From the very

The Florida

Board of Nursing

Meeting Agenda December 4-6, 2013 Doubletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

Lavigne A Kirkpatrick, BS, RN Chair

Linda Horton, EdD, PhD, MSN, NS-C Vice Chair

Joe Baker, Jr. Executive Director

Florida Board of Nursing Meeting Agenda December 4-6, 2013 Deerfield Beach, FL Board Members: Lavigne Ann Kirkpatrick, BS, RN - Chair Linda Horton, EdD, PhD, MSN, NS-C - Vice-Chair Ann-Lynn Denker, PhD, ARNP Jessie Colin, PhD, RN Leonard Connors, Esq., Consumer Cathy Oles Gordon, LPN, BPS Jody Bryant Newman, EdD, EdS Consumer Kathryn L. Whitson, MSN, RN JoAnn Trybulski, PhD, ARNP, DPNAP Elmira Gainey, Consumer Vacant LPN Position Vacant LPN Position Vacant RN Position

Attorneys: Lee Ann Gustafson, Senior Assistant Attorney General Rachel Clark, Assistant Attorney General Yolonda Green, Assistant General Counsel Casey Cowan, Assistant General Counsel Jodi-Ann Johnson, Assistant General Counsel Board Staff: Joe Baker, Jr., Executive Director William Spooner, Program Operations Administrator Sherri Sutton-Johnson, MSN, RN, Director of Nursing Education Deborah Hansen, BSN, RN

2 | Page

Meeting Schedule Wednesday @ 1:00 pm Credentials “A” Committee Required Appearances Applicants for licensure with criminal, discipline, and health history Applicants for licensure with False Answer on application Education and Credentials “B” Committee Required Appearances Exemption Applicants Education Credentials Applicants for licensure under 464.008, FS Applications Applicants for licensure under Section 464.009, FS Applications Items for Discussion Informational Items Ratification Lists

Thursday @ 8:30 am Full Board CNA, RN, LPN, and ARNP Discipline & General Business Disciplinary Variables Reinstatements and Compliance Issues CNA Informal Hearings RN, LPN, and ARNP Informal Hearings Licensure Informal Hearings Legislative Issues Approval of Minutes (Previous meeting) Declaratory Statements CNA Informal Waivers RN, LPN, and ARNP Informal Waivers

Friday @ 8:30 am Full Board CNA Settlement Agreements RN, LPN and ARNP Settlement Agreements CNA Voluntary Relinquishments RN, LPN, and ARNP Voluntary Relinquishments Intervention Project for Nurses Board Reports

3 | Page

Disciplinary Hearings & General Business Thursday, December 5, 2013 at 8:30 am Call to Order Roll call A. Reconsiderations None

B. Reinstatements and Compliance Issues 1. Hilton, Ramsey Douglas; 1702/116654 2. Kimak, Iris; Case #2007-24347; RN 9198300 3. Kelly, Patricia; RN

C. Recommended Orders 1. Pratt, Hosea; 1702/159721 Recused Members: Lavinge Kirkpatrick and Mary Jane Herrera 2. Chafe, Renea Justine, RN 9274699 Case #2012-10117 DOAH #13-000495

D. CNA Informal Hearings Recused Members: Barbara Kemp and Mary K. Habgood 1. Bradley, Kenoshia M., CNA 126098 Case #2012-15738 File #21819 Recused Members: Lavinge Kirkpatrick and Mary Jane Herrera 2. Walker, Julisa M., CNA 207481 Case #2012-16928 File # 484143 Recused Members: Linda Horton and Mary K. Habgood 3. Wallace, Sharon Denise, CNA 76525 Case #2013-09257 File #167957 Recused Members: Claydell Horne and Jody Bryant Newman 4. Irvin, Tracy L., CNA 203207 Case #2013-09228 File #499045 Recused Members: Mary K. Habgood and Sandra Walker 5. Span, Montice Shawntez, CNA 121922 Case #2013-07614 File #299894

E. RN, LPN, and ARNP Informal Hearings Recused Members: Lavinge Kirkpatrick and Mary K. Habgood 1. Taylor, Randolph Brain, RN 3248522 Case #2013-00744 File #189964 2. Scherenberg, Donald Walter, RN 9324101 Case #2013-04578 File #426211 Recused Members: Linda Horton and Mary K. Habgood 3. Campbell, Marsha Monell, LPN 5174806 Case #2013-09630 File #121526 Recused Members: Leonard Connors and Claydell Horne 4. Shim, Jennifer Anne, RN 9278283 Case #2012-11572 File #375074 Recused Members: Jessie Colins and Mary Jane Herrera 5. Waldron, Stormy Brooke, RN 9217586 Case #2013-08516 File #309054

12 | Page

Recused Members: Mary Jane Herrera and Lavigne Kirkpatrick 6. Hamann, Stacie Dawn, LPN 5172250 Case #2012-11948 & 2012-11941 File #117673 Pulled by PSU

F. Licensure Informal Hearing none

G. Petitions for Hearing/Modification 1. Livingston, Alexandra Paula; 1701/456545

H. CNA Informal Waivers Recused Members: Claydell Horne and Jody Bryant Newman 1. Perez, Ivon M., CNA 39657 Case #2012-06792 File #355090 2. Goodson, Nikita Nicholle, CNA 159138 Case #2013-02958 File #434483 3. Scott, Lakoshia J., CNA 78525 Case #2013-04335 File #300978 Recused Members: Mary K. Habgood and Sandra Walker 4. Buske, Sarah D., CNA 108960 Case #2011-20660 File #371140 5. Kirpes, Lisa Marie, CNA 249701 Case #2012-18504 File #574791 6. Reavis, Jenice C., CNA 179563 Case #2013-02930 File #455998 7. Goodson, Nikita Nicholle, CNA 159138 Case #2013-02969 File #434483 Recused Members: Linda Horton and Mary K. Habgood 8. Walters, Shronda Shanette, CNA 79072 Case #2013-05201 File #315445 9. Smith, Sharese D., CNA 201890 Case #2013-01744 File #478084 Recused Members: Mary K. Habgood and Barbara Kemp 10. Weaver, Jennifer N., CNA 209753 Case #2012-17885 File #505714 11. Burns, Katherine W., CNA 144438 Case #2013-01505 File #402501 Recused Members: Lavinge Kirkpatrick and Mary Jane Herrera 12. Clark, Karen E., CNA 167367 Case #2013-07545 File #440401 Recused Members: Mary K. Habgood and Ann-Lynn Denker 13. Manghram, Tiffany Tylonda, CNA 88271 Case #2012-07594 File #373506 Recused Member: Claydell Horne and Leonard Connors 14. Davis, Mary A., CNA 77111 Case #2012-11804 File #275538

I. RN, LPN, and ARNP Informal Waivers Recused Members: Lavinge Kirkpatrick and Mary Jane Herrera 1. Slobodzian, Emily Jean, RN 9292121 Case #2013-04188 File #390189 2. Brazil, Maurice Stallings, ARNP. 1007872 Case #2012-17611 File #7452 3. Asifor-Tuoyo, Lorie Ann, RN 2981202 Case #2013-01204 File #162392 4. Galati, Nancy Marie, RN 3269332 Case #2012-14411 File #192106 5. Eddy, Carolyn Jean, LPN 5178122 Case #2013-07474 File #125554 6. Segree, Maypetite O'Kelley, LPN 1330841 Case #2013-06368 File #70876 7. Clark, Laura Ann, RN 9238235 Case #2012-18107 File #329925 Recused Members: Barbara Kemp and Mary K. Habgood 8. Sparks, Keisha Marie, RN 9301462 Case #2012-14824 File #399379 9. Aronld, Shelly Lee, LPN 5189617 Case #2012-17218 File #138151

13 | Page

10. Dais, Theresa, LPN 5152789 Case #2012-18899 File #97055 Recused Members: Claydell Horne and Jody Bryant Newman 11. Lecompte, Carla Moore, ARNP 9269520 Case #2012-14881 File #356894 12. Clayton, Tammie D., LPN 1134341 Case #2013-01808 File #50752 13. Munoz, Lisa Leigh, RN 9340085 Case #2013-07511 File #435444 14. Rutherford, Stephanie Theresa, RN 9239337 Case #2013-07814 File #332044 15. Perry, Albert A., LPN 5182381 Case #2013-01256 File #130449 Pulled by PSU 16. Talarico, Bianca Louise, RN 9328344 Case #2013-02193 File #431317 Recused Members: Leonard Connors and Claydell Horne 17. Keyt, Jeffrey Alan, RN 9166688 Case #2012-13990 File #252156 18. Vega, Ashley Capitola, RN 9266942 Case #2012-12867 File #362379 19. Hocking, Rebecca Rose, RN 9294414 Case #2012-09197 File #391038 20. Bramlett, Megan Deanna, LPN 5206887 Case #2012-18901 File #158425 21. Vega, Ashley Capitola, RN 9266942 Case #2012-12846 File #362379 22. Hamilton, Tiffany Lynn, RN 9335933 Case #2012-13588 File #436339 Recused Members: Linda Horton and Mary K. Habgood 23. Hiers, Williams Robert, RN 9303380 Case #2013-04348 File #403175 24. Mullins, Megan Thompson, LPN 5207036 Case #2013-07335 File #139919 25. Treffeisen, Lee Allen, RN 9162935 Case #2013-05045 File #240138 Recused Members: Mary K. Habgood and Lavinge Kirkpatrick 26. Roman, Jennifer Marie, RN 9334167 Case #2013-02801 File #427509 27. Kja, Kyle James Ahler, RN, 9343360 Case #2013-08171 File #440798 28. Wolfe, Deborah Marie, RN 9333652 Case #2013-06738 File #436501 Recused Members: Barbara Kemp and Mary Jane Herrera 29. Reynolds, Ryan Kenneth, RN 9274706 Case #2012-09103 File #365449 Recused Members: Sandra Walker and Mary K. Habgood 30. Joiner, Opal Melane, RN 9206201 Case #2013-01786 File #294655 Recused Members: Ann Lynn Denker and Mary K. Habgood 31. White, Ellinda Anne Jones, LPN 889241 Case #2013-07887 File #26117 Pulled by PSU 32. Deist, Kathryn Elizabeth, RN 9171674 Case #2013-04553 File #256302

