14-002175 Bradenton Council On Aging, D/B/A Riverfront Nursing And Rehab Center vs. Agency For Health Care Administration Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Wednesday, May 21, 2014.

3 1 ~£

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION 2915 ' P 18 2. 0

THE WOODS OF MANATEE SPRINGS,

ENGAGEMENT NO. NH07- 063G

Petitioner,

V.

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Respondent.

FINAL ORDER

administrative hearing (" Request")

THIS CAUSE concerns a request for a formal

received pertaining to the

that the Agency for Health Care Administration (" Agency")

of Petitioner ( Exhibit A).

Agency' s Medicaid cost report audit

B), challenging some of

On October 17, 2008, Petitioner filed its Request ( Exhibit

cost report. The case was then held in

the Agency' s adjustments to Requester' s Medicaid

in order to pursue settlement negotiations.

abeyance at the request of the parties

of Voluntary Dismissal ( Exhibit

On September 1, 2015, Petitioner filed a Notice

C).

Based on the foregoing,

ADJUDGED THAT:

IT IS THEREFORE ORDERED AND

dismissal of its Request. The

The Agency hereby acknowledges Petitioner' s

final and this

audit of Petitioner is hereby upheld as

Agency' s Medicaid cost report

themselves accordingly.

matter is now closed. The parties shall govern

Tallahassee,

DONE and ORDERED this i7" day of SgPb" w 2015, in

Florida.

r

ELIZA TH DUD SECRETARY

AGENCY FOR H ALTH CARE ADMINISTRATION

NOTICE OF RIGHT TO JUDICIAL REVIEW

ORDER OF

A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL

WHICH

DISMISSAL WITH PREJUDICE IS ENTITLED TO JUDICIAL REVIEW,

OF APPEAL WITH

SHALL BE INSTITUTED BY FILING THE ORIGINAL NOTICE

THE FILING FEE

THE AGENCY CLERK OF AHCA, AND A COPY, ALONG WITH

APPEAL IN THE

PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF

MAINTAINS ITS

APPELLATE DISTRICT WHERE THE AGENCY

REVIEW PROCEEDINGS

HEADQUARTERS OR WHERE A PARTY RESIDES.

APPELLATE

SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA

30 DAYS OF THE

RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN

RENDITION OF THE ORDER TO BE REVIEWED.

CERTIFICATE OF SERVICE

Final Order

I HEREBY CERTIFY that a true and correct copy of the foregoing

on this

has been furnished to the persons named below by the method designated day

of 2015.

RICHARD J. SHOOP, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, MS 43

Tallahassee, FL 32308

850) 412- 3689

COPIES FURNISHED TO:

Richard A. Feldman, Esquire

5627 9`" Street East

Bradenton, Florida 34203

via electronic mail to feldman_ com) richard@yahoo.

Katharine B. Heyward, Esquire

Assistant General Counsel

via electronic mail to Katharine. myflorida. Heyward@ahca. com)

Zainab Day

Medicaid Program Finance

via electronic mail to Zainab. myflorida. Day@ahca. com)

FLORIDA

MEDICAID

BENSON

CHARLIE CRIST HOLLY SECRETARY

GOVERNOR

September 24, 2008 No.

Return Receipt

7005 3110 0001 6523 3399

WOODS OF MANATEE SPRINGS, THE

5627 9TH STREET, EAST

BRADENTON, FL 34203

Provider No.: 260321 No.: 30, 2004/ 063G NH07-

Audit Period/ Engagement September

Dear Administrator:

cost

We have completed the audit of your above. facility' A s copy Medicaid of the audit

report for the period for specified information.

report is attached your

Medicaid

Audit adjustments result from to costs the application as reported of on the Medicaid cost

reimbursement principles You have the right to request

report for or the informal period hearing specified. pursuant to Section 120. 57, Florida

a formal for a formal hearing is made, the petition

Statutes. If a petition with Section 28- 201, 106. Florida

must be made in compliance Please note that Section 28- 201( 106. 2)

Administrative Code. shall contain a concise discussion

specifies that items the in petition dispute. Additionally, you are hereby

of specific for a hearing is made, the request or

informed that if a request within twenty- one 21) days of your

petition of must this be letter, received and that failure to timely request a

receipt be deemed a waiver of your right to a hearing.

hearing shall

to

Please 2727 Mahan address Drive, allpetitionsforTalhearing Mail Sop 21, eeand/ or3questions

Sincerely,

Lisa D. Milton Services

Administrator of Audit

Medicaid Program Analysis

850) 487- 1240

Attachment ( s) INC.

cc: STERLING HEALTHCARE, SUITE 50- B

16 NORCROSS STREET,

ROSWELL, GA 30075

MS# 21 Visit AHCA online ida. co at at

2727 Mahan Drive, Florida 32308 http:// CA ahca.

Tallahassee,

EXHIBIT ~

The Woods at Manatee Springs, Inc.

Medicaid Audit Report

For the Period from April 1, 2003 to September 30, 2004

Gabriel & Associates, CPAs, PA

Certified Public Accountants

Jacksonville, Florida

Gabriel & Associates, CPAs, PA

Certified Public Accountants Rd. Suite 100

10117 St. Augustine

Jacksonville, Florida 260- 3820 32257

Phone ( 904) 260- 9725

Fax ( 904) Members

John J. Gabriel, CPA, MBA, MIS email JGabriel a@GACPAS. ORG Florida Institute of Certified Public Accountants

Victoria L. tiodgins, CPA, MA email VHodginsQGACPAS. ORG ORG American Institute of Certified Public Accountants

Harold Bachner, CPA, MBA email HBachnerQa GACPAS

INDEPENDENT ACCOUNTANTS' REPORT

Secretary

Agency for Health Care Administration

We have examined the accompanying schedules and statistical data, as listed in the Home Table Services of Contents, Providers

which were derived from the Cost Report for Florida Medicaid Inc. ( Program Nursing for the period from April 1,

the " Cost Report") of The Woods These of schedules Manatee and Springs, statistical the " data Provider") are the responsibility of the Provider' s

2003 to September 30, 2004. the schedules and statistical data based on our

management. Our responsibility is to express an opinion on

examination.

in accordance with

Except as discussed in the following the paragraph, American our Institute examination of Certified was conducted Public Accountants and,

attestation standards established by the schedules and

accordingly, included examination on test basis, evidence as we supporting considered necessary accompanying in the circumstances. We

statistical data and performing such other procedures for our

believe that our examination provides a reasonable basis opinion.

cost

The Provider is reimbursed under the Fair Rental Value on System (" the Schedule FRVS"). of Costs, Accordingly, equity capital property information

information for depreciation, interest and rent included and in capital assets

on the Schedule of Statistics and Equity Capital, capital replacement Data and related equity diem information on the

information on the Schedule of Fair Rental Value System to examination per

Schedule of Allowable Medicaid Costs have not been subjected procedures.

for the

Attachment A to this report includes adjustments for which, the in our opinion, from should 1, 2003 be recorded to September in order 30, 2004,

data, as reported, in the accompanying schedules and state Medicaid period reimbursement April principles as described in

to be presented in conformity with federal we have the adjustments described in

Note 1. To quantify the effect of the required adjustments, in the applied schedules.

Attachment A to the amounts and statistical data, as reported, accompanying

In our opinion, except for the effects of such adjustments as might been examined, have been determined and for the to effects be necessary of not

had amounts and data described in the third paragraph above the schedules and statistical

recording adjustments as discussed in the preceding in all paragraph, material respects, accompanying the amounts and statistical data

data, as listed in the Table of Contents Woods present, at Manatee Inc., for the period from April 1, 2003 to

derived from the Cost Report of The federal Springs, and state Medicaid reimbursement principles

September 30, 2004, are presented, in conformity with

as described in Note 1.

This report in intended solely for the information and use of the State Inc. of Florida and is not Agency intended for Health to be used Care by

Administration and management of The Woods at Manatee Springs,

anyone other than these specified parties.

August 31, 2007

The Woods at Manatee Springs, Inc.

