04-004635 Agency For Health Care Administration vs. Harbour Health Systems, Llc, D/B/A Harbour Health Center Status: Closed Recommended Order on Friday, June 3, 2005.

Summary: Respondent reduced Petitioner`s license from standard to conditional and asserts a $2500 administrative fine. The Class II deficiencies were not proved. Recommend the reissuance of the standard license with no fine.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

HARBOUR HEALTH CENTER, )

)

Petitioner, )

)

vs. ) Case No. 04 - 4498

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

)

AGENCY FOR HEALTH CARE )

A DMINISTRATION, )

)

Petitioner, )

)

vs. ) Case No. 04 - 4 635

)

HARBOUR HEALTH SYSTEMS, LLC, )

d/b/a HARBOUR HEALTH CENTER, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, the Division of Admini strative

Hearings, by its duly - designated Administrative Law Judge,

Jeff B. Clark, held a final administrative hearing in this case

on March 2, 2005 , in Port Charlotte , Florida.

APPEARANCES

For Petitioner/Respondent Harbour Health Center:

Karen L. Goldsmith, Esquire

Goldsmith, Grout & Lewis, P.A.

2180 North Park Avenue, Suite 100

Post Office Box 2011

Winter Park, Florida 32790 - 2011

For Respondent/Petitio ner Agency for Health Care

Administration:

Eric Bredemeyer, Esquire

Agency for Health Care Administration

2295 Victoria Avenue, Room 346C

Fort Myers, Florida 33901

STATEMENT OF THE ISSUE S

Whether, based upon a preponderance of the evidence, the

Agency f or Health Care Administration (AH C A) lawfully assigned

conditional licensure status to Harbour Health Center for the

period June 17, 2004, to June 29, 2004 ; whether, based upon

cl ear and convincing evidence, Harbour Health Center violated 42

Code of Federal Regulations (C.F.R.) Section 483.25, as alleged

by AHCA; and, if so, the amount of any fine based upon the

determination of the scope and severity of the violation, as

required by Subsection 400.23(8), Florida Statutes (2004).

PRELIMINARY STATEMENT

On November 3, 2004, Harbour Health Systems, LLC, d/b/a

Harbour Health Center (the facility), filed its Petition f or

Formal Administrative Hearing contesting the imposition of a

condi tional license from June 17, 2004, to June 29, 2004, based

on alleged deficiencies noted on a survey conducted on June 14

through 17, 2004. This petition was amended on November 2 4 ,

2004, by the filing of an Amended Petition f or Formal

Administrative Hear ing. In the Notice o f Assignment o f

Conditional Licensure Status , AHCA alleged that, at the time of

the survey, the facility was not in compliance with Chapter 400,

Part II, Florida Statutes ( 2004 ) , based on facts set forth in

the survey report. The surv ey report states that:

Based upon interview, observation, and

record review it was determined the facility

failed to assure that 1 (Resident #16) of

21 active sampled residents received the

necessary care and service to prevent and/or

treat pain in orde r for the resident to

attain and maintain her highest practicable

physical and mental well being; and the

facility failed to ensure communication

between the facility and outside agencies

provi di ng services for 1 residents [sic]

(Resident #10) to attain an d maintain

their [sic ] high est practicable physical and

mental well being; 3) Facility staff failed

to identify [a] sore in 1 (Resident #8).

This is evidenced by; 1) Resident #16

demonstrating pain during a treatment and

not receiving pain medication as ordered;

2) No interdisciplinary care plan between

Hospice and the facility, and a delay in

receiving treatment for an eye infection

resulted due to lack of communication

between Hospice and the nursing department

for Resident #10. 3 ) Resident #8 injurin g

foot by cast friction and facility did not

implement interventions to prevent re -

injury.

This case was designated DOAH C ase No. 04 - 4498 by the Division

of Administrative Hearings.

On November 17, 2004, AHCA filed its Administrative

Compl aint seeking to impose a $2,500 administrative fine for the

deficiencies allege d as a result of the June 14 through 17,

2004, survey. On November 2 4 , 2004, the facility requested an

administrative hearing contesting the proposed fine. This case

was designated DOAH C ase Nu mber 04 - 4635 by the Division of

Administrative Hearings.

