17-001589 Agency For Health Care Administration vs. Rsc Hidden Oaks Of Fort Myers, D/B/A Hidden Oaks Of Fort Myers Status: Closed Recommended Order on Tuesday, September 26, 2017.

Summary: Consolidated cases: AHCA substantiated the allegations in the 8-count AC. An admin. fine of $4500 and survey fees of $1500 are appropriate. The Notice of Intent to Deny the ALF license should be upheld based on the repeated deficiencies proven at hearing.

S TATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Petitioner,

vs. Case No. 17 - 1589

RSC HIDDEN OAKS OF FORT MYERS,

d/b/a HIDDEN OAKS OF FORT MYERS,

Respondent.

_______________________________/

RSC HIDDEN OAKS OF FOR T MYERS,

d/b/a HIDDEN OAKS OF FORT MYERS,

Petitioner,

vs. Case No. 17 - 1591

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Respondent.

_______________________________/

RECOMMENDED ORDER

Pursuant to notice, a final hearing was held in this matter

before Lynne A. Quimby - Pennock, Administrative Law Judge with the

Division of Administrative Hearings (DOAH), on June 19 and 20,

2017, in Fort Myers, Florida.

APPEARANCES

For the Agency for Health Care Administration :

Tho mas J. Walsh, II, Esquire

Agency for Health Care Administration

Suite 330

525 Mirror Lake Drive North

St. Petersburg, Florida 33701

For RSC Hidden Oaks of Fort Myers, d/b/a Hidden Oaks of

Fort Myers :

Shaddrick Haston, Esquire

Suite 103

1618 Mahan Cent er Boulevard

Tallahassee, Florida 32308

STATEMENT OF THE ISSUE S

The issues in these consolidated cases are whether the

Agency for Health Care Administration (AHCA or Agency) should

discipline (including the imposition of administrative fines and

survey f ees) RSC Hidden Oaks Fort Myers LLC, d/b/a Hidden Oaks of

Fort Myers (Hidden Oaks) , for the statutory and rule violations

alleged in the December 29, 2016 , Administrative Complaint ; and

whether AHCA should renew the assisted living facility (ALF)

license h eld by Hidden Oaks.

PRELIMINARY STATEMENT

On December 29, 2016, AHCA issued an eight - count

Administrative Complaint (AC) seeking to impose an administrative

fine of $4,500.00 and survey fees of $1,500.00 on Hidden Oaks .

AHCA sought to impose the administr ative fine and survey fees

pursuant to sections 429.19(2)(b), (2) (c), (7), and (10), Florida

Statutes (2016 ). Hidden Oaks timely filed a P etition for F ormal

Hearing (P etition) contesting the factual basis in the AC. On

Mar ch 16, 2017, AHCA referred the P etition to DOAH, where it was

designated DOAH Case No. 17 - 1589.

On January 17, 2017, AHCA issued a ÐNotice of Intent to Deny

for the Assisted Living Facility Renewal ApplicationÑ (NOID) to

Hidden Oaks. The NOID alleged Hidden Oaks failed to meet the

minim um licensure requirements pursuant to: section 408, p art II,

Florida Statutes; section 429, p art III, Florida Statutes (2016) ;

and Florida Administrative Code Rule 59A - 35. Further, the NOID

advised that pursuant to sections Ð 408.815(1)(c), 429.14(h), Ñ an d

rule 59A - 35.060(6)(c), the renewal application was denied. Hidden

Oaks timely requested a hearing, and on March 16, 2017, the matter

was referred to DOAH, where it was designated DOAH Case No. 17 -

1591.

The parties filed a ÐJoint Response to Initial Orde r and

Joint Motion to ConsolidateÑ on March 24, 2017. On March 27,

2017, an Order was issued consolidating the two cases. A Joint

Motion for Continuance was filed on April 27, 2017 , which was

denied. Thereafter, AHCA filed a Motion to Relinquish

Jurisdi ction and Hidden Oaks timely filed its response. A case

status telephonic hearing was held on May 12, 2017. As a result

of the telephonic hearing, an Order Canceling the May 17 and 18,

2017 , hearing was issued. On May 16, 2017 , an Order Re scheduling

Hea ring was issued.

On May 26, 2017, AHCA filed a Motion for Sanctions based on

Hidden Oaks Ó failure to file responses to discovery requests. A

telephonic motion hearing was held on June 5, 2017, and a separate

Order Imposing Sanctions Against Hidden Oaks wa s issued on June 6,

2017. 1/

At hearing, AHCA called the following witnesses to testify:

Jonathon Kummer, environmental specialist II (ES) for the Florida

Department of Health (DOH); AHCA employees: Jon Seehawer, an AHCA

field office manager; Nancy Furdell , Claire McGillivray, and

Daniel Turbyfill, AHCA s urveyors; Laura Werts, a n AHCA health

facility evaluator supervisor; Jon Alter, a n AHCA health facility

evaluator; and Robin Heimann, Wendy Snyder, Paul Asdale, and Lisa

Humphrie s, AHCA r egi stered n urse (RN ) specialists. Hidden Oaks

called the following witnesses to testify on its behalf: Rob

Icard, Hidden OaksÓ current facility administrator ; and Argen is

Gomez, Hidden OaksÓ director of maintenance.

AHCAÓs Exhibits A thro ugh V 2/ were received in evidence.

Hidden Oaks Exh ibits A through I and K ( pages 1, 2, 4, 5, 7, 8,

and 37 through 40) were received in evidence . 3/

At the conclusion of the first day of hearing, Hidden OaksÓ

counsel made an ore tenus motion asking th e undersigned to make an

onsite visit. T he undersigned took the motion under advisement,

and at the start of the second hearing day, the ore tenus motion

was denied.

Hidden Oaks subpoenaed its former executive director,

Danielle Inman , to testify at the hearing. Ms. Inman f ailed to

appear and H idden OaksÓ counsel motioned for the hearing record to

remain open to allow Ms. InmanÓs deposition to be taken. Counsel

for AHCA did not object, and Hidden Oaks was granted 30 days

(until July 20, 2017) in which to depose Ms. Inman.

On July 19, 2017, Hidd en Oaks filed a motion seeking to close

the hearing record and to establish an alternate date for the

post - hearing proposed orders to be filed. The Inman deposition

transcript was not filed , and by an Order dated July 20, 2017, the

hearing record was clos ed. The alternate date for submission of

post - hearing orders was not set because the hearing transcript had

not been filed and no submission date had been set .

