05-000072PL Department Of Health vs. Harvey J. Price, L.P.N. Status: Closed Recommended Order on Tuesday, May 24, 2005.

Summary: Respondent did not make adequate entries in his nurse`s notes for the patient.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, )

BOARD OF NURSING, )

)

Petitioner, )

)

vs. )

) Case No. 05 - 0072 PL

HARVEY J. PRICE, L.P.N., )

)

Respondent. )

)

RECOMMEND ED ORDER

Notice was provided and on March 17 , 200 5 , a formal hearing

was held in this case. Authority for conducting the hearing is

set forth in Sections 120.569 and 1 20.57(1), Florida Statutes

(2004 ). The hearing location was the Alachua County Civil

C ourthouse , 201 East University Avenue , Gainesville, Florida .

The hearing was conducted by Charles C. Adams, Administrative

Law Judge.

APPEARANCES

For Petitioner: Judith A. Law, Esquire

J. Blake Hunter, Esquire

4052 Bald Cypre ss Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

For Respondent: Harvey J. Price, pro se

Post Office Box 99

High Springs, Florida 32655

STATEMENT OF THE ISSUE

Should discipline be imposed by Petitioner against

Respondent's license to practice as a licensed practical nurse

(L . P . N . )?

PRELIMINARY STATEMENT

On September 23, 2004, Petitioner through its

Administrat ive Complaint in Case No. 200 3 - 16450 charged

Respondent in three count s with violations pertaining to his

practice as a L . P . N. The details of th e Administrative

C omplaint are discussed in the Conclusions of Law in this

Recommended Order. Respondent was provided an opportunity to

respond to the A dministrative C omplaint through a form referred

to as an " Election of Rights. " H e chose option three in the

election process pertaining to a formal hearing pursuant to

Section s 120.569(2)(a) and 120.57(1), Flori da Statutes, given

his contest o f the factual allegations and pr ovisions of law set

out in the A dministrative C omplaint.

On January 6, 2005, the case was received by the Division

of Administrative Hearing s (DOAH) calling for the assignment of

an administrative law judge to conduct the formal hearing. The

case was assigned DOAH Case No. 05 - 0072PL to be heard by the

undersigned. Following notice , the hearing took place on the

aforementioned date.

Petitioner presented Gloria Brown, L.P.N. , Meiko D. Mills,

R . N . , M . S . N . , A . R . N . P . , and Alice Bostick, as it witnesses.

Petitioner's Exhibits numbered one through five were admitted as

evidence. Petitioner's request for admissions propounded to

Respondent numbered one through eight and twelve through fifteen

were admit ted and form the basis for fact - finding in the

Recommended Order. Respondent testified in his own behalf.

Respondent did not offer exhibits.

On April 20, 2005, a hearing t ranscript was filed with

DOAH. On April 28, 2005, Petitioner filed a proposed

recommended order which has been considered in preparing the

Recommended Order .

FINDINGS OF FACT

Findings Established by Request for Admissions :

1. Petitioner is the State of Florida department charged

with regulating the practice of nursing pursuant to Section

20.43, Florida Statutes, Chapter 456, Florida Statutes, and

Chapter 464, Florida Statutes.

2. Respondent is and has been at all time material to the

complaint a L . P . N . in the State of Florida, having been issued

license number 9246217.

3. Respondent's address of record is Post Office Box 99,

High Springs, Florida 32655 - 0099.

4. At all times material to this case, Respondent was

employed as a L.P.N. by Suwannee Home Care and Medical

Personnel, a staffing agency.

5. At all times material to this case, Respondent was

assigned to work as a L.P.N. at Alachua Nursing and

Rehabilitation in Gainesville, Florida (A lachua).

6. At all times material to this case, Alachua in

Gainesville, was a licensed rehabilitation facility as defined

in Section 400.021(13), Florida Statutes.

7. At all times material to this case, Patient E.D. was

admitted to Alachua (having been admitted) on June 20, 2003,

with a diagnosis of status post CVA (stroke) .

8. On or about June 21, 2003, Respondent was assigned to

ca re for E.D. on the 3 to 11 p.m. shift, and at the end of the

shift, Respondent reported to the oncoming nurs e that he

as sisted with the car e of E.D. and that E.D. was okay and in no

acute distress.