An Initial Order was sent to the parties in both cases. On

January 14, 2005, an Order of Consolidation was entered. On

that same day , the cases were scheduled for final hearing on

February 17, 20 05, in Port Charlotte, Florida. On February 1,

2005, a n Order Granting Continuance and Rescheduling Hearing was

entered , granting the facility 's Motion for Continuance and

rescheduling the final hearing for March 2, 2005.

The final hearing took place as r escheduled on March 2,

2005. AHCA presented four witnesses: Donna Houk, r egistered

n urse s pecialist, qualified as an expert in nursing; Barbara

Pescatore, r egistered n urse s pecialist, qualified as an expert

in nursing; Ann Sarantos, Bachelor of Science i n Nursing,

qualified as an expert in nursing; and Marilyn Steiner, a

nursing home evaluator. AHCA int roduced five composite

exhibits, which were accepted into evidence and marked

Petitioner's Exhibits 1 through 5. Documentary exhibits of both

parties wer e accepted into evidence subject to appropriate

consideration of any possible hearsay objections. The facility

presented eight witnesses: Katherine Warden, r egistered n urse;

Alicia Lawrence, r egistered n urse; Lynn Ann Lima, Bachelor of

Science in Nursing ; Gloria Ramirez, Bachelor of Science in

Nursing, qualified as an expert in long - term care nursing;

Cheryl Cobb - Tellos, qualified as an expert in long - term care

nursing; William Lucky, M.D., board certified in wound care;

Cheryl Knott, c ertified n ursing a ssistant; and Catherine

Rollins, l icensed p ract ical n urse. The facility introduced four

composite exhibits which were received into evidence and marked

Respondent's Exhibits 1 through 4. By agreement of the parties,

the deposition of Dr. Michael Brinson taken on March 16, 2005,

was filed with the Clerk of the Division of Administrative

Hearings, on April 13, 2005, and considered as final hearing

testimony.

The two - volume Transcript of Proceedings was filed with the

Clerk of the Division of Administrative Hearings on April 12,

2005. Both parties timely filed Proposed Recommended Orders.

FINDINGS OF FACT

Based upon stipulations, deposition, oral and documentary

evidence presented at the final hearing, and the entire record

of the proceeding, the following relevant findings of fact are

made:

1. A t all times material hereto, AHCA was the s tate agency

charged with licensing of nursing homes in Florida under

Subsection 400.021(2), Florida Statutes (2004), and the

assignment of a licensure status pursuant to S ubsection

400.23(7), Florida Statut es (2004). AHCA is charged with the

responsibility of evaluating nursing home facilities to

determine their degree of compliance with established rules as a

basis for making the required licensure assignment.

Additional ly, AHCA is responsible for conducting federally

mandated surveys of those long - term care facilities receiving

Medicare and Medicaid funds for compliance with federal

statutory and rule requirements. These federal requirements are

made applicable to Flori da nursing home facilities pursuant to

Florida Administrative Code Rule 59A - 4.1288 , which states that

"[n]ursing homes that participate in Title XVIII or XIX must

follow certification rules and regulations found in 42 C.F.R.

§483, Requirements for Long Ter m Care Facilities, September 26,

1991, which is incorporated by reference."

2. The facility is a licensed nursing facility located in

Port Charlotte, Charlotte County, Florida.

3. Pursuant to Subsection 400.23(8), Florida Statu t es

(2004), AHCA must cla ssify deficiencies according to the nature

and scope of the deficiency when the criteria established under

Subsection 400.23(2), Florida Statutes (2004), are not met. The

classification of any deficiencies discovered is, also,

determinative of whether the licensure status of a nursing home

is "standard" or "conditional" and the amount of administrative

fine that may be imposed, if any.

4. Surveyors note their findings on a standard prescribed

Center for Medicare and Medicaid Services (CMS) Form 2567,

ti tled "Statement Deficiencies and Plan of Correction" and

which is commonly referred to as a "2567" form. During the

survey of a facility, if violations of regulations are found,

the violations are noted and referred to as "Tags." A "Tag"

identifies the applicable regulatory standard that the surveyors

believe has been violated, provides a summary of the violation,

sets forth specific factual allegations that they believe

support the violation, and indicates the federal scope and

severity of the noncompli ance . To assist in identifying and

interpreting deficient practices, surveyors use Guides for

Information Analysis Deficiency Determination/Ca tegorization

Maps and Matrices.