The two - volume hearing Transcript was filed on July 31, 2017.

On August 1, 2017, the parties w ere advised, via a Notice of

Filing, that any proposed orders were to be filed on or before the

close of business on August 21, 2017. Each party timely filed

their proposed order, and each has been reviewed in the

preparation of this Recommended Order. 4 /

Unless otherwise stated, all statutory references are to the

codification of the Florida Statutes in effect at the time of the

alleged violations. All rule references are to the Florida

Administrative Code rules in effect at the time of the alleged

violat ions.

Prior to the hearing, the parties submitted a pre - hearing

stipulation. Relevant factual stipulations are included in the

Findings of Fact . 5 /

FINDING S OF FACT

1. Hidden Oaks holds an ALF license issued by AHCA ,

number 5531. Hidden Oaks is located at 3625 Hidden Tree Lane,

Fort Myers, Flo rida, and has a capacity of 110 beds. At all times

material hereto, Hidden Oaks was required to comply with all

applicable rules and statute s for its continued operation.

2. AHCA is the state agency charged with t he licensure and

regulatory oversight of ALFs and enforcement of applicable state

statutes and rules governing ALFs pursuant to chapters 429,

part I, and 408, p art II, and Florida Administrative Code

Chapters 59A - 5 and 59A - 35.

3. AHCA is responsible for conducting ALF surveys annually

to determine compliance with Florida Statutes and rules. Surveys

may be classified as annual inspections or complaint

investigations. Section 408.813(2) provides that AHCA must

classify deficiencies (violations) according to the nature and

scope of the deficiency when the criteria for the facility

operations are not met. A Class II violation is defined as:

[ T ] hose conditions or occurrences related to

the operation and maintenance of a provider or

to the care of clients wh ich the agency

determines directly threaten the physical or

emotional health, safety, or security of the

clients, other than class I violations. The

agency shall impose an administrative fine as

provided by law for a cited class II

violation. A fine shal l be levied

notwithstanding the correction of the

violation.

A Class III violation is defined as:

[ T ] hose conditions or occurrences related to

the operation and maintenance of a provider or

to the care of clients which the agency

determines indirectly or potentially threaten

the physical or emotional health, safety, or

security of clients, other than class I or

class II violations. The agency shall impose

an administrative fine as provided in this

section for a cited class III violation. A

citation for a class III violation must

specify the time within which the violation is

required to be corrected. If a class III

violation is corrected within the time

specified, a fine may not be imposed.

§ 408.813(2)(b) and (2) (c).

4 . AHCA takes specific steps in s urveying facilities and

making decisions as to appropriate actions to be undertaken. Once

AHCA writes a citation, enumerating the violations, the facility

is given 30 days to make the corrections or repairs. After the

30 - day period ends, AHCA revisits t he facility to check on the

violations that prompted the citation(s). In typical cases, the

cited facility has responded to the citation(s), and the first

revisit finds the violations corrected; that ends the process. In

the event the original violations have not been corrected and/or

additional violations are discovered, another revisit may occur.

5. In addition to the AHCA surveys, DOH is charged with

conducting environmental health inspections to ensure the health

quality of ALFs. These health inspec tions are conducted on an

annual basis. Should a health inspection be deemed

unsatisfactory , DOH provides a date certain for the facility to be

re - inspected. High - risk violations could include trip hazards;

abrasion hazards; sanitation conditions related to human or animal

waste products (urine or feces); cleanliness of bed linens

(including mattresses and box springs); and sanitary procedures of

the housekeeping staff. Low - risk violations could include

furniture that no longer has a cleanable surface or insufficient

room lighting without any other hazard present.

6. On October 29, 2015, Surveyor Furdell conducted an

unannounced complaint survey at Hidden Oaks. During this survey,

the facility was found to have the following deficiencies: dirty,

staine d or frayed carpets; dirty or stained floors in rooms and

bathrooms; floor linoleum peeling up near toilets ; cracks in other

linoleum; holes or nails in various walls; rusted out and

inoperable stoves; dirty, missing or broken dresser drawers; dirty

window s or curtains; closet doors missing in some rooms; and a

lack of toilet paper in most bathrooms in the memory care unit. A

citation was issued based on these Class III deficiencies.

7. On November 18, 2015, ES Kummer conducted an inspection

of Hidden Oak s. ES Kummer observed the following violations:

significant maintenance deficiencies; a lack of vermin control;

soiled bedding, towels and personal items; and loose medication or

toxic substances issues. Based on these observations, the

inspection was m arked unsatisfactory. A notice of violation was

issued to Hidden Oaks and signed for by Argenis Gomez. Hidden

Oaks was advised that a revisit would be on December 8, 2015.

8. On December 8, 2015, ES Kummer conducted a re - inspection

of Hidden Oaks. ES K ummer observed the following cleanliness

issues: dirty sheets and linens; dirty walls; dirty floors;

soiled mattresses; the strong smell of urine; and feces on

mattresses. He also saw loose medications and other possible trip

hazards. Based on the numbe r of violations observed, Hidden Oaks

was advised the inspection was unsatisfactory, and if the

violations were not corrected by a revisit date of December 22,

2015, the matter would be referred to the legal department.

9. On December 9, 2015, an unannoun ced follow - up survey was

conducted at Hidden Oaks by Agency S urveyor McGillivray. During

this survey, the facility was found to have the following

deficiencies in the memory care unit: a strong urine odor 6 / ;

dried feces on a residentÓs shoes; missing win dow blind wands or

no curtains 7 / ; ceiling lights were not working; ceiling vents were

dirty; ceiling tiles were stained; a shower wall was caving in;

and some floors and walls were in disrepair. Additionally , she

observed: dirty mattresses; torn box - spri ngs; missing dresser

drawer handles; stained carpets and floors; dust on the walls; and

a loose shower grab bar. A citation was issued based on these

Class III deficiencies.

10. As part of her duties, A gency S urve yor McGillivray also

observed other regul atory violations involving medication issues

for Hidden Oaks residents.

• One resident, whose health assessment documented a need

for as sistance with her medication, actual ly had the

medication sitting next to her beds ide.

• Residents were refusing to take the ir medication, however

there was no documentation that their health care

professionals were notified of the refusal, or that the

refusal was documented in the residentsÓ medica tion

observation record (MOR).

