10-002180 Agency For Health Care Administration vs. Innovative Senior Care Home Health Of Tampa, Llc, D/B/A Innovative Senior Care Home Health Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Friday, July 2, 2010.

due and payable within thirty 30 days of the date of rendition of this

Order

3 Checks should be made payable to the Agency for Health Care

Administration The check along with a reference to these case numbers

should be sent directly to

Agency for Health Care Administration

Office of Finance and Accounting

Revenue Management Unit

2727 Mahan Drive MS 14

Tallahassee Florida 32308

4 Unpaid fines pursuant to this Order will be subject to statutory

interest and may be collected by all methods legally available

5 Respondent s petition for formal administrative proceedings is

hereby dismissed

6 Each party shall bear its own costs and attorney s fees

7 The above styled cases are hereby closed

DONE and ORDERED this day of 2010

in Tallahassee Leon County Florida

Elizal h ud k Interim Secretary

Agen for Health Care Administration

A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED

TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY

OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA AND A

SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW WITH

THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE

AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES

REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH

THE FLORIDA APPELLATE RULES THE NOTICE OF APPEAL MUST BE FILED

WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED

Conies furnished to

Stacey Meyer Esq Andrea M Lang Senior Attorney

Brookdale Senior Living Inc Agency for Health Care

6737 West Washington Street Administration

Suite 2300 2295 Victoria Avenue Room 346C

Milwaukee Wisconsin 53214 Fort Myers Florida 33901

U S Mail Interoffice Mail

Finance Accounting Daniel Manry

Agency for Health Care Administrative Law Judge

Administration Division of Administrative Hearings

Revenue Management Unit The DeSoto Building

2727 Mahan Drive MS 14 1230 Apalachee Parkway

Tallahassee Florida 32308 Tallahassee Florida 32399

Interoffice Mail U S Mail

Jan Mills

Agency for Health Care

Administration

2727 Mahan Drive Bldg 3 MS 3

Tallahassee Florida 32308

Interoffice Mail

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of this Final Order was

served on the above named person s and entities by U S Mail or the

0

method designated on this the day of 2010

Richard Shoop Agency

Agency for Health Care Administration

2727 Mahan Drive Building 3

Tallahassee Florida 32308 5403

850 3630 412

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA

AGENCY FOR HEALTH CARE

ADMINISTRATION

Petitioner

VS Case No 2010000858

INNOVATIVE SENIOR CARE HOME HEALTH OF TAMPA LLC

d b a INNOVATIVE SENIOR CARE HOME HEALTH

Respondent

ADMINISTRATIVE COMPLAINT

COMES NOW the Petitioner State of Florida Agency for Health Care Administration

hereinafter the Agency by and through its undersigned counsel and files this Administrative

Complaint against the Respondent INNOVATIVE SENIOR CARE HOME HEALTH OF

TAMPA LLC d b a INNOVATIVE SENIOR CARE HOME HEALTH hereinafter the

Respondent pursuant to Sections 120 569 and 120 57 Florida Statutes 2009 and alleges as

follows

NATURE OF THE ACTION

This is an action to impose an administrative fine in the amount of SIX THOUSAND

DOLLARS 6 000 00 against a home health agency pursuant to Sections 400 474 and

400 484 2 c Florida Statutes 2009 based upon one repeat Class III deficiency

JURISDICTION AND VENUE

1 This Court has jurisdiction over the subject matter pursuant to Sections 120 569

and 120 57 Florida Statutes 2009

2 The Agency has jurisdiction over the Respondent pursuant to Sections 20 42 and

EXHIBIT

1 I s Z

120 60 Florida Statutes 2009 Chapters 408 Part II and 400 Part III Florida Statutes 2009

and Chapter 59A 8 Florida Administrative Code

3 Venue lies pursuant to Rule 28 106 207 Florida Administrative Code

PARTIES

4 The Agency is the licensing and regulatory authority that oversees home health

agencies and enforces the applicable federal and state statutes regulations and rules governing

home health agencies Chapter 408 Part II and Chapter 400 Part III Florida Statutes 2009

and Chapter 59A 8 Florida Administrative Code The Agency is authorized to deny revoke or

suspend a license or impose an administrative fine for violations as provided for by Section

400 474 Florida Statutes 2009 and Rules 59A 8 003 and 59A 8 0086 Florida Administrative