Schedule of Costs 2004

For the Period from April 1, 2003 to September 30,

Cost Center Totals As Reported Decrease Increase As Adjusted

Cost to be allocated: 484, 498 4, 235) 480, 263

Plant operations 372, 000 90, 000)_ 282, 000

Housekeeping 856, 498 94, 235) 762, 263

Administration 1, 001 027, 60, 660) 1, 604 966, 728, 341

1, 499 883, 154, 895

Patient Care: 4, 433 395, 18, 464 4, 897 413,

Direct Care 879, 699 879, 699

Indirect Care 711, 612 711, 612

Dietary 88, 122 88, 122

Activities 226, 544 226, 544

Social Services 80, 747 80, 747

Medical Records 337, 962 271, 307) 66, 655

Central Supplies 6, 119 720, 252, 843) 6, 276 467,

Laundry and Linen 271, 307 271, 307

Allowable Ancillary1, 425 153, 1, 425 153,

Physical Therapy 257 910 257, 910

Speech Therapy 875, 177 13, 050) 862, 127

Occupational Therapy 20, 446 20, 446

Parenteral/ Enteral Therapy 27, 152 27, 152

Complex Medical Equipment 35 2fi6 35, 266

Medical Supplies 385, 723 385, 723

Inhalation/ Respiratory Therapy 104, 290 104, 290

IV Therapy 144 144

Other 2, 533 859, 13. 050) 2, 483 846,

Property. on not examined) 2, 000 520, 2, 000 520,

Rent Property

Amortization examined)

Interest on Property not examined) 3, 537 3, 537

Depreciation on not 44, 211 44, 211

Insurance Property 161, 593 161, 593

Taxes on Property Costs

Home Office Property

Other 2, 341 729, 2, 341 729,

Nonallowable Ancillary: 23, 356 23, 356

Radiology Lab 82, 418 82, 418

Pharmacy 72. 428 72, 428

Other 178, 202 178, 202

Other Non- Reimbursable:

Beauty and Barber Shop

Other

14, 213 221,

Total Operating Cost 14, 694 370, 149, 481)

Medicaid Bad Debts 14, 694 370, 149, 481) 14, $ 221, 213

Total Costs

The accompanying notes are an integral part of this schedule. NH07- 063G

2 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Charges 2004

For the Period from April 1, 2003 to September 30,

Increase

As Reported Decrease As Aalusted

Usual and Customary Daily Rate 310. 29 310. 29

Patient Charges:

Medicaid:

Ancillary cost centers 18, 858 18, 858

Physical Therapy 7, 243 7, 243

Speech Therapy 11, 888 11, 888

Occupational Therapy 20, 559 20, 559

Complex Medical Equipment 27, 266 27, 266

Medical Supplies 453, 839 453, 839

Inhalation/ Respiratory Therapy

IV Therapy 4, 548 380, 4, 548 380,

Room and Board 4, 201 920, 4, 201 920,

Totals

Medicare:

Ancillary cost centers 2, 155 431,

Physical Therapy 475, 956 2, 155 431475,, 955

Speech Therapy 2, 344 124, 2, 344 124,

Occupational Therapy 10, 938 10, 938

Complex Medical Equipment 89, 867 89, 867

Medical Supplies 1, 563 153, 1, 153, 563

Inhalation/ Respiratory Therapy 73, 271 73, 271

IV Therapy 12, 125 793, 12, 125 793,

Room and Board 19, 219 152, 19, 219 152,

Totals

Private and Other:

Ancillary cost centers 121 046 121, 046

Physical Therapy 19, 057 19, 057

Speech Therapy 107, 998 107, 998

Occupational Therapy 296 1, 296

Complex Medical Equipment 12,, 494 2, 294

Medical Supplies 60, 758 60, 758

Inhalation/ Respiratory Therapy 16, 694 16, 694

IV Therapy 1, 400 370, 1, 400 370,

Room and Board 1, 743 699, 1, 743 699,

Totals

25, 163 772,

Total Charges 25, 163 772,

The accompanying notes are an integral part of this schedule.

N H07- 063G

3 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Statistics and Equity Capital 2004

For the Period from April 1, 2003 to September 30,

Increase sted

As Adiu

Statistics As Reported Decrease

120 120

Number of Beds

Patient Days: 24, 208 24, 208

Medicaid 31, 840 31, 840

Medicare 5, 478 5, 478

Private and other 61, 526 61, 526

Total patient days

39. 35%

Percent Medicaid 39. 35% 0. 00%

Facility Square Footage: cost centers:

Allowable ancillary 4, 773 167) 4, 606

Physical Therapy 361 361

Speech Therapy 1, 122 167 1, 289

Occupational Therapy 70 70

Complex Medical Equipment 680 7 757

Medical Supplies 490 490

Inhalation/ Respiratory Therapy 39, 035 39, 035

Patient care 965 140 1, 105

Laundry and linen

Radiology 83 83

Lab

Pharmacy 277 277

Beauty and barber

Other 47, 856 217 46, 073

Equity Capital: 3, 824 506, 3, 824 506,

Ending equity capital 1, 412 753, 1, 412 753,

Average equity capital 0. 000% 4. 167% 4. 167%

Annual rate of return 109 597 109. 597

Return on equity before apportionment

Type of ownership: Corporation September 6, 2006

Date cost report accepted:

The accompanying notes are an integral part of this schedule.

NH07- 063G

4 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Allowable Medicaid Costs 2004

For the Period from April 1, 2003 to September 30,

Total Costs Allocations & Costs After

Costs as Apportionment Allocations & or ~--

Reimbursement Class Adjusted Note 2) ti- onment--~--

Operatin g 4, 897 1, 911 999, 413, 1, 978) 2, 205) 355, 677, 164336, 933

Direct Patient Care 4, 862 899, 3, 341) 945, 954, 521

Indirect Patient Care examined) 2, 341 729, 1, 474) 655, 1, 867 073,

Property not 178, 202 9, 998 633, 9, 200 812,

Nonreimbursable 14, 213 221, 14, 213 221,

Total ( page 2) 109, 597 75 618) 33, 979

Return on equity ( page 4) not examined) 75, 618 75, 618

Non- Medicaid 14, 810 330, 14, 810 330,

Totals

Allowable Medicaid Costs: Increase

Decrease) As Adjusted

Reimbursement Class As Reported Note 1)

Operating 586, 404 57, 529 1, 692 643, 736, 933

Direct Patient Care 1, 427 729, 7, 265 954, 521

Indirect Patient Care 1, 486 1, 867 061, 073, 106, 965) 1, 867 073,

Property not examined) examined) 33, 979 33, 979

Return on equity not 4, 184 451, 8, 192) 4, 992 442,

Totals

Allowable Medicaid Per Diem Costs: Increase

Decrease) As Adjusted

Reimbursement Class As Reported Note 1)

Operating 24. 22 2. 0. 38 30 26. 71. 60 74

Qirect Patient Care 71. 44 42 39. 43

Indirect Patient Care 43. 44. 85 36 q) 44. 36

Property 1 qp 1. 40

Return on equity Diem ( 3) 183 87 0. 34) 183. 53

Initial Medicaid Per Note

The accompanying notes are an integral part of this schedule.

NH07- 063G

5 26032- 1

The Woods at Manatee Springs, Inc. Data

Schedule of Fair Rental 2003 Value to System 30, 2004

For the Period from April 1, September

Increase

As Reported Decrease As Adiusted

Capital Additions and Improvements:

Acquisition Costs:

4/ 1 / 03- 30/ 6/ 03

7/ 03- 31/ l/ 12/ 03

1 / 1 / 04- 30/ 6/ 04

7/ 1 / 04- 30/ 9/ 04

Totals

Original Loan Amount

Retirements

Capital Replacements: not examined)

Acquisition Cost

Original Loan Amount

Pass- through Costs ( Note 4)

Acquisitions.

4/ 1 / 03- 30/ 9/ 04

Depreciation

Interest

Prior to 4/ 1103

Depreciation

Interest

Totals

Equity in Capital Assets: not examined) 60, 757

Ending Equity in Capital Assets 60, 757 379

in Capital Assets 30, 379 4. 3767% 301,

Average Equity 0. 000%

Annual Rate of Return

Return on Equity in Capital Assets 899 1, 899

Before Apportionment

Return on Equity in Capital Assets 589 589

apportioned to Medicaid

Mortgage Interest Rates:

No Mortgage

The accompanying notes are an integral part of this schedule.