II. Other J. Practice Issues None

K. Advanced Practice Issues Protocols 1. Steven K. Yeager 2. Emily Smith 3. Tracie C. Rutledge 4. Milady Gomez 5. Karen Mercer 6. Heather Nicole Capezzuto 7. Stacy L. Hanners 8. Rachel D. Spikes 9. Edward C. McIntosh

14 | Page

10. Margaret Leigh Ann Stachowiak 11. LeeAnn Wisnowski 12. Michele Azzati 13. Kelley V. Cross 14. Rhonda Patrick 15. Marisa Bracero 16. Carol Eickhorn 17. David Sanjurjo 18. Lizbeth Marie Arroyo 19. Monica O. Webb 20. Lynn Peiffer 21. Shauna L. Kessler 22. Karen MacCollom 23. Laura Powell 24. Derrick Joseph Curzi 25. Vetlana Simpson

L. Special Education Issues None

M. Legislative Issues None

N. Approval of Minutes Previous Board Meeting Minutes: 1. Credentials "A" Committee recommendations 2. Credentials "B" Committee recommendations 3. October 2-4, 2013 Minutes

O. Declaratory Statements 1. Simmons, Lancia; RN1619302; 464.003(20), F.S. Administration of ketamine

15 | Page

::

December44, 2013 Florida Board of Nursing Meeting

Full Board

RN Approved

with Conditions! Requesting Reinstatement

Hilton, Ramsey Douglas; Applicant # 17021116654 12760 Linden Drive Springhill, FL 34609 Date of

October 10, 2013 Summary of

February 9, 2006, the Board approved Mr. Hilton for licensure by examination with the conditions of an IPN evaluation and compliance with IPN recommendations, a stayed suspension was also placed on any recommended monitoring requirements.

July 28, 2006, the Board office received notification that Mr. Hilton entered the active monitoring phase of the IPN program. February 28, 2007, the Board office received a memo regarding Mr. Hilton's dismissal from IPN. March 8, 2007, Board staff lifted the stayed suspension. October 10, 2013, Mr. Hilton submitted an application for reinstatement.

Supplemental Documentation Reinstatement Application Self Explanation Previous Board Order IPN Memo Letters of Recommendation Correspondence Previously Viewed Materials from the February 2006 Agenda

Prepared by: Vickie Boyd

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Applicant's Signature__________________________________ Date

o

Items Needed for Reinstatement Your Reinstatement Application must be completed in full.

Letter of Explanation: brief, typed letter (if possible) with signature and date of what occurred to cause the suspension of your license and what you have been doing since the suspension of your license. Plan of Action: Submit a detailed explanation of the actions you will take or are taking to maintain sobriety and return to nursing.

Proof of Sobriety: Proof must be in the form of a certificate or letters from program directors. Letters of Recommendation: Provide a minimum of 3 professional letters of recommendation. Family members are not considered professional contacts. Program directors, supervisors and people you have worked with are professional contacts, regardless of the profession. Once your file is complete, you will be sent a letter stating that your file will be presented to the Board of Nursing at the next available meeting. It is imperative that all information is submitted in a timely manner to correspond with the agenda deadlines. You will be mailed a Notice of Hearing approximately 21 days prior to the meeting informing you of the time, date and place the meeting will be held. If you wish to attend a specific meeting, please indicate your preference in a letter separate from your application and letter of explanation. We invite you to view our Board of Nursing meeting schedule on our website at: http://www.doh.state.fl.us/mgafnursinqlnur meeting.htmi or by calling our office at (850) 2454125.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

....

RLED

OEPARTMEWT QF HEALTh

C

STATE OF FLORIDA BOARDOFNURSING

•

IN RE THE APPLiCATiON FOR

LICENSURE OF:

•

RAMSEY DOUGLAS HiLTON

•

NOTICE OF INTENTTO APPROVEWITH CONDITIONS

•

RAMSEY DOUGLAS HILTON has applied for licensure by examination as a practical nurse. The application came before the Board of Nursing at a duly-noticed

public meeting• on February 9,2006, in Tallahassee, Florida. Upon review of the application file, the Board :has determined that the applicant was convicted of driving while impaired in 1994, 1997 and 2003.

Based on the foregoing, the Board may refuse to certify an applicant for•

licensure, or restrict the practice of the censee, or impose conditions, pursuant to •

Sections

.018(2) and 456.072(2), Flfrida Statutes.

It is therefore ORDERED that the application

for certification

tO be,

licensed of

RAMSEY DOUGLAS HILTON is hereby APPROVED subject to the following

conditions: The license of RAMSEY DOUGLAS HILTON will not be issued until,the applicant

undergoes an evaluation coordinated by the Intervention Project for Nurses (IPN), and complies with any and all terms and conditions imposed by

1PN as a

evaluation. it is the duty of the licenseeto contact the IPN at

.O.

result of said

Box 49130,

JacksOnville Beach, Florida 32240-9130, (904) 270-i620 within 30 days. If the licensee

1

is not in need

of monitoring or treatment and the IPN is not suitable, no:further action

will be required. If the licensee is in need of monitoring or treatment, the license of

RAMSEY DOUGLAS HILTON shalt be issued under

a

stayed suspension. The

licensee shall comply with all conditions of the IPN Advocacy Contract or she will be in •

violation of the Board Order. I

DONE AND ORDERED this

Li

day of

I

BOARD OF NURSNG

forPa da

ittman,.R ,Chair

NOTICE OF HEARING RIGHTS You may seek review of this Order, pursuant to SectiOns 120.569 and 120.57, Florida Statutes, by filing a petitionwith the Executive Director of the Board, 4Q52.Bald

Cypress Way, Bin C02, Tallahassee, Florida 32399-3252, within 21 days of receipt 61

this Order. if

dispute any material fact upon which the Board's decision is based,

you may request ahearing before an administrative law judge pursuant to Section

120.57(1)' Flprida Statutes; your pe$ion mustcontain The information required by Rule 28-106.201 ,FloridaAdrninistrative Code, including a

which are in dispute.

If you do not

statement of the material facts

dispute any material fact, you may request a

hearing before the BOard pursuant to Section 120.57(2), Florida Statutes; your petition must

lude the information required by Rule 28-106.301

2

,

Florida Administrative Code.

Pursuant to Section 120.573, Florida

1

you are 'hereby notified that

mediation pursuant to that section is not available.

CERTIFICATE,OF SERVICE I

'

HEREBY CERTIFY that a true and correct copy of the foregoing has been

furnished by certified mail, return receipt requested, to RAMSEY DOUGLAS HILTON, 5477 Nardello Avenue, Spring Hilt FL 34608 and Jean D'Aprix, P.O. Box 49130,

Jacksonville Beach, Florida 32249, and by interoffice mail to Lee Ann Gustafson, Senior Assistant Attorney General, Department of Legal Affairs, PLOI The Capitol,

Tallahassee'FL 32399-1 050 this 14f day of /Y}fTLVCJi200e.

'

F

Deputy Agency. Clerk

3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Dr. Leo Yason, M.D.

le,

Springbrook Hospital 7007 Grove Rd FL 34609

6/18/2013

Florida Board of Nursing Attn: Remediation Supervisor 4052 Bald Cypress Way Bin # C02 Tallahassee, FL 32399-3252 To Whom It May Concern:

Please accept this letter of reference as to Mr. Ramsey Hilton's good character. Mr. Hilton has been employed with Springbrook Hospital, a drug free work place for 4 years. Mr. Hilton has shown himself to be a dedicated, dependable employee who has shown initiative and dedication in his employment at Springbrook Hospital. During the course of the four years that I have known and worked with Ramsey he has demonstrated good character and judgment in his interactions with clients and colleagues. It is my recommendation to reinstate Mr. Hilton's nursing license free of restriction, having known Ramsey for four years it is my opinion that he will practice compassionate and empathetic nursing safely and soberly.

Dr Leo Yason, M.D. Spr'inghrook Hospital

/ I

V

Dr. Ayman Hanna, M.D. Springbrook Hospital 7007 Grove Rd Brooksville, FL 34609 6/26/2013

Rohda

Board of Nursing Attn: Remediation Supervisor 4052 Bald Cypress Way Bin # C02

Tallahassee, FL 32399-3252 To Whom It May Concern:

Please accept this letter of reference as to Mr. Ramsey Hilton's good character. Mr. Hilton has been employed with Springbrook Hospital, a drug free work place for 4 years. Mr. Hilton has shown himself to be a dedicated, dependable employee who has shown initiative and dedication in his employment at Springbrook Hospital. During the course of the four years that I have known and worked with Ramsey he has demonstrated good character and judgment in his interactions with clients and colleagues. He is kind, empathetic, caring and it is my recommendation to reinstate Mr. Hilton's nursing license free of restriction, having known Ramsey for four years it is my opinion that he will practice compassionate and empathetic nursing safely and soberly. I have no reservations in making this recommendation and providing him with this letter of reference.

Sincerely,

Dr. Ayman Hanna, M.D. Springbrook Hospital

June 6, 2013.

To

Florida Board of Nursing

4052 Bald Cypress Way been

U

C02

Tallahassee, Florida 32399—3252

To whom it may concern:

am writing this letter for Mr. Ramsey Hilton, who

known to me for over 3 years. He is currently working at Spring Brook Hospital and interacts with me on a daily basis. Over the years, he has learned I

a

lot and grow

is a

professional.

I

is

have personally assessed him during our hospital inter disciplinary

meetings. He has shown to have good insight and willingness to learn and improve. He is diligent, responsibility and honest, with this quality he is liked by his staff and friends. He is able to do this work

efficiently and without any reservation can recommend him to any nursing

duties. Please do not hesitate to contact me with any further inquiries.

Dr Syed Waqar Hasan, MD Access Health Care

14690 Spring Hill Drive, Spring Hill,

FL

352 397 4481

34609

I

Rick Scott

Mission:

Governor

To protect, promote & improve the health ot all people n Florida through integrated state, county & community etlorts.

John H. Armstrong,

HEALTH Vision:

D, FACS

Slate Surgeon General

&

SecretaG'

To be the Healthiest State in the Naton

STATE OF FLORIDA BOARD OF NURSING October 28, 2013 Ramsey Douglas Hilton 12760 Linden Dr Spring Hill, FL 34609

The Board of Nursing will consider your application for licensure at the following meeting: Date:

December 5, 2013

Time:

8:30 a.m. (or soon thereafter)

Type:

Full Board

Place:

Doubletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 (954) 427-7700

Your attendance is not required, unless it has been required by a previous board order. All applicants are encouraged to attend. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign-in. Additional materials may be Do not send additional materials to the board office at this time. considered at the meeting at the discretion of the committee or board chair. Copies of the meeting agenda will not be provided at the meeting; however, if you would like to view or print the agenda, please go to the following web address: http:/Iwww.doh.stateil.us/mgalnursing/nur meeting info.html If you do not want your application presented to the board at this time you will need to send in a written document indicating that you would like to waive your 90 day statutory requirement for review. This request must include your signature.