Code

5 The Respondent was issued a license by the Agency License No 299991676 to

operate a home health agency located at 8695 College Parkway Unit 275 Fort Myers Florida

33919 and was at all material times required to comply with the applicable federal and state

statutes regulations and rules for home health agencies

COUNTI

The Respondent Failed To Implement Treatment And Did Not Follow The Plan Of Care In

Violation Of Section 400 487 2 Florida Statutes 2009 And Rule 59A 8 0215 2

Florida Administrative Code

6 The Agency re alleges and incorporates by reference paragraphs one 1 through

five 5

7 Pursuant to Florida law when required by the provisions of Chapter 464 Part I

Part III or Part V of Chapter 468 or Chapter 486 Florida Statutes 2008 the attending

physician physician assistant or advanced registered nurse practitioner acting within his or her

respective scope of practice shall establish treatment orders for a patient who is to receive

skilled care The treatment orders must be signed by the physician physician assistant or

advanced registered nurse practitioner before a claim for payment for the skilled services is

submitted by the home health agency If the claim is submitted to a managed care organization

the treatment orders must be signed within the time allowed under the provider agreement The

treatment orders shall be reviewed as frequently as the patient s illness requires by the

physician physician assistant or advanced registered nurse practitioner in consultation with the

home health agency Section 400 487 2 Florida Statutes 2008

Pursuant to Florida law home health agency staff must follow the physician

physician assistant or advanced registered nurse practitioner s treatment orders that are

contained in the plan of care If the orders cannot be followed and must be altered in some way

the patient s physician physician assistant or advanced registered nurse practitioner must be

notified and must approve of the change Any verbal changes are put in writing and signed and

dated with the date of receipt by the nurse or therapist who talked with the physician physician

assistant or advanced registered nurse practitioner s office Rule 59A 8 0215 2 Florida

Administrative Code

8 On or about April 9 2007 through April 11 2007 the Agency conducted a

Relicensure Survey of the Respondent s facility

9 Based on a review of eleven 11 clinical records and administrative interview

care did not follow the plan of treatment in four 4 cases specifically Patient number two 2

Patient number five 5 Patient number nine 9 and Patient number ten 10

10 Patient number two 2 was admitted to the home health agency on January 6

2007 with a primary diagnosis listed as Attn REM Surg Dressing R T toe amputation The

patient was receiving skilled nursing visits for wound care A review of the record revealed the

skilled nurse completed daily visits for wound care dressing changes with orders received on

January 17 2007 for skilled nursing to continue daily wound care As of January 17 2007 QD x

9 2 PRNs as needed for soiled or loose dressing Patient scheduled for outpatient surgery on

January 26 2007 for removal of 1st digit of 2nd to left foot Skilled nursing care will resume

post op per MD orders Orders received on January 26 2007 Post op for skilled nursing

Leave op drsg intact Saturday sic January 27 2007 Change drsg on Sunday sic January 28

2007 Adaptic over surgery dry gauze kling Aquacel AG over 3rd web space pack into

cavity gauze kling A further review of nursing notes revealed the nurse made a visit to

Patient number two 2 on January 27 2007

11 The documentation in the record indicated Skilled Nurse assessed the patient

Left foot dressing saturated and dripping blood onto floor Removed dressing 2nd covered with

adaptic Wound on 3rd webspace oozing blood when pressure not applied Secured dressing with

adequate pressure There was no evidence in the record to indicate the nurse notified the

physician and received orders to change the Plan of Care on January 27 2007 From a review of

the record it was noted on January 29 2007 the Director of Nursing notified the physician about

the post op wound and dressing change that was completed on January 27 2007 without benefit

of a physician s order

12 A review of the record for Patient number five 5 revealed a start of care date of

March 28 2007 with orders in the plan of treatment for skilled nursing to complete wound care

observe any systems changes and perform finger stick PT INR Protime International

Normalized Ratio per MD orders

13 During a home visit on April 9 2007 with patient s permission the skilled nurse

at 15 2 m p was observed to perform a pulse oximetry procedure with results 98 on room air

without benefit of a physician s order Patient number five 5 had no respiratory complaints and

was not observed to be in any respiratory distress A further review of the clinical record

revealed there were no physicians orders in the record for this procedure to be done on that day

