429.26(7) FS; 59A-36.007(1) FAC Resident Care – Supervision
429.26
(7) The facility shall notify a licensed physician when a resident exhibits signs of……or ..w. . or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such or…………… , ………………The notification must occur within 30 days after the…………. acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility must notify the resident’s representative or designee of the need for health care services and must assist in making
for the necessary care and services to treat the condition. If the resident does not have a representative or designee or if the resident’s representative or designee cannot be located or is unresponsive, the facility shall arrange with the appropriate health care provider for the necessary care and services to treat the condition.
59A-36.007
An assisted living facility must provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities must offer personal supervision as appropriate for each resident,
including the following:
(a) Monitoring of the quantity and quality of resident diets in accordance with rule 59A-36.012, F.A.C.
(b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the resident.
(c) Maintaining a general awareness of the resident’s whereabouts. The resident may travel independently in the community,
(d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change.
(e) Contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services.
This Statute or Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure that;
(1) the facility make daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the resident.
(2) The facility also failed to contact the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change.
(3) The facility failed to Maintain a written record…………updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services for 1 of 3 sampled resident records reviewed: (Specifically, Resident #7).
The findings included:
On……….. A review of the facility’s Incident Report was conducted regarding Resident #7. The report was dated ………… The Administrator completed the incident Report. The incident report revealed the following:
On……… at 07:30 AM, Staff A observed Resident # 7 sitting on the toilet in the bathroom. Staff A stated, Resident # 7 complained of in her left side. Staff A asked the resident if she had……….. The resident stated that she had not Staff A proceeded to bathe the resident and feed her breakfast. Staff A stated Resident # 7 was seated on the couch, resting comfortably with her ………….. up. Staff A offered to apply ice to the affected area and the Resident refused.
On ……….. at 06:00 PM, the Administrator writes he arrived at the facility. He writes that he asked Resident # 7 how she was feeling and she replied “ok.” He stated he received a call from the resident’s daughter. The daughter stated that she had just spoken to Resident # 7. Resident # 7 advised her daughter that she had… The Administrator noted that this was the first time he had heard about this incident. He writes that he advised the resident’s daughter to take her mother to urgent care, because she needed to be evaluated immediately. He wrote that the daughter agreed to take her mother to the urgent care. He writes that he called the daughter in 30-45 minutes. The daughter indicated that she was having a difficult time finding an urgent care center that accepts her mother’s insurance. He explained that he advised the daughter that he would have to call 911 (Emergency transport). The report reads that he called 911 at 7:15 PM.
A review of the financial contract was conducted. It was revealed that the Resident’s Power of Attorney and Health Care Surrogate was her daughter, effective since 2015.
Further review of the document revealed the following persons were notified regarding Resident #7’s incident.
1) It was not documented that the Staff or Administration notified the POA/HCS at 07:30 AM,
2) It was not documented the time that the Physician was notified.
On…………at 02:42 PM, a request was made of the Administrator to provide the 1 and 15 day Adverse Incident Reports. The Administrator stated he was unable to locate copies of the reports. He stated he did not conduct an internal Investigation to determine how the injury occurred to the resident. He was not able to provide evidence that the incident was avoidable or unavoidable. An email was sent to the local field office, requesting verification that the adverse incident reports were submitted. It was confirmed by the office Supervisor, that the 1 and 15 day reports had not been submitted to the Agency for review.
On ………… a request was made for the Physician Order for the transport to the hospital for Resident #7. It could not be provided by the
Administrator. Further review of the Resident #7’sfile revealed the physician order was missing requesting a mobile
A review of Resident #7’s Health Assessment form (AHCA 1823 form) was conducted. The demographics form shows that Resident #7 was admitted into the facility on ……………. A review of the AHCA 1823 form dated revealed that the resident required assistance with her Activities of Daily Living (ADL’s); ambulation, bathing ……. eating, self care grooming, toileting and transferring. She suffers from the following diagnosis: , …, (DJ), and The Nursing/Treatment …,, Service Requirements call for Physical and………… .. Further review of the section of the AHCA 1823 form on oversight revealed that Resident # 7 required daily oversight for the following:
a. observing wellbeing
b. observing whereabouts
c. reminders for important tasks
A review of the progress notes was conducted for Resident # 7. The following was revealed.
a) ……….. – indicate that appetite was good, encouraging fluids, see Incident Report.
b) : 1202 – (time not documented) – Resident had difficult day. Resident’s behavior was Inappropriate. She was banging on the windows and tried to pull the Television (TV) from the wall. The Administrator contacted the resident’s daughter a number of times. The Administrator called 911 and local law enforcement came out and assessed her, but did not
On………….. at 09:45 AM, a tour of the facility was conducted with as the Administrator. It was
revealed that Resident # 7 previously resided in … # . The room is located directly across from the kitchen. It is the first room observed in the facility. The room has it’s own private bathroom. At the time of the incident, the resident did not have a roommate.
On ………… at 11:35 AM, an interview was conducted with the Administrator. He stated that on …………. at 07:30 AM, Staff A contacted him and advised him that Resident # 7 was found on the toilet in the bathroom. Staff A stated Resident # 7 was complaining of in her left .. He insisted that Staff A checked the resident and she did not find any marks or………..The Administrator stated he arrived to the facility routinely at 7:15 PM that same day. He stated the resident’s daughter called and spoke to him. She advised him that her mother had called complaining of… He stated that he advised the daughter to come and take Resident # 7 to the local urgent care facility. He stated that he made this suggestion to go to the Urgent Care, Instead of the hospital because he had concerns about the resident the Corona (COVID-19) at the hospital. He stated the daughter stated she could not do so, and advised him to call 911.
He stated that he never received a complaint from the resident’s daughter; who is also her Power of Attorney (POA), but did receive a law suit from their attorney regarding the incident involving Resident # 7. He stated he was later informed that the Resident had suffered a
…….to her left . He confirmed that the facility settled the lawsuit with the resident and her family. He confirmed that he did not conduct an investigation regarding the incident resulting in an injury to the left of Resident # 7. He stated he does not know what happened to cause the
……. Subsequently, he confirmed that he did not complete an adverse incident report determining if the injury was avoidable or unavoidable. He stated he was unable to obtain any hospital records to confirm that the resident had a…………. He stated the resident had been recently given a new prescription for…………in………………… He stated, that this new medication may have caused the resident to sleep more.
On………………at 01:38 PM, an interview was conducted with the Power of Attorney/Healthcare Surrogate (POASHCS) for Resident # 7. The POA stated that. on. ………, she received a call from Resident # 7 at approximately 06:30 PM. Resident # 7 was crying and saying she was in
An aide was in the room and stated “I found her on the toilet crying saying her left was hurting and she was in, I changed Resident # 7 and put her clothes on. She was in worse i , so put her night clothes on. The owner said to give her an every four hours”. The caller asked the aide why she wasn’t notified earlier. The aided stated “Oh he/owner didn’t call you. The POA called the owner and he stated “I’m on my way over there, I wanted to asses the situation first before I called you”. The owner called her ….. within 15 minutes and stated “you may want to call an urgent care and see if they will see her”. The POA told the owner to call Emergency Management System,( ), and that she was not calling any urgent care. The owner called and Resident # 7 was taken to the local Hospital. She was given a CT-scan and diagnosed with a left broken and admitted to the hospital. The POA stated Resident # 7 had to undergo surgery. She stated the Administrator never contacted her to provide explanation of the
incident. She stated she was extremely upset that It took 12 hours for the facility to contact her.
