13-004286MPI Agency For Health Care Administration vs. Angels Unaware, Inc. Status: Closed Recommended Order on Wednesday, April 2, 2014.

Summary: The Agency for Health Care Administration presented evidence to support the overpayment to Respondent.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Petitioner,

vs. Case No. 13 - 4286MPI

ANGELS UNAWARE, INC.,

Respondent.

_______________________________/

RECOMMENDED ORDER

Pursuant to noti ce, a n administrative hearing was conducted

in this case on January 9, 10, and 27, 2014 , in Tallahassee,

Florida, before Lynne A. Quimby - Pennock, an Administrative Law

Judge with the Division of Administrative Hearings (DOAH).

APPEARANCES

For Petitioner: Douglas James Lomonico, Esquire

Shena Grantham, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308 - 5407

For Respondent: Frank P. Rainer, Esquire

Broad and Cassel

Suite 400

215 South Monroe Street

Tallahassee, Florida 32301 - 1804

STATEMENT OF THE ISSUE

Whether the Agency for Health Care Administration (Agency)

is entitled to recover alleged Medicaid overpayments, sanctions ,

and investigative, legal and expert witness costs from Angels

Unaware , Inc. (Respondent ).

PRELIMINARY STATEMENT

On December 11, 2012, the Agency issued a Final Audit

Report (FAR) advising Respondent of its intention to seek

reimbursement of $50,357.90 in alleged Medicaid overpayme nts,

$10,071.58 in administrative fines, and $4,914.14 in costs from

Respondent based on Medicaid claims made by Respondent under

Provider No. 024115696 from January 1, 2008, through December 31,

2009 (the audit period). The FAR also notified Respondent t hat

it had the right to request an administrative hearing within

21 days from the receipt of the letter.

Respondent timely requested an administrative hearing under

section 120.57, Florida Statutes (2012), and on February 13,

2013, the Agency referred the case to DOAH. On February 22, a

Joint Motion to Relinquish Jurisdiction was filed, and the

original DOAH case was closed with leave to reopen it should the

parties be unable to execute a settlement.

On November 5, 2013, a Motion to Reopen and Set Forma l

Hearing was filed and the above case number was assigned. On

November 14, the case was set for final hearing for January 9

and 10, 2014, and an Order of Pre - hearing Instructions was issued

setting forth the discovery timeline and filing instructions.

On December 10, 2013, the Agency filed its witness

disclosure notice, and on December 11, the Agency filed an

Unopposed Motion to Restrict the Use and Disclosure of

Information Concerning Medicaid Applicants and Beneficiaries. On

December 12, this motion was granted. On December 20, Respondent

filed a Motion for Continuance, and the Agency filed its Response

to Motion for Continuance on December 23. An Order denying the

continuance was issued on December 30. On January 6, 2014, the

Agency filed its Preh earing Stipulation . 1/ Therein, the Agency

revised the amount of the overpayment to $48,525.83. On

January 6, Respondent filed it s witness and proposed exhibit

list. On January 7, Respondent ' s Joinder and Additional Items of

Agreement with Petitioner ' s Prehearing Stipulation was filed.

The Agency ' s Motion to Strike Respondent ' s Witness List was filed

later on January 7.

The hearing commenced on January 9, 2014. The Agency

withdrew its Motion to Strike Respondent ' s Witness List after

Respondent announc ed its witnesses for the hearing. The parties

stipulated that the statistical formula used by the Agency was an

appropriate method for the determination of the amount of the

overpayment within the meaning of section 408.809(5)(a), Florida

Statutes (2013) , 2/ such that no additional testimony or evidence

was required on the statistical information. Additionally, the

Agency announced another downward revision of the amount of the

overpayment it was seeking. In reducing the overpayment amount,

the sanction w as also reduced. At the end of the second hearing

day, testimony had not been completed, and by mutual agreement,

the case was continued to and concluded on January 27.