If

you

have

any

questions,

please

contact the

board

at

(850)

245-4125

or

by writing

MQA

www.floridasHealth.com

Florida Department of Health Division ot Medical Quality Assurance' Bureau of HCPR 4052 Bald Cypress Way, Bin 0-02 'Tallahassee, FL 32399-3252 PHONE: (850) 245-4125 'FAX (850) 245-4172

TWITTER:HeathyFLA FACEBOOK:FLDepartrnentotHealth 1 1

YQUTUBE: fldoh

Created on 10/28/2013 10:36AM

(—•.

Ma M. Viamontè

Charlie Crist Governor

Ros. M.D., M,P.H, Secretary of Health

March U, 2007

llo

Ramsey 0. Hilton 5477 Avenue Springhill, FL 34608 RE: Suspension of License

LPN 5173586

Dear Mr. Hilton:

The purpose of this letter is to inform youthat your license has been suspended and to remind you of the terms of your Notice of Intent to Approve Licensuré with Conditions. The Florida Board of Nursing has granted you a conditional license.

(

The Board office received, a letter dated February 28, 2007 from IPN indicating you have been dismissed from.the program. Your Board order calls for the immediate suspension of your license in this event Compliance with your Board Order and the Board's approval of a reinstatement, application will be required'prior to resuming practice as a nurse in Florida. If you have any questions p'ease feel free to, contact me at 850-245-4173 or by e-mail at vickie_boyd©doh.state.fl.us for any reason.

Vickie Remediation Supervisor

•

•

Florida Department of Health- Division of Medical Quality Assurance lorida Board of Nursing Tallahassee, FL 32399-3252 4052 Bald cypress Way, Bin Phone: (850) 245-4125 a FAX: (850) 245-4172 Web: www,dohstate.tl.us/mqa/nursing • Forum: http:F/forum.doh.state.fius/—MO/kNursing Email: [email protected]

fl:H

t:

FOR NURSES JJ'N is an

affiliate of The PlasMa

Association

MEMORANDUM Rick Garcia, MS, RN, CCM ExecUtive Director Florida Board of Nursing

FROM:

Linda Smith, ARNP, MN, CAP, CEAP IPN Program Consultant

RE:

Ramsey Douglas Hilton Florida License #LPN 5173586

IMMEDIATE DISMISSAL - REQUEST FOR iTION OF SUSPENSION IN ACCORDANCE WITH FINAL BOARD OF NURSING ORDER

DATE:

February 28, 2007

regret to inform you that Ramsey Hilton has failed to satisfactorily comply with his Board Ordered IPN participation. He was on the February 2006 Board of Nursing Agenda through the Credentials Committee ásan LPN via examination. It was the action of the Board to referMr. Hilton to IPN far evaluation as a V6B. I

On March 6, 2006, Mr. Hilton was evaluated by Addictionist, David Myers, MD, ASAM, Tampa,

who provided diagnoses of: AXIS I - alcohol dependency by history in reported full remission, rule out current alcohol On March 29, 2006, Mr. Hilton engaged in intensive outpatient treatment at Pathfinder, New Port

Richey, with successful completion Juhe 24, Mr. Hilton disputed the length of hisContract which was five (5) years in duration due to his diagnoses of substance dependence and requested a second opinion evaluatiozt

,2006, Mr. Hilton was evaluated by Martha Brown, Addiction Psychiatry, Tampa, who provided diagnoses of: AXIS 1 - alcohol dcpendency in sustained full remission per history On June

-

P.O. BOx 49130

-

JACKSONVILLE BEACH, FL 32240-9130 FAX: 904-270-1633

904-270-1620

1

Rick Garcia, MS, RN, CCM RE: Ramsey Douglas Hilton

•

Page Two

•.

February 28, 2007

Mr. Hilton executed an IPN Advocacy Contract with estimated monitoring July 2006 — July 2011 without narcotic access restriction and was approved to return to clinical nursing practice pending

licensure. Mr. Hilton was issued his Florida license in August 2006; however, to IPN's knowledge has not obtained employment as a nurse to date. On October 5,. 2006, Mr. Hilton failed to provide a drug screen when his color was called. The procedure issued by the Department cc Health regarding a first incident of material noncompliance wis followed, and Mr. Hilton provided a negative drug screen on October .20, 2006.

On February 13, 2007, Mr. Hilton contacted IPN advising his color was called on February 12, 13, 2007. 2007 and he did n& provide. He indicated he provided on

uary

•

An impending dismissal letter was sent to him providing him with a deadline by which to obtain an IPN-facilitated evaluation to determine his current status given the two (2) missed urine drug screens. A Voluntary Withdrawal from Practice form was also sent to him given the second •' incident of material noncompliance.

•

.

•

.

February 22, 2007, IPN received the results of the drug screen Mr. Hilton provided on February cocaine at an extremely high level; Mr. Hilton 13, 2007 which returned positive ingesting cocaine. Given thisthird incident of material noncompliance, Mr. Hilton was advised that .. he was dismissed from 1PN effective immediately: .

•

.

i

.

.

Therefore, due. to Mr. Hilton's continued instances of material noncompliance, I am unable to attest to his abilfty to practice his profession with reasonable skill and safety. I recommend that the Department evaluate this situation to determine whether immediate suspension in accordance with

Mr. ilton's Notice Of Intent To Approve WithConditions Order filedMarcb 14,2006 and/or additional investigation is necessary. •

If additional

•

•

information is nçeded,please do not hesitate to contaót me at (904) 270-1620. matter. appreciate your prompt attention to this mst SL/BoardMerno JKipj •

•

•

.

•

•

•

1

MEMORANDUM TO:

William Spooner, Regulatory Supervisor/Consultant Florida Board of Nursing E-Mail: WI 111am [email protected]

CC:

Anthony Jusevitch, Program Operations Administrator Florida Board of Nursing E-Mail: Anthony [email protected]

FROM:

Vicki Fitzpatrick, MS, Ph.D., CAAPP-2 Clinical Coordinator/BON Case Manager

RE:

Ramsey ). Hilton BON Referral February 2006 Board of Nursing Meeting

DATE:

July 28, 2006

This will validate the above-named nurse's active status in the Intervention Project for Nurses (IPN').

When the active monitoring phase of this program is completed, you will be informed.

VF/Jmb SUV6IMBON

MEMORANDUM

TO:

William Spooner, Regulatory Supervisor/Consultant Florida Board of Nursing E-Mail: William

CC;

Anthony Jusevitch, Program Operations Administrator Florida Board of Nursing E-Mail: Anthony [email protected]

FROM:

Sandra Hudson, RN, BSN Intake Case Manager

RE;

Ramsey D. Hilton IPN Case #63 118 PN Candidate for Licensure Via Examination BON Referral February 2006

DATE:

March 28, 2006

This is a preliminary memorandum intended to prevent any problems with the "failure to contact IPN" language in the Final Board Order.

The above-referenced nurse has contacted IPN within this allowed time period. IPN will provide you with additional written information, related to the outcome of this case, as soon as it is available. SHIing PC: Ramsey 5LIV6Bonp

ID.

Hilton

FLORIDA DEPARTMENT OF

HEALT Jeb Bush

M.

Governor

RonyFrançois, M.D., M.S.P.H., Ph.D. Secretary, Department

of Health

July 25, 2006 Ramsey D. Hilton 5477 Nardello Avenue Springhill, FL 34608 RE: Conditional Licensure

PN 5173586

Dear Mr. Hilton:

The purpose of this letter is to remind you of the terms of your Notice of Intent to Approve Licensure with Conditions. The Florida Board of Nursing has granted you a conditional license. The following are the terms of your Board order. 1. 2. 3.

Compliance with your IPN (Intervention Project for Nurses) contract. Notify the Board office of any change of address within 10 days Notify and supply a copy of Notice of Intent to Approve with Conditions your employer within 5 days of employment

Failure to send there required documents would result in the immediate suspension of your license to practice. In the event your license is suspended you would be required to submit an official request for reinstatement and appear before the Board. There may be other requirements. Please read your Board order carefully.

Please feel free to contact me at 850-245-4173 or by e-mail at vickie boyd©doh.state.fl.us for any reason.

Vickie Boyd Remediation Supervisor

4052 Bald Cypress Way BIN C02.

lahassee, FL 32399-3252

::

February 8-10, 2006 Florida Board of Nursing Meeting

CREDENTIALS

LPN Exam Applicant with Previous Criminal History and Health History

Listed on Application Ramsey Douglas Hilton 5477 Nardello Avenue Spring Hill, FL 34608 Date of

December 13, 2005

10/13/1994

owl Misdemeanor Plea - Guilty Drivers License Suspended- 90 days OWl School Required Liability Insurance Required Confinement- 1 Day Fine- $614.00

06/15/1997 DWI

Misdemeanor Guilty Drivers License Suspended- 90 Days Fine- $467.00 10/30/2003 DWJ

Misdemeanor Guilty Drivers License Suspended- 120 Days Alcohol Safety Class PA Meetings- 10 Confinement- 1 Day Court Cost- $300.00 Fine- $295.00

'

:

Civil Rights: Not Taken Away.

Applicant Answered Yes to Question #7A on Application. Supplemental

Date of Completion Letter Self Explanation FDLE Report Court DocUments Supporting Documentation Recommendation Letlers Correspondence

Report Prepared By: Sheronda McMillan

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

____________________________________________ ___________ ___________ _______________ ____________ ___________

NAME

l

1;t+n

fl Yes

Special Testing Accommodations:

Please complete supplemental documentation form and send in with application.

Attach additional sheets. it necessary

APPLICANT BACKGROUND

3.

A. List any other name(s) by which you have been known in the past.

/

B. What name(s) did you use when you received your nursing education? B

C. What name did you use when you were first licensed?

D. Have you ever applied for RN ticensure by examination in Florida?

DYes

E. Have you ever applied for LPN licensure by examination in Florida?

o

for RN licensure by endorsement in Florida?

o

Yes

G. Have you ever applied for LPN licensure by endorsement in Florida?

o

Yes

Date________

N. Have you ever been licensed in Florida as an RN?

DYes

Date_______

DYes

Date_________

F. Have you ever applied

-

Have you ever been licensed in Florida as an LPN?