On ……….. at 02:10 PM, an interview was conducted with Staff A and the following was revealed. She stated, Resident # 7 resided in
# . She did not have roommate. She found her on the toilet seat. She says Resident # 7 complained of, of her left side. She asked if she ., she said no she did not. She had to clean her up and she checked her left side. She did not see any signs or symptoms of …….. She called the Administrator at 08:00 AM on the date day. She told him that she complained of…………….. He says he was going to call the daughter. She then told her daughter that she had … (He did not call the daughter). Staff A says she called 911 at about 07:00 PM. She stated the resident was not complaining of 1. , due to her sleeping more that day. She noticed that she ate all meals: breakfast, lunch and dinner without any instance.
Staff A further stated, that she and the Administrator were never informed by the resident that she had.. .She stated, the resident could go to the bathroom by herself. She says she had been looking for her in her bedroom. She stated she had gone to shower her and found her on the toilet. She stated the resident had been sleeping without any problem. She says the resident had rails, but she could scoot down and get around them. She says she had never : previously. She says she did noticed that the toilet seat had moved a little bit when she saw Resident # 7.
On ………….. at 03:00 PM, the Administrator confirmed that they were unable to make contact with the Physician on ……….. He stated the
resident sees a physician in the community. He stated that they could not contact the facility physician. He acknowledged the findings that he did not conduct an investigation, and make the proper notifications.
Class III
59A-36.007(2) FAC Resident Care – Social & Leisure Activities
(2) SOCIAL AND LEISURE ACTIVITIES. Residents shall be encouraged to participate in social, recreational, educational and other activities within the facility and the community.
(a) The facility must provide an ongoing activities program. The program must provide diversified Individual and group activities in keeping with each resident’s needs, abilities, and interests.
(b) The facility must consult with the residents in selecting, planning, and scheduling activities. The facility must demonstrate residents’ participation through one or more of the following methods: resident meetings, committees, a resident council, a monitored suggestion box, group discussions, questionnaires, or any other form of communication appropriate to the size of the facility.
(c) Scheduled activities must be available at least 6 days a week for a total of not less than 12 hours per week. Watching television is not an activity for the purpose of meeting the 12 hours per week of scheduled activities unless the television program is a special one-time event of special interest to residents of the facility. A facility whose residents choose to attend day programs conducted at adult day care centers, senior centers, mental health centers, or other day programs may count those attendance hours towards the required 12 hours per week of scheduled activities. An activities calendar must be posted in common areas where residents normally congregate.
(d) If residents assist in planning a special activity such as an outing, seasonal festivity, or an excursion, up to 3 hours may be counted toward the required activity time.
This Statute or Rule is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide an ongoing activities program. The program must provide diversified individual and group activities in keeping with each resident’s needs, abilities, and Interests for 6 of 6 sampled residents observed Resident’s #1 – #6).
The findings included:
On………..from 09:10 AM – 04:00 PM through ……….. from 09:00 AM – 03:00 PM, an observation was made of the 6 residents in the facility. The staff failed to engage the resident’s In the facility’s scheduled activities during the noted survey dates.
On …….. a review of the activity schedule was conducted. It revealed the following group
activities scheduled for…………….:
Sit and Be Fit 09:00 AM – 10:00 AM
Hydration Hour and Snack 10:30 AM – 11:00 AM
Coloring Activities 01:00 PM – 02:00 PM
Hydration Hour and Snacks 03:30 PM – 04:00 PM (See activity calendar attached)
On……………. at 12:00 PM, an interview was conducted with a family member for Resident # 1. He stated that he visits daily, but doesn’t see any activities taking place for his relative. He states all she does is watch Television (TV). He thinks they could use more activities to stimulate the residents during the Pandemic.
On……….. at 12:10 PM, Resident # 5 stated that they don’t participate in any activities.
On ……. at 03:50 PM, an interview was conducted with Resident # 3. She stated that the Staff don’t provide any activities. She stated that the Staff stick to themselves. She says she works on an electronic game for activities. She stated it gets boring.
On…………. a review of the Activity Calendar was conducted.
The following was scheduled:
Ball Toss 09:00 AM – 10:00 AM
Hydration Hour and Snack 10:30 AM – 11:00 AM
Puzzle Time 01:00 PM – 02:00 PM
Hydration Hour and Snack 03:30 PM – 04:00 PM
On ……………. at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings that the staff were not following the Activity schedule.
Class
59A-36.007(6) FAC; 429.281 ) FS 429.27 Resident Care – Rights & Facility Procedures
59A-36.007
(6) RESIDENT RIGHTS AND FACILITY PROCEDURES.
(a) A copy of the Resident Bill of Rights as described in section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Program must be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to rule 59A-36.006, F.A.C.
(b) In accordance with section 429.28, F.S., the facility must have a written grievance procedure for receiving and responding to resident complaints and a written procedure to allow residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is Implemented upon receipt of a complaint.
(c) The telephone number for lodging complaints against a facility or facility staff must be posted in full view in a common area accessible to all residents. The telephone numbers are: the Long-Term Care Ombudsman Program, 1(888)831-0404; … Rights Florida, 1(800)342-0823; the Agency Consumer Hotline 1(888)419-3456, and the statewide toll-free telephone number of the Florida Hotline, 1(800)96- ….. or 1(800)962-2873. The telephone numbers must be posted in close proximity to a telephone accessible by residents and the text must be a minimum of 14-point font. (d) The facility must have a written statement of its house rules and procedures that must be included in the admission package provided pursuant to rule 59A-36.006, F.A.C. The rules and procedures must at a minimum address the facility’s policies regarding:
1. Resident responsibilities;
2. and tobacco use;
3. Medication storage;
4. Resident elopement;
5. Reporting resident …….., neglect, and
6. Administrative and housekeeping schedules and requirements;
7. …… control, sanitation, and universal precautions; and,
8. The requirements for coordinating the delivery of services to residents by third party providers.
(e) Residents may not be required to perform any work in the facility without compensation. Residents may be required to clean their own sleeping areas or apartments if the facility rules or the facility contract includes such a requirement. If a resident is employed by the facility, the resident must be compensated in compliance with state and federal wage laws.
(f) The facility must provide residents with convenient access to a telephone to facilitate the resident’s right to unrestricted and private communication, pursuant to section 429.28(1)(d), F.S. The facility must allow unidentified telephone calls to residents. For facilities with a licensed capacity of 17 or more residents in which residents do not have private telephones, there must be, at a minimum, a readily accessible telephone on each floor of each building where residents reside.