At the hearing, the Agency presented the testimony of Robi

Olmstead, the case manageme nt unit (CMU) manager for the Agency ' s

Office of Medicaid Program Integrity (MPI) ; Kristen Koelle, a

special projects coordinator and a former medical health care

program analyst/investigator with the CMU; and Gregory Riley, an

Agency registered nurse (RN) consultant. The Agency offered

Exhibits 1 through 13, 3/ which were received into evidence without

objection, and Exhibits 15 4/ and 16, 5/ which were received into

evidence over Respondent ' s objection. Without objection,

official recognition was taken of the relevant handbooks: the

Developmental Disabilities Waiver Services Handbook dated

November 5, 2007; the Developmental Disabilities Waiver Services

Handbook dated November 26, 2008; the Provider General H andbook

dated July 2008; and the Provider Genera l H andbook dated January

2007; and the applicable statutes and rules.

Respondent presented the testimony of Ross O ' Banion, Jr.,

executive director of Respondent; James Epperson, personnel

director of Respondent; and Sonya Seabrook, licensed practical

nurs e (LPN) and home manager of Respondent. Respondent o ffered

composite Exhibit 1 , which was admitted over the Agency ' s

objections.

At the close of the hearing, Respondent requested 30 days

from the filing of the transcript within which to file proposed

reco mmended orders (PROs). The request was granted.

The five - volume Transcript of these proceedings was filed on

February 10, 2014. On March 11, the Agency ' s Notice of Filing

Cost Affidavits was filed at DOAH along with five affidavits.

These affidavits hav e not been reviewed as the parties were

advised that any costs would be resolved at a later time. Both

parties timely filed a PRO, and both have been duly considered by

the undersigned in the preparation of this Recommended Order.

FINDING S OF FACT

PRELIMI NARY

1. The Agency is the state agency responsible for

administering the Florida Medicaid Program (Medicaid). Medicaid

is a joint federal/state partnership to provide health care and

sometimes related services to certain qualified individuals

(disabled o r indigents). Among its duties, the Agency is

required to conduct audits and to recover " overpayments . . . as

appropriate. "

2. Section 409.913(1)(e), Fl orida Statutes , defines

" overpayment " to mean " any amount that is not authorized to be

paid by the Me dicaid program whether paid as a result of

inaccurate or improper cost reporting, improper claiming,

unacceptable practices, fraud, abuse, or mistake. " As found in

section 409.913(1)(a)1., " abuse " includes " [p] rovider practices

that are inconsistent with generally accepted business or medical

practices and that result in an unnecessary cost to the Medicaid

program or in reimbursement for goods or services that are not

medically necessary or that fail to meet professionally

recognized standards of health ca re. "

3 . The Agency ' s Bureau of Medicaid Services has the

responsibility for implementing the rules and policies regarding

the Developmental Disabilities (DD) Waiver and Provider

Reimbursement P rograms.

4 . One method the Agency uses to discover Medicaid

overpayments is by auditing billing and payment records of

Medicaid providers. Such audits are performed by staff in the

Agency ' s MPI. MPI is responsible for reviewing providers to

assure that the services rendered were done in accordance with

the appli cable rules, regulations and handbook(s). MPI looks to

ensure that the provider is enrolled, the recipient is eligible,

the service billed is covered, and the service is billed

appropriately.

5 . In order to participate in the voluntary Medicaid

program, providers have to enroll in a fee - for - service program.

The provider submits an application to the Agency and undergoes a

background screening check to ensure they meet the qualifications

for enrollment and are not listed on a federal exclusion roster.

On ce accepted they are issued a provider number, and they receive

handbooks and instructions on how to bill for the services they

provide. Those providers who provide DD waiver services must

also have a contract with the Agency for Persons With

Disabilities ( APD ) , as well as a Medicaid Services Agreement

with APD.

6 . Every individual recipient has a support plan (SP),

which identifies the supports and services designed to meet the

needs of th at recipient. A physician determines the medical

necessity for ea ch recipient . Each SP is to include the most

appropriate, least restrictive and most cost - beneficial

environment for the recipient to accomplish SP's objectives and a

specification of all services authorized. The SP delineates who

is to provide the servi ces. Once the SP is approved, the support

coordinator will develop a cost plan to determine how payment for

those needed supports will be made. A cost plan is " a document

used by the waiver support coordinator that lists all waiver

services requested by the recipient on the support plan and the

anticipated cost of each waiver service. The cost plan is

updated annually based on the results of the support planning

process to reflect current needs and situations. " Although a

cost plan usually lasts for a y ear at a time, it may be amended

" only if there is a documented significant change in the

recipient ' s condition or circumstance that affects the

recipient ' s health or welfare. "

7 . When the Agency audits a Medicaid provider for possible

overpayments , it " m ust use accepted and valid auditing,

accounting, analytical, statistical, or peer - review methods, or a

combination thereof. " See § 409.913(20) , Fla. Stat. The parties

stipulated to the statistical analysis that was performed, thus ,

n o additional testimon y or evidence was received on it, and the

amount of overpayments is not at issue, other than Respondent ' s

position that there were no overpayments.