N H07- 063G

6 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Direct Patient Care

For the Period from April 1, 2003 to September 30, 2004

As Increase As

Reported Decrease) Adjusted

RN Data 661, 317 25, 987 687, 304

Productive Salaries 18, 393 53, 972

Non- Productive Salaries 35, 579 44, 380 741, 276

Total Salaries 696, 896

FICA 63, 261 6, 6, 553) 553 56, 6, 708 553

Unemployment Insurance 57, 821 57, 821

Health Insurance 38, 731

Workers Compensation 38, 731

Other Fringe Benefits 159, 813 159, 813

Total Benefits

Productive Hours 30, 1, 741 601 246) 246 30, 1, 495 847

Non- Productive Hours 32, 342 32, 342

Total Hours

LPN Data 20, 121) 1, 920 343,

Productive Salaries 1, 041 62, 364, 893 26, 688 89, 581

Non- Productive Salaries 6, 567 1, 501 433,

Total Salaries 1, 934 426,

109, 663

FICA 129, 532 19, 19, 869) 869 19, 869

Unemployment Insurance 118, 391 118, 391

Health Insurance 79, 304 79, 304

Workers Compensation

Other Fringe Benefits 327, 227 327 227

Total Benefits

Productive Hours 74, 3, 480 375 955 698 75, 4, 435 073

Non- Productive Hours i 77, 855 1, 653 79, 508

Total Hours

The accompanying note is an integral part of this schedule.

NH07- 063G

7 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Direct Patient Care 2004

For the Period from April 1, 2003 to September 30,

As Increase As

Reported Decrease) Adjusted

CNA Data 1, 140 392, 72, 679) 1, 461 319,

Productive Salaries 59, 525 40, 196 gg 721

Non- Productive Salaries 1, 665 451, 32 483 1, 182 419,

Total Salaries

108, 567

FICA 131, 776 23, 23, 209) 209 23, 209

Unemployment Insurance 120, 443 120, 443

Health Insurance 80 679 80, 679

Workers Compensation

Other Fringe Benefits 332, 898 332, 898

Total Benefits

Productive Hours 126, 518 4, 868) 121, 7, 650 176

Non- Productive Hours 3 985 3 191 128, 826

Total Hours 130, 503 1, 677)

Agency Data

RN Costs

LPN Costs

CNA Costs

Total Agency Costs

RN Hours

LPN Hours

CNA Hours

Total Agency Hours

Pediatric Offset - RN

Productive Salaries

Non- Productive Salaries

Total Salaries

Productive Hours

Non- Productive Hours

Total Hours

The accompanying note is an integral part of this schedule.

NH07- 063G

8 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Direct Patient Care 2004

For the Period from April 1, 2003 to September 30,

As Increase As

Reported Decrease) Adjusted

Pediatric Offset - LPN

Productive Salaries

Non- Productive Salaries

Total Salaries

Productive Hours

Non- Productive Hours

Total Hours

Pediatric Offset - CNA

Productive Salaries

Non- Productive Salaries

Total Salaries

Productive Hours

Non- Productive Hours

Total Hours

Pediatric Offset - Agency

RN Costs

LPN Costs

CNA Costs

Total Agency Costs

RN Hours

LPN Hours

CNA Hours

Total Agency Hours

AIDS Offset - RN

Productive Salaries

Non- Productive Salaries

Total Salaries

Productive Hours

Non- Productive Hours

Total Hours

The accompanying note is an integral part of this schedule.

NH07- 063G

9 26032- 1

The Woods at Manatee Springs, Inc.

Schedule of Direct Patient Care 2004

For the Period from April 1, 2003 to September 30,

As Increase As

Reported Decrease) Adjusted

AIDS Offset - LPN

Productive Salaries

Non- Productive Salaries

Total Salaries

Productive Hours

Non- Productive Hours

Total Hours

AIDS Offset - CNA

Productive Salaries

Non- Productive Salaries

Total Salaries

Productive Hours

Non- Productive Hours

Total Hours

AIDS Offset - Agency

RN Costs

LPN Costs

CNA Costs

Total Agency Costs

RN Hours

LPN Hours

CNA Hours

Total Agency Hours

Data for All Departments 5, 989 155, 5, 989 155,

Total Salaries

394, 433

FICA 442, 536 48, 48, 103) 103 48, 103

Unemployment Insurance 427, 787 427, 787

Health Insurance 286 552 286, 552

Workers Compensation

Other Fringe Benefits 1, 875 156, 1, 875 156,

Total Benefits

The accompanying note is an integral part of this schedule.

NH07- 063G

10 26032- 1

The Woods at Manatee Springs, Inc.

Notes to Schedules

For the Period April 1, 2003 to September 30, 2004

Note 1 - Basis of Presentation

The Schedules, which were derived from the Cost Report for Florida have been Medicaid Program in conformity Nursing

Home Services Providers ( Cost Report) for the current period, in prepared the State of Florida

with federal and state Medicaid reimbursement principles, as specified and

Medicaid Program and as defined by applicable cost reimbursement as principles, Provider policies

regulations according to Medicare Pub. reimbursement Florida principles Title XIX Long- interpreted Term Care by Reimbursement

Reimbursement Manual ( CMS 15- 1), Services of the for

Plan and the policies and procedures manuals for Nursing Home Agency

Health Care Administration of the State of Florida.

The balances in the " As Reported" columns of the schedules As are the assertions columns and responsibility are the result

of the management of the nursing home. The balances in the " Adjusted" columns to the balances in the

of applying the adjustments reflected in the " Increase/( Decrease)"

As Reported" columns.

Note 2 - Allocations and Apportionment

and

Schedules G, G- 1 and H of the cost report allocate allowable administrative, care, laundry plant and operation linen and

housekeeping costs to allowable and nonallowable ancillary, statistical patient bases, such as square footage or

nonreimbursable cost centers based on predetermined then allowable costs after

total costs, as explained in the Cost Report. These schedules apportion such as care days or

allocations to the Medicaid program based on other statistical effect bases, of such allocations patient and

ancillary charges, as explained in the cost report. is The net in the Schedule of Allowable Medicaid

apportionment on each reimbursement class presented

Costs.

Note 3 - Initial Medicaid Per Diem

the

Medicaid per diem costs for property and return on equity have been calculated Plan, excluding under fair rental

provisions of the Florida Title XIX Long- of the Term fair rental Care value Reimbursement system, will be determined during the

value provisions. The effect, if any, rates will be calculated by applying

rate setting process, and where applicable, prospective

inflation factors, incentives, low utilization penalties and reimbursement ceilings.

Note 4 - Capital Replacement Pass- through Costs

and interest are presented

Capital Replacement pass- through costs in the form if of depreciation to full fair rental value system phase- in.

without regard to the number of years remaining, any, based on the amounts equal to or less

Accordingly, pass- through reimbursement will as be calculated costs. Once full

than fifty percent of the costs presented herein capital replacement pass- costs are through allowed to be

fair rental value system phase- in has occurred, no capital replacement

passed- through.

NH07- 063G

11 26032- 1

The Woods at Manatee Springs, Inc.

Attachment A- Audit Adjustments to 30, 2004

For the Period from April 1, 2003 September

Account Comment Decrease Increase

Classification Number

Adiustments to Costs fpaQe 2)

Plant Operation: 710720 To adjust due to lack of documentation. 4, 235

1. Maintenance Expense Section 2304, CMS Pub. 15- 1)

235) 4

Housekeeping: 720510 To disallow unreasonable/ duplicate 90, 000

2. Contract Service- Housekeeping laundry costs.

Section 2101. 1, CMS Pub 15- 1) 80, 000)

Administration: 730500 To record adjustments to home office 41, 642

3. Home Office costs.

Section 2150, CMS Pub. 15- 1)

4. Home Office 730500 To reclassify home office costs. 554)

Section 2150, CMS Pub. 15- 1)

5. Salary- Other A& G 730190 To adjust A& G salary to audit 18, 464)

findings.