(g) In addition to the requirements of section 429.41(1)(k), F.S., the use of physical by a facility on a resident must be reviewed by the resident’s physician annually. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance, is not considered a physical ……
429.28 Resident bill of rights.
(1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges quarantined by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to:
(a) Live in a safe and decent living environment, free from ……. and neglect.
(b) Be treated with consideration and respect and with due recognition of personal dignity, Individuality, and the need for privacy.
(c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, Impractical, or an infringement upon the rights of other residents,
(d) Unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and Visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall make provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar situations.
(e) Freedom to participate in and benefit from community services and activities and to pursue the highest possible level of independence, autonomy, and interaction within the community.
(f) Manage his or her financial affairs unless the resident or, if applicable, the resident’s representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide safekeeping for funds as provided in s. 429.27.
(g) Share a room with his or her spouse if both are residents of the facility.
(h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather.
(i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any resident,
(j) Assistance with obtaining access to adequate and appropriate health care. For purposes of this paragraph, the term “adequate and appropriate health care” means the management of medications, assistance in making .. for health care services, the provision of or arrangement of transportation to health care ……., and the performance of health care services in accordance with s. 429.255 which are consistent with established and recognized standards within the community.
(k) At least 45 days’ notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally ………., the guardian shall be
given at least 45 days’ notice of a nonemergency relocation or residency termination. Reasons for relocation must be set forth in writing and provided to the resident or the resident’s legal representative. The notice must state that the resident may contact the State Long-Term Care Ombudsman Program for assistance with relocation and must include the statewide toll-free telephone number of the program. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show good cause in a court of competent jurisdiction.
(l) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without , interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents’ exercise of this right. This right Includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups.
(2) The administrator of a facility shall ensure that a written notice of the rights, and prohibitions set forth in this part is posted in a prominent place in each facility and read or explained to residents who cannot read. The notice must include the statewide toll-free telephone number and e-mail address of the State Long-Term Care Ombudsman Program and the telephone number of the local ombudsman council, the Elder Hotline operated by the Department of Children and Families, and, if applicable……………Rights Florida, where complaints may be lodged. The notice must state that a complaint made to the Office of State Long-Term Care Ombudsman or a local tong-term care ombudsman council, the names and identities of the residents involved in the complaint, and the identity of complainants are kept confidential pursuant to $. 400.0077 and that retaliatory action cannot be taken against a resident for presenting grievances or for exercising any other resident right. The facility must ensure a resident’s access to a telephone to call the State Long-Term Care Ombudsman Program or local ombudsman council, the Elder………… Hotline operated by the Department of Children and Families, and ……., Rights Florida.
429.27 Property and personal affairs of residents –
(1) (a) A resident shall be given the option of using his or her own belongings, as space permits; choosing his or her roommate; and, whenever possible, unless the resident is adjudicated .. . or …… under state law, managing his or her own affairs.
(b) The admission of a resident to a facility and his or her presence therein shall not confer on the facility or its owner, administrator, employees, or representatives any authority to manage, use, or dispose of any property of the resident; nor shall such admission or presence confer on any of such persons any authority or responsibility for the personal affairs of the resident, except that which may be necessary for the safe management of the facility or for the safety of the resident.
This Statute or Rule is not met as evidenced by: Based on observation, interview and record review, the facility failed to honor residents rights by:
1) failing to display the telephone numbers for lodging complaints against the facility in full view, in a common area, easily assessable to all residents. The facility failed to display the phone numbers for the licensing agency Agency for Healthcare Administration (AHCA), the …….
Advocacy Hotline and the Hotline 2 The facility also failed to follow their internal grievance policy and procedure for 1 of 4 sampled residents: (Specifically, Resident # 7).
The findings included:
On . … at 09:45 AM, a tour of the facility was conducted with the Administrator. It was revealed that the only advocacy poster displayed in the facility was the Long Term Care Ombudsman poster. It was hung in the Activity Room, where all of the residents congregate. The AHCA, …. and … poster were not displayed. At this time, the Administrator asked the Surveyor where could these posters be located. Also, at this time the suggestion box was not observed in the facility.
A review of the facility policy and procedure was conducted. The policy was undated. The policy was entitled: Resolution of Complaints, Policy and Procedure.
a. We also have a suggestion box kept in a common area of the facility where all residents have access to it should they want to remain anonymous. Residents will be made aware of its location, upon admission.
b. A facility log will be kept, showing all dates box was checked and any complaints and suggestions and resolution of same.
PROCEDURE:
a. The Administrator will meet with the resident or representative and inquire about the complaint to understand the concerns. b. If the issue pertains to that individual alone, we will try to find an acceptable solution immediately.
RESOLUTION :
a. Residents will asked how they would like to see the issues addressed.
b. Staff will follow-up on all issues or suggestions made, notifying the resident of progress/resolutions made as soon as possible.
c. Staff will do everything possible to resolve issues in a satisfactory manner.
d. When a favorable outcome is not possible or the resident disagrees with how the issue was handled, an explanation will be provided.
e. If the resident/family or representative are dissatisfied with the resolution, they have a right to file a formal complaint with the Administrator.
f. The Administrator will meet again with the parties involved to try and get an amicable decision, and if not possible, to arrive at some sort of compromise. (See policy attached) On ………… a request was made for the facility grievance tog. The Administrator could not provide a log of any complaints made for the past two years to current (2019 and 2020), both verbal and written,
On …….. at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings.
Class
59A-36.007(8) FAC Resident Care – Elopement Standards
59A-36.007
(8) ELOPEMENT STANDARDS.
(a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified So staff can be alerted to their needs for support and supervision. All residents must be assessed for risk of elopement by a health care provider or a mental health care provider within 30 calendar days of being admitted to a facility. If the resident has had a health assessment performed prior to admission pursuant to paragraph 59A-36.006(2) (a), F.A.C., this requirement is satisfied. A resident placed in a facility on a temporary emergency basis by the Department of Children and Families pursuant to section 415.105 or 415.1051, F.S., is exempt from this requirement for up to 30 days.
1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff trained pursuant to paragraph 59A-36.011(10)(a) or (c), F.A.C., must be generally aware of the location of all residents assessed at high risk for elopement at all times.
2. The facility must have a photo identification of at risk residents on file that is accessible to all facility staff and law enforcement as necessary. The facility’s file must contain the resident’s photo identification upon admission or upon being assessed at risk for elopement subsequent to admission. The photo identification may be provided by the facility, the resident, or the resident’s representative. (b) Facility Resident Elopement Response Policies and Procedures. The facility must develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures must provide for:
1. An immediate search of the facility and premises,
2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities,
3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to
subparagraph (8)(b)1.; and,
4. The continued care of all residents within the facility in the event of an elopement,
(c) Facility Resident Elopement Drills. The facility must conduct and document resident elopement
drills pursuant to sections 429.41(1)(a)3. and 429.41(1):), F.S.