• Another resident was not receiving medication bec ause

there was none in the medication cart. There was no

indication that the health care professional had been

contacted to obtain a refill.

A citation was issued based on these multiple Class III

deficiencies.

11. On December 22, 2015, ES Kummer conduct ed a re -

inspection of Hidden Oaks. ES Kummer again observed serious

violations regarding cleanliness and maintenance issues.

ES Kummer observed fecal matter in the same area as it was seen

in his prior inspections. Based on the number of violations

obs erved, Hidden Oaks was advised the inspection was

unsatisfactory . Hidden Oaks was advised that a return inspection

would be on January 12, 2016.

12. On January 12, 2016, ES Kummer conducted a re -

inspection of Hidden Oaks. ES Kummer again observed cleanl iness

issues: feces present on residentÓs shoes and wall; dirty

mattress covers, bed linens, tub, and sink; and ants in the

kitchenette . He also found maintenance issues : floors peeling

near toilets (moisture present); loose toilets; broken windows;

and insufficient lighting. For some reason, ES Kummer checked

ÐSatisfactory,Ñ yet provided four pages of issues that needed to

be corrected.

13. On Februar y 9, 2016, an unannounced follow - up survey

was conducted at Hidden Oaks by RN Heimann. This survey wa s

completed to determine whether the issues cited during AHCAÓs

December 9, 2015 , survey had been corrected. The following

deficiencies were observed: laminate flooring continued to be in

disrepai r (peeling up and/ or uneven in places); walls were in

disr epair 8 / ; carpets remained stained; ceiling tiles were stained;

and a strong urine odor was present in the memory care unit. A

citation was issued based on these Class III deficiencies.

14. On March 28, 2016, an unannounced follow - up survey was

conducted at Hidden Oaks by RN Snyder. This survey was completed

to determine whether the issues cited during the February 9,

2016 , survey had been corrected. The following deficiencies

remained outstanding: the flooring continued to be in disrepair;

the walls an d ceiling continued to be in disrepair; and there was

a smell of urine. A citation was issued based on these Class III

deficiencies.

15. Between May 23 and 26, 2016, an unannounced follow - up

survey was conducted at Hidden Oaks by supervisor Werts. This

survey was completed in conjunction with a complaint survey and

in collaboration with the county health department to determine

whether the issues cited during the previous three revisits had

been corrected. The following violations were observed: carpet s

remained in disrepair; holes still found in the walls; and a

sprinkler head and other electrical outlets were not flush with

the walls. She also observed: feces on floors, shoes, clothing

or smeared on walls; ceiling tiles dropped in at least one room

because of a water leak; peeling wallpaper; and urine stains on

the floor. In one room, dead bed bugs were seen on the mattress

and the floor was damaged. When the mattress was raised, a

container with dried urine was found. In another room, the

carpet was damaged such that it presented a tripping hazard to

all who entered. Supervisor Werts photographed the bedbugs,

floor damage, carpet damage, sprinkler head, and ceiling tile

damage.

16. Supervis or Werts observed a Hidden Oaks employee with a

mop and liquid solution, cleaning up urine or feces in one room.

That same employee then went to the next room and, without

changing or cleaning the mop and liquid solution, used the same

to mop the next area.

17. Supervisor Werts, who has over 30 years of exper ience,

issued a citation regarding resid entÓs rights, based on the long -

term deficiencies noted above. The citation was for failing to

have a safe and clean living environment .

18. ES Kummer conducted an annual inspect ion of Hidden Oaks

from May 23 throu gh May 26, 2016. ES Kummer observed: dirty

beds and linens; rust - c olored water; feces (including a soiled

adult diaper in the bushes in the facilityÓs garden area) ; loose

medications; full sharps container; trip hazards; cracked

flooring; and dogs in the facility without proper rabies

vaccinations or documentation of same. ES Kummer saw staff using

the same bucket of water to clean urine and feces off the floor

in one room, and then go to another room and use the same bucket

to clean that floor. The pho tographs attached to AHCAÓs

Exhibit M provided an appalling picture of the living conditions

at Hidden Oaks. Based on the number of violations observed,

Hidden Oaks was advised the inspect ion was unsatisfactory, and

was advised that a return inspection w ould be on July 5, 2016.

19. On July 5, 2016, ES Kummer conducted a re - inspection

of Hidden Oaks. He returned on July 6, 2016 , to complete the

re - inspection. During the two - day inspection ES Kummer again

observed: trips hazards; abrasion hazards; dir ty floors;

loose grab bars; and cleanliness issues throughout the areas.

ES Kummer also observed Hidden Oaks staff using a bucket of water

and mop to clean up urine in one room and then using the same

bucket of water and mop to clean in another area. T he

photographs attached to AHCAÓs Exhibit N provided a grim picture

of the living conditions at Hidden Oaks. Based on the number of

violations observed, Hidden Oaks was advised the inspec tion was

unsatisfactory, and was advised that a return inspection wo uld be

on July 26, 2016.

20. On July 26, 2016, ES Kummer conducted a re - inspection

of Hidden Oaks. He also returned on July 27, 2016 , to complete

the re - inspection. He did not observe any appreciable

improvement in the conditions at Hidden Oaks. His ob servations

included: dirty floors; floors in disrepair; furniture in

disrepair; wet underwear hanging from a door handle; and feces on

different surfaces. ES Kummer also smelled urine throughout the

facility. The photographs attached to AHCAÓs Exhibit O provided

an unattractive picture of the living conditions at Hidden Oaks.

Based on the number of violations observed, Hidden Oaks was

advised the inspection was unsatisfactory. Hidden Oaks was

advised that a return inspection would be on August 22, 2016 .

21. On July 27, 2016, an unannounced follow - up survey was

conducted at Hidden Oaks by RN Asdale. This s urvey was conducted

as a follow - up to prior surveys combined with three complaints.

The following deficiencies were observed: rusty facets, sinks o r

drains; dirty floors; dirty carpets; soiled, ripped, stained or

missing mattress covers; stained mattresses; pinwheel worms in

common areas and rooms; doors in disrepair; and caulking in

disrepair or missing altogether. These violations are classified

a s Class III.

22. During this survey, RN Asdale found two residents who

were not receiving their medication s according to their health

assessment forms. One resident had returned to Hidden Oaks with

a prescription for a pain killer. His prescription ran out and

for four days he did not receive the prescribed pain medication.

The other resident did not receive her seizure medication for

three or four days. These violations are classified as Class II.