9. Respondent's nurse's notes regarding the care he

provided to patient E.D. d o not mention whether he suctioned the

tracheostomy care being provided; and do not contain any

ph ysical assessment of the patient.

10. Respondent should have performed and documented

tracheostomy care, including but not limited to frequency of

suctioning, amount of color of sputum suctioned, cleaning of the

tracheostomy device, oral hygiene, and met hod of communication

with the patient.

11. Respondent should have performed and documented a

physical assessment of the patient that included respiratory

rate and effort, color , pulse rate, and exertional level.

12. Respondent should have monitored and followed up on

patient E.D.'s vital signs.

Additional Facts:

13. Alice Bostick, is a Medical Malpractice Investigator

for Petitioner. She was involved in the investigation leading

to the drafting of the Administrative Complaint. As part of the

process she attempted to notify Respondent of the allegations

made against him. On July 15, 2003, she sent a letter of

notification to Respondent at an address obtained from a

printout of license information associated with Respondent.

That address was 13134 No rth 22nd Street, Apartment 109, Tampa,

Florida 33612. The information sent to Respondent was a Uniform

Complaint Form and a Nursing Home Adverse Incident Report. The

information sent to Respondent was returned as undeliverable and

not subject to forwardi ng , absent a forwarding request made from

Respondent to the U.S. Postal Service.

14. Having failed to notify Respondent at the Tampa

address, Ms. Bostick took advantage of a ccess which the

Petitioner has to the Florida Department of Highway Safety and

Mo tor Vehicles r ecords to locate Respondent's address maintained

by the other state agency. The address provided by the other

agency was Post Office Box 99 , High Springs, Florida 32655 - 0099.

This was the proper address. Utilizing the new address, the

same information was dispatched a second time from Petitioner to

Respondent. This time it was not returned as undelivered.

Instead Respondent contacted Petitioner's office in person and

by his remarks made it known that he received the communication

from Pet itioner concerning the investigation.

15. A t times relevant to this case Respondent worked for

the Suwannee Valley Nursing Agency. That a gency assigned him to

work on a shift at Alac hua, now the Manor of Gainesville.

16. On June 21, 2003, Respondent worked the 3:00 p.m., to

11:0 0 p.m., shift at Alachua . One of the resident's in his care

at that time was E.D.

17. Resident E.D. was born on May 18, 1920. She had been

released from the hospital on June 20, 2003, and transferred to

Alachua. She was receiving oxygen. P hysician's orders called

for tracheostomy care ( trach care ) to be administered "Q 6

hours." She had a cathe te r which was last changed on the date

of her release from the hospital . The order indicated that the

catheter should be change d every Friday beyond that point. The

resident was being fed by tube.

1 8 . As Respondent describes it , E.D. was among 30 patients

in his care on the shift. Other residents included p ersons with

G - tubes and insulin - dependent diabetics. Respondent was ve ry

busy during his shift helping the residents.

19 . Another staff member at the nursing home reminded the

Respondent that he needed to suction E.D's trach . At some point

in time Respondent and the other staff member suctioned the

trach . When this func tion was performed during the shift is not

established in the nursing home record pertaining to resident

E.D. , a s that record was presented at the hearing . T herefore it

was not shown an entry was made in the resident's record for

care confirming the sucti oning of the trach .

20 . The only reference to patient E.D. made in writing by

Respondent presented at hearing , was from nursing notes related

to resident E.D. In the nurse ' s note Respondent made an entry

at the end of his shift as to vital signs for the resident ,

pulse rate 92, respiration rate 24 and a notation that

Respondent " A ssisted e - care no acute distress noted."

21 . Contrary to the nurse ' s note made by Respondent ,

resident E.D. was in distress as discovered by Gloria Brown,

L.P.N. , who c ame on shift to work from 11:00 p.m. June 21, 2003,

until 7:00 a.m. June 22, 2003.

22 . Ms. Brown was familiar with the need to suction a

trach and to make appropriate entry in the nursing notes in

caring for a trach patient . Notes are also made in relation to

oxygen saturation for that resident if a doctor's order calls

for that entry. Ms. Brown properly expect ed the prior shift

nurse to notify her concerning the resident's condition as to

the number of li ters of O 2 provided the resident and if the

resident had a fever. If the resident had a Foley c atheter

placed reference would be made to that circumstance. Generally

if the resident was experiencing a problem, Ms. Brown would

expect the outgoing nurse to mention that fact.