14 Patient number nine 9 had s physician orders for a nurse to do a finger stick

PT INR Protime International Normalized Ratio on Friday February 9 2007 This was not

done There was no evidence in the record to indicate the nurse notified the physician the test

was not done On February 12 2007 the nurse performed the finger stick test There were no

physicians orders in the record for this procedure to be done on that day

15 A review of the record for Patient number ten 10 revealed a start of care date of

January 11 2007 with a current certification period of March 12 2007 through May 10 2007

and services provided by skilled nursing and physical therapy On March 22 2007 a physician s

telephone order was received for the skilled nurse to repeat a UA Urinalysis C S Culture

Sensitivity three 3 days post antibiotic therapy on January 30 2007 Patient number ten 10

was to take Bactrim DS one 1 tablet BID twice a day for five 5 days A further review of the

record revealed the skilled nurse did not complete a home visit on January 30 2007 and did not

obtain the Urinalysis Culture Sensitivity until April 5 2007 There were no physician s orders

in the record for this procedure to be done on that day

16 An interview with the Director of Nursing on April 11 2007 at approximately

10 30 a m confirmed the Urinalysis Culture Sensitivity had not been completed on January

30 2007 as ordered Per physical therapy orders visits were to be completed two 2 times per

week for five 5 weeks A record review revealed the physical therapist completed only one 1

visit from March 19 2007 through March 26 2007 The record had no explanation for the

missed visit including no evidence the physician was aware of the missed visit and approved this

change to the Plan of Care

17 The Respondent s act omission or practice had an indirect adverse effect on the

health safety or security of a patient constituting a Class III deficiency Section 400 484 2 c

Florida Statutes 2006

18 The Agency cited the Respondent for a Class III violation in accordance with

Section 400 484 2 c Florida Statutes 2006

19 The Respondent was given a mandatory correction date of May 11 2007

20 On or about May 17 2007 the Agency conducted a Follow up visit to the

Relicensure Survey of April 9 2007 through April 11 2007 and determined that the Respondent

had corrected the deficiency

21 On or about December 7 2009 through December 10 2009 the Agency

conducted a Relicensure Survey of the Respondent s facility

22 Based on clinical record review and staff interview the home health agency failed

to ensure six 6 of seventeen 17 sampled patients received care and services in accordance

with the physician s established Plan of Care specifically Patient number one 1 Patient number

five 5 Patient number seven 7 Patient number 9 Patient number twelve 12 and Patient

number seventeen 17

23 Patient number twelve 12 was admitted to the home health agency on August

18 2009 and was recertified for care on October 17 2009 The Plan of Care included specific

orders for the skilled nurse to monitor the s patient weight weekly and notify the physician of a

included the

weight variation of five 5 pounds Documentation in the skilled nurse s notes

patient had 2 to 3 edema swelling of the legs bilaterally The medication regimen of Patient

number twelve 12 included the use of Lasix to help with the fluid retention and decrease the

swelling There was no documentation in the record the skilled nurse monitored Patient number

twelve s 12 weight as ordered

24 An interview on December 9 2009 at 2 50 m p with the Assistant Director of

dated

Nursing confirmed the findings A review of the record noted a physician s order

November 23 2009 to clean Patient number twelve s 12 left buttock ulcer with normal saline

apply skin prep to the peri wound area and cover with a foam dressing

25 During a home visit on December 9 2009 at 10 11 a m the skilled nurse was

observed cleaning Patient number twelve s 12 ulcer The nurse washed her hands with soap

and water and applied a clean pair of gloves She exposed Patient number twelve s 12 buttocks

applied skin prep to the peri wound area and covered with a foam dressing The skilled nurse did

not wash Patient number twelve s 12 wound with the normal saline as per the physician s order

The observation was confirmed by the skilled nurse at the completion of the wound care

26 Patient number seven 7 was admitted to the home health agency on September

10 2009 with diagnoses including but not limited to osteoarthritis of shoulders osteoporosis

and muscle weakness The Plan of Care for the recertification period of November 9 2009 to

January 7 2010 included orders for physical therapy three 3 times a week for three 3 weeks

and occupational therapy three 3 times a week for three 3 weeks A review of the clinical

record on December 9 2009 documented Patient number seven 7 refused several physical

therapy visits November 19 2009 November 25 2009 and November 27 09 Patient number

seven 7 refused several occupational therapy visits November 13 2009 November 19 2009