I.

Date__________

J. List all nursing licenses (active, inactive or lapsed). Submit a License Verification Form to your original and an active state of licensure. TrACH ADDITIONAL SHEET, IF NECESSARY)

License No.

StptelCountry

If no tonqer licensed, state why

Date Of Licensure

RN or LPN

rJiA

&/

lA

)IA

'4

A

—

K

"s/A

/A.

when

A3

A

A

IA

K. Are you in active military, reserve military or do you have a military connected spouse?

0

Yes

'

No

NURSING EDUCATION HISTORY

4. A.

Address City

&

)

.

In

Level

I

(-t

V

Pc(i

B. Type of Program (LPN,

State

DIPI, ADN, BSN)

-

ç Zip

Sil.

country

(JcA

C. DateGraduated or Anticipated Graduation

A

0. ADDITIONAL NURSING PROGRAM ATtENDED:

F. Date Graduated or Anticipated Graduation

E. Type of Program (LPN, DIPL, AUN,

-

al

28-

r'J/A

ut.

NAME•

CRIMINAL HISTORY

8.

Have you EVER been convicted of, or entered a plea of gufity, nob contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if or driving while impaired (DWI) is not a adjudication was withheld. Driving under the influence minor traffic offense for purposes of this question. (Review Questi2y & Answers section in instructions.)

I)

If you answered YES, please send a typed or printed letter with arrest

dispositions/ If you were convicted of a felony, were your civil rights taken away? If yes you must show proof your civil rights have been restored.

.

0

No Yes City and State, charges and final

0

Yes

No

You must have arrest and court records of final disposition for each offense listed. Your application will not be If the records are no longer available, you must have certification considered complete until these records are of their unavailability.

Ived.

Attach add) tional sheets, if necessa'y

DISCIPLINARY HISTORY

9.

'

Have you ever been denied or is there now any proceeding to deny your application for any health care license to practice in Yes Florida or any other state, jurisdiction or country?

Have you ever had disciplinary action taken against your license to practice any health care related profession by the licensing authority in Florida or in any other state, jurisdiction or country? Have you ever surrendered a license to practice any health care related profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you? Do you have any disciplinary action pending against your license?

l

0 0

Yes

0

Yes

No

0

Yes

No

No

If you answered YES to any of the above questions please send a typed or printed description of the discipline. You must contact the Board(s) in the States in which you were disciplined and request order be sent directly to the Florida Board of official copies of the administrative complaint and

Nursing.

APPLICANT SIGNATURE the undersigned, state that I am the person referred to in this application for Ilcensure in the State of Florida.

10. I,

information may result in disciplinary action I affirm these statements are true and correct and recognize that providing false against my license or criminal penalties pursuant to Sections 456.3067, 775.0083 and 775.084, Florida Statues.

-

answered them completely, without reservations of I have carefully read the questions in the foregoing application and have any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application I hereby agree that such act shall constitute cause for denial, suspension or revocation of my license to practice as a Registered Nurse or Licensed Practical Nurse in the State of Florida.

6489, Florida Administrative Code as I further state I have read and understand Chapter 464, Florida Statutes, and Chapter they pertain to the practice of nursing (Note: A current copy of Ch 464 and Ch 64B9 may be obtained by calling 0595 or via the internet at http:f/www.doh.state.fl.usfmqaf). Florida Law requires you to immediately inform the Board of any material change in any circumstances or condition stated in the application which takes place between the initial filing and the final granting or denial of the license and to supplement the information on this application as needed. I

affirm that

I

will comply with all requirements for licensure renewal including continuing education credits.

Date

Applicant's

-

30-

C

Mr. Ramsey D.

lton

5477 Nardello AVE Spring Hill, FL 34608

phone 352-596-747 cell 352-232-3654

October 28, 2005

florida Board of Nursing Post Office Box 6330 Tallahassee, FL 32314 Dear Sir or Madam: I am applying for licensure in the state of Florida as a LPN. This letter is to explain the circumstances and disposition of my previous police record, which Unfortunately is rather lengthy and embarrassing.

To get right to the point of the matter, my police record as it pertains to this matter is as follows: Date 10/13/94 06/15/97 0112512002

10/30/2003

Charqe

Disposition

Location

DWI 1 Clark county, AR DWI I Hot Springs, AR Battery Ul(Misdemeanor) Hot Spring County, AR DWI I

Hot Spring County, AR

Court order met Court order met Court order met

Court order met

Concerning these charges, there is no good reason or explanation for any of them. it was simply extremely poor judgment on my part. I have however recognized the seriousness of these eriors and that alcohol has played a major role in every single instance. I have attended numerous alcoholics anonymous both voluntarily and as mandated by court order. The battery II charge was the result of allowing myself to become involved in a destructive relationship where alcohol was used by both of us in the relationship. I did complete an anger management course, which taught me much about and people's coping mechanisms in general. I have learned that alcohol use has no positive effects or outcomes. I have quite drinking and focused my energy on improving myself. I am going to use my energy and growing knowledge to help make my community a better place. I pray that you will allow me to do this by granting me the privilege of sitting for the LPN Board Exam.

,

I believe that I have included all, perhaps more than required, of the needed Should there be any documentation to prove the statements that I have made additional assistance that I may provide please do not hesitate to call on me. I have

•

Page 2

l

October 28, 2005

also included letters of recommendation from the Nursing School Director, my Nursing Instructor, and acquaintances of mine that I have known as both professionals and as friends. I am also currently continuing my education with hopes and aspirations to continue on to being a Registered Nurse.

Thank you all for your time, consideration, and assistance in my endeavor to become a Nurse. I can not summarize in words the extent of my hope and excitement at the opportunity to help people in this critically vital field. -

Sincerely,

Ramsey D. Hilton Student LPN

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Jocket #:

23705172

S

MUNICIPAL

COURT

MALVERN,

OF

vs.

ARKANSAS

Ramsey D Milton 195 Benjamin Pearcy AR '71964

Statute/Code :5-65-103 18 Offense: DWI 1ST DRIVING WHILE INTOXICATED Comments: (.14) Race Sex DOE Age Weight Height Waiver

Make of Vehicle: Toyota :95 Year & Type :AR Tag State :140-HDN Tag Number :AR D/L State 904-83-5174 D/License# Warrant #

:W :M

:02111975 :28 :180

:Gft/Oin

Date of Offense:09J28/2003 Date of Arrest :09/28/2003 Prepaid Bond Bond Rec. # Reset for :10/30/2003

:

:

:

Ticket

B/T OFFICER: Arr.OFFICER: Staley BONDSMAN: BAIL BOND: $ Attorney f or Defendant: Date Issued: F.T.A. Warrant STATEMENT OF INES

Court Cost

Pines

.

Aflo

$

300.00

Total Fines and Cost.$

$

250.00

Restitution

COST

#

:H964735

FORFEITURE: PLEA FINDING DATE DUE

:

:

$

C

12302003

-

DaU Time tays.

550.00

Cornrr/$erv

$

Refund it.

WITNESSES

ORDERS OF THE COURT

D.t.

SUSP 120 DAYS,

X

S!tFETY CLASS.

10

P.A

MEETINGS.

I

DAY JAIL CREDIT FOR

TIME.

certify thai lie

Cowl ClerIc. 00 r.ereby above s a True and Correct oopy of the proceedinos

Dated

this_.,....,rtey

,

this court

or

Court Clerk

Municipal Court Judge

FROM

H.S.C.

:

MUNICIPflL COURT CLERK

5@1 332 3144

:

23705172

S

Docket

HO.

COURT

,

Date: october

Pearcy AR 72964 13

Race Sex

Year

Age

:28 :180

Ratnsey D 295 Benjamin

vs.

2003

DRIVING WHILE

:02111975

Weisht Height :6ft/Oin Waiver

02:17P11 P2

28

ARKANSAS

OF

STATE OF ARThNSAS

statute/Code offense: DWI 1ST CommentS: (.14)

DOB

Ncv.

:95

Type state Tag Tag Number D/Ja State &

:AR

:140N0N :AR :

904-83-5174

Warrant

Date of ArreSt :09/28/2003 prepaid Bond Rend Rec. # :20/30/2003 Reset for Ticket

:H964735 0

BAIL BOND: $ Attorney for Defendant: F.T.A. Warrant

Court

Cost.

$

30000

s

.00

Total

Flflfl

PLEA FINDING DATE DUE

Date Issue&

.ia:l flew

595CC

ore

Rtst&tutiOr

$

Refund Cit.

$

:

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Cower./C€?V

WITNESSES

ORDERS OF THE COURT

SUSP 120

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MF$?DtNG$.

t

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ckED:T FOR

TIME.

Judge

At

29 05 04:lip

DRIVER SERVICES

SlATE

Driver Control

Department of Finance and Administration

Date:

.

p.1

I

IS Second Street, Suite L

Hot Springs, AR

719fl

FAX COVER SHEET

Ii/29/2005

OF

ff.ALTW.. ATTN:

TO;

FL

FROM:

Danette Jennings

TRANSMWflNG

_2

PROCESSIWO

S$O—245-4112

PAGE(S) rNCLUDJNG COVER PAGE

IF YOU DO NOT RECEIVE ANY OF THESE PAGES, PLEASE CALL:

DRIVER CONTROL TELEPHONE: 501-623-1239 FAX NUMBER: 501-623-3098 cOM1..ThNTS/INSTRUCTXONS:

IMPORTtIlfl:

This message

is intended

-

only for the use of the intva.dual or

it is ity tofron disclosure which

and exempt contain information that is pritñleged, recipient, you are bereky the intended is not massage this of under applicable law. If the reader is strictly communication this of copying notified that any dissemination, distribution or immediately by notify us please prohibited. If you have received this communication in error, Postal Sorvrcs. the U.S. via telephone, and return the original message to us at the above address

addressed and

may

n — YOU DRINK

V

+

YOU DRIVE

YOU

l

,

p.2 DRIVER SERVICES

2$ OS 04:Ilp

grATE OF ARKANSAS

Driver Control

Department of Finance and Administration

Eagland

Room 1070 Office Box 1272 Arkansas 72203.1272 Post

Link

Rock,

Phone: (501) 682.1631 Fax: (SQL) 682-7109

CLEARANCE LETTER To Whom it

Hay Concern:

AR DL#:

195 Benjamin Lane

AR

Pearcy

DL

CLASS:

ISSUE:

03—14 —20c3

U

November 29, 2005

DATE:

Ramsey Hilton.