8 . In the DD program, once an entity is selected for the

review, an Agency investigator develops a request for records and

sends it to the entity with a list of the recipients to be

reviewed along with the applicable review period. The entity

then sends in the records. In a DD program review, the

investigator reviews the records and then, if necessary, a

qual ified nurse reviews any nursing services records. The

qualifications of the entity ' s staff who are providing the

service(s) are reviewed first. If the staff is ineligible, then

the services provided are disallowed. Once the staff is

validated, the revie w continues to the individual recipients,

their SP , including any prescriptions, the cost plan and the

documentation for the services provided.

9 . The service authorization authorizes a provider to

provide a service and bill for that service at a specific rate.

If a provider does not have a service authorization, it cannot

provide the service , and it cannot submit a claim or be

reimbursed for the service.

10. In - home support services are provided to recipients as

long as they are authorized and required . In - home support

services may include: companionship ; personal care or hygiene ;

and help with different things around the home , including

housekeeping, grocery shopping and/or cooking. In - home support

is billed in either a unit of service (UOS), which i s 15 minutes

at a time or at a daily live - in rate, which is eight hours or

more. In - home support rates are roughly $3.00 per UOS, and may

go up to $120 for a daily live - in rate f or 24 hours.

1 1 . Supported living coaching (SLC) is more involved. SLC

is limited to adults who rent or own their residence and cannot

exceed six hours or 24 quarter hours of service each day. SLC

provides one - on - one assistance which may include: locating

housing; acquiring, retaining or improving skills related to the

activit ies of daily living (ADLs) , which may include household

chores; meal preparation; shopping; personal finances; and social

and adaptive skills necessary to stay in the residence. SLC

rates are roughly $8.00 for a UOS. It may be necessary for a

recipient t o have SLC and in - home support; however, providers

must coordinate their activities to avoid duplicate billing for

the two services.

1 2 . After an Agency investigator reviews the submitted

records, an Agency nurse consultant reviews all the nursing

records for the recipients to determine whether the care plan has

been serviced adequately for the claims billed. This review

includes any prescriptions, the nursing service log(s), and the

nursing daily assessment or notes.

1 3 . After the Agency ' s staff comple tes the review of the

records, a preliminary audit report (PAR) is prepared and sent to

the provider along with the Agency ' s worksheets and overpayment

calculations. The provider is given the opportunity to submit

any additional documentation it may have, and the provider

usually does so.

1 4 . Once all the additional records have been received and

reviewed, the Agency issues the FAR, along with the Agency ' s work

papers.

ANGELS UNAWARE, INC.

1 5 . Respondent is a 501(c)3 not - for - profit corporation that

has b een in operation for 40 years, specializing in assisting the

severe, profound and/or moderately developmentally disabled

population. Respondent 's expressed goal and purpose is to

provide quality residential living options and services to the

developmental ly disabled population in the Tampa Bay area.

Respondent provides residential habitation, transportation,

nursing, behavioral services , as well as supportive living, in -

home supports and other non - remunerative services.

1 6 . Respondent is (and was at all times relevant to this

action) enrolled as an authorized provider in the Florida

Medicaid Developmental Disabilities Waiver Program (DD Program),

having been issued Medicaid provider n o. 024115696. Respondent,

as an enrolled provider, is required to compl y with the Florida

Medicaid Provider General Handbook, the Developmental

Disabilities Waiver Services Coverage and Limitations Handbook,

the Provider Reimbursement Handbook, and the applicable laws and

rules. Respondent acknowledged that it used the Medic aid

Provider General Handbook, the Developmental Disabilities Waiver

Services Coverage and Limitations Handbook, and the Provider

Reimbursement Handbook in providing services to and billing for

those services on behalf of the recipients. Florida Medicaid

providers are required by their agreements with the state to

comply with the requisite handbooks, laws and regulations. The

handbooks outline the requirements for record - keeping, as well as

other pertinent information to assist providers. Additionally,

t he Agency staff is available should providers have questions.