November 23 2009 and November 27 2009 Patient number seven 7 complained of not

of

feeling well each time There was no documentation in the record the physician was notified

frequent refusal of the therapy visits

27 An interview on December 9 2009 at 4 10 p m with the Administrator confirmed

the findings She stated the physician should have been notified each time and the

communication documented on the missed visit form

28 A review of Patient number one s 1 clinical record noted on March 10 2009 the

physical therapist instructed Patient number one 1 in the use of moist heat to the shoulders

There were no physician s orders for this modality

29 An interview with administrative staff on December 10 2009 at 2 45 p m

confirmed there were no physician s orders in the record

30 Patient number five 5 was admitted to the home health agency s care on August

25 2009 The initial orders on the Plan of Treatment were for the nurse to visit every other day

for seven 7 days There after although there continued to be nursing visits there were no

physician s orders for the visits to be made

31 On October 24 2009 and November 3 2009 the therapist instructed Patient

number five 5 in the use of moist heat to the shoulders and knees There were no physician s

orders for this care in the record

32 This was confirmed with administrative staff on December 7 2009 at 2 00 p m

33 Patient number nine 9 was receiving wound care from the home health agency

Included among the physician s orders was the application of a hydrocolloidal dressing to the

wound A review of the nursing notes for October 26 and October 28 revealed the nurse did not

provide the wound care in accordance to the physician s orders On these two 2 visits the

documentation revealed the application of PolyMem to the wound in addition to the

hydrocolloidal dressing There were no physician s orders for the use of this product The

documentation between October 30 2009 through November 27 2009 noted the nurses added a

foam dressing to Patient number nine s 9 wound There were no physician s orders for the use

of this product

34 Patient number seventeen 17 had physician s orders on the referral dated

November 4 2009 for physical and occupational therapy to provide care to the patient Care was

begun on November 9 2009 and neither of the therapies was provided to Patient number

seventeen 17 There was no explanation noted in the record for not providing the service or

notification of the physician

35 An interview with administrative staff on December 8 2009 at 2 00 p m

indicated they were unsure as to the reason this service did not begin as ordered Later the

administrative staff indicated she thought it was related the Power of Attorney had refused these

services However she agreed there was no documentation in the record to explain the issue

36 The Respondent s act omission or practice had an indirect adverse effect on the

health safety or security of a patient constituting a Class III deficiency Section 2 400 484 c

Florida Statutes 2009

37 The Respondent s deficient act omission or practice constitutes a repeated Class

III deficiency Section 400 484 2 c Florida Statutes 2009

38 The Respondent was given a mandatory correction date of January 10 2010

WHEREFORE the Petitioner State of Florida Agency for Health Care

Administration intends to impose an administrative fine against the Respondent in the amount of

SIX THOUSAND DOLLARS 6 000 00 based upon six 6 occurrences of a repeated Class III

deficiency pursuant to Sections 400 474 and 400 484 2 c Florida Statutes 2009

CLAIM FOR RELIEF

WHEREFORE the Petitioner State of Florida Agency for Health Care Administration

respectfully requests the Court to enter a final order granting the following relief against the

Respondent

1 Make findings of fact and conclusions of law in favor of the Agency

2 Impose an administrative fine against the Respondent in the amount of SIX

THOUSAND DOLLARS 6 000 00

3 Enter any other relief that this court deems just and appropriate

Respectfully submitted on this day of t1 2010

1

Andrea M Lang Assistant General C Ansel

Florida Bar No 0364568

Agency for Health Care Administration

Office of the General Counsel

2295 Victoria Avenue Room 346C

Fort Myers Florida 33901

Telephone [phone]

NOTICE

THE RESPONDENT IS NOTIFIED THAT IT HE SHE HAS THE RIGHT TO REQUEST

AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120 569 AND 120 57

FLORIDA STATUTES IF THE RESPONDENT WANTS TO HIRE AN ATTORNEY

IT HE SHE HAS THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS

MATTER SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN

THE ATTACHED ELECTION OF RIGHTS FORM

THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM

IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION

WITHIN TWENTY ONE 21 DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE

COMPLAINT A FINAL ORDER WILL BE ENTERED

THE ELECTION OF RIGHTS FORM SHALL BE MADE TO THE AGENCY FOR

HEALTH CARE ADMINISTRATION AND DELIVERED TO AGENCY CLERK

AGENCY FOR HEALTH CARE ADMINISTRATION 2727 MAHAN DRIVE

BUILDING 3 MAIL STOP 3 TALLAHASSEE FLORIDA 32308 TELEPHONE 850

922 5873

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and

Election of Rights form have been served to Lisa Suzanne Roberson Administrator Innovative

