02-001965 Shady Rest Care Pavilion, Inc., D/B/A Shady Rest Care Pavilion vs. Agency For Health Care Administration Status: Closed Recommended Order on Monday, August 26, 2002.

Summary: Evidence showed nursing home resident`s severe weight loss was expressly directed by her physician and was justified based on resident`s serious medical conditions and past treatment history. Change in license status and imposition of fine not justified.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Petitioner, )

)

vs. ) Case No. 02 - 1291

)

SHADY REST CARE PAVILION, INC., )

d/b/a SHADY REST CARE PAVILION, )

)

Respondent. )

_______________________________ )

)

SHADY REST CARE PAVILION, INC., )

d/b/a SHADY REST CARE PAVILION, )

)

Petitioner, )

)

vs. ) Case No. 02 - 1965

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

)

RECOMM ENDED ORDER

Pursuant to notice, a formal hearing was held in this case

on June 21, 2002, by video teleconference between sites in

Ft. Myers and Tallahassee, Florida, before T. Kent

Wetherell, II, the designated Administrative Law Judge of the

Division of Administrative Hearings.

APPEARANCES

For Petitioner: Dennis L. Godfrey, Esquire 1

Agency for Health Care

Administration

525 Mirror Lake Drive, North

Room 310L

St. Petersburg, Florida 33701

For Respondent: Karen L. Goldsmith, Esquire

Goldsmith, Grout & Lewis, P.A.

2180 North Park Avenue, Suite 100

Post Office Box 2011

Winter Park, Florida 32790 - 2011

STATE MENT OF THE ISSUE

Whether Shady Rest Care Pavilion, Inc. failed to maintain

the nutritional status of one of its residents so as to justify

the imposition of a conditional license rating upon the facility

and an administrative fine of $2,500.

PRELIMINARY STATEMENT

The Agency for Health Care Administration (Agency)

conducted a survey of Shady Rest Care Pavilion, Inc. (Shady

Rest) from July 30, 2001, to August 2, 2001. On August 22,

2001, the Agency issued a notice of intent to assign Shady Rest

conditio nal licensure status based upon several deficiencies

identified during the course of the survey. However, the only

deficiency still at issue in this proceeding is the Tag F325

which was based upon Shady Rest's alleged failure to ensure that

the nutritiona l needs of one resident, Resident 11, were met.

On September 4, 2001, Shady Rest timely requested a formal

administrative hearing to contest the change in the status of

its license. On May 14, 2002, Shady Rest's petition was

referred to the Division of A dministrative Hearings (Division)

where it was assigned DOAH Case No. 02 - 1965.

On December 13, 2001, the Agency filed a one - count

Administrative Complaint against Shady Rest. The Complaint

alleged that Shady Rest violated Rule 59A - 4.1288, Florida

Adminis trative Code, and the federal regulations incorporated

therein, based upon the deficiencies referenced above. On

January 7, 2002, Shady Rest timely filed a petition contesting

the allegations in the complaint and requesting a formal

administrative hearing . The petition was referred to the

Division on March 29, 2002, where it was assigned DOAH Case

No. 02 - 1291.

By Order dated May 29, 2002, DOAH Case Nos. 02 - 1291 and 02 -

1965 were consolidated. Subsequently, the cases were

transferred to the undersigned f or the purpose of conducting the

hearing requested by Shady Rest.

The hearing was held on June 21, 2002. At the hearing, the

Agency presented the testimony of Lori Riddle, R.D., who was

accepted as an expert in dietetics. The Agency's Exhibits,

numbered R1, P5, P6, P12, P21 - P23, and P68 - P73, were received

into evidence. At the hearing, Shady Rest presented the

testimony of Sonja Reece, R.N., who was accepted as an expert in

geriatric nursing, and Ann Marie Shields, R.D., who was accepted

as an expert in nutrition and dietetics. Shady Rest's Exhibits,

numbered R2, R4, R6, R7, R9, and R10, were received into

evidence.

At the conclusion of the hearing, the record was left open

to allow Shady Rest to submit the deposition testimony of

Robert Heiser, M.D. D r. Heiser was unexpectedly called into

surgery on the day of the hearing. The transcript of

Dr. Heiser's deposition was filed with the Division on July 26,

2002. Dr. Heiser is accepted as an expert in medicine and

gastroenterology.