2 3 . On June 21, 2003, at 11:45 p.m., as Ms. Brown

described in the nursing notes , " O n first rounds observed

resident E.D. with shallow breathing, skin color grayish, O 2 on a

2 liter per trach mask. Attempt to suctio n, felt resistance.

Sat. 24. O 2 increased to three liters. Able to palpate pulse.

911 was calledansported to Shands at UF via 911.

Respiratory distress."

24. Resident E.D. was transported to Shands Hospital at

12:00 midnight. When resident E.D. was transported to the

hospital she was experiencing respi ratory distress. She had a

baseline level of consciousness in the alert range.

25 . Petitioner presented an expert to comment on

Respondent's care rendered resident E.D. in the context of the

allegations set forth in the A dministrative C omplaint. That

expert was Meiko D. Mills, R . N . , M . N . S . , A . R . N . P. Ms. Mills is

licensed to practice nursing in Florida. She has a business

that involves the preparation f or graduate s of L.P.N. schools

and R . N . schools to take the National Licensing Examination for

those fields.

2 6 . Ms. Mills is familiar with trach care. She has had

occasion to write nursing notes pertaining to tr a c h care. She

is generally familiar with the requirements for nursing notes in

the patient record concerning any form of patient care render ed

by the nurse practitioner. She was recognized in this case as

an expert in the field of nursing related to patient care and

L.P.N.s .

27 . In providing trach care, Ms. Mills re fers to the need

for a sterile environment and the part of the trach device that

she refers to as a tube , requires a lot of cleaning because of

secretion s from the patient. She describes the fa c t that the

trach device will form a crust . As a result the center portion

of the device sometimes has to be taken out and soaked in

ster ile water to clean it . The suctioning process associated

with trach care involves the use of a suctioning machine in

which all the encrustations and saliva are removed. It is

possible for a hard mucus plug to form if suctioning is not done

appropriately, according to Ms. Mills .

28 . Ms. Mills express ed her opinion concerning

Respondent's care provided resident E.D. , as to a reasonable

degree o f certainty a n d whether Respondent met the minimal

standards f or acceptable and prevailing care and treatment of

E.D. She described that care as l ac king. Ms. Mills comments

that the nursing note that was made by Respondent at the end of

his shift was inadequate in describing the kind of care provided

to the r esident. In particular she describes the lack of

refe rence to the trach issue and the oxygen saturation issue .

S he perceives that E.D. required considerable attention and that

attention is not reflected in the nursing note.

2 9 . As a person responsible for providing care to E.D.,

who had a trach , Ms. Mills refers to the need for the Respondent

to establish a baseline at the beginning of the shift. That

baselin e is constituted of vital signs and oxygen saturation , as

well as a basic assessment of the resident. There was the need

to compare the vital sign s assessment to the shift before

Respondent came on duty to gain an impression of any trend s .

The observations by Respondent should have been documented in

nursing notes beginning with the baseline as to vital signs,

oxygen sat uration, reference to the cond ition of the trach ,

respiratory effort and so forth, and there was the need to go

back and reassess over time.

30 . As Ms. Mills explains the resident's condition was

reaching an abnormal state on the shift before. Without entries

concerning the resident 's condition , the assumption is made by

Ms. Mills , that the patient care and in particular trach care

was not performed by Respondent .

31 . Ms. Mills refers to a normal pulse rate as 80 to 100,

but Ms. Mills cautions her students that a pulse rate close t o

100 bears watching. A respiration rate approaching the highest

normal demands a ttention. Anyt hing above that creates concern.

Higher readings tend to manifest themselves with shallower

breathing by patient at more frequent intervals , given the

body's attempt to compensate for a lack of oxygen. To address

this condition a baseline oxygen saturation should be

established at the beginning of a shift to help set a plan of

care. A resident such as E.D. with a pulse rate of 97 and

respiration rate of 24 is a person who needs t o be closely

monitored. There was no re c ord by Respondent refl ecting the

establishment of monitoring to address the se circumstances . The

resident ' s progress should have been noted as to pulse rate and

respiration rate several times d uring Respondent's shift, as

Ms. Mills perceives it. Respondent should have also notified

the oncoming nurse for the following shift tha t the patient wa s

not doing well. T his was not done.