Section 2304, CMS Pub. 15- 1) 60, 660)

Patient Care: To adjust costs per audit findings. 44, 380

6. Salaries- RN 810120 2304, CMS Pub. 15- 1) 6, 567

Salaries- LPN 810130 Section 32, 483)

Salaries- CNA 810140

271, 307)

7. Central Supply- Non- Related 917510 To center. ( reclassify Section expense 2304, to CMS proper Pub. cost 15- 1)

Party 252, 843)

aund : To reclass expense to proper cost 271, 307

8. Laundry- Contract Service 918710 center. ( Section 2304, CMS Pub. 15- 1)

271, 307

Allowable Ancillary: To disallow for tack of documentation. 13,) 050

9. Non- related party- Contract 923510 2304, CMS Pub. 15- 1)

Services Section 13, 050)

NH07- 063G

12 26032- 1

The Woods at Manatee Springs, Inc.

Attachment A- Audit Adjustments to 30, 2004

For the Period from April 1, 2003 September

Account Comment Decrease) Increase

Classification Number

Property 930940 To reclassify Home Office costs. 554

10. Home Office Section 2150, CMS Pub 15- 1)

11. Home Office 930940 To record adjustment to Home Office 554)

costs. Pub

Section 2150, CMS 15- 1)

Net to Costs 59, 481)

Adjustment

Adiustments to Ending Equity Capital ( page 4)

No Adjustments

Adiustments to Statistics ( gage 41

Facility Square Footage To adjust to audit findings. 167)

12. Physical Therapy Section 2304, CMS Pub. 15- 1) 167

Occupational Therapy 140 77

Medical Supplies

Laundry and Linen to Facility Square Footage 217

Net Adjustment

Ad ustments affecting Direct Patient Care Information ( gages 7- 10)

RN Salaries To adjust salaries per audit findings. 25, 987

13. Productive Florida Title XIX Long- Term Care 18, 393

Non- productive Reimbursement Plan, Section V. B.)

44, 380

RN Fringe Benefits To adjust benefits per audit findings. 553)

14. FICA Insurance Florida Title XIX Long- Term Care 66, 553

Unemployment Reimbursement Plan, Section V. B.)

RN Hours To adjust hours per audit findings. 246)

15. Productive Florida Title XIX Long- Term Care 246

Non- productive Reimbursement Plan, Section V. B.)

LPN Salaries To adjust salaries per audit findings. 20, 121

16. Productive Florida Title XIX Long- Term Care 26, 688

Non- productive Reimbursement Plan, Section V. B.)

6, 567

NH07- 063G

13 26032- 1

The Woods at Manatee Springs, Inc.

Attachment A - Audit Adjustments 30, 2004

For the Period from April 1, 2003 to September

Increase

Classification Comment Decrease

Ad ustments affecting Direct Patient Care Information ( continued)

LPN Fringe Benefits To adjust benefits per audit findings.

17 FICA Florida Title XIX Long- Term Care 1919. 869869)

Unemployment Insurance Reimbursement Plan, Section V. B.)

LPN Hours To adjust hours per audit findings. 955

18. Productive Florida Title XIX Long- Term Care 698

Non- productive Reimbursement Plan, Section V. B.)

1, 653

CNA Salaries To adjust salaries per audit findings. 72, 679)

19. Productive Florida Title XIX Long- Term Care 40, 196

Non- productive Reimbursement Plan, Section V. B.)

32, 483)

CNA Fringe Benefits To adjust benefits per audit findings.

20. FICA Florida Title XIX Long- Term Care 2323,, 209209)

Unemployment Insurance Reimbursement Plan, Section V. B.)

CNA Hours To adjust hours per audit findings. 4, 868)

21. Productive Florida Title XIX Long- Term Care 3, 191

Non- productive Reimbursement Plan, Section V. B.)

1, 677)

All Departments - Fringe Benefits To adjust benefits per audit findings.

22. FICA Florida Title XIX Long- Term Care 4848,, 103103)

Unemployment Insurance Reimbursement Plan, Section V. B.)

NH07- 063G

14 26032- 1

The Woods at Manatee Springs, Inc.

Attachment A- Audit Adjustments 30, 2004

For the Period from April 1, 2003 to September

The following adjustments reported rental value in the Schedule provisions of Fair of Rental the Florida Value Title System XIX Data are

in accordance with the fair Plan system where appropriate, the applicable sections of

Long- Term Care Reimbursement and 2300, Adequate and, Cost Data and Cost Findings, of the

Chapter 100, Depreciation Manual ( CMS Pub. 15- 1). The Provider has been furnished with

Provider Reimbursement of the audit which detail allowable components of

schedules developed during the course

the fair rental value system.

Increase

Fair Rental Value System Data Decrease

Classification

Ca itai Additions and Im rovements:

1. Acquisition Casts

2. Retirements

Capital Replacements: not examined)

3. Acquisition Costs

4. Pass- through Costs

Equity in Capital Assets: not examined)

5. Ending Equity

6. Average Equity

7. Return on Equity Before Apportionment 1, 899

8. Return on Equity Apportioned to Medicaid 589

NH07- 063G

15 26032. 1

The Woods at Manatee Springs, Inc.

Sterling Healthcare, Inc. ( Home Office) Home Office

Attachment A - Audit Adjustments - 2004

For the Period from April 1, 2003 to September 30,

Account Decrease) Increase

Classification Number Comment

Adjustments to Home Office Administrative Costs

1. Other Bonus Expense 730290 To adjust 2304, to examined CMS Pub amount. 15- 1) 988, 386)

Section

2. Legal 730580 To adjust 2304, to examined CMS Pub amount. 15- 1) 3. 991)

Section

3. Accounting 730560 To adjust 2304, to examined CMS Pub amount. 15- 1) 2, 475)

Section

4. Maintenance 710710 To adjust 2304, to examined CMS Pub amount. 15- 1) 20, 124)

Section

5. Travel 730902 To adjust 2304, to examined CMS Pub amount. 15- 1) 4, 202)

Section

6. Contract Services Non 730510 To Section adjust 2304, to examined CMS Pub amount. 15- 1) 110, 861)

Related Party

Net Adjustment affecting Administrative Costs 1, 039) 130,

Portion allocated to The Woods at Manatee Springs 41, 642)

Adjustments to Home Office Property Costs

7. Leases NonRelated Party 730510 To adjust to examined amount. 23, 510

Section 2304, CMS Pub 15- 1) 23, 510)

Net Adjustment affecting Property Costs

Portion allocated to The Woods at Manatee Springs 554)

Adjustments to Home Office Ending Equity Capital

No Adjustments

NH07- 063G

16 26032- 1

SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY

Complete item 4 if items 1, 2, and 3. Also complete A. Signature

0 Restricted Delivery is desired. x E3 Agent

Print your name and address on the reverse Addre ssee

I so that we can return the cans to you. B. Received by ( Fri ame) C v

Attach this card to the back of the mallpiece,

or on the front if space permits.

1. Article Addressed to D. Is delivery address different from item 1? Ye

If YES, enter delivery address below: No

I

Woods of Manatee Springs

5627 9th Street, East 3.

Bradenton, FL 34203 Service Certified Type Mail Express Mail

Registered Retum Receipt for Merchandise

Insured Mail C. D. O.

4. Restricted Deliver)? ( Ex6a Fee) Yes

2. Article I

I rransfE 7005 3110 3001 6523 3399

I PS Form 3811, February 2004 Domestic Return Receipt 102595v2• 1540 , M- l

l

rA Healthcare , ERL NG Inc.

October 15, 2008

Ms. Lisa Milton, Administrator

Florida Agency for Health Care Administration

Medicaid Audit Services

2727 Mahan Drive

Building 3, Mail Stop 21

Tallahassee, Florida 32308

CERTIFIED MAIL:

Provider Name: The Woods of Manatee Springs

Provider Number: 260321

Audit Engagement: NH07- 063G

Fiscal Year Ended: September 30, 2004

Dear Ms. Milton:

We are in receipt of the audit report for the Woods of Manatee Springs for the period April 1, 2003 through

September 30, 2004. We have reviewed the audit report and the related and adjustments that two other and believe that made the

auditor posted an adjustment based, not on fact but, on misjudgment adjustments

for lack of supporting documentation do, in fact, have supporting documentation.

Therefore, please accept this letter as our request for an appeal of the aforementioned cost worked report out audit. We

wish to have the actual appeal held in abeyance as we believe that the issues can be through

concerted teamwork on both our parts.

Please contact me as soon as possible to conform acceptance of this appeal and so that we may arrange for

copies of the work papers to be sent to us and/ or our cost report preparer for further review.