1 7 . Respondent submitted bills which were processed and

paid through the Florida Medicaid payment system. The Medicaid

billing services in question include in - home support, home and

community based services under the DD waiver, supported living

coaching, residential hab i tation, skilled nursing, and

residential nursing.

SETTING

1 8 . In May 2011, the Agency notified Respondent that MPI

was " in the process of completing a review of claims billed t o

Medicaid during the period January 1, 2008 through December 31,

2009 , to determine whether the claims were billed and paid in

accordance with Medicaid policy. " In July 2011, Respondent

provided over 13,000 pages of the " Medicaid - related records

requeste d by the Agency. "

1 9 . Investigator Koelle, an experienced MPI investigator,

completed the steps of the audit process according to established

Agency protocols. She reviewed Respondent ' s provider information

and billing (excluding the nursing records, whi ch were reviewed

by an Agency nurse) to determine the staff qualifications, the

types of services that were provided, the claims that were

submitted, and how much was paid by Medicaid. The Agency

identified 20 recipients (or " consumers , " as Respondent cal ls

them) who received services from Respondent for which there were

billing issues. Following a preliminary review and notification

by the Agency, Respondent provided more records to the Agency for

its consideration. A PAR was sent to Respondent in May 2 012.

Thereafter , Respondent provided additional records for the

Agency ' s consideration.

20 . Investigator Koelle reviewed the supported living

services and coaching services provided to t he consumers. An

Agency nurse consultant initially reviewed the nur sing records

and provided Investigator Koelle with those findings .

2 1 . In those instances when the SP provided for the in - home

support services, only the in - home support provider could

properly bill for services. When SLC occurred , but was not

authoriz ed by the SP, the coach could not bill for the coach ' s

time. Further, neither the in - home support provider nor the

coach could bill for certain activities. Mr. Epperson conceded

several billing errors in that " unauthorized activities , " such as

watching T V and/or coloring , are not billable activities and

should not have been billed.

2 2 . On December 11, 2012, after reviewing the additional

records , Investigator Koelle prepared the FAR , which CMU manager

Olmstead executed and sent to Respondent. In the FAR , the Agency

notified Respondent of the completion of its review of claims for

Medicaid reimbursement for the audit period. Included with the

FAR were: the overpayment calculations; a listing of the billing

claims by recipient name; and the staff file re view findings.

The FAR contained an overpayment amount (which was approximately

$103,100.00 less than the PAR), sanctions (which were less than

the PAR), and costs. The FAR was attached to the request for

hearing that was submitted by Respondent. The ov erpayment amount

and the sanction amount were revised (downward to $48,191.35 and

$9,638.27, respectively) at the start of the hearing. 6/ These

amounts have not been repaid to the Agency.

2 3 . RN Riley provided an additional review of the nursing

services records , including the billing records , in preparation

for the hearing . 7/ In those instances where RN Riley determined

there were no adjustments to the billing, he would write " no

change " and initial the work papers. However, in those instances

where RN Riley found an adjustment was necessary, he would make

that notation to the side of the entry and sign or initial the

adjustment.

2 4 . RN Riley found numerous instances of the nursing

services billing more units than were prescribed. Examples of

the ty pes of prescriptions issued to various consumers (during

the audit period) included the following:

Residential Nursing One hour per Day

Residential Nursing 1 1/2 hours per Day

Medically Necessary Residential Nursing

1 hour (one) per day

Residential Nur sing 3 hours/day

Residential Nursing 1 hr per day

Residential nursing x 1 hr per day

Residential Nursing 2 hours per week

Residential Nursing Care 4 hours per week

Residential Nursing 6 hours per month

Only prescriptions for nursing care per week or mont h allow the

nursing staff flexibility to vary daily when those nursing

services can be provided. Respondent's theory , that the nurse on

duty can provide excess nursing units on any " per day " basis as

long as they do not exceed the cost plan or service

aut horization , is rejected . A prescription is a physician ' s

directive as to how to treat a patient/consumer and is not

subject to change without that physician ' s authorization. (This

is not to mean that emergent care should not be rendered when

necessary, b ut that if additional nursing/medical services are

necessary in addition to what was prescribed, the attending

physician must be notified and a prescription , or authorization ,

obtained. As to the cost associated with the increased nursing

services , that w ould require another cost plan adjustment.)