32 . Overall , Ms. Mills feel s that Respondent was deficient

in h is documentation concerning resident E.D. through the

nursing notes . The general comment by Respondent that he

assisted with care is not sufficient to establish that trach

care was performed in Ms. Mills opinion.

33 . According to Ms. Mills , some of the vital signs

reflected in the resident 's record would create the possibility

that they were in relation to a mucus plug in the trach .

34 . When the Resident E.D. was transported from the

nursing home on June 21, 2003, at 11:30 the oxygen sat uration at

that time was 78 percent and her pulse was 159. I n Ms. Mills

opinion those values represented the fact that the resident was

in distress.

35 . Ms. Mills believes that Respondent engaged in

unprofessional conduct by acts of omission.

3 6 . Ms. Mills compared the nursing notes made by

Respondent to those made by nurses on t he prior two shifts at

the nursing home . T he prior notes were described as good notes

talking about the care, while Ms. Mills did not get the same

feeling about the notes made by Respondent.

37 . Ms. Mills compared the circumstances when Respondent

came on shift when resident E.D. had a pulse of 100 and

respiration rate of 20 and the change from the respiration of 20

to the respiration rate of 24 at the end of the shift, as

indicating that th e resident had shallow compensatory

respiration because of a lack of oxygen. This leads Ms. Mills

to the conclusion that the vital signs look worse and the person

was significantly compromised over the day. Whether this

circumstance was brought about by the formation of a plug due to

a lack of trach care, Ms. Mills is not certain , but the vital

signs indicate that the resident was sufficient ly compromised to

alert a health professional to that possibility . Earlier in the

day the resident had a r espiratio n rate of 28 and a pulse of

110 . T he change in those values over time up through the

Respondent's shift did not ind icate improvement in resident's

condition in Ms. Mills' opinion.

38 . Ms. Mi lls ' opinions that have been described are

accepted.

3 9 . Based upon the facts found and Ms. Mills ' expert

opinion, Respondent failed to meet minimal standards of

acceptable and prevailing nursing practice in the care provided

resident E.D.

CONCLUSIONS OF LAW

40 . The Division of Administrative Hearings has

juris diction over the parties and the subject matter of this

proceedings i n accordance with Sections 120.569, 120.57(1), and

456.001( 5 ), Florida Statutes (200 4 ) .

41 . The A dministrative C omplaint left open the possibility

that the Board of Nursing would ente r a final order imposing

suspension or permanent revocation as discipline against

Respondent's license to practice nursing. Consequently, t o

prove the allegations in the A dministrative C omplaint,

Petitioner must do so by clear and convincing evidence. Se e

Department of Banking and Finance, Division of Securities and

Investor Protection v. Osborne Stearn and Company , 670 So. 2d

932 (Fla. 1996); Ferris v. Turlington , 510 So. 2d 292 (Fla.

1987).

42 . The meaning of c lear and convincing evidence has been

ex plained in the case I n re: Davey , 645 So. 2d 398 (Fla. 1994),

quoting with approval from Slomowitz v. Walker , 429 So. 2d 797

(Fla. 4th DCA 1983).

43 . The material allegations in the Administrative

Complaint are:

1. Petitioner is the state department

charged with regulating the practice of

nursing pursuant to Section 20.436, Florida

Statutes ; Chapter 456, Florida Statutes ; and

Chapter 464, Florida Statutes .

2. At all times material to this Complaint,

Respondent was a licensed practical nurse

(L.P.N. ) within the state of Florida, having

been issued license number 924621.

3. Respondent 's current address of record

is P.O. Box 99, High Springs, Florida 32655 -

0099.

4. At all times material to this Complaint,

Respondent was employed as a L.P.N. by

Su wannee Home Care and Medical Personnel, a

staffing agency. On June 21, 2003,

Respondent was assigned to work as a L . P . N .

at Alachua Nursing and Rehabilitation in

Gainesville, Florida (Alachua).

5. Patient E.D. was a then eighty - three

year - old woman who had been admitted to

Alachua on June 20, 2003, with a diagnosis

of status post CVA (stroke) and she had a

tracheostomy that required regular care and

suctioning.