WEIGHT:

RE 1 GET:

135

6CC

.E.:

71964

S: 005 SEX:

February

11,

1975

ENDORS:

REST: B

RACE:

HAIR:

EYES: BR

H

This licensee's driv±nc privileges are not suspended or revoked in this State for any reason.

r flfl

1

s

.

are unable to locate any record on you having been issued an Arkansas driver license in the past five (5)

verify

an We are unable tc maintain such records on file for

a

driver license, as we only year period. five

Has never been licensed in the State of Arkar.sas. revoked This licensee's driving privileges were suspeneded or in longer no is revocation or suspension This in this State.

effect.

U

This licensee's driving privileges

are

currently under

suspension or revocation in Arkansas. OTHER

U

CONTROL

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

A

ILT

Jeb Bush Governor

DEPAICMENT OF

MS.P.H., Ph.D. Secretary

December 13, 2005

Ramsey Douglas Hilton 5477 Nardeflo Ave Spring Hill, Fl 34608 Application ID: 116654 Re: Presentation of File to Board

Dear Mr. Hilton:

Your file for Licensed Practical Nurse licensure may be presented to the Board of Nursing at the next available meeting. Our next scheduled Board meeting is set for February 8-10 2006. You will receive a notice of that meeting approximately 21 days before informing you of the time, date and location of the meeting.

Nothing is required of you at this time. You may reach me by e-mail at (850)245-4125 ext. 344t

@doh.State.f1.US or by telephone at Sincerely,

Sheronda Mcmillan Board Staff

FLORIDA BOARD Of NURSING 4052 Bald Cypress Way, Bin C02 TaUahassee FL 32399-3252 www.doh.state.fl.us/mqa

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

\

Assurance

COMPAS DataMart Reporting System CMU Board Summary/Case File 200724347 Report November 4, 2013

Processed: 5:05:30PM

Page

1

of 3

Current Issue:

The Respondent is requesting to appear before the board to have her license reinstated and be Board ordered to participate in the Intervention Project for Nurses. The Uoard imposed a final order on July 14. 2008. The final order required the respondent to pay fines and costs prior to the application for reinstatement of the license and imposed a reprimand. The Final Order suspended the respondent for 3 years and thereafter until she personally appeared before the Board and demonstrate the ability to engage in the safe practice of nursing. On September 1 2011, an Order on Petition for Reinstatement was filed. It ordered that the application for reinstatement was approved with conditions. The Order suspended the license; however, it was stayed upon the Respondent's entry into the IPN. The department received notification on May 29, 2013, that the Respondent was dismissed from IPN. The stayed suspension was lifted on May 29, 2013 and respondent's license is suspended. •

Reinstatement will require compliance with all terms set forth in any previous Board Order and an appearance by the respondent. Reinstatement will require compliance with all terms and conditions set forth in any previous Board Order and an appearance before the Board and a demonstration of two years of documented continuous sobriety.

Out ol Profession: Licensee:

Iris Dana Kimak

License Nbr:

9196300

1701

:

Registered Nurse File Nbr:

287022

Primary Location:

3928 SW 89th Ave Ocala, FL 34481

Appeal:

N

License Status: Suspended/Active Mailing Address:

16455 NW Gainesville Rd Reddick, FL 32686

Phone:

352-857-3125

Attorney:

None on Record

Mon itor:

None on Record

Supervisor:

None on Record

Respondent:

Iris Dana Kimak

Address:

103 Ne Tuscawilla Avenue Ocala, FL 34470

File Date:

7/14/2008

Disposition:

Suspension

Violation: Summary:

Fail to perform legal obligat; Impaired from alc/drugs/other

Info Package Mailed Date:

7/15/2008

Possible violation of 456.072(1)(hh) F.S., 464.018(1)(h)(j)(l) F.S., 64B9-8.005(2)(k) F.A.C. and pursuant to 456.074(3) F.S. for possible ESO. IPN reports that subject's file has been closed effective 8/13/07 due to failure to complete required treatment. Subject contacted IPN 11/16/06 at the direction of her employer, Monroe Regional Medical Center, Ocala, because she had been arrested for a 11/5/06. Subject was evaluated 12/27/06 and diagnoses were AXIS - Rule out alcohol abuse, adjustment reaction NOS, stress of DUI, loss of work role, stress of marital separation. This Contract was written as a 2 year substance abuse Contract. On 4/26/07, IPN I

I

received information from Nurse Support Group Facilitator that subject missed 2 groups. IPN also received subsequent information from subjects friend that she had been placed in jail and was serving due to driving under a suspended license. Subject would be out of jail on or about 5/9/07. On 30 6/1/07 1PN received a drug screen that subject provided Qfl 5/22/07 which returned positive for methadone. Subject initially lied and said she received the methadone from a friend. It was later discovered that subject received methadone from a Methadone Treatment Center for opiate addiction. Subject admitted she had been having cravings since her discharge from jail. She was refrained from practice and was directed to provide a drug screen on 6/6/07. On 6/15/07 IPN received a urine drug screen/EtG subject provided on 6/6/07, which returned positive for methadone and positive EtG. Subject admitted to drinking. On 7/2/07 subject was evaluated and assigned diagnoses AXIS I - alcohol abuse, rule out dependency; chronic pain with opiate dependence, rule out major depression, rule out anxiety disorder. lOP treatment was recommended. On 816/07 IPN received the final evaluation recommendations, which were for in-patient treatment. This recommendation changed because subject's drug screen and hair test returned p

1

Discipline Imposed: Emergency Suspension Reprimand Suspension

Start Date 10/08/2007 07/14/2008 07/14/2008

Obligations and Conditions Suspension

09/01/2011 05/29/2013

Compliance:

Record Reinstatement Appearance IPN Evaluation Re-entry plan Documented Sobriety

NO

NO

Comments

09/01/2011

3 years and

thereafter until personally appears and can demonstrate the present ability to engage in the safe practice of nursing including an MMPI 9/1/11 FO to reinstatement respondent, 9/6/11 active in IPN .

Due Date

CmpI Date

09/13/2011 09/13/2011

;,4a2.65 11/04/2013

Reinstatement Sobriety Intervention Proj. Nurses ONLY IPN Dismissal

Amt Imposed

08/04/2011 09/13/2011

Costs Order Granting Reinstatement

NO

End Date 08/31/2011

05/29/2013 05/29/2013

Amt Paid

Activities:

Activity Date

Actv Code

Activity Description

07115/2008 07/17/2008

901

Info pack mailed DHI-IS notified

10/06/2009 10/08/2010 02/11/2011 05/18/2011 05/23/2011 05/27/2011 05/31/2011 05/31/2011 06/01/2011 06/24/2011 07/05/2011 07/06/2011 07/06/2011 07/29/2011 08/09/2011 09/07/2011 09/13/2011

931

10/1 9/2Q11

01/25/2012 07/10/2012 08/28/2012 08/28/2012 08/29/2012 05/29/2013 05/29/2013 06/17/2013 10/31/2013

Contact History: Contact Date 05/27/2011 10/19/2011 05/29/2013 05/29/2013

903 967 931 931

915 923 923 916 932 931 931 931

976 931 941

932 982 932 931 931 931

969 968 983 907 952 923

Respondent Contacted CO Audited by CO Respondent Contacted CO Respondent Contacted CO Mail Received in CMU Mail Processed/Reviewed Mail Processed/Reviewed Fax Received CO Contacted Respondent Respondent Contacted CO Respondent Contacted CO Respondent Contacted CO Board Summary Submitted Respondent Contacted CO Contact with IPN/PRN CO Contacted Respondent IPN/PRN Active CO Contacted Respondent Respondent Contacted CO Respondent Contacted CO Respondent Contacted CO Employer Contacted CO CO Contacted Employer 1PN/PRN Dismissal Compliance License Status Change CO File Sent For Archiving Mail Processed/Reviewed

Letter Code

Letter Description

NN175

CMU RECEIVED LETTER CMU COMPLIANCE LETTER IPN DISMISSAL SUSPENDED STATUS LETTER RETURN OF LICENSE LETTER

I51

NN195 NN188

Attach rnents: 1. Compliance Tracking File 2. Correspondence from Respondent 3. Final Order for Case

Florida Department of Health

- FOR INTERNAL USE ONLY

—,

0002;J

1/04/2013 17:0523 OND

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

STATE OF FLORIDA BOARD OF NURSING IN RE

PETITION FOR REINSTATEMENT OF

FILED

ERK DATE

An ci Sanders 0 12011

IRIS DANA KIMAK,

I ORDER ON PETITION FOR REINSTATEMENT This cause came before the Board of Nursing on August 4, 2011, in Tampa, Florida, for the purpose of determining whether to grant the Petition for Reinstatement

of IRIS DANA KIMAK. Petitioner entered into a settlement agreement that provided for suspension of her license for three years and until she appeared to demonstrate safety to practice. The Final Order adopting the agreement was filed on July 14, 2008. Petitioner

appeared before the Board and submitted an evaluation by Dr. Timothy Bird which recommended treatment and a contract with the Intervention Project for Nurses. Section 464.018(3), Florida Statutes, provides that the Board shall not reinstate the

license of a nurse until such time as it is satisfied that the nurse has complied with all the terms and conditions set forth in the Final Order and is presently capable of

engaging in the safe practice of nursing. It is hereby ordered that the application

for reinstatement of IRIS DANA KIMAK

is approved under the following conditions:

The suspension of the license of IRIS DANA KIMAK is stayed upon her entry into the Intervention Project for Nurses (IPN), and shall remain stayed as long as she

I

complies with any and all terms and conditions imposed by IPN. Failure to comply shall result in the immediate lifting of the stay of suspension. Reinstatement will require

compliance with all terms and conditions set forth in any previous Board Order, and the licensee's appearance before the Board to demonstrate her present ability to engage in

the safe practice of nursing, which shall include a demonstration of two years of documented continuous sobriety. The Board reserves the right to impose reasonable conditions of reinstatement at the time of appearance before the Board. Petitioner is granted an extension of 24 months to pay the fine and costs imposed in Case No. 2007-24347.