23. RN Humphries was also at Hidden Oaks during the

July 27, 2016 , survey. The following violations were observed:

numerous pinwheel worms on the carpets, in sink drains, in shower

drains, and in the ceiling fixtures. These violations were

Class III.

24. RN Humphries also conducted medications complian ce

reviews. She determined that one resident needed medication

which was not being administered . Regarding a different

resident, RN Humphries could not determine from the MOR whether

the resident was continually refusing her medication or the

medication wasnÓt being provided. These violations were

Class III.

25. On August 29, 2016, ES Kummer conducted a re - inspection

of Hidden Oaks. ES Kummer observed: trips hazards; abrasion

hazards; dirty floors; loose grab bars; and cleanliness issues

throughout t he facility. The photographs attached to AHCAÓs

Exhibit P showed the substandard living conditions at Hidden

Oaks. Based on the number of violations observed, Hidden Oaks

was advised the inspection was unsatisfactory, and the matter was

r eferred to legal .

26. On October 6, 2016, an unannounced follow - up survey was

conducted at Hidden Oaks by health facility evaluator Alter.

Evaluator Alter performed a staff training review. Three members

of the Hid den Oaks staff, who had been on site for at least four

m onths , did not have certificates evidencing they had received

proper training to perform their duties. When staff is not

properly trained, staff cannot provide proper care, which could

cause injury or harm to residents. These violations are

Class III.

2 7. Additionally, Evaluator Alter noted that Hidden Oaks

staff was not posting the daily menus for residents, as required.

Residents could not know what options they had for each meal.

This violation is a Class III.

28. Agency S urveyor Turbyfill is a re gistered nurse who

also participated in t he survey at Hidden Oaks in Fort Myers with

Evaluator Alter. Agency S urveyor Turbyfill conducted a

medication review and discovered that medication ordered to be

provided two hours before the morning meal was actua lly being

given after the meal had been eaten. Hidden OaksÓ staff was not

following the doctorÓs orders. The effectiveness of the

medication may be altered by some foods. Additionally, on two

occasions, Agency S urveyor Turbyfill observed that staff was not

telling residents what medication they were being given.

29. Argenis Gomez worked for Ðthe company (Hidden Oaks)

about three years.Ñ He initially worked as a Ðmed techÑ and

resident caregiver (RCA) for Hidden Oaks. While working as the

med tech and RCA, he would come in on weekends to do odd jobs,

such as paint ing . The prior executive director noted his work

and hired Mr. Gomez as the maintenance director. 9 / Mr. Gomez does

not have any prior training to be a maintenance director.

Further, he admit ted that once he became the maintenance director

he found there was too much work for one person, and a part - time

assistant was h ired. There are now three full - time maintenance

workers at Hidden Oaks.

30. It remains unclear when Hidden Oaks actually enga ged

Mr. Gomez as its maintenance director. During his testimony , he

claimed to be the maintenance director for about a year, which

would be about June 2016, give or take a month or two. However,

testimony by both ES Kummer and Mr. Gomez corroborate that

Mr. Gomez accompanied the inspectors when they arrived at Hidden

Oaks. Evidence as to how long Mr. Gomez had been working as the

maintenance director is found on AHCA Exhibit I, which reflects

that he signed the November 18, 2015 , inspection report. The

undersigned finds that it is highly improbable that a Ðmed techÑ

or RCA would have the authority to accept a citation or

inspection report.

31. Mr. Gomez acknowledged the multiple violations at

Hidden Oaks to include: feces inside and around the grounds , the

disrepair of various furnishings, the smell of urine within

Hidden Oaks, and the lack of caulking at certain fixtures.

Mr. Gomez took notes as to what needed to be addressed, but

conceded that he did not have time to check on what should have

been corrected. In some instances , outside contractors were

necessary, but some repairs were inadequate at best . Mr. Gomez

did not have the time to check on those repairs .

32 . In addition to his maintenance duties, Mr. Gomez was

also in charge of supervising the housekeeping staff. He again

admitted that he could not effectively supervise the four

housekeepers. Thereafter, Hidden Oaks eng aged a housekeeper

supervisor.

33. To his credit, Mr. Gomez determined the cause of the

l oose toilets. He determined th at prior workers failed to fix

the moisture issues at various toilets. Prior workers had merely

placed more flooring over the old flooring, instead of rippi ng

out the water - damaged flooring at the base of the toilet.

However, despite determining how to c orrect t he problem,

Mr. Gomez did not correct it, and the problem persisted .

34. On November 29, 2016, ES Kummer conducted a re -

inspection of Hidden Oaks. ES Kummer observed: trips hazards;

abrasion hazards; dirty floors; loose grab bars; leaks at the

water main; and cleanliness issues throughout the facility. The

photographs attached to AHCAÓs Exhibit Q showed the living

conditions at Hidden Oaks. Based on the number of violations

observed, Hidden Oaks was advised the inspection was

unsatisfactory, a nd the matter was referred to legal.

35. In January 2017, RN Humphries conducted an unannounced

follow - up survey at Hidden Oaks. With respect to one resident,

Hidden OaksÓ staff was not providing medication as prescribed in

the resident Ó s health assessme nt form. The direction was for the

medication to be administered Ðon an empty stomach,Ñ which is

usually two to four hour s before meals, to allow for proper

absorption. In this instance, the resident was provided the

medication at 7:15 a.m., and went to breakfast at 7:30 a.m.

36. There were numerous surveys or inspections conducted on

Hidden Oaks over 15 months. Each survey or inspection recorded

numerous violations, either Class II or Class III, which Hidden

Oaks failed to timely address.

CONCLUSIONS O F LAW

37 . The Division of Administrative Hearings has jurisdiction

over the parties to and the subject matter of this proceeding

pursuant to sections 120.569 and 120.57(1), Florida Statutes.

38. This case combines an AC to assess fines on various

grounds (DOAH Case No. 17 - 1589) and the denial of an application

to renew an ALF on some of the same grounds (DOAH Case No. 17 -

1591). A threshold legal issue to be determined is the burden of

proof to apply.