5. On, or about, June 14 through 17, 2004, AHCA conducted

an annual recertificat ion survey of the facility. As to federal

compliance requirements, AHCA alleged, as a result of this

survey, that the facility was not in compliance with 42 C . F . R .

Section 483.25 (Tag F309) for failing to provide necessary care

and services for three of 2 1 sampled residents to attain or

maintain their respective highest practicable physical, mental ,

and psychosocial well - being.

6. As to the s tate requirements of Subsections 400.23(7)

and (8), Florida Statutes (2004), and by operation of Florida

Administ rative Code Rule 59A - 4.1288 , AHCA determined that the

facility had failed to comply with s tate requirements and, under

the Florida classification system, classified the Federal Tag

F309 non - compliance as a s tate Class II deficiency.

7. Should the facility be found to have committed any of

the alleged deficient practices, the period of the conditional

licensure status would extend from June 17, 2004 , to June 29,

2004.

Resident 8

8. Resident 8's a ttending physician ordered a protective

device to protect the uninjured left ankle and lower leg from

injury caused by abrasive contact with the casted right ankle

and leg.

9. Resident 8 repeatedly kicked off the protective device,

leaving her uninjured ankle and leg exposed. A 2.5 cm abrasion

was noted on the unp rotected ankle. The surveyors noted finding

the protective device in Resident 8' s bed but removed from her

ankle and leg.

10. Resident 8 was an active patient and had unsupervised

visits with her husband who resided i n the same facility but who

did not s uffer from dementia. No direct evidence was received

on the cause of the abrasion noted on Resident 8's ankle.

11. Given Resident 8's demonstrated propensity to kick off

the protective device, the facility should have utilized a

method of affixing the p rotective device , which would have

defeated Resident 8's inclination to remove it.

12. The facilit y' s failure to ensure that Resident 8 could

not remove a protective device hardly rises to the level of a

failure to maintain a standard of care which compr omises the

resident's ability to maintain or reach her highest practicable

physical, mental or psychosocial well - being. The failure to

e nsure that the protective device could not be removed would

result in no more than minimal discomfort.

Resident 10

13. Resident 10 has terminal diagnoses which include end -

stage coronary artery disease and progressive dementia and

receives hospice services from a local H ospice and its staff.

In the H ospice nurse's notes for Resident 10 , on her weekly

visit , on May 17, 20 04, was the observation that the right eye

has drainage consistent with a cold. On May 26, 2004, the same

H ospice nurse saw Resident 10 and noted that the cold was gone.

No eye drainage was noted. No eye drainage was noted between

that date and June 2, 2004.

14. On June 3, 2004, eye drainage was noted and, on

June 4, 2004, a culture of the drainage was ordered. On June 7,

2004, the l ab report was received and showed that

Resident 10 had a bacterial eye infection with Methicillin

Resistant Staphyloco ccus Aureus (MRSA) bacteria. On June 8,

2004, the attending physician, Dr. Brinson, referred the matter

to a physician specializing in infectious disease , and

Resident 10 was placed in contact isolation. The infectious

disease specialist to whom Residen t 10 was initially referred

was not available, and, as a result, no treatment was undertaken

until a second specialist prescribed Bactrim on June 14, 2004.

15. From June 8, 2004, until June 14, 2004, Resident 10

did not demonstrate any outward manifestati ons of the diagnosed

eye infection. A June 9, 2004, quarterly pain assessment failed

to note any discomfort, eye drainage or discoloration. In

addition to noting that neither infectious control specialist

had seen Resident 10, the nurses notes for this p eriod note an

absenc e of symptoms of eye infection .

16. Colonized MRSA is not uncommon in nursing homes. A

significant percentage of nursing home employees test positive

for MRSA. The lab results for Resident 10 noted "NO WBC'S

SEEN," indicating that th e infection was colonized or inactive.

17. By placing Resident 10 in contact isolation on June 8,

2004, risk of the spread of the infection was reduced, in fact,

no other reports of eye infection were note d during the relevant

period.