Senior Care Home Health of Tampa LLC d b a Innovative Senior Care Home Health 8695

College Parkway Unit 275 Fort Myers Florida 33919 by United States Certified Mail Return

Receipt No 7008 1140 0003 8887 7855 and to C T Corporation System Registered Agent for

Innovative Senior Care Home Health of Tampa LLC d b a Innovative Senior Care Home Health

1200 South Pine Island Road Plantation Florida 33919 by United States Certified Mail Return

Receipt No 7008 1140 0003 8887 7862 on this day of Y k r kr 2010

Andrea M Lang Assistant Genera ounsel

Agency for Health Care Administration

Office of the General Counsel

2295 Victoria Avenue Room 346C

Fort Myers Florida 33901

Telephone [phone]

Copies furnished to

Lisa Suzanne Roberson Administrator Andrea M Lang

Innovative Senior Care Home Health of Tampa LLC Assistant General Counsel

d b a Innovative Senior Care Home Health Agency for Health Care Administration

8695 College Parkway Unit 275 Office of the General Counsel

Fort Myers Florida 33919 2295 Victoria Avenue Room 346C

U S Certified Mail Fort Myers Florida 33901

Interoffice Mail

C T Corporation System Registered Agent for Harold Williams

Innovative Senior Care Home Health of Tampa LLC Field Office Manager

d b a Innovative Senior Care Home Health Agency for Health Care Administration

1200 South Pine Island Road 2295 Victoria Avenue Room 340A

Plantation Florida 33324 Fort Myers Florida 33901

U S Certified Mail Interoffice Mail

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA

AGENCY FOR HEALTH CARE

ADMINISTRATION

Petitioner

vs Case No 2010000858

INNOVATIVE SENIOR CARE HOME HEALTH OF TAMPA LLC

d b a INNOVATIVE SENIOR CARE HOME HEALTH

Respondent

ELECTION OF RIGHTS

This Election of Rights form is attached to a proposed action by the Agency for Health Care

Administration AHCA The title may be an Administrative Complaint Notice of Intent to

Impose a Late Fee or Notice of Intent to Impose a Late Fine

Your Election of Rights must be returned by mail or by fax within twenty one 21 days of the

date you receive the attached Administrative Complaint Notice of Intent to Impose a Late Fee or

Notice of Intent to Impose a Late Fine

If your Election of Rights with your elected Option is not received by AHCA within one twenty

21 days from the date you received this notice of proposed action by AHCA you will have given

up your right to contest the s Agency proposed action and a Final Order will be issued

Please use this form unless you your attorney or your representative prefer to reply in accordance

with Chapter 120 Florida Statutes 2009 and Rule 28 Florida Administrative Code

PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS

Agency for Health Care Administration

Attention Agency Clerk

2727 Mahan Drive Mail Stop 3

Tallahassee Florida 32308

Phone [phone] Fax [phone]

PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS

OPTION ONE 1 I admit the allegations of fact and law contained in the Notice of

Intent to Impose a Late Fine or Fee or Administrative Complaint and I waive my right to

object and to have a hearing I understand that by giving up my right to a hearing a action Final Order

will be issued that adopts the proposed agency action and imposes the penalty fine or

OPTION TWO 2 I admit the allegations of fact and law contained in the Notice of

Intent to Impose a Late Fine or Fee or Administrative Complaint but I wish to be heard at

an informal proceeding pursuant to Section 120 57 2 Florida Statutes where I may submit

testimony and written evidence to the Agency to show that the proposed administrative action is

too severe or that the fine should be reduced

OPTION THREE 3 I dispute the allegations of fact and law contained in the Notice of

Intent to Impose a Late Fee the Notice of Intent to Impose a Late Fine or Administrative

Complaint and I request a formal hearing pursuant to Subsection 120 57 1 Florida Statutes

before an Administrative Law Judge appointed by the Division of Administrative Hearings