The Transcript of the hearing was filed with the Division

on August 5, 2002. At the conclusion of the hearing, the

parties agreed to file their proposed recommended orders no

later than 10 days after the filing of the Dr. Heiser's

deposition or the Transcript of the hearing, whichever occurred

later. The parties' Proposed Recommended Orders were timely

filed on August 14, 2002, and were considered by the undersigned

in preparing this Recommended Order.

FINDINGS OF FACT

Based upon the testimony and evidence received at the

h earing and the parties' stipulations, the following findings

are made:

1. Shady Rest is licensed by the Agency as a skilled

nursing facility. Shady Rest's license number is SNF1497096.

2. The Agency conducted an on - site survey of Shady Rest

from July 30, 2001, to August 2, 2001. At the time of the

survey, Shady Rest's licensure status was standard.

3. The survey was conducted by a "team" that included

dietitian Lori Riddle and other health care professionals.

4. The survey team identified several de ficiencies at the

facility. The deficiencies were detailed on the Form 2567 which

was provided to Shady Rest by the Agency.

5. The only deficiency still at issue in this proceeding

is the Tag F325 which was summarized on the Form 2567 as

follows:

Based on observations, clinical record

review and staff interviews, the facility

failed to ensure that nutritional needs were

met for 3 (Residents 11, 21 and 22) of 5

active sampled residents receiving tube

feeding who were at high risk for

malnutrition as evid enced by significant

weight loss, low albumin and total protein

levels and recurring pressure sores.

6. The survey team classified the Tag F325 at Level "G"

( i.e. , isolated actual harm) on the federal scope and severity

matrix, which corresponds to an i solated Class II deficiency

under the Florida classification scheme.

7. Based upon the cited Class II deficiency, the Agency

issued a notice of intent to change Shady Rest's licensure

status from standard to conditional, and the Agency initiated a

separa te action to impose an administrative fine upon Shady

Rest. This proceeding followed.

8. At the hearing, the Agency narrowed the focus of the

alleged deficiency from the three residents identified on the

Form 2567 to only one, Resident 11. No evidence or testimony

was presented regarding any other residents.

9. Resident 11 is a female. At the time of the survey,

she was 89 years old, 64 inches (five feet, four inches) tall,

and weighed 145 pounds. She has been at Shady Rest since 1987.

10. A care plan for Resident 11 was developed by a "team"

that included the director of nursing at Shady Rest, a nurse

(Sonja Reece, R.N.), a dietitian (Ann Marie Shields, R.D.), two

care plan coordinators, and social service and activity

personnel. Members of the c are plan team worked closely with

Resident 11's physician, Dr. Lakshmi Bushan, to manage Resident

11's medical conditions.

11. Dr. Bushan was actively involved with the care of

Resident 11 and was very familiar with her conditions.

Dr. Bushan was at the facility on a weekly basis and sometimes

several times per week.

12. Resident 11 is totally dependent on Shady Rest and its

staff for the provision of nutrition. She is fed through a tube

connected directly to her stomach.

13. Resident 11 is a "very complex resident" as a result

of a myriad of serious medical conditions, including heart

attack, seizure disorder, edema ( i.e. , swelling of the tissues

due to fluid retention), hiatal hernia with reflux, pemphagus

( i.e. , an autoimmune disease resulting in blisters around the

body), congestion in the lungs which caused breathing problems,

kidney disease, and liver problems. She was also prone to skin

breakdown.

14. The treatment of Resident 11 was complicated by the

fact that management of one of her con ditions would exacerbate

another. For example, the Prednisone she was taking to treat

her pemphagus increased her fluid retention and, hence, her

edema; but, Lasix, the diuretic she was taking for the edema,

caused her to have diarrhea which led to the br eakdown of her

skin from constant cleaning and put her at risk of dehydration

and kidney failure.

15. Resident 11's edema was at a dangerous level, referred

to as "3 pitting edema." Relieving the edema was determined to

be of critical importance to Res ident 11 by her physician. The

fluid retention in Resident 11's lungs caused her to suffer from

shortness of breath which could ultimately lead to congestive

heart failure.