18. According to D r. Brinson, Resident 10's attending

physician, not treating Resident 10 for MRSA would have been

appropriate. The infectious disease specialist, however,

treated her with a bacterial static antibiotic. That is, an

antibiotic which inhibits further growth , not a bactericide,

which actively destroys bacteria. Had this been an active

infectious process, a more aggressive treatment regimen would

have been appropriate.

19. Ann Sarantos, who testified as an expert witness in

nursing, opined that there was a l ack of communication and

treatment coordination between the facility and H ospice and that

the delay in treatment of Resident 10's MRSA presented an

unacceptable risk to Resident 10 and the entire resident

population. Hospice's Lynn Ann Lima, a registered nurse,

testified with specificity as to the level of communication and

treatment coordination between the facility and H ospice. She

indicated a high level of communication and treatment

coordination. Dr. Brinson, who, in addition to being

Resident 10's attending physician, was the facilit y's medical

director, opined that Resident 10 was treated appropriately. He

pointed out that Resident 10 was a terminally - ill patient, not

in acute pain or distress, and that no harm was done to her.

The testimony of H ospice Nurse Lima and Dr. Brinson is more

credible.

Resident 16

20. Resident 16 was readmitted from the hospital to the

facility on May 24, 2004, with a terminal diagnosis of chronic

obstructive pulmonary disease and was receiving H ospice care.

Roxanol, a morphine pain medication, had been prescribed for

Resident 16 for pain on a p ro r e n ata (p.r.n.), or as necessary,

basis, based on the judgment of the registered nurse or

attending physician. Roxanol was given to Resident 16 in May

and on June 1 and 2, 2 004 . The observations of the surveyor

took place on June 17, 2004.

21 . On June 17, 2004, at 9:30 a.m ., Resident 16 underwent

wound care treatment which required the removal of her sweater,

transfer from sitting upright in a chair to the bed, and being

pl aced on the left side for treatment. During the transfer and

sweater removal, Resident 16 made noises which were variously

described as "oohs and aahs" or "ows , " depending on the

particular witness. The noises were described as typical noises

for Residen t 16 or evidences of pain , depending on the observer.

22. Nursing staff familiar with Resident 16 described that

she would demonstrate pain by fidgeting with a blanket or

stuffed animal, or that a tear would come to her eye, and that

she would not necessa rily have cr ied out. According to facility

employees, Resident 16 did not demonstrate any of her typical

behaviors indicating pain on this occasion , and she had never

required pain medication for the wound cleansing procedure

before.

23. An order for pai n medication available "p.r.n. , "

requires a formalized pain assessment by a r egistered n urse

prior to administration. While pain assessments had been done

on previous occasions, no formal pain assessment was done during

the wound cleansing procedure. A p ain assessment was to be

performed in the late afternoon of the same day ; however,

Resident 16 was sleeping comfortably. The testimony on whether

or not inquiry was made during the wound cleansing treatment as

to whether Resident 16 was " in pain, " " ok ay , " or " comfortable, "

differs. Resident 16 did not receive any pain medication of any

sort during the period of time she was observed by the surveyor.

24. AHCA determined that Resident 16 had not received the

requisite pain management, and, as a result, Res ident 16’s pain

went untreated , resulting in harm characterized as a State

Class II deficiency. AHCA 's determination is not supported by a

preponderance of the evidence. In the context that the surveyor

considered what she interpreted as Resident 16's a pparent pain,

deference should have been given to the caregivers who regularly

administered to Resident 16 and were familiar with her

observable indications of pain. Their interpretation of

Resident 16's conduct and their explanation for not undertaking

a formal pain assessment are logical and are credible.

CONCLUSIONS OF LAW

25. The Division of Administrative Hearings has

jurisdiction over the subject matter of and the parties to this

proceed in g pursuant to Section 120.569 and Subsection 120.57 (1) ,

Flori da Statutes (2004) .

26. The regulatory provisions of the Code of Federal

Regulations set forth in that section under which A HCA alleges a

violation exists, read as follows:

42 C . F . R . § 483.25 Quality of care.

Each resident must receive and the facility

m ust provide the necessary care and services

to attain or maintain the highest

practicable physical, mental, and

psychosocial well being, in accordance with

the comprehensive assessment and plan of

care .