Based on interview and record review, the facility failed to conduct and document that all direct care staff and Administration had participated in two (2) mock elopement drills per year.
The findings included:
On……………… at 10:00 AM, a request was made for two years of mock elopement drills including all direct care staff and Administration. The Administrator indicated that he had left the documentation at home. The Administrator provided the evidence on the following survey date of
Review of the documents revealed the following.
a) …………………….only 2 staff and the Administrator participated.
b) …………. , 10:15 AM, only 2 staff and the Administrator participated.
c) …………… 01:30 PM, only 2 staff and the Administrator participated. (See attachment)
On……………… at 03:00 PM, an interview was On …. a review of the Staffing Schedule was conducted. The direct care staff includes 3 direct care staff and the Administrator.
On …. a review of the mock elopement drills were conducted. The following drills were conducted for 2019 and 2020: conducted with the Administrator. He acknowledged that he had not conducted mock elopement drills including all direct care staff twice per year.
Class III
429.256(..); 59A-36.008(3) Medication – Assistance with Self-Admin
429.256
(3) Assistance with self-administration of medication includes:
(a) Taking the medication, in its previously dispensed, properly labeled container, including an . syringe that is prefilled with the proper dosage by a pharmacist and an , that is prefilled by the manufacturer, from where it is stored, and bringing it to the resident.
(b) In the presence of the resident, confirming that the medication is intended for that resident, orally advising the resident of the medication name and dosage, opening the container, removing a prescribed amount of medication from the container, and closing the container. The resident may sign a written waiver to opt out of being orally advised of the medication name and dosage. The waiver must identify all of the medications intended for the resident, including names and dosages of such medications, and must immediately be updated each time the resident’s medications or dosages change.
(c) Placing an oral dosage in the resident’s or placing the dosage in another container and helping the resident by lifting the container to his or her……………
(d) Applying,……… medications.
(e) Returning the medication container to proper storage.
(f) Keeping a record of when a resident receives assistance with self-administration under this section.
(g) Assisting with the use of a , including removing the cap of a ……, opening the unit dose of solution, and pouring the prescribed premeasured dose of medication into the dispensing cup of the
(h) Using a…….. to perform ………….. level checks
(i) Assisting with putting on and taking off …… stockings.
(j) Assisting with applying and removing an ir . .. but not with titrating the prescribed. settings.
(k) Assisting with the use of a continuous positive airway pressure device but not with titrating the prescribed setting of the device. (1) Assisting with measuring vital signs.
(m) Assisting with ……. ,bags.
(4) Assistance with self-administration does not include:
(a) Mixing, i we converting, or ……. medication doses, except for measuring a prescribed amount of liquid medication or breaking a scored tablet or
crushing a tablet as prescribed.
(b) The preparation of syringes for Injection or the administration of medications by any injectable route.
(c) Administration of medications by way of a tube inserted in a … of the body.
(d) Administration of……………. preparations.
(e) The use of irrigations or debriding agents used in the treatment of a skin condition.
(f) Assisting with …. ….., or preparations.
(g) Assisting with medications ordered by the physician or health care professional with prescriptive authority to be given “as needed,” unless the order is written with specific parameters that preclude independent judgment on the part of the unlicensed person, and the resident requesting the medication is aware of his or her need for the medication and understands the purpose for taking the medication.
(h) Medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration requires judgment or discretion on the part of the unlicensed person.
(5) Assistance with the self-administration of medication by an unlicensed person as described
in this section shall not be considered administration as defined in s. 465.003. 59A-36.008
(3) ASSISTANCE WITH SELF-ADMINISTRATION.
(a) Any unlicensed person providing assistance with self-administration of medication must be ………. or older, trained to assist with self administered medication pursuant to the training requirements of rule 59A-36.011, F.A.C., and must be available to assist residents with self-administered medications in accordance with procedures described in section 429.256, E.S. and this rule.
(b) In addition to the specifications of section 429.256(3), F.S., assistance with self-administration of medication includes, in the presence of the resident, reading the medication label aloud and verbally prompting a resident to take medications as prescribed.
(c) In order to facilitate assistance with self-administration, trained staff may prepare and make available such items as water, juice, cups,
and spoons. Trained staff may also return unused doses to the medication container. Medication, which appears to have been contaminated, must not be returned to the container.
(d) Trained staff must observe the resident take the medication. Any concerns about the resident’s reaction to the medication or suspected noncompliance must be reported to the resident’s health care provider and documented in the resident’s record.
(e) When a resident who receives assistance with medication is away from the facility and from
facility staff, the following options are available to enable the resident to take medication as prescribed:
1. The health care provider may prescribe a medication schedule that coincides with the
resident’s presence in the facility,
2. The medication container may be given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record,
3. The medication may be transferred to a pill organizer pursuant to the requirements of subsection (2), and given to the resident, a friend, or family member upon leaving the facility, with this fact noted in the resident’s medication record, or
4. Medications may be separately prescribed and dispensed in an easier to use form, such as unit dose packaging (0) Assistance with self-administration of medication does not include the activities detailed in section 429.256(4), F.S.
1. As used in section 429.256(4)g), F.S., the term “competent resident” means that the resident is cognizant of when a medication is required and understands the purpose for taking the medication.
2. As used in section 429.256(4)(h), F.S., the terms “judgment” and “discretion” mean interpreting vital signs and evaluating or assessing a resident’s condition,
(g) All trained staff must adhere to the facility’s………….. control policy and procedures when assisting with the self-administration of medication.
This Statute or Rule is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that Unlicensed Staff who assist with self-administration of medication follow the proper policies and procedures when assisting a resident with their self administered medications, for 4 of 4 sampled residents (Residents #1, #2, #3 and #
4).
The findings included:
On…………..at 11:45 AM, an observation of the medication pass was conducted with Staff A. Staff A is an unlicensed Medication Technician (Med Tech). She was observed pre-filling the medication cups in the Kitchen area. She placed the pills into the pill cups there and placed the medications into the locked medication cabinets. She delivered the medications to the residents in their bedrooms and the general activity room without their original packaging, She also failed to orally announce the names of the medications for the following residents:
1. Resident # 1. Aprazałam 1 mg, Sucralate 1 mg, 12:00 PM
2. Resident # 2, ….. 0.5 mg, 12:00 PM
3. Resident # 3, Hydrazaline 10 mg, 01:00 PM.
3. Resident # 4, Cranberry 450 mg, H . Sprinkle 125 mg, Cod Oil Therems M. (See Medication Observation Record)
On ………….. a review of the records for the residents (Resident #1-#6) was conducted. It was revealed that the residents nor the legal
guardian had signed a written waiver to opt out of being orally advised of the medication name and dosage,
On……………….at 02:00 PM, an interview was conducted with the Administrator. He confirmed that the residents nor their representatives had not signed a waiver to opt out of the Unlicensed Staff to announce the names of the medications,
On………………….at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings.