39 . The burden of proof in DOAH Case No. 17 - 1589 is o n AHCA

to prove the allegations in its Administrative Complaint by clear

and convincing evidence. Dep Ó t of Banking & Fin. v. Osborne Stern

& Co. , 670 So. 2d 932, 933 - 34 (Fla. 1996) ; Ferris v. Turlington ,

510 So. 2d 292 (Fla. 1987).

40 . The Supreme Court has stated:

Clear and convincing evidence requires that

the evidence must be found to be credible; the

facts to which the witnesses testify must be

distinctly remembered; the testimony must be

precise and lacking in confusion as to the

facts in issue. T he evidence must be of such

a weight that it produces in the mind of the

trier of fact a firm belief or conviction,

without hesitancy, as to the truth of the

allegations sought to be established.

In re Henson , 913 So. 2d 579, 590 (Fla. 2005)(quoting Slomo witz v.

Walker , 429 So. 2d 797, 800 (Fla. 4th DCA 1983)).

41. The burden of proof in DOAH Case No. 17 - 1591 is on AHCA ,

as its stated intention is to deny the renewal of Hidden OaksÓ

license is tantamount to revoking the license. See Wilson v. Pest

Contro l CommÓ n , 199 So. 2d 777, 781 (Fla. 4th 1967). AHCA Ós

burden of persuasion on this issue is by clear and convincing

evidence. Coke v. Dep Ó t of Child. & Fam. Servs. , 704 So. 2d 726

(Fla. 5th DCA 1998); Dubin v. DepÓ t of Bus. Reg. , 262 So. 2d 273,

274 (Fla . 1st DCA 1972); DepÓ t of Banking & Fin., Div. of Sec. &

Investor Prot. v. Osborne Stern & Co. , supra .

42. Section 429.28 provides in pertinent part:

(1) No resident of a facility shall be

deprived of any civil or legal rights,

benefits, or privileges gu aranteed by law,

the Constitution of the State of Florida, or

the Constitution of the United States as a

resident of a facility. Every resident of a

facility shall have the right to:

(a) Live in a safe and decent living

environment, free from abuse and neglect.

(b) Be treated with consideration and

respect and with due recognition of personal

dignity, individuality, and the need for

privacy.

* * *

(3) (c) During any calendar year in which no

survey is conducted, the agency shall conduct

at lea st one monitoring visit of each facility

cited in the previous year for a class I or

class II violation, or more than three

uncorrected class III violations.

43. Rule 58A - 5.0185 provides in pertinent part:

Pursuant to Sections 429.255 and 429.256,

F.S., and this rule, licensed facilities may

assist with the self - administration or

administration of medications to residents in

a facility. A resident may not be compelled

to take medications but may be counseled in

accordance with this rule.

* * *

(3) ASSISTANCE WITH SELF - ADMINISTRATION.

(a) Any unlicensed person providing

assistance with self administration of

medication must be 18 years of age or older,

trained to assist with self administered

medication pursuant to the training

requirements of Rule 58A - 5.0191, F.A.C., and

must be available to assist residents with

self - administered medications in accordance

with procedures described in Section 429.256,

F.S. and this rule.

(b) In addition to the specifications of

Section 429.256(3), F.S., assi stance with

self - administration of medication includes

verbally prompting a resident to take

medications as prescribed.

(c) In order to facilitate assistance with

self - administration, trained staff may prepare

and make available such items as water, juic e,

cups, and spoons. Trained staff may also

return unused doses to the medication

container. Medication, which appears to have

been contaminated, must not be returned to the

container.

(d) Trained staff must observe the resident

take the medication. A ny concerns about the

residentÓs reaction to the medication or

suspected noncompliance must be reported to

the residentÓs health care provider and

documented in the residentÓs record.

(e) When a resident who receives assistance

with medication is away fr om the facility and

from facility staff, the following options are

available to enable the resident to take

medication as prescribed:

1. The health care provider may prescribe a

medication schedule that coincides with the

residentÓs presence in the facil ity;

2. The medication container may be given to

the resident, a friend, or family member upon

leaving the facility, with this fact noted in

the residentÓs medication record;

3. The medication may be transferred to a

pill organizer pursuant to the requ irements of

subsection (2), and given to the resident, a

friend, or family member upon leaving the

facility, with this fact noted in the

residentÓs medication record; or

4. Medications may be separately prescribed

and dispensed in an easier to use form, such

as unit dose packaging;

(f) Assistance with self - administration of

medication does not include the activities

detailed in Section 429.256(4), F.S.

1. As used in Section 429.256(4)(h), F.S.,

the term Ðcompetent residentÑ means that the

resident is cognizant of when a medication is

required and understands the purpose for

taking the medication.

2. As used in Section 429.256(4)(i), F.S.,

the terms ÐjudgmentÑ and ÐdiscretionÑ mean

interpreting vital signs and evaluating or

assessing a residentÓs cond ition.

* * *

(5) MEDICATION RECORDS.

(a) For residents who use a pill organizer

managed in subsection (2), the facility must

keep either the original labeled medication

container; or a medication listing with the

prescription number, the name and address of

the issuing pharmacy, the health care

providerÓs name, the residentÓs name, the date

dispensed, the name and strength of the drug,

and the directions for use.

(b) The facility must maintain a daily

medication observation record (MOR) for e ach

resident who receives assistance with self -

administration of medications or medication

administration. A medication observation

record must include the name of the resident

and any known allergies the resident may have;

the name of the residentÓs heal th care

provider, the health care providerÓs telephone

number; the name, strength, and directions for

use of each medication; and a chart for

recording each time the medication is taken,

any missed dosages, refusals to take

medication as prescribed, or med ication

errors. The medication observation record

must be immediately updated each time the

medication is offered or administered.

(c) For medications that serve as chemical

restraints, the facility must, pursuant to

Section 429.41, F.S., maintain a rec ord of the

prescribing physicianÓs annual evaluation of

the use of the medication.

* * *

(7) MEDICATION LABELING AND ORDERS.

(a) The facility may not store prescription

drugs for self - administration, assistance with

self - administration, or admi nistration unless

it is properly labeled and dispensed in

accordance with Chapters 465 and 499, F.S. and

Rule 64B16 - 28.108, F.A.C. If a customized

patient medication package is prepared for a

resident, and separated into individual

medicinal drug containe rs, then the following

information must be recorded on each

individual container:

1. The residentÓs name; and

2. Identification of each medicinal drug in

the container.

(b) Except with respect to the use of pill

organizers as described in subsection (2), no

individual other than a pharmacist may

transfer medications from one storage

container to another.