16. Because Resident 11 did not respond well to Lasix and

because it actually exacerbated her other medical problems

( i.e. , skin breakdown), a fluid reduction diet was deemed

necessary by her physician.

17. Resident 11 was overweight, partially due to her

edema. Resident 11's weight contributed to and exacerbated her

medical c onditions, particularly her congestion and breathing

problems, and it enhanced her risk of congestive heart failure.

18. On April 3, 2001, Dr. Bushan ordered an evaluation of

Resident 11's nutritional status and the adequacy of her tube

feeding. Residen t 11 weighed 163 pounds on that date.

19. On April 4, 2001, Ms. Shields, performed the

evaluation ordered by Dr. Bushan. Ms. Shields calculated the

total calories per day (cal/day) needed by Resident 11 based

upon a standard formula. She then subtracted 400 cal/day to

take into account the weight loss desired by Dr. Bushan. Ms.

Shields' calculation resulted in an estimated caloric need for

Resident 11 of 1,100 to 1,200 cal/day.

20. Because the feeding ordered at that time provided

1,125 cal/day, which was within the range computed by

Ms. Shields, no changes were made to Resident 11's diet at that

time.

21. Resident 11 was, however, taken off Lasix at that time

because it was not contributing significantly to her weight loss

and it was putting her at r isk for dehydration and kidney

failure.

22. Resident 11's weight dropped only slightly after the

April 4, 2001, evaluation. On May 1, 2001, she weighed 159

pounds and on June 1, 2001, she weighed 158 pounds.

23. Dr. Bushan wanted Resident 11 to lose m ore weight more

rapidly to stabilize her serious medical conditions.

Accordingly, on June 13, 2001, Dr. Bushan requested a dietary

consultant to check the amount of Resident 11's tube feedings in

order to implement a planned weight loss program to reduce

Resident 11's weight to 145 to 150 pounds.

24. Ms. Shields conducted the assessment on June 14, 2001,

and after consulting with Resident 11's care plan team, she

recommended to Dr. Bushan that Resident 11's caloric intake be

reduced from 1,125 cal/day to 750 cal/day to accomplish the

rapid and significant weight loss desired by Dr. Bushan.

25. Dr. Bushan accepted Ms. Shield's recommendations and

ordered the reduction in calories on June 14, 2001. On that

date, Resident 11 weighed 158 pounds.

26. Residen t 11's care plan was updated on June 14, 2001,

to reflect the goal of reducing her weight by not more than five

pounds per week until she reached less than or equal to 150

pounds.

27. The dietary change achieved the desired effect of

rapidly reducing Resi dent 11's weight and stabilizing her

medical conditions. Her weight records showed the following:

Date Weight

June 20, 2001 153

June 27, 2001 153

July 4, 2001 152

July 11, 2001 153

July 18, 2001 152

July 25, 2001 n/a

August 2, 2001 145

28. The dietary notes for August 1, 2001, indicate that

Resident 11's "weight goal was met" and recommended a dietary

change to increase Resident 11's caloric intake to 1,000

cal/day. The record does not include the doctor's order

implementi ng that recommendation. However, by August 8, 2001,

Resident 11's weight was at 151 pounds, suggesting that the

dietary change was implemented.

29. Between the June 14, 2001, dietary change and the

August 2, 2001, survey, Resident 11 lost 13 pounds, whi ch is an

8.2 percent weight loss. For the three - month period of May 1,

2001 through August 2, 2001, Resident 11 lost 14 pounds, which

is an 8.8 percent weight loss.

30. Resident 11's edema improved significantly during this

period; it was no longer at th e "3 pitting edema" level. In

this regard, some of Resident 11's weight loss is attributable

to the elimination of retained fluids ( i.e. , reduction in her

edema), which was a significant purpose of the weight loss

program. The amount of the weight loss attributable to the

fluid loss is not quantifiable.

31. The federal guidelines discussing Tag F325, which the

Agency's survey team uses in its evaluation of a facility, state

that "weight loss (or gain) is a guide in determining

nutritional status" and identify parameters to be used in

evaluating the significance or severity of weight loss. The 8.8

percent weight loss experienced by Resident 11 over a three -

month period would be considered "severe" based upon the

parameters.