27. Subsection 400.23(8), Florida Statutes (2004),

provides the definitions of isolated, patterned , and widespread

deficiencies as follows:

An isolated deficiency is a deficiency

affecting one or a very limited number of

residents, or involving one or a very

limited number of staff, or a situation that

occ urred only occasionally or in a very

limited number of locations.

A patterned deficiency is a deficiency where

more than a very limited number of residents

are affected, or more than a very limited

number of staff are involved, or the

situation has occurr ed in several locations,

or the same resident or residents 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 facility.

A widespread deficiency is a deficiency in

which the problems causing the deficiency

are pervasive in the facility or represent

systemic failure that has affected or has

the potential to affect a large porti on of

the facility’s residents.

28. Subsection 400.23(8), Florida Statutes (2004),

requires AHCA to classify alleged deficiencies “according to the

nature and the scope of the deficiency” and to cite the scope as

“isolated, patterned or widespread.”

2 9. Subsection 400.23(8), Florida Statutes (2004), also

requires AHCA to classi fy every alleged deficiency in term s of a

class in accordance with statutory definitions of classes, which

are set forth below:

A class I deficiency is a deficiency that

the agency determines presents a situation

in which immediate corrective action is

n ecessary because the facility’s

noncompliance has caused, or is likely to

cause, serious injury, harm, impairment, or

death to a resident receiving care in a

facility. The condition or practice

constituting a class I violation shall be

abated or eliminate d immediately, unless a

fixed period of time, as determined by the

agency, is required for correction. A class

I deficiency is subject to a civil penalty

of $10,000 for an isolated deficiency,

$12,500 for a patterned deficiency, and

$15,000 for a widespre ad deficiency. . . .

A fine must be levied notwithstanding the

correction of the deficiency.

A class II deficiency is a deficiency that

the agency determines has compromised the

resident’s ability to maintain or reach his

or her highest practicable phy sical, mental

or psychosocial well - being, as defined by an

accurate and comprehensive resident

assessment, plan of care, and provision of

services. A class II deficiency is subject

to a civil penalty of $2,500 for an isolated

deficiency, $5,000 for a patt erned

deficiency, and $7,500 for a widespread

deficiency. . . . A fine must be levied

notwithstanding the correction of the

deficiency.

A class III deficiency that the agency

determines will result in no more than

minimal physical, mental or psychosoci al

discomfort to the resident or has the

potential to compromise the resident’s

ability to maintain or reach his or her

highest practicable physical, mental or

psychosocial well - being, as defined by an

accurate and comprehensive resident

assessment, plan o f care, and provision of

services. A class III deficiency is subject

to a civil penalty of $1,000 for an isolated

deficiency, $2,000 for a patterned

deficiency, and $3,000 for a widespread

deficiency. . . . A citation for a class

III deficiency must spec ify the time within

which the deficiency is required to be

corrected. If a class III deficiency is

corrected within the ti me specified, no

civil penalty shall be imposed.

A class IV deficiency is a deficiency that

the agency determines has the potentia l for

causing no more than a minor negati ve impact

on the resident. If the class IV deficiency

is isolated, no plan of correction is

required.

30. The regulatory provision of the Florida Administrative

Code under which AHCA alleges a violation exists, r eads as

follows:

59A - 4.106 Facility Policies.

(4) Each facility shall maintain

policies and procedures in the following

areas:

* * *

(aa) Specialized rehabilitative and

restorative services

31. In t he conditional licensure case, AHCA ha s the burden

of proving, by a preponderance of the evidence, the existence of

the alleged violation of the referenced Quality of Care

regulatory provision.

32. In the fine case, AHCA has the burden of proving, by

clear and convincing evidence, the existen ce of a violation of

the referenced Quality of Care regulatory provision, before a

fine may be imposed.

33. In the fine case, AHCA has the burden of proving by

clear and convincing evidence, the alleged violation .

Department of Banking and Finance Divisi on of Securities and

Investor Protection v. Osborne Stern and Co. , 670 So. 2d 932

(Fla. 1996).