(c) If the directions for use are Ðas neededÑ

or Ðas directed,Ñ the health care provider

must be contacted and requested to provide

revised instruc tions. For an Ðas neededÑ

prescription, the circumstances under which it

would be appropriate for the resident to

request the medication and any limitations

must be specified; for example, Ðas needed for

pain, not to exceed 4 tablets per day.Ñ The

revise d instructions, including the date they

were obtained from the health care provider

and the signature of the staff who obtained

them, must be noted in the medication record,

or a revised label must be obtained from the

pharmacist.

(d) Any change in direc tions for use of a

medication for which the facility is providing

assistance with self - administration or

administering medication must be accompanied

by a written medication order issued and

signed by the residentÓs health care provider,

or a faxed or elec tronic copy of such order.

The new directions must promptly be recorded

in the residentÓs medication observation

record. The facility may then place an

ÐalertÑ label on the medication container that

directs staff to examine the revised

directions for use in the medication

observation record, or obtain a revised label

from the pharmacist.

(e) A nurse may take a medication order by

telephone. Such order must be promptly

documented in the residentÓs medication

observation record. The facility must obtain

a written medication order from the health

care provider within 10 working days. A faxed

or electronic copy of a signed order is

acceptable.

(f) The facility must make every reasonable

effort to ensure that prescriptions for

residents who receive assis tance with self -

administration of medication or medication

administration are filled or refilled in a

timely manner.

(g) Pursuant to Section 465.0276(5), F.S. and

Rule 61N - 1.006, F.A.C., sample or

complimentary prescription drugs that are

dispensed by a health care provider, must be

kept in their original manufacturerÓs

packaging, which must include the

practitionerÓs name, the residentÓs name for

whom they were dispensed, and the date they

were dispensed. If the sample or

complimentary prescription drug s are not

dispensed in the manufacturerÓs labeled

package, they must be kept in a container that

bears a label containing the following:

1. PractitionerÓs name;

2. ResidentÓs name;

3. Date dispensed;

4. Name and strength of the drug;

5. Directions for use; and

6. Expiration date.

(h) Pursuant to Section 465.0276(2)(c), F.S.,

before dispensing any sample or complimentary

prescription drug, the residentÓs health care

provider must provide the resident with a

written prescription, or a faxed or el ectronic

copy of such order.

44. Florida Administrative Code Rule 58A - 5.019 provides in

pertinent part:

(2) STAFF.

* * *

(b) Staff must be qualified to perform their

assigned duties consistent with their level of

education, training, preparat ion, and

experience. Staff providing services

requiring licensing or certification must be

appropriately licensed or certified. All

staff must exercise their responsibilities,

consistent with their qualifications, to

observe residents, to document observ ations on

the appropriate residentÓs record, and to

report the observations to the residentÓs

health care provider in accordance with this

rule chapter.

(c) All staff must comply with the training

requirements of Rule 58A - 5.0191, F.A.C.

45. Rule 58A - 5. 191 provides in pertinent part:

(2) STAFF IN - SERVICE TRAINING. Facility

administrators or managers shall provide or

arrange for the following in - service training

to facility staff:

(a) Staff who provide direct care to

residents, other than nurses, cer tified

nursing assistants, or home health aides

trained in accordance with Rule 59A - 8.0095,

F.A.C., must receive a minimum of 1 hour

in - service training in infection control,

including universal precautions, and facility

sanitation procedures before provi ding

personal care to residents. Documentation of

compliance with the staff training

requirements of 29 CFR 1910.1030, relating to

blood borne pathogens, may be used to meet

this requirement.

(b) Staff who provide direct care to

residents must receive a minimum of 1 hour

in - service training within 30 days of

employment that covers the following subjects:

1. Reporting major incidents.

2. Reporting adverse incidents.

3. Facility emergency procedures including

chain - of - command and staff roles relatin g to

emergency evacuation.

(c) Staff who provide direct care to

residents, who have not taken the core

training program, shall receive a minimum of

1 hour in - service training within 30 days of

employment that covers the following subjects:

1. Resident rights in an assisted living

facility.

2. Recognizing and reporting resident abuse,

neglect, and exploitation.

(d) Staff who provide direct care to

residents, other than nurses, CNAs, or home

health aides trained in accordance with

Rule 59A - 8.0095, F .A.C., must receive 3 hours

of in - service training within 30 days of

employment that covers the following subjects:

1. Resident behavior and needs.

2. Providing assistance with the activities

of daily living.

(e) Staff who prepare or serve food, who have

not taken the assisted living facility core

training must receive a minimum of 1 - hour - in -

service training within 30 days of employment

in safe food handling practices.

(f) All facility staff shall receive in -

service training regarding the facilityÓs

resident elopement response policies and

procedures within thirty (30) days of

employment.

1. All facility staff shall be provided with

a copy of the facilityÓs resident elopement

response policies and procedures.

2. All facility staff shall demonstra te an

understanding and competency in the

implementation of the elopement response

policies and procedures.

* * *

(12) TRAININ G DOCUMENTATION AND MONITORING.

(a) Except as otherwise noted, certificates,

or copies of certificates, of any traini ng

required by this rule must be documented in

the facilityÓs personnel files. The

documentation must include the following:

1. The title of the training program;

2. The subject matter of the training

program;

3. The training program agenda;

4. Th e number of hours of the training

program;

5. The traineeÓs name, dates of

participation, and location of the training

program;

6. The training providerÓs name, dated

signature and credentials, and professional

license number, if applicable.

(b) Upon successful completion of training

pursuant to this rule, the training provider

must issue a certificate to the trainee as

specified in this rule.

(c) The facility must provide the Department

of Elder Affairs and the Agency for Health

Care Administration with training

documentation and training certificates for

review, as requested. The department and

agency reserve the right to attend and monitor

all facility in - service training, which is

intended to meet regulatory requirements.

46 . Rule 58A - 5.023 pr ovides in pertinent part:

(3) OTHER REQUIREMENTS.

(a) All facilities must:

1. Provide a safe living environment pursuant

to Section 429.28(1)(a), F.S.;

2. Be maintained free of hazards; and

3. Ensure that all existing architectural,

mechanical, e lectrical and structural systems,

and appurtenances are maintained in good

working order.

* * *

(e) Facilities must make available linens and

personal laundry services for residents who

require such services. Linens provided by a

facility must be free of tears, stains and

must not be threadbare.

47 . Rule 58A - 5.024 provides in pertinent part:

(2) STAFF RECORDS.