This Order shall become effective upon filing with the Clerk of the Department of Health. DONE AND ORDERED this'3J day

of_______

2011.

BOARD\DF NURSING

JoeR. 4We Director for Jessie Cohn, RN, PhD, Chair

NOTICE TO APPLICANT You may seek review of this Order, pursuant to Sections 120.569 and 120.57, Florida Statutes, by filing a petition with the Executive Director of the Board, 4052 Bald Cypress Way, Bin #C02, Tallahassee, Florida 32329-3252, within 21 days of receipt of this Order. If you dispute any material fact upon which the Board's decision is based, you may request a hearing before an administrative law judge pursuant to Section 120.57(1), Florida Statutes; your petition must contain the information required by Rule 28-106.201, Florida Administrative Code, including a

statement of the material facts

2

which are in dispute. If you do not dispute any material fact, you may request

a

hearing before the Board pursuant to Section 120.57(2), Florida Statutes; your petition must include the information required by Rule 28-106.301, Florida Administrative Code. Pursuant to Section 120.573, Florida Statutes, you are hereby notified that mediation pursuant to that section is not available. CERTIFICATE OF SERVICE

HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. mail to IRIS DANA KIMAK, 16455 NW Gainesville Road, Reddick FL 32686 and Jean D'Aprix, IPN, P.O. Box 49130, Jacksonville FL 32240, and by I

interoffice mail to TerriSue Aidridge, Board of Nursing, 4052 Bald Cypress Way, Bin C02, Tallahassee, Florida 32399-3252 and Lee Ann Gustafson, Senior Assistant

Attorney General, Department of Legal Affairs, 32399-1050 this

of

1

The Capitol, Tallahassee, Florida ,

2011.

Deputy Agency

3

Clerk

Fmu] Ordcr No FILED D.&1E

STATE OF FLORIDA BOARD OF NURS ING

By

,

F½1u444

—

Agency Clerk

DEPARTHENT OF HEALTH,

Petitioner, vs.

Case No.: 2007-24347 License No.: 9198300

IRIS DANA KINAK,

Respondent. FINAL ORDER THIS CAUSE came before the BOARD OF NURSING to Sections 120.369 and 120.57(4),

2008, in

Florida,

(Board) pursuant

Florida Statutes, on June

6,

for the purpose of considering a

settlement agreement (attached hereto as Exhibit

between the parties in this cause.

A)

entered into

Upon consideration of the

settlement agreement, the documents submitted in support thereof, the arguments of the parties, and being otherwise fully advised in the premises,

it is hereby

ORDERED AND ADJUDGED that the settlement agreement as submitted be and is hereby approved and adopted intoto and

incorporated herein by reference.

The costs are $1,40265.

Accordingly, the parties shall adhere to and abide by all the terms and conditions of the settlement -reement.

This Final Order shall take effect upon being filed with the

Clerk of the Department of Health.

DONE AND ORDERED

this_____

day of

2008

BOARD OF

Garcia,

Executive Director for Vicky Stone-Gale, MSN, ARNP Chair

CERTIFICATE OF SERVICE I

HEREBY CERTIFY that a true and correct copy of the

foregoing Final Order has been provided by KIRAX, 3928 SW P.O. Box 49130,

13.5.

Rail to IRIS DANA

Avenue, Ocala FL 34481 and Jean D'Aprix,

iPw,

Jacksonville FL 32240; and by interoffice

delivery to and by interoffice delivery to Lee Ann Gustaf son, Senior Assistant Attorney General, Department of Legal Affairs, PL—Ol The Capitol, Tallahassee FL 32399-1050; William Miller,

Assistant General Counsel, Department of Health, 4052 Bald C

eas Way, Bin

Florida 32399-3265

this

day of

Deputy Agency Clerk

2

Case No. 2007—2434'

STATEOFFLORIDA DEPARTMENT OP HEALTH 'I

7

DEPARTMENT OF HEALTH,

PETITIONER, V.

tRIS DANA KIMAK, R.N.,

CASE NO.

2007-24347

RESPONDENT.

ADMINISTRATIVE COMPLAINJ COMES NOW, Petitioner, Department of Health (Department), by and through its undersigned counsel, and files this

Complaint before the Board of Nursing against Respondent, Iris Dana Kimak,

RN,

1.

and in support thereof alleges:

Petitioner is the state department charged with regulating the

praclice of nursing pursuant to Section 20.43, FlorIda Statutes; Chapter 456, Florida Statutes; and Chapter 461, Florida Statutes. 2.

At all times material to this Complaint, Respondent was a

licensed Registered Nurse within the state of Florida, having been issued license number RN 9198300. 3.

Respondent's address of record Is 103 NE Tuscawilla Avenue,

Ocala, Florida 34470.

4.

On or about November 16, 2006, Ms. Khnak

contacted the

Intervention Project for Nurses ("IPN") and reported that she had been arrested for DrMng Under the Influence ("DUI"). IPN is

5.

the impaired practitioner program for the Board of

Nursing, pursuant to Section d456.076, Florida Statutes.

IPN is an

independent program that monitors the evaluation, care and treatment of impaired nurses. IPN oversees random drug screens and provides for exchange of information between

the

treatment providers, evaluators and the

Department for the protection of the public. 6.

On or about December 27, 2006, Ms. Kimak underwent an IPN-

facilitated, evaluation conducted by Richard Saini,

a specialist in

addiction psychiatry. Dr. Saini diagnosed Ms. Kimak with rule-out alcohol abuse and recommended

that Ms. Kimak engage

In

educational treatment

for addiction and be monitored by IPN for one to two years. 7.

On or about March 5, 2007, IPN requested Ms. Kimak to submit

to an EtG test, a drug test specifically for alcohol.

Ms. Kimak

failed to

submit to the EtG test.

01 Health

Case

v.

LU.

2

EtC or ethyl glucuronide, is an alcohol biomarker, detectable in

8.

urine. An EtG test is highly sensitive and can detect alcohol exposure over

the previous several days. On or about March 1, 2007,

9.

1

Kimak signed a two-year IPN

advocacy contract which required her to remain free frorn all mooci

altering, controlled, or addictive substances including alcohol, attend

facilitated

nurse

support

group

weekly,

attend

alcoholics

anonymous/narcotics anonymous meetings weekly, and submit to random

testing. Ms. Kirriak was approved to return to nursing practice. 10.

On or May 22, 2007, Ms. Kimak submitted to an IPN required

urine drug test that returned positive for methadone. 11.

Methadone is an opiold class controlled substance prescribed to

treat pain and also occasionally prescribed to manage opiate withdrawal on patients who are opiate dependent

According to Section 893.03(2),

Florida Statutes, methadone is a Schedule a high

potential for abuse and has

a

II

controlled substance that has

currently accepted but severely

restricted medical use in treatment in the United States, and abuse of

methadone may lead to severe psychological or physical dependence.

ease number 2007-24347

•

12.

On or about

June 6, 2007,

Ms. Kirnak

submitted to

an IPN

required urine drug test that induded an EtG test. That drug test returned positive for methadone and the EtG test returned positive, Indicating exposure to alcohol.

The IPN case manager contacted Ms. Kimak who

admitted to having an alcoholic beverage over dinner. 13.

On or about )uly 2, 2007, Ms. Kimak submitted

facilitated evaluation conducted by David

P.

Myers, M.D.,

a

to

an IPN-

specialist in

addiction medicine. 14.

On or about, July 25,

2007,

Ms.

Kimak began intensive

outpatient substance abuse treatment at Perspectives, located in Ocala, Florida. 15.

On or about August 8, 2007, IPf'J received the final evaluation

from Dr. Myers. According to that evaluation, Ms. Kimak admitted to being prescribed opiates In the past and enrolled in a methadone clinic to stabilize her opiate use. Following her DUI arrest, Ms. Kimak reported she

returned to the methadone clinic to prevent relapse into opiate drug use, 16.

During the evaluation, Ms. Kimak reported daily alcohol use

stating her last drink was the previous evening. Ms. Kimak denied using or

of Health Case

is

-24347

R.N.

Page

use

of alcohol, drugs, narcolics, or chemicals or any Other type of material

or as a result of any mental or physical condition. 26.

Respondent is unable to practice nursing with reasonable skill

and safety to patients by reason of her diagnosed cocaine use and optate dependence. 27.

Based on the foregoing, Respondent has violated Section

464.018(1)0), Florida Statutes (2007), by being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a

result of any mental or physical condition.

of Heat v Ins flm*, Case

nunter

R.N.

7

WHEREFORE, the Petitioner respectfully requests that the Board of Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

day of

SIGNED this

.

Viamorite

2007.

Ros, M.D., MPH.

irgeon General

MLED DEPARTMENT OF

HEALTh

DATE

PCP: PCP Members:

Walter 1. S. Widener Assistant General Counsel 00K Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar Number 0037258 (850) 245-4640 (850) 245-4683 Fax

10/22/07

IL

Depaitmeit of Health v. hts 2007.24347 Case

R.N.

Page 8

-..--,--1

Department of Health v. Iris Kimak, RN. Case number NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or, her behalf if a hearing is requested. NOTICE REGARDING ISSESSI4ENT OF COSTS

Respondent is plwed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant. to Section 456072(4), 'Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

tf Health v. C$se

2007-24347

RN.

Page 9

STATE OF FLORIDA DEPARTNENTOFHEAITH

41110:49

DEPARTNEfIT OF HEALTh,

Petitio.ier,

i,

CASE

NO:

IRIS KIMAK, RN., Respondent,,

Pursuant to SectIon

1.20.57(4), FlorIda Statutes, the above named parties hereby

offer this Agreement to the Board of Nursing as dlspositlofl of the Administrative Complaint, attached hereto as Exhibit A", in lieu of any other

proceedings.

The terms herein become effecUve only If and when a Final Order accepting this Agreement Is Issued by the Board and filed. In considering this Agreement, the Board may review all investigative materIals regarding this case. If this

Agreement

is re

th Board, shall riot be used against

either party. STIPUlATED FACTS 1.

Respondent

a REGISTERED NURSE

In

the State of Florida holding

license number 9198300 2.

The Respondent Is charged by an Administrative Complaint filed by the

Department and property served upon Respondent with violations of Chapters 456 and/or 464, Florida Statutes. A true and correct copy of the Administrative Complaint is attached hereto and incorporated by reference as Exhibit A.

Pepwtmunt of

v. K1MAK, RN

-

I-

Respondent neither admits nor denies the factual allegations contained In

3.

the Administrative Complaint

Respondent admits 'that he/she

1.