Thank you for your assistance in this matter.

Sincerely,

Putna Council, Inc.

RECEIVED

Robert Hagan OCT 16 2008

President SERVICES

ACUCT

16 Norcross Street, Suite 100, Roswell, GA 30075

Telephone: [phone] • 993- Fax: [phone]-

EXHIBIT 13

ry

lea1thr: TERL Rlu , £ nc. G.

October 15, 2008

Ms. Lisa Milton, Administrator

Florida Ageney for Health Care Administration

Medicaid Audit Services

2727 Mahan Drive

Building 3, Mail Stop 21

Tallahassee, Florida 32308

CERTIFIED MAJIL!

Provider Name: The Woods of Manatee Springs

Provider Number: 260321

Audit Engagement: NH07- 3 063(

Fiscal Year Ended: September 30, 2004

Dear Ms. Milton:

We are in receipt of the audit report for the Woods of Manatee Springs for the period April 1, 2003 through

September 30, 2004_ We have reviewed the audit report and the related adjustments and believe that the

auditor posted an adjustment based, not on fact but, on misjudgment and that two other adjustments made

for lack of supporting documentation do, in fact, have supporting documentation.

Therefore, please accept this letter as our request for an appeal of the aforementioned cost report audit. We

wish to have the actual appeal held in abeyance as we believe that the issues can be worked out through

concerted teamwork on both our parts.

Please contact me as soon as possible to conform acceptance of this appeal and so that we may arrange for

copies of the work papers to be sent to us and/ or our cost report preparer for further review.

Thank you for your assistance in this matter.

Sincerely,

Puma Council, Inc.

Robert Hagan

President

16 Norcross Street Suite 100, Roswell, GA 30075

Telephone: [phone] • 993- Fax: [phone]-

STEEL NG

Healthcare, Inc.

Costs may vary from one institution to another because of scope of services, level of care,

geographical location, and utilization. It is the intent of the program that providers are

reimbursed the actual costs of providing high quality care, regardless of how widely they

may found vary to from provider to provider, except where a particular s inst' itution' costs are

be substantially out of line with other institutions in the same area which are

similar in size, scope of services, utilization, and other relevant factors. Utilization, for

this purpose, refers not to the provider' s occupancy rate but rather to the mariner in which

the institution is used as determined by the characteristics of the patients treated ( i. e., its

patient mix - age of patients, type of illness, etc.).

Implicit in the intention that actual costs be paid to the extent they are reasonable is the

expectation that the provider seeks to minimize its costs and that its actual costs do not

exceed what a prudent and cost conscious buyer pays fora ven item or service. ( See

2103.) If costs are determined to exceed the level that such buyers incur, in the absence

of clear evidence that the higher costs were unavoidable, the excess costs are not

reimbursable under the program.

In the event that a provider undergoes bankruptcy proceedings, the program snakes

payment to the provider based on the reasonable or actual cost of services rendered to

Medicare beneficiaries and not on the basis of costs adjusted by bankruptcy

arrangements.

The Provider subsequently provided copies of the contracts and paid invoices that clearly indicate these are

legitimate services and that the invoices were paid on a timely basis. The Provider contends that these

services were not duplicative ( otherwise a binding legal contract would not have been entered) and are

necessary and prudent in order to maintain a clean and healthy building which leads, in turn, to cleaner and

more comfortable residents.

We are again including topics of the contracts and letters from Healthcare Services, an unrelated party,

discussing the services they provide.

Adjustment 9:

A]] owable Ancillary: To adjust due to lack of r13, 050>

documentation ( Section 2304,

CMS Ptib_ 15- I)

Copy of invoice attached.

161domross Street, Shire 100, Roswell, GA 30075

Telephone: [phone] • 993- Fax: [phone]-

Whitley Bros. Construction

6432 Tamiarni Trail, South

Sarasota, FL 34321

941- 2584. 923-

4/ 04 12/

Woods of Manatee Nursing Center

16 Norcross Street, Suite 50

Roswell, GA 30075

Roof repair.

Labor and materials S 4, 00 235.

Whitley Bros, Construction

6432 Tarniau- i Trail, South

Sarasota, FL 34321

941923- 2854.

4/ 04 12/

Woods of Manatee Nursing Center

16 Norcross Street, Suite 50

Roswell, GA 30075

Roof repair;

Labor and materials - .

4, 00 235.

Flsal1 - STERL Eire, NG fnn.

STERE, yIY~ 1 ffFA1T1IC11~ I~ lC.

Fy Nororosc Suva, Suite ] 00

ROM11, WilliQm GA Schwaflc 30075

Controrlcr

770) 4000- 993. Phone

wa 770493- Fax 9014- I

September 5, 2007

Mr. John Gabriel

Gabriel & Associates Cl' A

MediearelLL2 - A& R Reopening

Mutual of Omaha

Mutual of Omaha Plaza Omaha, XE 68175

John:

We, have been reviewing and evaluating your fax that the received

2007. the afternoon of Friday August 31,

While we have not completed our evaluation, I wanted to

monthly contractual payments far hilly respond to your denial of the $ 5, 000

for the I8 Healtb. Care Services Laundry Services at Woods of Manatee, ($

months of the audit) 90, 000

l believe that there was some confusion, because Woods of

Services ( Angelica Textile and Manatee utilizes two contractors for Laundry

HealthCare Services),

Angelica Textile provides the liner, services for Woods ofMmatee, which Donna

her note to you. Steiermann detailed in

HealthCare Services has provided laundry services at the Woods of

Laundry services provided, are Manatee since April, 2003„ The

Laundry service specifically detailed under the " Scope of Work" in the Housekt eping and

agreeanent. Health Care Services has provided smices to wash, fold and deliver

personal clothes for the residents, as well as other dry

heads, residents' blankets and other laundering facility items such as tablecloths, mop

miscellaneous items as requested by Woods of Manatee personnel.

HealthCare Services also sorts the clean linen items that come into the

Laundry Service, Angelica Textile, and building from the other outside

nursing and residents. picks up and delivers all laundry items to the floors for use by

The laundry at the facility operates every day, and is staffed a full

Care Service employee, and requires regular the by time Health

Housekeeper. oversight by Health Care Service Lxeoutive

I am also faxing the copy of the contract, Note that

Health Care Services details Exhibit I of the Woods of Manatee Springs and

that Health Care Services provided all and

to the 120 bed facility. laundry staffing laundry supplies

We will let you know of any other audit issues, Please

Monday September 10, 2007 contact me if you have any questions prior to our

10: 00 AM exit conference.

I

T7/ I fA

Woods of Manatee

k ibit III

Healthcare Services Group will provide the following laundry services:

Wash, dry, fold, and deliver personal clothing for residents of this facility

Wash, dry, fold, and deliver tablecloths as needed to Dietary Dept

Wash and dry bed blankets and other nziso, items that do not get sent out to an

outside service

Wash soiled mop heads as needed

Sot clean linens as they are delivered from the outside service to the facility

Deliver clean linen items to the floors for use by nursing and residents

r i

f` h

rran ygT ate pTa s

Divisional Vice .' P' resident

Healthcare Services' Group Sterling Health Care

T I. O0 Z/ p 30dd r/ T7 4, f 7- T nnn~ nr inr

HEALTHCARE

SERVICES

GROUP, INC.

THE WOODS OF MANATEE SPRINGS

HOUSEKEEPING

APRIL 1, 2003

Divisional Office: 16 Norcross Street • Suite 200 Roswell, CA 30075 - ( 800) 433. 2710 • ( 770) 657. 3580 • t' ax ( 770) 587- 3623

Corporate Office, 3220 Tillman Drive Suite 300 Bensalem, PA 19020 • ( 275) 639. 4274 • ( 800) 523. 2246 • Fax, ( 215) 639- 2752

T7 IF M 4PW- 4 u~~ H T) T r

HEALTHCARE

SERVICES

GROUP, INC.

S E R V I C E A ORE I MEN T

AGREEMENT, made this 1st day of April, 2003 by and between HEALTHCARE

SERVICES GROUP, INC. ( hereinafter referred to as " a

corporation, with offices at 3220 Tillman Healthcare'"), Pennsylvania

Bensalem, PA Drive, Suite 300, Glenview Corporate Center,

19020,

and

The Woods of Manatee Springs, Inc., A FL which

Home known as The corporation, operates a Nursing

Woods of Manatee Springs located at 5627 9th Street East,

Bradenton, FL, 34203 ( hereinafter referred to as " Facility"").