2 5 . Respondent ' s nursing staff provided services to one

consumer after that consumer ' s prescription lapsed. Respondent ' s

staff acknowledged that the Agency ' s adjustments for this billing

were correct.

2 6 . Res pondent ' s consumers are complex. It is

understandable that some consumers may require more nursing

services than are prescribed. However, the nursing staff has a

method to communicate with each consumer ' s physician to secure an

appropriate prescription f or the requisite services. The fact

that Respondent did not exceed the overall cost plan , in

instances where nursing services exceeded the " per day "

prescription , is of no consequence because the actual

prescription controlled what nursing services were a vailable for

each consumer on each day. Respondent ' s staff communicates with

the consumer ' s physicians " every couple of months, if not

monthly , according to LPN Seabrook . " In an emergency,

Respondent ' s staff, whether it i s a nurse, support staff or

coach , would contact the appropriate emergency services.

Respondent 's thought , that providing nursing services beyond that

which was prescribed but was within the cost plan , is incorrect.

2 7 . According to Respondent ' s residential nursing staff , if

the SP has a prescription for nursing services, the cost for that

prescribed nursing service is usually determined after the cost

plan is made. This is not an accurate description of the

process, as the DD h andbook provides that the cost plan " lists

all waiver servi ces requested by the recipient on the support

plan and the anticipated cost of each waiver service. "

2 8 . Respondent did not dispute that it was a provider.

Respondent did not dispute it was subject to the handbooks and

pertinent guidelines. Respondent did not dispute it was required

to maintain records to support the claims. Respondent did not

dispute it was paid for the claims submitted to the Agency.

Respondent disputed that there was overbilling ; however , the

audit report and work papers prove d oth erwise.

CONCLUSIONS OF LAW

2 9 . The Division of Administrative Hearings has

jurisdiction over the parties and subject matter of this

proceeding. §§ 120.569, 120.57(1), and 409.913(31), Fla. Stat.

30 . The burden of proof is on the Agency to prove the

mate rial allegations by a preponderance of the evidence. S. Med.

Servs., Inc. v. Ag. for Health Care Admin . , 653 So. 2d 440 (Fla.

3rd DCA 1995); Southpoint Pharmacy v. D e p ' t of HRS , 596 So. 2d

106, 109 (Fla. 1st DCA 1992). The sole exception regarding the

st andard of proof is that clear and convincing evidence is

required for fines. Dep ' t of Banking & Fin. v. Osborne Stern &

Co. , 670 So. 2d 932, 935 (Fla. 1996).

3 1 . To meet its burden of proof , the Agency may rely on the

audit records and report. Subsecti ons 409.913(21) and (22)

provide:

(21) When making a determination that an

overpayment has occurred, the agency shall

prepare and issue an audit report to the

provider showing the calculation of

overpayments. The agency ' s determination

must be based sole ly upon information

available to it before issuance of the audit

report and, in the case of documentation

obtained to substantiate claims for Medicaid

reimbursement, based solely upon

contemporaneous records. The agency may

consider addenda or modificatio ns to a note

that was made contemporaneously with the

patient care episode if the addenda or

modifications are germane to the note.

(22) The audit report, supported by agency

work papers, showing an overpayment to a

provider constitutes evidence of the

o verpayment. A provider may not present or

elicit testimony on direct examination or

cross - examination in any court or

administrative proceeding, regarding the

purchase or acquisition by any means of

drugs, goods, or supplies; sales or

divestment by any me ans of drugs, goods, or

supplies; or inventory of drugs, goods, or

supplies, unless such acquisition, sales,

divestment, or inventory is documented by

written invoices, written inventory records,

or other competent written documentary

evidence maintained i n the normal course of

the provider ' s business. A provider may not

present records to contest an overpayment or

sanction unless such records are

contemporaneous and, if requested during the

audit process, were furnished to the agency

or its agent upon req uest. This limitation

does not apply to Medicaid cost report

audits. This limitation does not preclude

consideration by the agency of addenda or

modifications to a note if the addenda or

modifications are made before notification of

the audit, the addend a or modifications are

germane to the note, and the note was made

contemporaneously with a patient care

episode. Notwithstanding the applicable

rules of discovery, all documentation to be

offered as evidence at an administrative

hearing on a Medicaid over payment or an

administrative sanction must be exchanged by

all parties at least 14 days before the

administrative hearing or be excluded from

consideration.

