was supervising. Ms. Gainer inspected Youth in Action on March 22, 2005. She found that the facility did not have complete records for some of the child care personnel. In response to a complaint, Ms. Gainer inspected Youth in Action on May 4, 2005. She found a staff-to-child ratio deficiency. There should have been two staff persons for eight children, but there was only one staff person supervising the children. She observed that there was an uncovered vent in the ceiling of the bathroom that allowed rain to enter the facility and that the toilet seats were loose. Ms. Gainer inspected Youth in Action on October 11, 2005. She found that the facility did not have documentation to show completion of a five-hour literacy training course by June 30, 2005, for staff hired on or before December 31, 2004. Additionally, records or copies of records were not being maintained at the facility for review by the Department. Files were being maintained across the street from the facility. On November 14, 2005, Ms. Gainer again inspected Youth in Action. A bathroom light did not work. Cleaning supplies in the kitchen were accessible to the children. Bedding did not fit against the crib, leaving a big gap. The bedding was dirty and brown in color. Several sheets found on the infant beds were badly stained. On November 29, 2005, Ms. Gainer re-inspected Youth in Action. Cleaning supplies in the kitchen were accessible to the children. A radio cord was hanging within reach of the children in the toddlers' room. Ms. Gainer inspected Youth in Action on December 20, 2005. There was a deficiency in the staff-to-children ratio. Two staff were needed for five children in the infant group, and only one staff person was supervising the five children. Ms. Gainer observed that the white lattice by the walkway was coming undone. On February 23, 2006, Ms. Gainer inspected Youth in Action and noted a staff-to-children ratio deficiency. There was one staff person supervising seven children, consisting of four one-year-olds and three two-year-olds. Two persons were required to supervise that particular age group. Based on a complaint, Ms Gainer made an inspection of Youth in Action on March 1, 2006, and she observed another staff-to-children ratio violation. One staff person was present with 18 children, three of whom were one-year-old and 15 of whom were two and three-year-old. Based on another complaint, Ms. Gainer made an inspection of Youth in Action on March 13, 2006. She found there were 13 children in one room watching television with one staff person. There were seven one-year-old children in with a group of two, three, and four-year-old children. On April 12, 2006, Ms. Gainer was advised by an employee of Youth in Action that the director of the facility was employed full time by the local school district and was not at the facility a majority of the operating hours. On April 13, 2006, Ms. Gainer inspected Youth in Action and found that the emergency plan was not posted. She observed a volunteer left alone supervising three one-year-old children in a classroom.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered finding that Youth in Action violated Section 402.305, Florida Statutes, and Florida Administrative Code Rules 65C-20.001, 65C-20.002, 65C-20.003, 65C-20.004, and 65C-20.006, and revoking it license to operate a child care facility. DONE AND ENTERED this 29th day of January, 2007, in Tallahassee, Leon County, Florida. S SUSAN B. HARRELL 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 29th day of January, 2007.