456 and 464, Florida Statutes, and the

Is subject

to the

of the

of Chapters and the Board.

Respondent admits that the stipulated facts, If proven true, constitute

2.

violations of laws as alleged In the Administrative Complaint Respondent admits that the Agreement

3.

Is

a

fair, appropriate and

to this pending matter.

reasonable

1.

The Board of Nursing shall reprimand the I,cetise of the Respondent.

2.

Respondent shall pay administrative costs In art amount not to exceed

'ILl (ciu

TONE SEYEN DOLLARS

The fine and costs are to be paid by the

Respondent to the BOard of Nursing within six months' of the filing of a Final Order acceptinç and Incorporating this Agreement

However, If the Respondent is

Intervention Project for Nurses (IPN), the payment Is due If. the Is

license Is suspended by

miof to completion of

placed on probation,

he

payment is due

IPN.

the terms of this agreement, the payment

to the application for reinstatement of the license.

due

the

If the Respondent Is

to the completion of the probationary

period. The Respondent has the responsibility to document financial hardshIp p!iq1 to the due date of the payment. Payment must be by money order. Partial payments shall be accepted.

Please send

payments to the Department of Health, DMsIon of

MQAJalent Services Unit, P.O.Box 6320, Tallahassee, Florida 323146320.

01

v. KIMAX. RM

-2—

3.

The Respondent shall not violate Chapter 456 or 464, FlorIda Statutes, the

rules promulgated pursuant thereto, any other state or federal law, rule, or regulation relating to the practice or the óbliity to practice nursing. V!olatlon or an order from another state/jurisdiction shall constituth grounds for violation of the Board Order adopting this Agreement. 4,

The license of IRIS KII4AK, RN.,

is

suspended for 3 years and

thereafter until he/she personally appears before the Board and demonstrates his/her present ability to engage In the safe practice or nursIng. That demonstration shad Include at least a currentS in-depth

logical

evaluation (with

!]

from a

psychiatrist, psyèhologlst, or other licensed mental health counselor experienced in the

treatment of the problem specified In the Administrative Complaint. shalE supp'y

a

copy of this order to the evaluator.

The Respondent

The evaluation must contain

evidence that the evaluator knows of the reason for, referral.

The evaluator must

specifically advise this Board that the Respondent Is presently able to engage In the safe practice of nursing or recommend the conditions under which safe practice could

be obtained.

The Respondent must submit, prior to appearance before the

plan for re-enlry into practice related to the reason for referral and proof of continued

treatment and counseling, If recommended in the psychological evaluation and dmonstmtlon of' at least two (2) years of continuous sobriety. Unconditional reinstatement Is not guaranteed, The Board reserves the right to impose conditions of reinstatement at the time of reinstatement. 5.

It

Is expressly understood

of the Board and Department and

that this Agreement

Is

subject to the approval

has no force and effect until an Order Is entered

adopting the Agreement. 6.

This Agreement is executed by the Respondent for the purpose of

avoiding further administrative action by the Board of Nursing regarding the acts or omissIons specifically seE forth In the Administrative complaint attached hereto. In this Daparuneit of HSttI v. IQMNc, FIN

-

regard, Respondent aüthoilms The Board to review and examine all investigative file

rnateriiis concething Respondent prior to, or in conjunction with, consideration of the Agreement Furthermore, should, this joint Agreement not be accepted by the Board, It is agreed that presentation to, and consideration of; this Agreement and other

documents and matters by the Board shall not unfairly or Illegally prejudice the Board or any of Its members from further participation, conEideratlon or resolution

of these

proceedings. Respondent shall of!er no evidence, testimony or argurñent that disputes

or conttavenes any stipulated fact brconduslon of law. 7.

Respondent and the Department fully understand

that this joint

Agreement and subsequent Final Order incorporating same will In no way preclude additional proceedings by the Board arid/or Department against the Respondent for acts or omissions not specifically set forth In the Mmlnistiabve Complaint attached

hereto.

This Agreement relates solely to the current disiplinary proceedings arising

from the above-mentioned Mmlnlstratlve Complaint and does not preclude further action by other dMsions, departments, and/or sections of the Department, Including

but not limited to the Agency for Heath Care Administration's Medicaid Program

integrity Office. 8. •

The Respondent waives the right to seek any attomefl fees or costs

fitni

the Department in connection with this .dlsdpiinary proceeding.

9.

,'Respondent waives all rights to appeai and further review of this

Agreement arid these proceedingi.

.EPsThuSnqirraS Department at Healthy. IUMAK RH

PaSVCkntk,7.243474ac

.4 —

WHEREFORE, the parties

hereto request the Board to enter a Final Order accepting and

implementing the terms contained herein,

SIGNED

Beftnze I—

day Of

personally appeared

f..J?L

I

XR!SKIMAK R.N.

is

(type of

and who under oath, adcnowkdges that his/he

stgnature appears above. Sworn

and subscribed

A day of Pr

before me

of.

APPROVED

Ma

M.

Ros,

M.P.H.

Counsel for •WalterT.S.W)dener Assistant General Counsel FBN: 0037258

Department of Health Prosecution Services Unit 4052 Bald Cypress Way, BIN #C-65 Tallahassee, Floilda 32399-3265

4

P

Depsnrnelt or

V.

KrMM. RN

-

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

of all

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H Vision: To

be the Healthiest State in the Nation

NOTICE OF HEARING

November 12, 2013 Case #2013-16489 To:

Iris Kimak

16455 NW Gainesville Rd Reddick, FL 32686 YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30 AM or thereafter

Type:

RN Reinstatement and Compliance Issues

Re:

Iris Kumak

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Attendance Requirement: Respondents are not required to attend unless otherwise indicated on this notice. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in. Reinstatement and Compliance Issues, Motion to Vacate, Recommended Orders, Petitions for Hearing/Modification, Petitions for Declaratory Statement and other items for Board consideration are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance

Board of Nursing

4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE: 850/245-4125 FAX 850! 245-4172

www.FloridasNursing.gov T\NITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

Florith

people in Fionda through uitegrated

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H Vision: To

be the Healthiest State in the Nation

NOTICE OF HEARING

November 12, 2013 Case #2013-16489 To:

Iris Kimak 3928 SW 89th Ave Ocala, FL 34481

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30 AM or thereafter

Type:

RN Reinstatement and Compliance Issues

Re:

Iris Kumak

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Attendance Requirement: Respondents are not required to attend unless otherwise indicated on this notice. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in. Reinstatement and Compliance Issues, Motion to Vacate, Recommended Orders, Petitions for Hearing/Modification, Petitions for Declaratory Statement and other items for Board consideration are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under 'Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance

Board of Nursing

4052 Bald Cypress Way, Bin 0-02 Tallahassee, FL 32399-3252 PHONE: 850/245-4125• FAX 850! 245-4172

loridasNursing.gov T\NITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

of all

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H Vision: To

be the Healthiest State in the Nation

NOTICE OF HEARING

November 12, 2013 Case #2013-16489 To:

Iris Kimak 103 NE Tuscawilla Ave Ocala, FL 34470

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30 AM or thereafter

Type:

RN Reinstatement and Compliance Issues

Re:

Iris Kumak

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Attendance Requirement: Respondents are not required to attend unless otherwise indicated on this notice. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in. Reinstatement and Compliance Issues, Motion to Vacate, Recommended Orders, Petitions for Hearing/Modification, Petitions for Declaratory Statement and other items for Board consideration are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance

Board of Nursing

4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE: 850/245-4125 FAX 850! 245-4172

www.FloridasNursing.gov T\NITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

08/30/13

05:28

HUMPHREY

INDUSTIES

18504880795

NO.558

Patricia E

Humphrey Kelly

347 Mossie Road

Wewahitchka FlorIda 32465 State Board of Nursing 4052 Bald Cypress Way

C02

Tallahassee FlorIda 32399-3252

Case# 2010-08389

License# RN2215902

would like to ask the Board of Nursing to personally appear before them at their next regular Board Meeting in October I

2013, for reinstatement of license. IPN Case# 09691a

Case Manager: Debra

RN

Projected ActIve Monitoring; 5/21/2013 through 5/20/2013

Monitoring Agreement Signed: 6/7/2013

SIncerely,

E

Humphrey Kelty

MiQuality Assurance

COMPAS DataMart Reporting System CMU Board Summary/Case File 201008389 Report September 17,2013 Page

Processed: 2:13:34PM

1

of 2

Current Issue: Per the Final Order terms, the respondent is requesting to appear before the board to have his/her license reinstated.

The Board imposed a final order on January 3, 2011. The final order required the respondent to pay fines and costs prior to the reinstatement of her license and suspended the Respondent for 2 years and thereafter until she personally appears before the Board. The Respondent has to demonstrate the present ability to engage in the safe practice of nursing. The demonstration shall include at least an in-depth psychological evaluation coordinated through IPN, with an MMPI or other appropriate testing. Respondent had an IPN Evaluation on April 29, 2013; however, IPN is unable to verify if the Respondent is or is not currently enrolled in their program.

Another Final Order was imposed on May 22, 2007, requiring the respondent to obtain an IPN Evaluation, reprimanding the Respondent's license, and placing her on probation for 2 years if monitoring or treatment was not needed and IPN was not suitable. The Respondent's probation has been tolled since April 30, 2008, due to the Respondent not working in the field.

In Compliance Profession: Licensee:

Patricia E Humphrey Kelly

License Nbr:

2215902

1701

:

Registered Nurse

File Nbr:

108093

License Status: Suspended/Active Mailing Address:

347 Mossie Road Wewahitchka, FL 32465

Attorney:

None on Record

Monitor:

None on Record

Supervisor:

None on Record

Respondent:

Patricia E Humphrey Kelly

Address:

114 Fieldstone Road Wewahitchka, FL 32465

File Date:

1/3/2011

Disposition:

Suspension

Violation: Summary:

Positive PreEmploy Drug Screen

Primary Location:

Not Practicing In Florida P 0 Box 6320 Tallahassee, FL 32314-6320

Appeal:

N

Info Package Mailed Date:

1/7/2011

464.018(1)(h)(i)(j) F.S., 64B9-8.005(12) F.A.C. and pursuant to 456.074(3) F.S. for possible ESO. Received information from The Bridge at Bay St. Joe, indicating that subject had been terminated from her employment effective 04/23/2010. Subject had been suspended since 04/06/2010 pending an investigation for reasonable cause related to an investigation for possible narcotic diversion. She was terminated after she produced positive results for amphetamines on a drug screen. Shannon Seroogy

Discipline Imposed: Obligations and Conditions Emergency Suspension Reprimand Suspension

Compliance:

NO NO NO NO

NO NO

Activities:

Start Date 01/03/2010 07/06/2010 01/03/2011 01/03/2011

End Date

Comments

01/03/2011

Record

Suspended for 2 years and thereafter until she personally appears before the Board and can demonstrate the present ability to engage in the safe practice of nursing. That demonstration shall include at least an in depth psychological evaluation coordinated through the Intervention Project for Nurses, with an MMPI or other appropriate testing from a psychiatrist, psychologist, or other licensed mental health counselor experienced in the treatment of chemical dependency.