PLEASE NOTE Choosing OPTION THREE 3 by itself is NOT sufficient to obtain a

formal hearing You also must file a written petition in order to obtain a formal hearing before

the Division of Administrative Hearings under Section 120 57 1 Florida Statutes It must be

received by the Agency Clerk at the address above within 21 days of your receipt of this proposed

administrative action The request for formal hearing must conform to the requirements of Rule 28

106 2015 Florida Administrative Code which requires that it contain

1 Your name address telephone number and the name address and telephone number of

your representative or lawyer if any

2 The file number of the proposed action

3 A statement of when you received notice of the Agency s proposed action

4 A statement of all disputed issues of material fact If there are none you must state that there

are none

Mediation under Section 120 573 Florida Statutes may be available in this matter if the Agency

agrees

License Type Assisted Living Facility Nursing Home Medical Equipment

Other

Licensee Name License Number

Contact Person

Name Title

Address

Street and Number City State Zip Code

Telephone No Fax No E Mail optional

I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency

for Health Care Administration on behalf of the above licensee

Signature Date

Print Name Title

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA

AGENCY FOR HEALTH

CARE ADMINISTRATION

Petitioner

vs Case No s 2010000858

10 2180

INNOVATIVE SENIOR CARE HOME

HEALTH OF TAMPA LLC d b a

INNOVATIVE SENIOR CARE HOME

HEALTH

Respondent

SETTLEMENT AGREEMENT

Petitioner State of Florida Agency for Health Care Administration hereinafter the

Agency through its undersigned representatives and Respondent Innovative Senior Care

Home Health of Tampa LLC d b a Innovative Senior Care Home Health hereinafter

Respondent pursuant to Section 120 57 4 Florida Statutes each individually a party

collectively as parties hereby enter into this Settlement Agreement Agreement and agree

as follows

WHEREAS Respondent is a home health agency licensed pursuant to Chapters 400 Part

III and 408 Part II Florida Statutes Section 42 20 Florida Statutes and Chapter 59A 8 Florida

Administrative Code and

WHEREAS the Agency has jurisdiction by virtue of being the regulatory and licensing

authority over Respondent pursuant to Chapter 400 Part III Florida Statutes and

EXHIBIT

Z

WHEREAS the Agency served Respondent with an administrative complaint on or

about March 17 2010 notifying the Respondent of its intent to impose administrative fines in

the amount of Six Thousand Dollars 6 000 and

WHEREAS Respondent requested a formal administrative proceeding by filing a

Petition for Formal Administrative Proceedings and

WHEREAS the parties have negotiated and agreed that the best interest of all the parties

will be served by a settlement of this proceeding and

NOW THEREFORE in consideration of the mutual promises and recitals herein the

parties intending to be legally bound agree as follows

1 All recitals herein are true and correct and are expressly incorporated herein

2 Both parties agree that the whereas clauses incorporated herein are binding

findings of the parties

3 Upon full execution of this Agreement and subject to the Agency s entry of a

Final Order adopting without amendment the terms of this Agreement Respondent agrees to

waive any and all appeals and proceedings to which it may be entitled including but not limited

to an informal proceeding under Subsection 120 57 2 Florida Statutes a formal proceeding

under Subsection 120 57 1 Florida Statutes appeals under Section 120 68 Florida Statutes and

declaratory and all writs of relief in any court or quasi court of competent jurisdiction and

agrees to waive compliance with the form of the Final Order findings of fact and conclusions of

law to which it may be entitled provided however that no agreement herein shall be deemed a

waiver by either party of its right to judicial enforcement of this Agreement

4 Upon full execution of this Agreement Respondent agrees to pay Four Thousand

Five Hundred Dollars 500 4 in administrative fines to be paid to the Agency within thirty 30

days of the entry of the Final Order

5 Venue for any action brought to enforce the terms of this Agreement or the Final

Order entered pursuant hereto shall lie in Circuit Court in Leon County Florida

6 By executing this Agreement Respondent neither admits nor denies and the

Agency asserts the validity of the allegations raised in the administrative complaint referenced

herein No agreement made herein shall preclude the Agency from imposing a penalty against

Respondent for any deficiency violation of statute or rule identified in a future survey of

Respondent which constitutes a repeat or uncorrected deficiency from surveys identified in

the administrative complaint The parties agree that in such a repeat or uncorrected case the

deficiencies from the surveys identified in the administrative complaint shall be deemed found

without further proof Respondent retains the right to challenge the validity of any such

deficiency and the deficiency identified in the Administrative Complaint

7 No agreement made herein shall preclude the Agency from using the deficiencies

from the surveys identified in the administrative complaint in any decision regarding licensure of