32. The parameters in the f ederal guidelines specifically

refer to "unplanned and undesired weight loss." By contrast,

the weight loss experienced by Resident 11 was planned and

desirable. It was directed by Dr. Bushan after Ms. Shield's

dietary consultation in order to reduce Res ident 11's fluid

intake and her edema while also promoting rapid weight loss to

minimize her congestion and related breathing problems.

33. The estimated protein needs for Resident 11 were 53 to

57 grams per day. The protein that she was being given, bot h

prior to and after the June 14, 2001, dietary change was within

that range. Increasing Resident 11's protein to offset the

calorie reduction was not considered a viable option for

Resident 11 because her history showed that the more protein she

received the more weight she gained. Moreover, too much protein

could cause liver failure, which was a risk for Resident 11.

34. When the body is not receiving enough calories, it can

metabolize protein as a calorie source rather than for the

purposes protein i s normally used, such as health of the skin.

Resident 11 experienced skin breakdown ( i.e. , pressure sores or

decubitus ulcers) after the June 14, 2001, dietary change. The

sores were very small in size and, consistent with Resident 11's

past history, the sores healed quickly. Therefore, they are not

indicative of a protein deficiency. Indeed, subsequent to the

dietary change, Resident 11's skin turgor was good.

35. The laboratory reports for Resident 11 showed her

having low albumin levels after the d ietary change. Low albumin

is generally an indicator of insufficient protein in the body.

However, as noted above, the rate at which Resident 11's skin

healed suggests that she was getting sufficient protein.

36. Resident 11's low albumin level, in an d of itself, is

not determinative of her nutritional status. Indeed, the

federal guidelines provided to the survey team state:

Because some healthy elderly people have

abnormal laboratory values, and because

abnormal values can be expected in some

disease processes, do not expect laboratory

values to be within normal ranges for all

residents. Consider abnormal values in

conjunction with the resident's clinical

condition and baseline abnormal values.

37. Even before the June 14, 2001, dietary change,

Re sident 11's albumin level was not within the normal range.

Her abnormal albumin levels may have been the result of her

liver problems.

38. Dr. Bushan and the care plan team at Shady Rest

managed Resident 11's care based upon their clinical

observat ions of her in conjunction with their experience

regarding what worked for her in the past, not simply based upon

her laboratory values. They were constantly weighing standards

of practice with what was actually happening with Resident 11.

CONCLUSIONS OF LAW

39. The Division of Administrative Hearings has

jurisdiction over the parties to and subject matter of this

proceeding pursuant to Sections 120.569 and 120.57(1), Florida

Statutes. (All references to Sections and Chapters are to the

Florida Statute s. All references to Rules are to the Florida

Administrative Code.)

40. The Agency has regulatory authority over skilled

nursing home facilities such as Shady Rest pursuant to Part II

of Chapter 400 and Rule 59A - 4.

Burden of Proof

41. Unless there is a statute which provides otherwise,

the party asserting the affirmative of an issue has the burden

of proof. See Dept. of Transportation v. J.W.C. Co., Inc. , 396

So. 2d 778, 788 (Fla. 1st DCA 1981).

42. Contrary to the Agency's argument in its Proposed

Recommended Order (addressed below), the burden of proof in this

proceeding is not established by statute. Accordingly, because

the Agency is the party seeking to change the status quo and is

asserting the affirmative on the issues in this proceeding, it

has the burden of proof. See Amico v. Division of Retirement ,

352 So. 2d 556 (Fla. 1st DCA 1977); Balino v. Dept. of Health

and Rehabilitative Servs. , 348 So. 2d 349 (Fla. 1st DCA 1977).

And see Spanish Gardens Nursing & Convalescent Center v. Agency

fo r Health Care Administration , DOAH Case No. 98 - 2149,

Recommended Order, at 25 (September 18, 1998).

43. The standard of proof is a preponderance of the

evidence with respect to the change in Shady Rest's licensure

status (DOAH Case No. 02 - 1965), see Spani sh Gardens , supra , at

25 - 26, and clear and convincing evidence with respect to the

imposition of the civil penalty or administrative fine (DOAH

Case No. 02 - 1291). See Dept. of Banking & Fin. v. Osborne Stern

& Co. , 670 So. 2d 932 (Fla. 1996).