3 2 . The term " overpayment " is defined as " any amount that

is not authorized to be paid by the Med icaid program , whether

paid as a result of inaccurate or improper cost reporting,

improper claiming, unacceptable practices, fraud, abuse, or

mistake. " § 409.913(1)(e), Fla. Stat.

3 3 . A claim presented under the Medicaid program imposes on

the provider an affirmative duty to be responsible for and to

assure that each claim is true and accurate and that the service

for which payment is claimed has been provided to the Medicaid

recipient prior to the submission of the claim. § 409.913(7),

Fla. Stat.

3 4 . The Agency is required to conduct, or cause to be

conducted by contract or otherwise, reviews, investigations,

analyses, audits, or any combination thereof, to determine

possible fraud, abuse, overpayment, or recipient neglect in the

Medicaid program and t o report the findings of any overpayments

in audit reports as appropriate and to prepare and issue audit

reports documenting overpayments. § 409.913(2) , (21) , Fla. Stat .

3 5 . The audit report, if accompanied by supporting work

papers, is " evidence of the overpayment. " § 409.913(22) , Fla.

Stat . Although the statute could be clearer, section 409.913(22)

provides that the audit report and work papers establish the

overpayment, absent contrary evidence. Respondent ' s evidence did

not establish the contrary. In fact, Respondent ' s own team

conceded there were errors in some billing which should have been

caught, but w ere not.

3 6 . The Agency met its prima facie burden to establish the

overpayment. This overpayment has been determined through

Petitioner ' s Exhi bits 6, 8, and 15 and the testimony of

Investigator Koelle and RN Riley.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that t he Agency for Health Care

Administration enter a final order sustaining the Med icaid

overpayment in the amount of $ 48,191.35.

Further, jurisdiction is retained to determine the amount of

sanctions, costs and attorney ' s fees, if the parties are unable

to agree to the amount , and either party may file a request for a

hearing within 30 days after entry of the final order to

determine the appropriate amounts.

DONE AND ENTERED this 2nd day of April , 2014 , in

Tallahassee, Leon County, Florida.

S

LYNNE A. QUIMBY - PENNOCK

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 2nd day of April , 2014 .

ENDNOTE S

1/ The Agency should have filed a " Unilateral Prehearing

Statement , " as Respondent did not join in the " Agency ' s

Prehearing Stipulation. "

2/ All references to Florida Statutes are to Florida Statute s

(2013) , unless otherwise noted.

3/ Su pplemented pages were added to Exhibit 8 during the hearing .

4/ The Bate - stamp pagination of this exhibit was inconsistent,

which caused diffic ulty in comparing pages to the T ranscript.

5/ Respondent ' s witnesses were allowed ten days in which to

comple te the errata sheets to the depositions comprising

composite Exhibit 16. The errata sheets for Mr. Epperson and

Mr. O ' Banion were timely filed . Ms. Seabrook ' s deposition was

transcribed correctly and did not require an errata sheet .

6/ When the undersi gned stated the overpayment amount as provided

in the pre - hearing statement, the Agency ' s counsel revised the

amount downward to $48,191.35, and the sanction was reduced to

$9,638.27. Respondent ' s counsel did not object to the lower

figures.

7/ The orig inal Agency nurse reviewer was no longer employed by

the Agency.

COPIES FURNISHED:

Elizabeth Dudek, Secretary

Agency for Health Care Administration

Mail Stop 1

2727 Mahan Drive

Tallahassee, Florida 32308 - 5407

Stuart Williams, General Counsel

Agency f or Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308 - 5407

Richard J. Shoop, Agency Clerk

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308 - 5407

Frank P. Rainer, Esquire

Broad and Cassel

Suite 400

215 South Monroe Street

Tallahassee, Florida 32301 - 1804

Douglas James Lomonico, Esquire

Shena L. Grantham, Esquire

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308 - 5407

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.