Respondent including but not limited to licensure for limited mental health limited nursing

services extended congregate care or a demonstrated pattern of deficient performance The

Agency is not precluded from using the subject events for any purpose within the jurisdiction of

the Agency Further Respondent acknowledges and agrees that this Agreement shall not

preclude or estop any other federal state or local agency or office from pursuing any cause of

action or taking any action even if based on or arising from in whole or in part the facts raised

in the administrative complaint Notwithstanding the above should the Agency use the

deficiencies from the survey s identified in the Administrative Complaint in any decision

regarding licensure of Respondent Respondent reserves the right to challenge the validity of any

such action before an appropriate tribunal

8 Upon full execution of this Agreement the Agency shall enter a Final Order

adopting and incorporating the terms of this Agreement and closing the above styled case

9 Each party shall bear its own costs and attorney s fees

10 This Agreement shall become effective on the date upon which it is fully executed

by all the parties

11 Respondent for itself and for its related or resulting organizations its successors

or transferees attorneys heirs and executors or administrators does hereby discharge the State

of Florida Agency for Health Care Administration and its agents representatives and attorneys

of and from all claims demands actions causes of action suits damages losses and expenses

of any and every nature whatsoever arising out of or in any way related to this matter and the

Agency s actions including but not limited to any claims that were or may be asserted in any

federal or state court or administrative forum including any claims arising out of this agreement

by or on behalf of Respondent or related facilities

12 This Agreement is binding upon all parties herein and those identified in

paragraph eleven 11 of this Agreement

13 In the event that Respondent was a Medicaid provider at the subject time of the

occurrences alleged in the complaint herein this settlement does not prevent the Agency from

seeking Medicaid overpayments related to the subject issues or from imposing any sanctions

pursuant to Rule 59G 9 070 Florida Administrative Code

SEP 21 2010 TUE 09 44 AM BROOKDALE SENIOR LIVING FAX NO P 02

09 16 2010 TBU 9 16 FA i 2002 002

t

89 10 16 10 12 RW T498 P816 907 F 128

la Respondent agmos dw if eay horde t ba paid under this egrcemmt to the y Ag

not ere paid within thirryone 31 days of entry of the Final Order in this maltmr the Agawy

may deduct amo the rots assessed against dent Rasnot m the Rini Ordeoro or any portion t woo4

owed by Awpandent to 1te Agency from any p at or future finds owed to Respondent by to

Agency and that tare Agency dM bold a lien agibist pmom and iittwo fimds owed to

RMondogt by tbo Agency for said amounts nail paid

15 The undeesiped have read and understand ibis Agreement and have the nut w ft

to lid their ragwtive principals to it I

16 This Agreemart contaixe d b the ontira tmderstiandiag9 end

agereme ofthepathos

17 This Agreenteat prior oral or written agreements betweeat the

I agy supersedea

18 Thie Agreementmay pot be maended axeept in writes Any attempted

aeaignnacttt of this Agreemat ho void

19 All parties agree that a ihcsimila signature sumcoa fvr an original edgoaft

The following mproeanat w hereby admovAWV tW W are duly authorized to eater

Into tbia Avmmea

Sire Arms Aida Wwatae

A fto Deputy Smkbw innovadve Bonier Carc Homo Had

Agency for Heatth Cure Adn g ttat 8695 CoUege Patkway U mit 27

2727 bbban Drive Bldg 41 Pori AQm Florida 33919

Talle nassee F1 08

y3 to

DATED DATED 7 1

SEP 10 2010 FRI 11 00 AM BROOKDALE SENIOR LIVING FAX NO P 07

09 10 10 10 13 FROM T 498 P007 007 F 128

6 I

J Seni Gencral Counsel Andrea M Tang Esq 3

Agency for Health Care Administration Agency for Health Care Administration

2727 Mahan Drivc Mail Stop 3 2295 Victoria Avenue Room 346C

Tallahassee Florida 32308 Ft Myers Florida 33901

DATER 1 1Z2 iQ DATED 1 C

M or Esq

Attorney for Innovative Senior Care Home

Health of Tampa LLC d b a Innovative

Senior Care Home Health

6737 West Washington Street No 2300

Milwaukee Wisconsin 53214

DATED q AI v