6. On or about June 21, 2003, Respondent

was assigned to care for E.D. on the 3 to 11

p.m. shift. At the end of the shift,

Respondent reported to the oncomning nurse

that E.D. was okay and in no acute distress.

Respondent recorded in the nurses notes at

11 p.m. that E.D. had 130/80 blood pressure,

98.1 temperature, 97 pulse rate, 24

respi ratory rate. He also reported in the

notes that he had assisted with care and no

acute distress was noted.

7. On or about June 21, 2003, at 11:45

p.m., the nurse from the next shift made

rounds and found E.D. to be in respiratory

distress, with grey s kin color, shallow

respirations and oxygen saturation at 24%

(95 - 100% is normal). The nurse was unable

to suction the hard mucous plug from the

trache o stomy tube and immediately called

911. Patient E.D. was transferred to the

hospital where a hard mucous plug was

finally suctioned from the tracheostomy

device.

8. Respondent 's nurse's notes regarding the

care he provided to Patient E.D. do not

mention whether he suctioned the

tracheostomy device at any time during his

shift; do not document any trache ostomy care

being provided; and do not contain any

physical assessment of the patient.

9. At a minimum, Respondent should have

performed and documented tracheostomy care,

including but no limited to, frequency of

suctioning, amount and color of sputum

suctioned, cleaning of the tracheostomy

device, oral hygiene, and method of

communication with the patient.

Additionally, Respondent should have

performed and documented a physical

assessment of the patient that included

respiratory rate and effort, color , pulse

rate, and exertional level.

10. Respondent should have monitored and

followed up on Patient E.D. 's vital signs

because the patient's pulse rate was high

normal as occurs in cases of compromised

respirations and the rate of respiration was

24 p er minute (normal is 12 - 18). Oxygen

saturation should have been determined at

the beginning of the shift and any deviation

from that baseline should have been

monitored, especially when the patient

showed signed of hypoxia (low oxygen).

11. On or about July 15, 2003, the

department attempted to contact the

Respondent by mail to give Respondent

notification of the pending investigation, a

copy of the Uniform Complaint Form, and

supporting documentation. This notification

letter was sent to Respondent 's then address

of record. The notification letter was sent

to Respondent 's then address of record.

This notification was returned to the

department by U.S. Postal Service on

July 29, 2003, marked, "no forward order on

file, unable to forward."

12. On or about August 5, 2003, the

department forwarded the notification letter

to P.O. Box 99, High Springs, Florida, an

address that was provided from the

Department of Highway Safety and Motor

Vehicles.

13. On or about October 3, 2003, the

Respondent finally updated his official

address of record to his correct address.

44 . Count O ne of the A dministrative C omplaint accuses

Respondent of violating Section 464.018(1)(n), Florida Statutes

(2002), which states:

(1) The following acts constitute g rounds

for denial of a license or disciplinary

action, as specified in s. 456.072(2):

* * *

(n) Failing to meet minimum standards of

acceptable and prevailing nursing practice,

including engaging in acts for which the

licensee is not qualified by training or

experience.

45 . Count Two o f the A dministrative C omplaint accuses

Respondent of violating Section 464.018(1)(h), Florida Statutes

(2002), referring to:

Unprofessional conduct, as defined by

b oard rule.

4 6 . The Board rul e referred to in Count Two is Florida

Administrative Code Rule 64B9 - 8 . 005(1)(e) which states:

(1) Unprofessional conduct shall include:

* * *

(e) Acts of negligence either by omission

or commission .

47 . Concerning Counts O ne and T wo , Respondent is said to

have violated the statute and rule in the following manner:

a. By failing to mention the tracheostomy

in his end shift report and nurses notes;

b. By failing to provide or failing to

document having provided tracheostom y care,

including frequency of suctioning, amount

and color of sputum suctioned, cleaning of

the tracheostomy device, oral hygiene, and

method of communication with the patient;

c. By failing to perform and document a

physical assessment of the patient,

including respiratory rate and effort,

color, pulse rate, and exertional level;

d. By failing to monitor and follow up on

Patient E.D.'s elevated pulse rate;

e. By failing to monitor and follow up on

Patient E.D.'s elevated rate of respiration;

and

f. By failing to determine a baseline for

oxygen saturation for the patient at the

beginning of the shift and failing to

monitor the oxygen saturation when the

patient showed signs of hypoxia (low

oxygen).