(a) Personnel records for each staff member

must contain, at a minimum, a copy of the

employment application, with references

furni shed, and documentation verifying freedom

from signs or symptoms of communicable

disease. In addition, records must contain

the following, as applicable:

1. Documentation of compliance with all staff

training and continuing education required by

Rule 58 A - 5.0191, F.A.C.;

2. Copies of all licenses or certifications

for all staff providing services that require

licensing or certification;

3. Documentation of compliance with level 2

background screening for all staff subject

to screening requirements as specified in

Section 429.174, F.S. and Rule 58A - 5.0 19,

F.A.C.;

4. For facilities with a licensed capacity of

17 or more residents, a copy of the job

description given to each staff member

pursuant to Rule 58A - 5.019, F.A.C.;

5. Documentation verifying direct care staff

and administrator participation in resident

elopement drills pursuant to paragraph 58A -

5.0182(8)(c), F.A.C.

48 . Rule 59A - 35.060, Licensure Application Process, provides

in pertinent part:

( 6) An application is considered complete

upon receipt of:

(a) All required documents and information

and appropriate fee;

(b) All required background screening

results; and,

(c) Completion of a satisfactory inspection

if required by authorizing statutes or rules.

Satisfactory inspection means n o regulatory

violations exist, or all prior violations

found have been determined by the Agency to be

corrected.

49 . Section 408. 813 provides in pertinent part:

Administrative fines; violations. Ï As a penalty

for any violation of this part, authorizing

st atutes, or applicable rules, the agency may

impose an administrative fine.

* * *

(2) Violations of this part, authorizing

statutes, or applicable rules shall be

classified according to the nature of the

violation and the gravity of its probable

effect on clients. The scope of a violation

may be cited as an isolated, patterned, or

widespread deficiency. An isolated deficiency

is a deficiency affecting one or a very

limited number of clients, or involving one or

a very limited number of staff, or a situation

that occurred only occasionally or in a very

limited number of locations. A patterned

deficiency is a deficiency in which more than

a very limited number of clients are affected,

or more than a very limited number of staff

are involved, or th e situation has occurred in

several locations, or the same client or

clients have been affected by repeated

occurrences of the same deficient practice but

the effect of the deficient practice is not

found to be pervasive throughout the provider.

A widespr ead deficiency is a deficiency in

which the problems causing the deficiency are

pervasive in the provider or represent

systemic failure that has affected or has the

potential to affect a large portion of the

providerÓs clients. This subsection does not

af fect the legislative determination of the

amount of a fine imposed under authorizing

statutes. Violations shall be classified on

the written notice as follows:

* * *

(b) Class ÐIIÑ violations are those

conditions or occurrences related to the

op eration and maintenance of a provider or to

the care of clients which the agency

determines directly threaten the physical or

emotional health, safety, or security of the

clients, other than class I violations. The

agency shall impose an administrative fi ne as

provided by law for a cited class II

violation. A fine shall be levied

notwithstanding the correction of the

violation.

(c) Class ÐIIIÑ violations are those

conditions or occurrences related to the

operation and maintenance of a provider or to

the care of clients which the agency

determines indirectly or potentially threaten

the physical or emotional health, safety, or

security of clients, other than class I or

class II violations. The agency shall impose

an administrative fine as provided in this

section for a cited class III violation. A

citation for a class III violation must

specify the time within which the violation is

required to be corrected. If a class III

violation is corrected within the time

specified, a fine may not be imposed.

50 . Section 429.14 provides in pertinent part:

(1) In addition to the requirements of

part II of chapter 408, the agency may deny,

revoke, and suspend any license issued under

this part and impose an administrative fine in

the manner provided in chapter 120 against a

licensee for a violation of any provision of

this part, part II of chapter 408, or

applicable rules, or for any of the following

actions by a licensee, any person subject to

level 2 background screening under s. 408.809,

or any facility staff:

* * *

(h) Failure of the license applicant, the

licensee during relicensure, or a licensee

that holds a provisional license to meet the

minimum license requirements of this part, or

related rules, at the time of license

application or renewal.

5 1 . Section 429.19(2) provides in pertinent part:

(2) Each violation of this part and adopted

rules shall be classified according to the

nature of the violation and the gravity of its

probable effect on facility residents. The

agency shall indicate the classification on

the written notice of the violation as

follows:

* * *

(b) Class ÐIIÑ violations are defined in

s. 408.813 . The agency shall impose an

administrative fine for a cited class II

violation in an amount not less than $1,000

and no t exceeding $5,000 for each violation.

(c) Class ÐIIIÑ violations are defined in

s. 408.813 . The agency shall impose an

administrative fine for a cited class III

violation in an amount not less than $500 and

not exceeding $1,000 for each violation.

52 . Section 408. 815 provides in pertinent part:

(1) In addition to the grounds provided in

authorizing statutes, grounds that may be used

by the agency for denying and revoking a

license or change of ownership application

include any of the following acti ons by a

controlling interest:

* * *

(c) A violation of this part, authorizing

statutes, or applicable rules.

53 . Count I alleges that Hidden Oaks failed to: provide a

safe living environment pursuant to section 429.28(1)(a); be

maintained fr ee of hazards; and ensure that all existing

architectural, mechanical, electrical and structural systems and

appurtenances were main tained in good working order. These

violations constituted Class III deficiencies. The allegations

were proven by clear an d convincing evidence .

54 . Count II re - alleges all the paragraphs in C ount I. It

allege s that in addition to any administrative fines imposed, AHCA

Ðmay assess a survey fee equal to the lesser of one half of a

facilityÓs biennial license and bed fee or $ 500, to cover the cost

of conductingÑ an initial complaint investigation that is

conducted pursuant to section 429.28(3)(c) and results in a

finding of the complained violation . The basis to impose t he

survey fee was proven.

55 . Count III alleges that AH CA completed a third re visit

survey of Hidden Oaks and found identified deficiencies that were

cited on previous surveys, which constituted Class III offenses,

as defined i n section 429.19(2)(c), above. The allegations were

proven by clear and convincing evidence .

56 . Cou nt IV was the result of AHCA re visiting Hidden Oaks

to determine whether previously cited deficiencies had been

corrected. The deficiencies had not been corrected. The

allegations were proven by clear and convincing evidence .

5 7 . Count V detailed conditions found at a third re visit to

Hidden Oaks regarding alleged failures Ðto maintain a clean and

safe environment for residents . Ñ This continual failure

constituted an uncorrected Class III deficient practice for the

third time. The all egations were proven by clear and convincing

evidence .