The parties hereto, intending to be legally bound as follows:

hereby agree

1. SCOPE OF WORK:

Healthcare will provide all necessary management, supervision, labor and

perform the housekeeping and laundry services on the materials necessary to

equipment will be assumed Healthcare In premises of the Facility. All existing housekeeping

addition to, by performing its duties. Any repair of, replacement of, or

housekeeping equipment will be Healthcare' s responsibility. The value and utilization of the

existing housekeeping equipment was a consideration in determining the service The of

work described will be In compliance with the specifications and schedules price. scope

and 11 to this Service Agreement, attached hereto as Exhibits I

2. CONTRACT AMOUNT:

2. 1 In consideration of Healthcare providing the aforesaid

the sum of Three Hundred Forty Thousand and services, the Facility will pay to Healthcare

be paid in twelve with Eight each no/ 100 dollars ($ 348, 00) 000. per year, said sum to

dollars payments, payment due in the amount of Twenty Nine Thousand and no/ 100

the the dot services were ren ered through. Sales tax, if applicable, will be added to

service blllif 91 i~)

3. TERM: 1 1- 7?

The tear, of this Service Agreement shall commence on

in accordance with the provisions contained herein. April 1, 2003 and will continue unless canceled

party One hundred This Service Agreement can be canceled by either

been given. twenty ( 120) days after services begin provided a ninety ( 90) day written notice has

Dlvfslonal Office: 16 War= Stre® t • Suite 200 • Roswell, GA 30075 - ( 800) 433. 2710 • ( w wwv Ww. Mw iww.

Corporara Office, 3220 Tillman Orlve w 5ulto 300 Bensalem, PA 19020 w ( 770) 557- 3580 • Fax ( 770) 587- 3623

215) 639- 4274 - ( 900) 523. 2P46 • Fax: ( 215) 639. 2152

T7/ nT r1H I v~~ H r~

r

4. INSURANCE COVERAGE, EMPLOYEE TAKES, RATES AND BENEFITS:

Healthcare will provide and pay Workmen' s Compensation, General Liability, FICA, Federal and

Stata Unemployment, managers salary, employee hourly wages and benefits for its employees. Should

any rate increase occur in any of these ca* Qdes, the billing will be adjusted to reflect these changes. .

Healthcare will notify the Facility in writing of the increases and effective dates of these changes.

5. CUSTOMER COOPERATION:

5. 1 during the term of this Service Agreement, the Facility will make all of its facilities available to

Healthcare so that the aforesaid services may be performed by Healthcare. Further, during the term of

this Service Agreement, the Facility will provide Healthcare personnel with the necessary utilities, including

but not limited to electricity and water, so that its services may be performed by Healthcare.

5. 2 The proposal price is based upon the ongoing operation of the existing laundry equipment of similar

or greater capacity to that of the facility at the time of the proposal presentation.

6. GENERAL PROVISIONS:

6. 1 Any notices given either party may be given by mail, registered or Certified, postage prepaid, with

return receipt requested. Mailed notices shall be deemed communicated, thirty ( 30) days after mailing and

should be addressed to the parties at the addresses in the introductory paragraph of this Service

Agreement, but each party may change its address by written notice in accordance with this paragraph.

6. 2 This Service Agreement supersedes any and all other agreements, either oral or written, between

the parties hereto with respect to the engagement of Healthcare by the Facility and contains all the

covenants and agreements between the parties with respect to its subject matter. T Ws Service Agreement

shall not affect or modify any other agreements bm% v= the parties with respect to the payment of any existing debts

or obligations awed by the Facility to Healthcare.

6. 3 This Service Agreement shall be governed and construed in accordance with the laws of the State

of the commonwealth of Pennsylvania.

6. 4 To the best of Healthcare' s ability, the housekeeping and laundry departments will be in complete

compliance with all state and federal regulatory agencies.

6. 5 Neither party, in the performance of this Service Agreement, shall discriminate against any patient,

employee, or other person because of race, color, creed, sex, ancestry, national origin, or handicap. Both

parties to this Service Agreement shall comply with the requirements of Title VI of the Civil Rights Act of

1964 and Section 504 of the Rehabilitation Act of 1973.

6. 6 Healthcare shall, until the expiration of four years after the furnishing of services pursuant to. this

Service Agreement, upon written request, make available to the Secretary of the Department of

Health and Human Services ( HHS), or the Secretary' s duly authorized representatives, or upon

request to the Comptroller General or the Comptroller General' s duly authorized representatives,

this Service Agreement and such books, documents and records that are necessary to certify the

nature and extent of costs under this Service Agreement. This provision shall apply if the amounts

paid under the Service Agreement are $ 14, 000 or more over a twelve month period. The

availability of Healthcare' s books, documents and records shall be subject at all times to such

criteria and procedures for seeking or obtaining access as may be promulgatedby the Secretary

of HHS in regulations and other applicable laws. Healthcare' s disclosure under this paragraph

shall not be construed as a waiver of any other legal rights to which Healthcare or the Facility may

be entitled. Each party will notify the other within 10 days of receipt of a request for access.

LZ/ L L gklfl u~, H T7 1. 7 •( T l!] 1T I' inn inT

If pursuant to this Service Agreement, any of Healthcare' s duties and obligations are to be carved

out by any individual or entity under a contract with Healthcare with a value of $ 10, ooo or more, over a

twelve month period, The availability of Healthcare' s books, documents and records shall be

subject at all times to such criteria and procedures for seeking or obtaining access as may be

promulgated by the Secretary of WHS in regulations and other applicable laws. Healthcare' s disclosure

under this paragraph shall not be construed as a waiver of any other legal rights to which Healthcare or

the Facility may be entitled. each party will notify the other within 10 days of receipt of a request for

access.

if pursuant to this Service Agreement, any of Healthcare' s duties and obligations are to be carried

out by any individual or entity under a contract with Healthcare with a value of $ 10, 000 or more, over a

twelve month period, and that subcontractor is to a significant extent, associated or affiliated with, owns, or

is owned by or has control of or is controlled by Healthcare, each such subcontractor shall itseff by subject

to the access requirements and Healthcare shall require such subcontractor to meet the access

requirements.

6. 7 This Service Agreement shall be binding upon, and inure to the benefit of, the parties and their

respective heirs, successors, personal representatives and assigns.

6. 8 During the term of this Agreement, and for a period of one year after the termination of this

Agreement, neither party shall hire management personnel ( i. e., managers or supervisors) ( a) SO

employed by the other; or ( b) who had been employed by the other at any time within one year before or

after the termination of this Agreement.

IN WITNESS WHEREOF, the parties hereto, or their duly authorized officers or agents, have

executed, sealed and delivered this Service Agreement, in duplicate, intending to be legally bound hereby.

HEALTHCARE SER ICES GROUP, INC.

E3

Print Name: Brian Waters

Title: Vice President Operations

The Wood f Manatee Springs

By:

Print

Full Name: Bob Hagan

Title: President

T7 / 7T gr1H. 4

HEALTHCARE

SERVICES

GROUP, INC.

EXHIBIT I

The Woods of Manatee Springs

PROPOSAL

HEALTHCARE SERVICES GROUP, INC. will provide the following:

Full time executive housekeeper

District Manager to oversee operation

All staffing and payroll responsibilities for housekeeping and laundry

salaries

taxes and insurance

fringe benefits.

All laundry supplies to include the following:

M detergent softener

bleach sour

All housekeeping supplies listed

Heavy housekeeping equipment - Floor machines etc.

Employee advertising

Uniforms

Monthly unit inspections and regular district manager visits

Regular employee in- service program

All housekeeping equipment necessary for start up

The cost of this service will be: $- 29; 9 Month,

The above cost does not include the outside laundry service.

Divisional Office; 16 NororoBS Street • Suire 200 • Roswell, DA 30075 1 ( 800) 433- 2710 • ( 770) 587. 3580 • Fax ( 587• 3623 o

Corporate bfflw $ 220 Tlllman Drlve • Suite 300 • Bensalem, PA 18020 • ( 216) 639. 4274 • ( 770)

800) 5232248 • Fax: ( 275) 639. 2152

T7 / CT 7C1HJ V71H T7 4, 7 ' CT onn7 Inc inT

HEALTHCARE

SERVICES

GROUP, INC.