3 4 . Clear and convincing evid ence requires that the

evidence

. . . must be found to be credible; the

facts to which the witnesses testif y must be

distinctly re membered; the testimony must be

precise and explicit and the witnesses must

be lacking confusion as to the facts in

issue. The evidence must be of such a

weight that it produces in the mind of the

trier of fact a firm belief or conviction,

without hesitan cy, as to the truth of the

allegations sought to be established .

Inquiry Concerning Judge Davey , 645 So. 2d 398, 404 (Fla. 1994)

(quoting Slomowitz v. Walker , 429 So. 2d 797, 800 (Fla. 4 th

DCA 1983)).

3 5 . AHCA must demonstrate by clear and convincing ev idence

both the existence of a violation and the classification of the

deficiency alleged in the Administrative Complaint; Agency for

Health Care Administration v. Blue Haven Retirement, Inc. , Case

No. 02 - 4170 (DOAH May 30, 2003) .

3 6 . AHCA is limited to t he allegations in its

Administrative Complaint, the charging document. See Tampa

Health Care Center v. Agency for Health Care Administration ,

Case No. 01 - 0734 ( DOAH August 22, 2001) .

3 7 . A preponderance of the evidence revealed that the

facility had fa iled to adequately secure a protective device to

protect Resident 8's non - casted ankle and lower leg. While

there is no actual evidence that the abrasion that was noted on

the unprotected ankle was caused by the rough surface of the

cast, it is a probable cause. The facility's failure to secure

the protective device hardly rises to the level of failure to

provide the necessary care and services which compromised

Resident 8’s ability to maintain or reach her highest

practicable physical, mental or psychoso cial well - being, as

defined by an accurate and comprehensive resident assessment,

plan of care, and provision of services. The evidence

demonstrates a Class III deficiency, and, as a result, AHCA has

failed to prove that the facility's failure to secure t he

protective device is a Class II deficiency.

3 8 . AHCA failed to demonstrate a lack of communication

between the H ospice care providers and the facility or the lack

of an interdisciplinary care plan. The delay in treatment of

the colonized MRSA bacteria l infection did not harm Resident 10.

By placing Resident 10 in contact isolation when lab results

revealed MRSA bacterial infection, appropriate precautionary

measures were taken in the event an infectious disease

specialist determined that the MRSA was non - colonized. The care

and treatment provided Resident 10 did not fall below the

requisite standard of care.

3 9 . The care and treatment received by Resident 16 during

her wound cleansing procedure was appropriate. The facility

staff familiar with Resid ent 16 did not believe that she neede d

pain medication. The subjective assessment of the surveyor, who

was exposed to Resident 16 for only a few minutes , is not given

as much credence as is the asse ssments of caregivers who know

Resident 16. AHCA failed to prove that Resident 16's care and

treatment was below the requisite standard of care.

RECOMMENDATION

Based on the for e going Findings of Fact and Conclusions of

Law, it is

RECOMMENDED that a f inal o rder be entered finding :

1. The facility' s failure to s ecure the protective device

to Resident 8's lower leg is not a Class II deficiency, but a

Clas s III deficiency. The facility's care and treatment of

Residents 10 and 16 did not fall below the requisite standard.

The imposition of a conditional license fo r the period of

June 17 to June 29, 2004, is unwarranted . The facility should

have its standard licensure status restored for this period.

2. No administrative fine should be levied.

DONE AND ENTERED this 3rd day of June , 2005 , in

Tallahassee, Leon Co unty, Florida.

S

JEFF B. CLARK

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 3rd day of June , 2005 .

COPIES FURNISHED :

Karen L. Goldsmith, Esquire

Goldsmith, Grout & Lewis, P.A.

2180 North Park Avenue, Suite 100

Post Office Box 2011

W inter Park, Florida 32790 - 2011

Eric Bredemeyer, Esquire

Agency for Health Care Administration

2295 Victoria Avenue, Room 346C

Fort Myers, Florida 33901

Richard Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Station 3

T allahassee, Florida 32308

William Roberts, Acting General Counsel

Agency for Health Care Administration

Fort Knox Building, Suite 3431

2727 Mahan Drive

Tallahassee, Florida 32308

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to subm it 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.