44. In its Proposed Recommended Order, the Agency argues

that the burden of proof in both cases is on Shady Rest. In

support of its argument, the Agency cites Section 400.121(9)

which provides:

Notwithstanding any other provision of law

to the contrary, agency actio n in an

administrative proceeding under this section

may be overcome by the licensee upon a

showing by a preponderance of the evidence

to the contrary.

(Emphasis supplied).

45. The Agency's current position on this issue is

inconsistent with the Joint Prehearing Stipulation which was

signed by the Agency's counsel of record and which included the

following "agreed issues of law":

The Agency has the burden of proof in this

proceeding and must show by a preponderance

of the evidence that there existed a basis

for imposing a conditional license on [Shady

Rest's] license.

The Agency has the burden of proof and must

prove by clear and convincing evidence that

a $2,500 fine should be imposed against

[Shady Rest] for the alleged violation.

Joint Prehearing S tipulation, at 7 - 8.

46. The Agency's Proposed Recommended Order was not

submitted by the same attorney who signed the Joint Prehearing

Stipulation and represented the Agency at the hearing. See

Endnote 1. Nevertheless, the Agency is bound by its

stipula tions as to the burdens of proof in this proceeding.

47. In any event, the Agency's reliance on Section

400.121(9) in this proceeding is entirely misplaced. 2 As the

language underscored above makes clear, that provision only

relates to proceedings unde r Section 400.121. That statute sets

forth the grounds upon which the Agency may deny, suspend, or

revoke a facility's license or impose a moritorium on admissions

at a facility. None of those issues are involved in this

proceeding. Indeed, Section 400. 121 was not cited by the Agency

as a basis of either its notice of intent to change Shady Rest's

licensure status in DOAH Case No. 02 - 1965 or its Administrative

Complaint in DOAH Case No. 02 - 1291. Moreover, there is nothing

in Section 400.121 suggesting t hat it in anyway relates to a

proceeding to change a facility's licensure status, and the only

portion of the statute relating to administrative fines -- i.e. ,

Section 400.121(2) -- confirms that proceedings under Section

400.121 and Section 400.023(8) are separate and distinct.

Change in Licensure Status (DOAH Case No. 02 - 1965)

48. Section 400.23(7) requires the agency to "assign a

licensure status of standard or conditional to each nursing

home." These statuses are explained as follows:

(a) A stand ard licensure status means

that a facility has no class I or class II

deficiencies and has corrected all class III

deficiencies within the time established by

the agency.

(b) A conditional licensure status means

that a facility, due to the presence of one

or more class I or class II deficiencies, or

class III deficiencies not corrected within

the time established by the agency, is not

in substantial compliance at the time of the

survey with criteria established under this

part or with rules adopted by t he agency.

If the facility has no class I, class II, or

class III deficiencies at the time of the

followup survey, a standard licensure status

may be assigned.

Section 400.23(7)(a) - (b).

49. The change in Shady Rest's licensure status to

conditional was based upon an alleged Class II deficiency, which

is:

a deficiency that the agency determines has

compromised the resident's ability to

maintain or reach his or her highest

practicable physical, mental, and

psychosocial well - being, as defined by an

acc urate and comprehensive resident

assessment, plan of care, and provision of

services.

Section 400.23(8).

50. The Class II deficiency identified at Shady Rest was a

Tag F325 which corresponds to 42 Code of Federal Regulations

Section 483.25(i)(1). That r egulation, which is incorporated by

reference into the Agency's Rule 59A - 4.1288, provides:

(i) Nutrition. Based upon a resident's

comprehensive assessment, the facility must

ensure that a resident --

(1) Maintains acceptable parameters of

nutritiona l status, such as body weight and

protein levels, unless the resident's

clinical condition demonstrates that it is

not possible

(Emphasis supplied).

51. The Agency failed to meet its burden to prove the

existence of a Class II deficiency. The evidence is

insufficient to show that the change in Resident 11's diet

compromised her ability to maintain or reach her highest

practicable physical, mental, and psychosocial well - being. To

the contrary, the weight of the evidence shows that the dietary

change ac tually improved Resident 11's medical condition by

reducing her edema, and it did so without significantly

compromising her nutritional health.