58 . Count VI alleges that AHCA, on another revisit to Hidden

Oaks , found its continued failure to ensure a safe and decent

living environment, free from abuse and neglect . Th e residents

were not bein g treated with consideration and respect regarding

their personal dignity, individuality, or the need for privacy in

their environs. Hidden Oaks was again cited with a Class III

deficiency and afforded the requisite 30 days to correct the

conditions. Suc h corrections were not evident when AHCA revisi ted

Hidden Oaks 30 days later. The allegations were proven by clear

and convincing evidence .

59 . Count VII alleges that Hidden Oaks failed to ensure that

residentsÓ medications were filled o r refilled in a t imely manner.

The allegations were proven by clear and convincing evidence .

60 . Count VIII re - alleges that a survey fee may be imposed

should those deficiencies fail to be corrected during the

applicable time following notification of the deficiencies. The

basis to impose t he survey fee was proven.

61 . Under section 408.815(1)(d), AHCA may deny a license for

a Ð demonstrated pattern of deficient performance. Ñ There is no

case law construing this phrase. An a ccepted definition of the

word Ð pattern Ñ is: Ð a reliable sample of traits, acts,

tendencies, or other characteristics of a person, group, or

institution . Ñ Merriam - Webster Online Dictionary (2017 ). The

repeated violations amount to a troubling pattern.

6 2 . The evidence was clear and convincing tha t Hidden Oaks

was not in compliance with the minimal requirements to maintain an

ALF. The violations noted from the multiple surveys and

inspections, while relatively minor , reflect a troubling pattern

of deficient performance involving inadequate staffin g, inadequate

supervision , and in appropriate attention to the cleanliness and

maintenance of the ALF and its residents. Despite notification of

the deficiencies, Hidden Oaks failed to appreciate their

significance and correct them. Those violations can b e considered

in determining whether AHCA proved a pattern of deficient

performance that would warrant license discipli ne under section

408.815(1)(d) . AHCA proved the allegation by clear and convincing

evidence.

6 3 . Based on these allegations, AHCA seeks to impose

$4,500.00 in administrative fines and $1,500.00 in survey fees.

6 4 . An applicant for renewal of an ALF license must

demonstrate compliance with the authorizing statutes and

applicable rules during an inspection pursuant to section 408.811,

as re quired by authorizing statute s. § 408.806(7)(a), Fla. Stat.

65 . AHCA presented clear and convi ncing evidence that Hidden

Oaks failed to maintain a clean and safe environment for its

residents.

66 . AHCA presented clear and convincing evidence that Hidden

Oaks committed multiple C lass III violations within six months and

failed to correct those violations in a timely manner.

RECOMMENDATION S

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Agency for Health Care

Adm inistration enter a final order finding that the AC

allegations were proven by clear and convincing evidence , fining

the facility a total of $6,000.00 ($4,500.00 in administrative

fines and $1,500.00 in survey fees) ; and denying Hidden Oaks

license renewal application . 10 /

DONE AND ENTERED this 2 5th day of September , 2017 , in

Tallahassee, Leon County, Florida.

S

LYNNE A. QUIMBY - PENNOCK

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Ap alachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 2 5th day of September, 2017 .

ENDNOTE S

1/ That Order stated in per tine nt part:

2. The Motion for Sanctions is granted to

the extent that AHCA is entitled to

attorneyÓs fees and costs as it relates to

the review of the late filed material in

response to the RFP, the creation and filing

of the Motion for Sanctions. Such aff idavit

as to the amount of attorneyÓs fees and costs

associated with these tasks shall be attached

to any proposed recommended order submitted

following the hearing in this matter. Hidden

Oaks shall be afforded an opportunity to

respond solely to AHCAÓs a ffidavit for

attorneyÓs fees and costs no later than ten

days after such affidavit is filed. The

undersigned shall issue an order with respect

to the sanctions once the deadline for Hidden

OaksÓ response expires.

The undersigned did not find an affidavit attached to the

proposed recommended order.

2 / AHCAÓs Exhibits R through V were inspection reports or surveys

completed by AHCA, the Department of Health, or the local county

health department after the dates listed in either the AC or the

NOID. (empha sis added).

3 / Hidden Oaks provided pictures of its facility , which were

taken after the AC and the NOID were issued.

4/ Hidden OaksÓ proposed recommended order is replete with

grammatical and typographical errors making it virtually

incomprehensible, and therefore of no assistance to this process.

5/ Hidden Oaks provided responses to AHCAÓs First Request for

Admissions. AHCA attached those responses to the pre - hearing

stipulation averring that ÐHidden Oaks has admitted some material

facts related to the allegations.Ñ Of the twelve responses

provided: one does not reflect any response; five statements are

ÐDENIED Ñ ; and of the remaining six responses admitted, one

involved two residents paying for their own transportation to

physician appointments in contravention to Hidden OaksÓ

contractual obligation to provide transportation and five

involved employees who failed to receive required training in a

timely or documented manner.

6/ Surveyor McGillivray is a licensed registered nurse with years

of exp erience. I n describing the permeating odor of urine, she

testified that the odor was so strong ÐIt kind of made my eyes

water because the door shut behind me.Ñ

7/ Missing blinds or a lack of curtains are issues that go

directly to each residentsÓ right to privacy and is a personal

dignity issue.

8/ The holes in the walls had been spackled or caulked, but the

surface was not sanded, finished or painted, thus creating an

abrasion hazard.

9 / Prior to hiring Mr. Gomez as the maintenance director, Hidden

OaksÓ prior maintenance director had been on medical leave for

two to three months. Outside service individuals were called in

to address issues.

10 / AHCA should provide for sufficient time to allow the current

residents to relocate.

COPIES FURNISHED:

Shaddrick Haston, Esquire

Suite 103

1618 Mahan Center Boulevard

Tallahassee, Florida 32308

(eServed)

Thomas J. Walsh, II, Esquire

Agency for Health Care Administration

Suite 330

525 Mirror Lake Drive North

St. Petersburg, Florida 33701

(eServed)

R ichard J. Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Justin Senior, Secretary

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 1

Tallahassee, Florida 3230 8

(eServed)

William Roberts, Acting General Counsel

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Shena L. Grantham, Esquire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

T allahassee, Florida 32308

(eServed)

Thomas M. Hoeler, Esquire

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.