Class III
429.52(1 & 7) FS; 59A-36.011( ) – FAC Training – Staff In-Service
429.52(1)
(1) Each new assisted living facility employee who has not previously completed core training must attend a pre-service orientation provided by the facility before interacting with residents. The pre-service orientation must be at least 2 hours in duration and cover topics that help the employee provide responsible care and respond to the needs of facility residents. Upon completion, the employee and the administrator of the facility must sign a statement that the employee completed the required pre service orientation. The facility must keep the signed statement in the employee’s personnel record.
(7) Facility staff shall participate in in service training relevant to their job duties as specified by agency rule. Topics covered during the pre service orientation are not required to be repeated during in service training. A single certificate of completion that covers all required in service training topics may be issued to a participating staff member if the training is provided in a single training course.
59A-36.011
(2) STAFF PRESERVICE ORIENTATION,
(a) Facilities must provide a pre-service orientation of at least 2 hours to all new assisted living facility employees who have not previously completed core training as detailed in subsection (1).
(b) New staff must complete the preservice orientation prior to interacting with residents.
(c) Once complete, the employee and the facility administrator must sign a statement that the employee completed the preservice orientation which must be kept in the employee’s personnel record,
(d) In addition to topics that may be chosen by the facility administrator, the preservice orientation must cover:
1. Resident’s rights; and,
2. The facility’s license type and services offered by the facility.
(3) STAFF IN-SERVICE TRAINING. Facility administrators or managers shall provide or arrange for the following in-service training to facility staff:
(a) Staff who provide direct care to residents, other than nurses, certified nursing assistants, or home health aides trained in accordance with rule 59A-8.0095, F.A.C., must receive a minimum of 1 hour in-service training in … control, including universal precautions and facility sanitation procedures, before providing personal care to residents. The facility must use its ….. control policies and procedures when offering this training. Documentation of compliance with the staff training requirements of 29 CFR 1910.1030, relating to ….borne
, may be used to meet this requirement.
(b) Staff who provide direct care to residents must receive a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects: 1. Reporting adverse incidents. 2. Facility emergency procedures including chain-of-command and staff roles relating to emergency evacuation.
(c) Staff who provide direct care to residents, who have not taken the core training program, shall receive a minimum of 1 hour in-service training within 30 days of employment that covers the following subjects:
1. Resident rights in an assisted living facility.
2. Recognizing and reporting resident neglect, and ………The facility must use its prevention policies and procedures when offering this training,
(d) Staff who provide direct care to residents, other than nurses, CNAS, or home health aides trained in accordance with rule 59A-8.0095, F.A.C., must receive 3 hours of in-service training within 30 days of employment that covers the following subjects:
1. Resident behavior and needs.
2. Providing assistance with the activities of daily living
(e) Staff who prepare or serve food, who have not taken the assisted living facility core training must receive a minimum of 1-hour-in-service training within 30 days of employment in safe food handling practices.
(f) All facility staff shall receive in-service training regarding the facility’s resident elopement response policies and procedures within thirty (30) days of employment.
1. All facility staff shall be provided with a copy of the facility’s resident elopement response policies and procedures.
2. All facility staff shall demonstrate an understanding and competency in the implementation of the elopement response policies and procedures.
This Statute or Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure that each new assisted living facility employee attend a 2 hr pre-service orientation training provided by the facility before Interacting with residents, for 1 of 4 sampled employee personnel records ( Staff C).
The findings included:
On……………………….at 09:00 AM, the Surveyor observed Staff C providing direct care assistance to residents by assisting them with their Activities of Daily Living (ADL’s).
On …., a review of the employee personnel records was conducted for Staff C. It was revealed that Staff C was hired on
as a Home Health Aide. She provides direct resident care, assisting with their Activities of Daily Living, (ADL’S). The file failed to indicate that the employee had completed the required 2 hour preservice orientation training.
On………………………….. at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings.
59A-36.012(2) FAC Food Service – Dietary Standards
(2) DIETARY STANDARDS.
(a) The meals provided by the assisted living facility must be planned based on the current USDA Dietary Guidelines for Americans, 2010, which are incorporated by reference and available for review at: http://www.firules.org/Gateway/reference.asp?No
Ref-04003, and the current summary of Dietary Reference Intakes established by the Food and Nutrition Board of the Institute of Medicine of the National Academies, 2010, which are incorporated by reference and available for review at: http://iom.edu/Activities/Nutrition/SummaryDRIS/ /media/Files/Activity%20Files/Nutrition/DRIs/New %20Material/5DRI%20Values%20Summary Table s%2014.pdf. Therapeutic diets must meet these nutritional standards to the extent possible.
(b) The residents’ nutritional needs must be met by offering a variety of meals adapted to the food habits, preferences, and physical abilities of the residents, and must be prepared through the use of standardized recipes. For facilities with a licensed capacity of 16 or fewer residents, standardized recipes are not required. Unless a resident chooses to eat less, the facility must serve the standard minimum portions of food according to the Dietary Reference Intakes.
(c) All regular and therapeutic menus to be used by the facility must be reviewed annually by a licensed or registered dietitian, a licensed nutritionist, or a registered dietetic technician supervised by a licensed or registered dietitian, or a licensed nutritionist to ensure the meals meet the nutritional standards established in this rule. The annual review must be documented in the facility files and include the original signature of the reviewer, registration or license number, and date reviewed. Portion sizes must be indicated on the menus or on a separate sheet. 1. Daily food servings may be divided among three or more meals per day, including snacks, as necessary to accommodate resident needs and preferences. 2. Menu items may be substituted with items of comparable nutritional value based on the seasonal availability of fresh produce or the preferences of the residents.
(d) Menus must be dated and planned at least 1 week in advance for both regular and therapeutic diets. Residents must be encouraged to participate in menu planning. Planned menus must be conspicuously posted or easily available to residents. Regular and therapeutic menus as served, with substitutions noted before or when the meal is served, must be kept on file in the facility for 6 months.
(e) Therapeutic diets must be prepared and served as ordered by the health care provider.
1. Facilities that offer residents a variety of food choices through a select menu, buffet style dining, or family style dining are not required to document what is eaten unless a health care provider’s order indicates that such monitoring is necessary. However, the food items that enable residents to comply with the therapeutic diet must be identified on the menus developed for use in
the facility.
2. The facility must document a resident’s refusal to comply with a therapeutic diet and provide notification to the resident’s health care provider of such refusal.
(f) For facilities serving three or more meals a day, no more than 14 hours must elapse between the end of an evening meal containing a protein food and the beginning of a morning meal. Intervals between meals must be evenly distributed throughout the day with not less than 2 hours nor more than 6 hours between the end of one meal and the beginning of the next. For residents without access to kitchen facilities, snacks must be offered at least once per day Snacks are not considered to be meals for the purposes of the time between meals.