The Woods of Manatee 506nf{ s

EXHIBIT 11

SUPPLIES

The following is a list of supplies and chemicals provided by Healthcare Services

Croup, Inc.

Germicidal Detergent Dust Mops and Handles

All Purpose Degreaser dust Cloths

Degreaser Mops and Mop Handles

Ammoniated Stripper Buff Pads

Floor Finish Stripping Pads

Sealer ( 22` Y4 Solid) All Supplementary Tools For

Glass Cleaner Light Housekeeping

Ammonia All Laundry Chemicals

Cleanser

Bowl Cleaner

Furniture Cleaner

Furniture Polish

Metal Polish

Carpet Shampoo

The client will be responsible for the following supplies,

All paper and plastic for housekeeping

All Hand Soap

All Laundry Equipment Repair

All Hampers, Sins & Racks For The Laundry

All Spreads - Curtains - Pillows

Blankets etc.

e..•. aruv-~ a

Dlvlslonal Office: 16 Norvoss Street • Suite 2013 • Roswell, GA PA 30075 • ( 600) 433- 639. 2710 • ( 4274 • ( 770) 3580 • 5& 523- 7. 2248 • Pax ( Fex: ( 770) $ 87- 6394152 3823

Corporate Office. 3220 Tillman Drive • Sulfa 300 • Bensalem, 19020 • ( 275) 800) 275)

T7/ bT 4r1H, 4 V7:]- I1 T~ a~' IT rr

HEALTHCARE

SERVICES

GROUP, INC.

THE WOODS OF MANATEE SPRINGS

HOUSEKEEPING

APRIL, 1, 2003

Dlvfslonal Office: 16 Norcross Street ~ Suite 203 - Roswell, GA 3005 - ( 433. 8710 - ( 587- 3580 - Fax ( M , AwI. Wn` YY• YUm YII~ W

Office, 3220 Tillman Drive 1 800} 770) 770) 587. 3623

Corporate Suite $ 00 • Bensalem, PA ! B92D , ( 215) 639. 4274 • ( 800) 523. 2248 - Faxr ( 215) 639, 2152

T7/ GT. InH, A Y'- q1H T7 b7 : PT PnM7/ L1T Gig'/

HEALTHCARE

SERVICES

GROUP, INC.

EXHIBIT I

The Woods of Manatee Springs

PROPOSAL

HEALTHCARE SERVICES GROUP, INC. will provide the following:

Full time executive housekeeper

District Manager to oversee operation

All staffing and payroll responsibilities for housekeeping and laundry

salaries

taxes and insurance

fringe benefits

All laundry supplies to include the following:

detergent softener

bleach sour

All housekeeping supplies fisted

Heavy housekeeping equipment - f= loor machines etc.

Employee advertising

Uniforms

Monthly unit inspections and regular district manager visits

w Regular employee in- service program

All housekeeping equipment necessary for start up

The cost of this service will be: $. 2Q-, Month. 0eM/

The above cost does not include the outside laundry service.

Divisional Office! 16 Nororass 51reat y 5ulle 200 , a Roswell, GA 30075 • ( 800) 433. 2710 * ( 770) 567. 3560 • Fax ( Fax; ( 7701587. 3623 639. 2152

corporate Office' 3220 Tillman Drive • suite 300 Bensalem, PA 19020 • ( 215) 839. 4274 • ( 800) 523. 2249 • 215)

TZ/ 9T. nti~ X~~ H T7 1, 7 ' CT oaa7lac inT

HEALTHCARE

SERVICES

GROUP, INC.

S E RV ICE AGRE EME bTT

AGREEMENT, made this 1st day of April, 2003 by and between HEALTHCARE

SERVICES GROUP, INC. ( hereinafter referred to as " Healthcare"), a Pennsylvania

corporation, with offices at 3220 Tillman Drive, Suite 300, Glenview Corporate Center,

Bensalem, PA 19020,

and

The Woods of Manatee Springs, Inc., A FL corporation, which operates a Nursing

Home known as The Woods of Manatee Springs located at 5627 9th Street East,

Bradenton, FL, 34203 ( hereinafter referred to as " Facility").

The parties hereto, intending to be legally bound hereby agree as follows;

1. SCOPE OF WORK:

Healthcare will provide all necessary management, supervision, labor and materials necessary to

perform the housekeeping and laundry services on the premises of the Facility. All existing housekeeping

equipment will be assumed by Healthcare in performing its duties. Any repair of, replacement of, or

addition to, housekeeping equipment will be Healthcare' s responsibility. The value and utilization of the

existing housekeeping equipment was a consideration in determining the service price. The scope of

work described will be in compliance with the specifications and schedules attached hereto as Exhibits I

and ii to this Service Agreement.

2. CONTRACT AMOUNT:

2. 1 In consideration of Healthcare providing the aforesaid services, the Facility will pay to Healthcare

the sum of Three Hundred Forty Eight Thousand and no/ 100 dollars ($ 349, 000. 00) per year, said sum to

be paid In twelve payments, with each payment due in the amount of Twenty Nine Thousand and nofl00

dollars the da services were ren erect through. Sales tax, if applicable, will be added to

the service billing.

3. TERM:"

The term of this Service Agreement shall commence on April 1, 2003 and will continue unless canceled

in accordance with the provisions contained herein. This Service Agreement can be canceled by either

party One hundred twenty ( 120) days after services begin provided a ninety ( 90) day written notice has

been given.

Divisional Offlce: 16 Norcross street • Suite 200 • Roenrall, GA 30075 - ( 800) 438- 2710 - ( 770) 587. 3580 • Fax ( 770) 587. 3 362.

Corporate Office; 3220 Tillman Drive - Suite 300 @ Bensalem, PA 19020 , ( 215) 639. 4274 ( 800) 523- 2248 - Fax; ( 215) 8382152

TZ/ LT 39dd X~ 1ky T7 b7' T C' OCIM7 JnC' InT

4. INSURANCE COVERAGE, EMPLOYEE TAXES, RATES AND BENEFITS:

Healthcare will provide and pay Workmen' s Compensation, General Liability, FICA, Federal and

State Unemployment, managers salary, employee hourly wages and benefits for its employees. Should

any rate increase occur in any of these categories, the billing will be adjusted to reflect these changes.

Healthcare will notify the Facility in writing of the increases and effective dates of these changes.

6. CUSTOMER COOPERATION:

5. 1 During the term of this Service Agreement, the Facility will make all of ft facilities available to

Healthcare so that the aforesaid services may be performed by Healthcare. Further, during the term of

this Service Agreement, the Facility will provide Healthcare personnel with the necessary utilities, including

but not limited to electricity and water, so that its services may be performed by Healthcare.

5, 2 The proposal price is based upon the ongoing operation of the existing laundry equipment of similar

or greater capacity to that of the facility at the time of the proposal presentation.

6. GENERAL PROVISIONS:

5. 1 Any notices given either party may be given by mail, registered or certified, postage prepaid, with

return receipt requested. Mailed notices shall be deemed communicated thirty ( 30) days after mailing and

should be addressed to the parties at the addresses in the introductory paragraph of this Service

Agreement, but each party may change its address by written notice in accordance with this paragraph.

6. 2 This Service Agreement supersedes any and all other agreements, either oral or written, between

the parties hereto with respect to the engagement of Healthcare by the Facility and contains all the

covenants and agreements between the parties with respect to its subject matter, This Service Agreement

slWl not affect or modify any other ageements between the parties with respect to the payment of any oxWing debts

or obligations oared by the Facility to Healthcare.

6, 3 This Service Agreement shall be governed and construed in accordance with the laws of the State

of the commonwealth of Pennsylvania-

6. 4 To the best of Healthcare' s ability, the housekeeping and laundry departments will be in complete

compliance with all state and federal regulatory agencies.

6. 5 Neither party, in the. performance of this Service Agreement, shall discriminate against any patient,

employee, or other person because of race, color, creed, sex, ancestry, national origin, or handicap. Both

parties to this Service Agreement shall comply with the requirements of Title V1 of the Civil Rights Act of

1964 and Section 604 of the Rehabilitation Act of 1973.