52. The evidence further shows that the dietary change was

medically necessary, was justified based upon Resid ent 11's

conditions and treatment history, and was the result of a

risk/benefit analysis in which Resident 11's physician was

actively involved. In this regard, the weight loss experienced

by Resident 11 was not unplanned; it was expressly directed by

her physician. Moreover, her abnormal albumin levels during

this period were not inconsistent with her typical albumin

levels and were explained by her history of liver problems.

Administrative Fine (DOAH Case No. 02 - 1291)

53. Section 400.23(8)(b) authoriz es the Agency to impose a

civil penalty against the facility for a Class II deficiency.

The amount of the penalty depends on the scope of the

deficiency, i.e. , "$2,500 for an isolated deficiency, $5,000 for

a patterned deficiency, and $7,500 for a widespr ead deficiency."

Section 400.23(8)(b).

54. The deficiency at issue in this proceeding, Tag F325,

was alleged to be a isolated deficiency, cf. Section 400.23(8)

(defining an isolated deficiency as "a deficiency affecting one

or a very limited numb er of residents, . . ."), and the Agency

is seeking to impose a $2,500 fine.

55. In light of the foregoing determination that the

Agency failed to meet its burden of proof with respect to the

change in licensure status, it follows that the Agency did not

meet the higher burden of proof necessary to impose an

administrative fine. Indeed, having failed to prove the

existence of a Class II deficiency at Shady Rest, there is no

basis to impose an administrative fine under Section

400.23(8)(b).

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions

of Law, it is

RECOMMENDED that the Agency for Health Care Administration

issue a final order which:

1. Dismisses the Administrative Complaint against Shady

Rest Care Pavilion in DOAH Case No. 02 - 1291; and

2. Rescinds the notice of intent to assign conditional

licensure status to Shady Rest Care Pavilion in DOAH Case

No. 02 - 1965 and retains the facility's standard licensure

status.

DONE AND ENTERED this 26th day of August, 2002, in

Tallahassee, Leon County, Florida.

___________________________________

T. KENT WETHERELL, II

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675 SUNCOM 278 - 9675

Fax Fi ling (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 26th day of August, 2002.

ENDNOTES

1/ Mr. Godfrey represented the Agency from the inception of these

cases through at least the post - hearing deposition of Robert

Heiser, M.D., which was taken on July 19, 2002. However, the

Agency's Proposed Recommended Order was not filed by

Mr. Godfrey; it was filed by Agency attorney Kathryn F. Fenske.

The case file does not include a notice of appearance f rom Ms.

Fenske, nor does it include a notice of substitution of counsel.

2/ Application of Section 400.121(9) in a penal proceeding such

as DOAH Case No. 02 - 1291 would also raise constitutional

concerns because the statute not only relieves the Agency of its

heightened burden of proof, but it relieves the Agency of any

burden whatsoever. Cf. Osborne , 670 So. 2d at 935 (Due Process

requires agency seeking to impose an administrative fine to meet

a heightened burden of proof because such a proceeding is p enal

in nature and impacts constitutionally - protected property

interests); Ferris v. Turlington , 501 So. 2d 292 (Fla 1987)

(same in cases involving license revocation).

COPIES FURNISHED :

Dennis L. Godfrey, Esquire

Agency for Health Care Administrat ion

525 Mirror Lake Drive, North

Room 310L

St. Petersburg, Florida 33701

Kathryn F. Fenske, Esquire

Agency for Health Care Administration

8355 Northwest 53rd Street, First Floor

Miami, Florida 33166

Karen L. Goldsmith, Esquire

Goldsmith, Grout & Lewis , P.A.

2180 North Park Avenue, Suite 100

Post Office Box 2011

Winter Park, Florida 32790 - 2011

Virginia A. Daire, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive

Fort Knox Building, Suite 3431

Tallahassee, Florida 32308

William Rober ts, Acting General Counsel

Agency for Health Care Administration

2727 Mahan Drive

Fort Knox Building, Suite 3431

Tallahassee, Florida 32308

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.