(g) Food must be served attractively at safe and palatable temperatures. All residents must be encouraged to eat at tables in the dining areas. A supply of eating ware sufficient for all residents, including adaptive equipment if needed by any resident, must be on
(h) A 3-day supply of nonperishable food, based on the number of weekly meals the facility has ……….. with residents to serve, must be on
at all times. The quantity must be based on the resident census and not on licensed capacity. The supply must consist of foods that can be stored safely without refrigeration. Water sufficient for drinking and food preparation must also be stored, or the facility must have a plan for obtaining water in an emergency, with the plan coordinated with and reviewed by the local disaster preparedness authority.
This Statute or Rule is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow the menus and ensure that substitutions are of the same comparable nutritional value served. The facility also failed to ensure that their 3-day supply of nonperishable food, based on the number of weekly meals the facility has ………. with residents to serve, must be on at all times. The quantity must be based on the resident census and not on licensed capacity. The facility failed to ensure that the food was served
attractively, at a safe palatable temperature for 6 of 6 residents observed during the lunch meal: (Specifically, Resident’s # 1 – #6).
The findings included:
On …………………. at 11:45 AM, an observation was made of the lunch meal. Staff A, was observed preparing the meal. She served the meal to only 3 of the 6 residents. The dining room table could accommodate 6 residents, but there were only 2 residents seated at the table (Resident # 3 and # 5). Resident # 1 was being fed in her room in her hospital bed by Staff B. Staff A ensured that 3 residents received their lunch meal at this time and the 3 remaining residents did not receive their meal until 12:30 PM. At this time, she stated she had to social distance the residents. The facility did not make accommodations to feed all residents at the same hour while implementing social distancing.
A review of the lunch menu was conducted for ……. The menu included the following:
4 oz. Cesar Salad
6 oz. Baked Lasagna
1 slice of Garlic Bread Green Beans Pudding Fresh Fruit
6 oz. Coffee/Tea Beverage
8 oz. Milk
(See menu cycle attached)
The following items were served: Turkey and Gravy, Sweet Potatoes and Ice Cream.
On ………… a review of the emergency food and water supply Inventory List provided by the facility Dietitian was conducted. The following
items were not present in the supply cabinet:
On……………………..at 12:30 PM, an observation was made of the 3-day emergency food and water supply along with the Administrator. A. It was revealed that the following food items were missing from the supply:
1. Canned Beef Stew – 2 (48 oz. cans)
2. Canned Ravioli – 2( 48 oz. cans)
3. Canned Chili Con Carne – 2 (48 oz. cans)
4. Peanut Butter 4 – (16 oz. cans)
5. Canned Carrots 1 – 48 oz. can)
6. Canned Green Beans 1 – 48 oz. can)
7. Canned Mixed Vegetables – 1 (48 oz. can)
8. Dry Cereal – 2 dozen individual boxes
9. Puddings: Vanilla 2 (60 OZ.) & Chocolate 2 (60 oz.)
B. It was revealed that the following beverage items were missing from the supply
1. Water 36 gallons required. The facility had 15 gallons. (See emergency inventory attached)
On…………… at 03:00 PM, an interview was conducted with the Administrator. He stated he could provide the residents with tray tables so that they would not have to watch the other residents eat. He also acknowledged that the cook did not follow the menu, He acknowledged that he needed to restock the emergency food and water supply
Class III
59A-36.016 FAC Risk Mgmt & QA; Adverse Incident Report
429.23 Internal risk management and quality assurance program, adverse incidents and reporting requirements.
(1) Every facility licensed under this part may, as part of its administrative functions, voluntarily establish a risk management and quality assurance program, the purpose of which is to assess resident care practices, facility incident reports, deficiencies cited by the agency, adverse incident reports, and resident grievances and develop plans of action to correct and respond quickly to identify quality differences.
(2) Every facility licensed under this part is required to maintain adverse incident reports. For purposes of this section, the term, “adverse incident” means:
(a) An event over which facility personnel could exercise control rather than as a result of the resident’s condition and results in:
1………….
2……………… or .. damage,
3. Permanent
4. ….. or………… of bones or joints;
5. Any condition that required medical attention to which the resident has not given his or her consent, including failure to honor advanced directives;
6. Any condition that requires the transfer of the resident from the facility to a unit providing more acute care due to the incident rather than the resident’s condition before the incident; or
7. An event that is reported to law enforcement or its personnel for investigation; or (b) Resident elopement, if the elopement places the resident at risk of harm or injury,
(3) Licensed facilities shall provide within 1 business day after the occurrence of an adverse incident, through the agency’s online portal, or if the portal is offline, by electronic mail, a preliminary report to the agency on all adverse Incidents specified under this section. The report must include information regarding the identity of the affected resident, the type of adverse Incident, and the status of the facility’s investigation of the incident.
(4) Licensed facilities shall provide within 15 days, through the agency’s online portal, or if the portal is offline, by electronic mail, a full report to the agency on all adverse incidents specified in this section. The report must include the results of the facility’s investigation into the adverse Incident.
(6) ……, neglect, or. …… must be reported to the Department of Children and Families as required under chapter 415.
(7) The information reported to the agency pursuant to subsection (3) which relates to persons licensed under chapter 458, chapter 459, chapter 461, chapter 464, or chapter 465 shall be reviewed by the agency. The agency shall determine whether any of the incidents potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of s. 456.073 apply. The agency may investigate, as it deems appropriate, any such incident and prescribe measures that must or may be taken in response to the incident. The agency shall review each incident and determine whether it potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of S. 456.073 apply.
(8) If the agency, through its receipt of the adverse incident reports prescribed in this part or through any investigation, has reasonable belief that conduct by a staff member or employee of a licensed facility is grounds for disciplinary action by the appropriate board, the agency shall report this fact to such regulatory board.
(9) The adverse incident reports and preliminary adverse incident reports required under this section are confidential as provided by law and are not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the agency or appropriate regulatory board.
(10) The agency may adopt rules necessary to administer this section.
59A-36.016 Adverse Incident Report
(1) INITIAL ADVERSE INCIDENT REPORT. The preliminary adverse incident report required by section 429.23(3), F.S., must be submitted within 1 business day after the incident pursuant to rule 59A-35.110, F.A.C., which requires online reporting,
(2) FULL ADVERSE INCIDENT REPORT. For each adverse incident reported in subsection (1), above, the facility must submit a full report within 15 days of the incident. The full report must be submitted pursuant to rule 59A-35.110, F.A.C., which requires online reporting.
This Statute or Rule is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to complete and submit the initial adverse incident report and the full adverse incident report for a Resident’s Incident that resulted in a facture.
The findings included:
A review of the facility’s Incident Report was conducted regarding Resident #7. The report was dated ……….. The Administrator completed the incident Report. The incident report revealed the following:
On…………….at 07:30 AM, Staff A observed Resident # 7 sitting on the toilet in the bathroom. Staff A stated, Resident # 7 complained of in her left side. Staff A asked the resident if she had……………. The resident stated that she had not Staff A proceeded to bathe the resident and feed her breakfast. Staff A stated Resident # 7 was seated on the couch, resting comfortably with her………………up. Staff A offered to apply ice to the affected area and the Resident refused.