48 . Count T hree accuses Respondent of violating Section

456.072(1)(k), Florida Statutes (2003), which states:

The following acts shall constitute grounds

for which the disciplinary actions specified

in su bsection (2) may be taken:

* * *

(k) Failing to perform any statutory or

l egal obligation placed on a licensee. . . .

4 9 . The discipline that may be imposed for a violation of

Section 456.072(1)(k), Florida Statutes ( 2003 ), is as set forth

in Section 456.072(2), Florida Statutes (2003) .

50 . In relation to Count T hree, Sect io n 456.001(4),

Florida Statutes , states:

' Health care pract itioner ' means any person

license d under . . . chapter 464 . . .

51 . In relation to Count T hree, Section 456.035, Florida

Statutes (2003) , states :

(1) Each licensee of the department is

solely responsible for notifying the

department in writing of the licensee's

current mailing address and place of

practice, as defined by rule of the board or

the department if there is no board.

Electronic notification shall be allowed by

the department; howev er, it shall be the

responsibility of the licensee to ensure

that the electronic notification was

received by the department. A licensee's

failure to notify the department of a change

of address constitutes a violation of this

section, and the licensee ma y be disciplined

by the board or the department if there is

no board.

(2) Notwithstanding any other law, service

by regular mail to a licensee's last known

address of record with the department

constitutes adequate and sufficient notice

to the licensee f or any official

communication to the licensee by the board

or the department except when other service

is required under s. 456.076.

52 . Based upon the statutory references quoted in relation

to C ount T hree, Respondent is accused of the failure to noti fy

the Petitioner in writing of his current mailing address and

place of practice.

53 . References in C ount O ne through C ount T hree to the

Florida Statutes and Florida Administrative Code concerning the

text within those references have remained constant from the

time that the events were alleged to have occurred until the

present , notwithstanding revisions to Florida S tatutes or the

Florida Administrative Code.

54 . Clear and convincing evidence has been presented to

find Respondent in violation of Counts O n e and T wo . Respondent

failed to meet minimal standards of acceptable and prevailing

nursing practice and engaged in unprofessional conduct through a

negligent act of omission in carrying for Resident E.D. The

facts found and the opinion testimony offe red by Ms. Mills form

the basis for this conclusion , when compared to the underlying

allegations in the Administrative Complaint which are referenced

in these conclusions of law.

55 . Clear and convincing evidence has been presented to

establish the vio lation alleged in Count T hree . Respondent

failed to comply with the requirements to maintain his current

mailing address with Petitioner as required by Section 456.035,

Florida Statutes (2003), and by this failure did not perform a

statutory obligation pl aced upon him in violation of Section

456.072(1)(k), Florida Statutes (2003).

56 . Having found the violations, discipline may be imposed

pursuant to Section 456.072(2), Florida Statutes (2002), and

Section 456 .072(2), Florida Statutes (2003).

RECOMMEN DATION

Upon consideration of the facts found and the conclusions

of law reached, it is

RECOMMENDED:

That a final order be entered finding Respondent in

violation of those provisi ons of law set forth in Counts O ne

through T hree , calling for a written repr imand for those

violations, imposing an administrative fine of $500.00 , and

placing Respondent on probation for a period of two years.

DONE AND ENTERED this 24th day of May, 2005 , in

Tallahassee, Leon County, Florida.

S

________________________________ ___

CHARLES C. ADAMS

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 Cl erk of the

Division of Administrative Hearings

this 24th day of May, 2005 .

COPIES FURNISHED :

Judith A. Law, Esquire

J. Blake Hunter, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

Harvey J. Price

Po st Office Box 99

High Springs, Florida 32655

Dan Coble, Executive Director

Board of Nursing

Department of Health

4052 Bald Cypress Way

Tallahassee, Florida 32399 - 1701

R. S. Power, Ag en cy Cl erk

Department of Health

4052 Bald Cypress Way, Bin A02

Tallaha ssee, Florida 32399 - 1701

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 exc eptions

to this Recommended Order should be filed with the agency that

will issue the final order in this case.