6. 6 Healthcare shall, until the expiration of four years after the furnishing of services pursuant to this

Service Agreement, upon written request, make available to the Secretary of the Department of

Health and Human Services ( HHS), or the Secretary' s duly authorized representatives, or upon

request to the Comptroller General or the Comptroller General' s duly authorized representatives,

this Service Agreement and such books, documents and records that are necessary to certify the

nature and extent of costs under this Service Agreement. This provision shall apply if the amounts

paid under the Service Agreement are $ 10, 000 or more over a twelve month period, The

availability of Healthcare' s books, documents and records shall be subject at all times to such

criteria and procedures for seeking or obtaining access as may be promulgated by the Secretary

of HHS in regulations and other applicable laws. Healthcare' s disclosure under this paragraph

shall not be construed as a waiver of any other legal rights to which Healthcare or the Facility may

be entitled. Each party will notify the other within 10 days of receipt of a request for access.

T7/ RT gHJA 171H r~ r r

If pursuant to this Service Agreement, any of Healthcare' s duties and obligations are to be carried

out by any individual or entity under a contract with Healthcare with a value of $ 10, 000 or more, over a

twelve month period. The availability of Healthcare' s books, documents and records shall be

subject at all times to such criteria and procedures for seeking or obtaining access as may be

promulgated by the Secretary of HHS in regulations and other applicable laws. Healthcare' s disclosure

under this paragraph shall not be construed as a waiver of any other legal rights to which Healthcare or

the Facility may be entitled, each party will notify the other within 10 days of receipt of a request for

access.

If pursuant to this Service Agreement, any of Healthcare' s duties and obligations are to be can' ied

out by any individual or entity under a contract with Healthcare with a value of $ 10, 000 or more, over a

twelve month period, and that subcontractor is to a significant extent, associated or affiliated with, owns, or

is owned by or has control of or is controlled by Healthcare, each such subcontractor shall itself by subject

to the access requirements and Healthcare shall require such subcontractor to meet the access

requirements.

6. 7 This Service Agreement shall be binding upon, and inure to the benefit of, the parties and their

respective heirs, successors, personal representatives and assigns.

6. 8 During the term of this Agreement, and for a period of one year after the termination of this

Agreement, neither party shall hire management personnel ( i. e.; managers or supervisors) ( a) still

employed by the other, or ( b) who had been employed by the other at any time within one year before or

after the termination of this Agreement.

IN WITNESS WHEREOF, the parties hereto, or their duly authorized officers or agents, have

executed, sealed and delivered this Service Agreement, in duplicate, intending to be legally bound hereby.

HEALTHCARE SER ICES GROUP, INC.

ay.

Print Name: Brian Waters

Title: Vice President Operations

SOW

The Wood f Manatee Springs

Print c

Full Name; Bob Hagan

Title: President

Z/ 6 1. 3OVd X~, H T7 7 • cT nnn7 nr ins

HEALTHCARE

SERVICES

GROUP, INC.

The Woodl of Manatee Snrinos

EXHIBIT II

SUPPLIES

The following is a list of supplies and chemicals provided by Healthcare Services

Group, Inc.

Germicidal Detergent Dust Maps and Handles .

All Purpose Degreaser Dust Cloths

Degreaser Mops and Mop Handles

Ammoniated Stripper Buff Pads

Floor Finish Stripping Pads

Sealer ( 22% Solid) All Supplementary Tools For

Glass Cleaner Light Housekeeping

Ammonia All Laundry Chemicals

Cleanser

Bowl Cleaner

Furniture Cleaner

Furniture Polish

Metal Polish

Carpet Shampoo

The client will be responsible for the following supplies:

All Paper and plastic for housekeeping

All Hand Soap

All Laundry Equipment Repair

All Hampers, Bins & Racks For The Laundry

All Spreads w Curtains - Pillows

Blankets etc.

w

Dlvlslonal Office: 16 Noruoss street Suite 200 Roswell, GA 30075 - ( 600) 433- 2710 , ( 87- 3580 Fax ( 587. 38" 4•~ NCM w11w M.. T•

Corporate Office: 3220 Tillman Drive Sui1a 300 PA 19020 M) $ r 770)

8erisalem, 215) 8394274 ( 800) 5232248 Fax: ( 215) 839. 2152

TZ/ 9Z 3Jdd u~~ H T7 T r

FROM t MRHATEESPR i NGSCAREANDREHIRS F' RX NO, : 9417559365 Oct. 09 21306 02: 45PM P2

PEASE I$ MI ll' A COPY OF FIRST PAGE QEJHII, S I~ NVOjg j WITH

YQUR PAYMENT 03 WRITE TMIE IIN SCE NUTANER ( LQQ TED Al TH

RIO T T_ Q, KMgF Y„ QUR IhI DICE) YOUR CHECK THANK YOU

SUNOANCE REHABILITATION April 2, 2004

THERAPY SERVICES INVOICE Invoice: 10007876

Services for March, 2004

Faollity: Woods of Manatee Sprlnp Remit: SUNDANCE REHABILITATION

627 Ninth Street Heat R0, Sox 18072

Bradenton, FL 34203 Ashburn, VA 20146

per Diem

Serfte~ DasorlptlOn Cat Payor Pints 9111 Unit N Unite Rate Ext. Amount

TOTAL RUG DAYS 9NF Medloare A bays 1880. 00 116, 47 578.

OUTUER DAYS PRIOR SNF Medicare A Drays 80100 5, 68 081.

MONTH

Per Diem Total: 5121, 15 640.

ww rar* Dwarfa., ar. rwwrrwwwawrrwwarrwrrwrwMrwrarrr, akw, rrr w, t x. rawwrrw~ raa

Phy0cal

Seivicelpesaiption Cat Payor Ptnts Bill Unit p Units Rate Ext. Amount

PT RUG ALLOCATION SNF Medivara A Farb 1. 00 55, 40 127.

MEDICARE PART 13 SNF Medicare 8 CPT 369. 00 8, 66 422,

PT RUG OUTLIER SNF Medicare A Each 1. 00 2, 30 61$.

ALLOCATION

Phystaal Tntae 08, 37 106.

Occupational

ServlcWDescription cat Payor PtMS Bill Unit 0 Units Rata Ext. Amount

OT RUG ALLOCATION SNF Medicare A Each 1. 00 48. 83 678.

MEDICARE PART R SNF Medicare 8 CPT 246. 00 5, 94 422.

OT RUG OUTLIER NF Medicare A Each 1. 00 2, 20 169.

ALLOCATION

Occupational Total: 66, 86 768-

Speech

ServkPJDesrrlptlen Cat Payor Pints Brill Unit tr Un116 Bate Ext. Amount

ST RUG ALLOCATION 5NF Medicare A Each 1. 00 12. 35 774.

ST RUG OUTLIER SNF Medicare A Each 1. 00 276. 09

ALLOCATION

Speech Tot® l: 13, 44 050.

INVOICE TOYAL: 135, 67 486.

09/ 2015 01/ 11: 44 7709339014 STERLING

PAGE 02f02

l,, w1j

STATE OF FLORIDA MICA

AGENCY FOR HEALTH CARE ADMINISTRATION ACEH' Y U' CLERK{

THE WOODS OF MANATEE 2815 SEP - I P 3. 15

SPRINGS,

Petitioner,

VS. Engagement No.: NH07- 063G

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Respondent.

1

NOTICE OF VOLUNTARY DISMISSAL

Petitioner, The Woods of Manatee Springs, by and through its undersigned counsel,

hereby gives Notice of Voluntary Dismissal the above styled action. Each party will bear their

own attorney' s fees and costs.

Respectfully submitted,

q

ARichardLAA, Feldman, Esq.

5627 9t" St. East

Bradenton, FL 34203

FL Bar No.: 024130

Email: feldman richard~ 7a yahoo com

Attorney for Petitioner

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished by facsimile to the

Agency Clerk for the Respondent, at facsimile number ( 850) 921- 0158 and to Katharine B. Heyward, Esq.,

Assistant General Counsel for the Respondent, by email to Ka. com hca. Hevwardfa~ mvflolida. a. ftarinc. this i s day

of September, 2015.

Richard Attorney A. for Feldman, Petitioner Esq.

EXHIBIT ' G