On ………… at 06:00 PM, the Administrator writes he arrived at the facility. He writes that he asked Resident #7, how she was feeling and she replied “ok.” He stated he received a call from the resident’s daughter. The daughter stated that she had just spoken to Resident # 7. Resident # 7 advised her daughter that she had … The Administrator noted that this was the first time he had heard about this incident. He writes that he advised the resident’s daughter to take her mother to urgent care, because she needed to be evaluated immediately. He wrote that the daughter agreed to take her mother to the urgent care. He writes that he called the daughter in 30-45 minutes. The daughter indicated that she was having a difficult time finding an urgent care center that accepts her mother’s insurance. He explained that he advised the daughter that he would have to call 911 (Emergency transport).The report reads that he called 911 at 7:15 PM.
A review of Resident #7’s Health Assessment form (AHCA 1823 form) was conducted. The demographics form shows that Resident #7 was admitted into the facility on ……………. A review of the AHCA 1823 form dated revealed that the resident required assistance with her Activities of Daily Living (ADL’s): ambulation, bathing ……. we eating, self care grooming, toileting and transferring. She suffers from the following diagnosis: .. .. ..,
(DJ), and The Nursing/Treatment: …, Service Requirements call for Physical and Hrv. Further review of the section of the AHCA 1823 form on oversight revealed that Resident # 7 required daily oversight for the following:
a, observing wellbeing
b. observing whereabouts
c. reminders for important tasks
On ………….. at 02:42 PM, a request was made of the Administrator to provide the 1 and 15 day Adverse Incident Reports. The Administrator stated he was unable to locate copies of the reports. He stated he did not conduct an internal investigation to determine how the injury occurred to the resident. He was not able to provide evidence that the incident was avoidable or unavoidable. An email was sent to the local field office, requesting verification that the adverse Incident reports were submitted. It was confirmed by the office Supervisor, that the 1 and 15 day reports had not been submitted to the Agency for review.
Further interview with the Administrator on………. at 11:35 AM and Resident #7’s representative on ……… at 12:38 PM revealed the resident suffered a broken left, and had to undergo surgery. The facility had no further documentation available for review to determine how the resident substained the injury and whether it was due to the resident or facility staff failure to provide appropriate supervisor and/or assistance to the resident.
On………………. at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings.
Class
435.12(2)(-d), FS Background Screening Clearinghouse
435.12(2) Care Provider Background Screening Clearinghouse
(b) Until such time as the … are enrolled in the national retained print notification program at the Federal Bureau of Investigation, an employee with a break in service of more than 90 days from a position that requires screening by a specified agency must submit to a national screening if the person returns to a position that requires screening by a specified agency.
(c) An employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days.
(d) An employer must register with and initiate all criminal history checks through the clearinghouse before referring an employee or potential employee for electronic……….. submission to the Department of Law Enforcement. The registration must include the employee’s full first name, middle initial, and last name; social security number, date of birth; mailing address; … and race. Individuals, persons, applicants, and controlling interests that cannot legally obtain a social security number must provide an individual taxpayer identification number.
This Statute or Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure that an employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days for 2 of 4 sampled employee records reviewed: (Specifically. Staff A and Staff C)
The findings included:
On ……….. a review of the Background Screening Clearinghouse Roster was conducted Staff A and Staff C were not listed on the Roster. (See Background Screening Clearinghouse Roster attached, dated ………….)
On 12/292020 a review of the employee personnel records was conducted for Staff A. It was revealed that Staff A was hired on
She works as a Certified Nursing Assistant. She provides direct resident care, assisting with their Activities of Daily Living, (ADL’S). The staff was not listed on the Background Screening Clearinghouse Roster.
On ………… a review of the employee personnel records was conducted for Staff C. It was revealed that Staff C was hired on
She works as a Home Health Aide. She provides direct resident care, assisting with their Activities of Daily Living, (ADL’s). The staff was not listed on the Background Screening Clearinghouse Roster.
On………………….. at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings.
Unclassified
408.809; 435.02(2): 435.06 FS Background
Screening; Prohibited Offenses
408.809 Background screening; prohibited offenses.
(1) Level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the following persons, who are considered employees for the purposes of conducting screening under chapter 435:
(a) The licensee, If an individual.
(b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider.
(c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee of provider,
(d) Any person who is a controlling interest.
(2) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to provide personal care or services directly to clients or have access to client funds, personal property, or living areas, and any person, as required by authorizing statutes, ……… with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients, or with a licensee or provider to work 20 hours a week or more who will have access to client funds, personal property, or living areas. Evidence of contractor screening may be retained by the contractor’s employer or the licensee.
(3) All… must be provided in electronic format. Screening results shall be reviewed by the agency with respect to the offenses specified In s. 435.04 and this section, and the qualifying or disqualifying status of the person named in the request shall be maintained in a database. The qualifying or disqualifying status of the person named in the request shall be posted on a secure website for retrieval by the licensee or designated agent on the licensee’s behalf.
(4) In addition to the offenses listed in $. 435.04, all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an awaiting final disposition for, must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the following offenses or any similar offense of another jurisdiction:
(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud.
(d) Section 409.9201, relating to Medicaid fraud.
(e) Section 741.28, relating to domestic violence.
(f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense fisted in this subsection.
(g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
(h) Section 817.234, relating to false and fraudulent insurance claims.
(i) Section 817.481, relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony.
(j) Section 817,50, relating to fraudulently obtaining goods or services from a health care provider.
(k) Section 817.505, relating to patient brokering.
(l) Section 817.568, relating to criminal use of personal identification information,
(m) Section 817.60, relating to obtaining a credit card through fraudulent means.
(n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
(0) Section 831.01, relating to forgery.
(p) Section 831.02, relating to uttering forged instruments
(q) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
(r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.
(s) Section 831.30, relating to fraud in obtaining medicinal drugs.
(t) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony.
(u) Section 895.03, relating to racketeering and collection of unlawful debts.
(v) Section 896.101, relating to the Florida Money Laundering Act. If, upon rescreening, a person who is currently employed or ….. with a licensee and was screened and qualified under $. 435.04 has a disqualifying offense that was not a disqualifying offense at the time of the last screening, but is a current disqualifying offense and was committed before the last screening, he or she may apply for an exemption from the appropriate licensing agency and, if agreed to by the employer, may continue to perform his or her duties until the licensing agency renders a decision on the application for exemption if the person is eligible to apply for an exemption and the exemption request is received by the agency no later than 30 days after receipt of the rescreening results by the person.
(5) The costs associated with obtaining the required screening must be borne by the licensee or the person subject to screening. Licensees may reimburse persons for these costs. The
Department of Law Enforcement shall charge the agency for screening pursuant to s. 943.053(3). The agency shall establish a schedule of fees to cover the costs of screening.
(6)(a) As provided in chapter 435, the agency may grant an exemption from disqualification to a person who is subject to this section and who:
1. Does not have an active professional license or certification from the Department of Health; or 2. Has an active professional license or certification from the Department of Health but is not providing a service within the scope of that license or certification. (b) As provided in chapter 435, the appropriate regulatory board within the Department of Health, or the department itself if there is no board, may grant an exemption from disqualification to a person who is subject to this section and who has received a professional license or certification from the Department of Health or a regulatory board within that department and that person is providing a service within the scope of his or her licensed or certified practice.
(7) The agency and the Department of Health may adopt rules pursuant to ss. 120.536(1) and 120.54 to implement this section, chapter 435, and authorizing statutes requiring background screening and to implement and adopt criteria relating to retaining w … pursuant to s.
943.05(2).
(8) There is no reemployment assistance or other monetary liability on the part of, and no cause of action for damages arising against, an employer that, upon notice of a disqualifying offense listed under chapter 435 or this section, terminates the person against whom the report was issued, whether or not that person has filed for an exemption with the Department of Health or the agency
435.06 Exclusion from employment-
(1) If an employer or agency has reasonable cause to believe that grounds exist for the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity.
(2)(a) An employer may not hire, select, or otherwise allow an employee to have contact with any person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any ….. person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the agency as provided under $. 435.07.
(b) If an employer becomes aware that an employee has been for a disqualifying offense, the employer must remove the employee from contact with any person that places the employee in a role that requires background screening until the is resolved In a way that the employer determines that the employee is still eligible for employment under this chapter.
(c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to s. 435.07.
(d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with
persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment.
(3) Any employee who refuses to cooperate in such screening or refuses to timely submit the Information necessary to complete the screening, including……… if required, must be disqualified for employment in such position or, if employed, must be dismissed.
(4) There is no reemployment assistance or other monetary liability on the part of, and no cause of action for damages against, an employer that, upon notice of a conviction or for a disqualifying offense listed under this chapter, terminates the person against whom the report was issued or who was……., regardless of whether or not that person has filed for an exemption pursuant to this chapter,
435.02 Definitions.-For the purposes of this chapter, the term: (2) “Employee” means any person required by taw to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers.
This Statute or Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure that all staff members had obtained an eligible Level Il screening prior to employment and direct contact and interaction with residents, for 1 of 4 sampled employee personnel records reviewed (Staff C).
The findings included:
On……… at 09:00 AM, the Surveyor observed Staff C providing direct care assistance to residents by assisting them with their Activities of Daily Living (ADL’s).
On ………… a review of the online Background Screening system for the agency was conducted. It was revealed that the date of the screening revealed on…………the results show “not eligible.” On ………….., a review of the employee personnel records was conducted for Staff C. It was revealed that Staff C was hired on…………She works as a Home Health Aide. She provides direct resident care, assisting with their Activities of Daily Living, (ADL’s).
On…………..at 01:00 PM, the Administrator asked Staff C, why was her Level Il background
screening results showing “not eligible.” She stated she was not sure. At this time, she stated she needed to leave to take care of the matter.
On…………. at 03:00 PM, Staff C had not returned to the facility. During an interview with the Administrator on………. at 3:05, he stated he was not aware of the ineligible status and was not clear of the reason. He stated that he may have to contact the Home Health Aide Agency to find a replacement for Staff C’s shift for that day.
Unclassified
408.809(2a-c) 435.05(2) 59A-35.090(20-30 Background Screening-Compliance Attestation
408.809 Background screening; prohibited offenses-
(2) Every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person’s to the Federal Bureau of Investigation for a national criminal history record check unless the person’s are enrolled in the Federal Bureau of Investigation’s national retained print notification program. If the ……………of such a person are not retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h), the person must submit electronically to the Department of Law Enforcement for state processing, and the the Department of Law Enforcement shall forward to the Federal Bureau of Investigation for a national criminal history record check. The we shall be retained by the Department of Law Enforcement under s. 943.05(2)g) and (h) and enrolled in the national retained print …… notification program when the Department of Law Enforcement begins participation in the program. The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person……………….The agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, provided that:
(a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s. 435.04 and this section;
(b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and
(c) Such proof is accompanied, under penalty of perjury, by an attestation of compliance with chapter 435 and this section using forms provided by the agency.
435.05 Requirements for covered employees and employers.-Except as otherwise provided by law, the following requirements apply to covered employees and employers:
(2) Every employee must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if. …. for any of the disqualifying offenses while employed by the employer.
59A-35.090 Background Screening.
(2) Processing Screening Requests, Required Documents and Fees,
(d) An Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008, ….. .. , herein incorporated by reference, available at http://www.firules.org/Gateway/reference.asp?NORef-09106, and available from the Agency for Health Care Administration at: http://anca.myflorida.com/MCHQ/Central Service s/Background_Screening/Regulations Forms.shtml. This form must be completed by the individual and retained by the provider upon hire to attest that they meet the requirements for qualifying for employment, they have not been unemployed for more than 90 days from a position that requires Level 2 screening, and they agree to inform the employer immediately if for any disqualifying offense.
(e) An administrator or chief financial officer must be screened and qualified prior to ….to the position.
(3) Results of Screening and Notification.
(a) Final results of background screening requests will be provided through the Agency’s secure website that may be accessed by all health care providers applying for or actively licensed through the Agency that are registered with the Care Provider Background Screening Clearinghouse. The secure website is located at: apps,ahca.myflorida.com/Single SignOnPortal.
(b) If a Level 2 criminal history is incomplete, a certified letter will be sent to the individual being screened requesting the … report and court disposition information. If the letter is returned unclaimed, a copy of the letter will be sent by regular mail. Pursuant to section 435.05(1)(d), F.S., the missing information must be filed with the Agency within 30 days of the Agency’s request or the individual is subject to disqualification in accordance with section 435.06(3), F.S.
(c) The eligibility results of employee screening and the signed Attestation referenced in subsection 59A-35.090(2), F.A.C., must be in the employee’s personnel file, maintained by the provider.
This Statute or Rule is not met as evidenced by: Based on interview and record review, the facility failed to ensure that every employee must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if…….. for any of the disqualifying offenses while employed by the employer, for 3 of 4 sampled employee personnel records reviewed: (Staff A, B, and C).
The findings included:
On……………….a review of the employee personnel records was conducted. The following employee personnel records did not contain the signed and dated attestation of compliance form in the employee personnel file:
1. On 12/292020 a review of the employee personnel records was conducted. It was revealed that Staff A was hired on She works as a Certified Nursing Assistant. She
provides direct resident care, assisting with their Activities of Daily Living, (ADL’s).
2. On…………..a review of the employee personnel record was conducted. It was revealed that Staff B was hired on 11/10/2018. She works as a Home Health Aide. She provides direct resident care, assisting with their ADL’S.
3. On ……………. a review of the employee personnel records was conducted. It was revealed that Staff C was hired on 11/30/2020. She works as a Home Health Alde. She provides direct resident care, assisting with their ADL’s.
On ……. at 03:00 PM, an interview was conducted with the Administrator. He acknowledged the findings.
Unclassified