Due Date

IPN Evaluation Re-entry plan Fine

Cmpl Date

Activity Date

Actv Code

Activity Description

01/07/2011 06/17/2013 07/29/2013 09/03/2013 09/04/2013 09/05/2013 09/13/2013 09/17/2013

901

916 923 932 916 923

Info pack mailed CO File Sent For Archiving Respondent Contacted CO Fax Received Mail Processed/Reviewed CO Contacted Respondent Fax Received Mail Processed/Reviewed

Letter Code

Letter Description

NN157 NN179

CMU WELCOME LETTER INVOICE

01/07/2011 01/07/2011

Amt Paid

250.00 2,562.63

0.00 0.00

09/17/2013 09/17/2013

Costs Documented Sobriety Return license Employer-Suspension Acknowledgement Reinstatement Appearance

Contact History: Contact Date

Amt Imposed

952 931

Attachments: 1.

Compliance Tracking File Respondent

2. Correspondence from 3. Final Order for Case

Florida Department of Health

-- FOR INTERNAL USE ONLY --

13

14:13:20 OND

__________________________________________________/

I th

,,,pepartment

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH, Petitioner, vs.

Case No. 2010—08389 License No.: RN 2215902 :

PATRICIA E. HUMPHREY KELLY, Respondent.

FINAL ORDER This matter appeared before the Board of Nursing at a duly-

noticed public meeting on December a

3,

2010 in Miami, Florida,

for

hearing not involving disputed issues of material fact pursuant

to Sections 120.569 and 120.57(2),

Florida Statutes.

Petitioner

has filed an Administrative Complaint seeking disciplinary action

against the license.

attached to and made

A copy of the Administrative Complaint is a

part of this Final Order. Service of the

Administrative Complaint was made upon Respondent by certified mail,

return receipt requested.

Election of Rights.

Respondent has not filed an

Petitioner has filed

a

Motion for

Determination of Waiver and Entry of Final Order. Petitioner was represented by William Miller, Assistant General Counsel, Florida Department of Health.

Respondent was not present.

FINDINGS OF FACT Since the licensee has not replied to the Administrative

1

Case No. 2010—08389

I

Complaint nor contested the factual allegations, the prosecuting

attorney offered the investigative file to prove the facts as alleged.

The investigative file was received into evidence and

the Board finds the uncontested facts adequately support the

allegations.

Therefore, the Board adopts as its finding of facts

the facts set forth in the Administrative Complaint.

CONCLUSIONS OF LAW Based upon the Findings of Fact, the Board concludes the licensee has violated Section 456.072(1) (aa), Florida Statutes. The Board is empowered by Sections 464.018(2)

456.072(2),

licensee.

Florida Statutes, to impose

a

and

penalty against the

Therefore it is ORDERED that:

The license of PATRICIA E. HUMPHREY KELLY is hereby

REPRIMANDED. The licensee must pay an administrative fine of $250.00 and

investigative costs of $2,562.63 prior to reinstatement of her license.

Payment shall be made to the Board of Nursing and

mailed to, DOH-Compliance Management Unit, Bin C76, P.O. Box 6320, Tallahassee,

Florida 32314—6320, Attention: Nursing

Compliance Officer. The license of PATRICIA 2

HUMPHREY KELLY is suspended for

E.

years and thereafter until she personally appears before the

Board and can demonstrate the present ability to engage in the safe practice of nursing.

That demonstration shall include at 2

Case No. 2010—08389

least an in—depth

psychological evaluation coordinated through the Intervention Project for Nurses, with an MMPI or other appropriate testing

from

a

psychiatrist, psychologist, or other licensed mental

health counselor experienced in the treatment of chemical dependency.

The licensee shall supply

a

copy of this Order to

The evaluation must contain evidence that the

the evaluator.

evaluator knows of the reason for referral.

The evaluator must

specifically advise this Board that the licensee is presently able to engage in the safe practice of nursing or recommend the

conditions under which safe practice could be attained.

The

licensee must also submit prior to her appearance before the Board a reentry plan, proof of continued treatment and counseling if recommended in the psychological evaluation,

and demonstration

of two years of documented continuous drug free/alcohol free

living.

The Board reserves the right to impose reasonable

conditions of reinstatement at the time the licensee appears before the Board to demonstrate her present ability to engage in the safe practice of nursing.

Within 30 days, the licensee shall return her license to the board office,

4052 Bald Cypress Way,

Bin

#

C02,

Tallahassee,

Florida 32399—3252 or shall surrender the license to an

Investigator of the Department of Health. 3

Case No. 2010—08389

The licensee's

I

___________________,

employer shall

irrirnediately be

writing from the licensee with

informed of the suspension in a

copy to the Board office.

This Final Order shall become effective upon filing with the

Clerk of the Department of Health.

DONE

ORDERED this

2010.

day of

OF NURSING

£

JR.

JOE R.

Executive Director for

Jessie

Cohn,

RN,

PhD,

CHAIR

NOTICE OF APPEAL RIGHTS Pursuant to Section 120.569, Florida Statutes, the parties are hereby notified that they may appeal this Final Order by

filing one copy of

a

notice of appeal with the clerk of the

department and by filing

a

filing fee and one copy of a notice of

appeal with the District Court of Appeal within thirty days of the date this Final Order is filed.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing has been furnished by U.S. Mail and certified mail, return receipt requested to PATRICIA E. HUMPHREY KELLY, 114

Fieldstone Lane, Wewahitchka, FL 32465 and Jean D!Aprix, IPN P.O. Box 49130, Jacksonville Beach, Florida 32240-9130; by interoffice

4

Case No. 2010—08389

I

mail to Lee

Gustafson, Assistant Attorney General,

PL—0l, The

Capitol, Tallahassee, Florida 32399-1050; and William Miller,

Assistant General Counsel, Department of Health, 4052 Bald Cypress Way, Bin

#

C-65, Tallahassee, Florida 32399-32 65 on this

day

U.S. Postal Service

CERTIFIED MAIL RECEIPT (Domestic Mail Only: No Insurance Coverage Provided)

OFFICIAL USE

Deputy Agency Clerk

Postage $ Certified Fee

Postfliark

Return Receipt Fee (Endorsement Required)

H ere

Restricted DeIlve,y Fee (Endorsement Required)

Total Postage

&

Fees

$

To

.

orPO Box No. 4

5

Case No. 2010—08389

_________________________________I

I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, v.

CASE NO. 20 10-08389

PATRICIA E. HUMPHREY KELLY, R.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner,

Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Patricia E. Humphrey Kelly, R.N.,

and in support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice

of nursing pursuant to Section 20.43, Florida Statutes; Chapter

456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to this Administrative Complaint,

Respondent was a licensed registered nurse (R.N.) within .the state of Florida, having been issued license number RN 2215902.

55444

I

Respondent's address

3.

of record

is Post Office

Box 1461,

Wewahitchika, Florida 32465. On or about April 6, 2010, Respondent was required by

4.

Serenity Heatthcare,

skilled nursing facility in Port St. Joe, Florida, to

a

submit to an employer-ordered reasonable suspicion urine drug screen

after it was suspected that she was diverting medication. On or about April 6, 2010, Respondent provided a urine sample

5.

for use

in a

drug screen requested by her employer. The collector sealed

the sample, prepared

a

chain of custody form, and sent the sample to

LabCorp in Research Triangle Park, North Carolina. 6.

The sample arrived at LabCorp on or about April 8, 2010.

7.

On or about April 8, 2010, scientists at LabCorp performed an

initial drug screen of the sample using an enzyme immunoassay technique

with an automated analyzer. 8.

Immunoassay

the presence of drugs

is a

in

drug testing method used for determining human

1mm unoassay measures the presence

biological

fluids such as

urine.

of drugs by adding to the specimen

specific antibodies that bind with the drug being measured, enabling the

Department of

v. Patrtaa E. Humphrey Kelly, RN.

Case Number 2010-08:389

Casey\Drafted ACs\Crtmes, Drugs, IPN\Kehy, Pathda (RN, positive test) .doc

55445

2

I

scientist to determine the presence and amount of drug Respondent's sample was determined

9.

in

the specimen.

to be positive for

amphetamine and methamphetamine. 10.

According to Section 893.03(2), Florida Statutes, amphetamine

is a Schedule

II controlled substance that has

a

high potential for abuse

and has a currently accepted but severely restricted medical use in

treatment in the United States,

of amphetamine may lead to

and abuse

severe psychological or physical dependence. 11.

to

According

methamphetarnine is

a

Section

893.03(2),

Florida

Statutes,

Schedule II controlled substance that has a high

potential for abuse and has a currently accepted but severely restricted medical

use

treatment

in

metharnphetarnine

may

lead

in

the to

United

severe

States,

and

psychological

abuse

or

of

physical

dependence. 12.

On or about April 8, 2010, LabCorp conducted a confirmation

test of the initial positive screen using

a

gas chromatography/mass

spectrometry test (GC/MS). 13.

GC/MS is a drug testing method

principle than the immunoassay method. Department of Health v. Patrlda Case Number 2010-083B9

E.

is

different in scientific

A special instrument, the gas

Humphrey Kelly, R.N.

Casey\Drafted ACs\Cñrnes, Drugs, JPN\Kelly,

5 5446

that

3

(RN, posttive test).doc

I

chrornatographer, utilizes the chemical properties, such as boiling point, of

chemical compounds in order to separate the compounds that are present in a specimen. After separating the compounds in the specimen, another insl:rument, the mass spectrometer, is used to identify each chemical

compound based on the compound's mass. 14.

The GC/MS test confirmed the presence of amphetamine and

methamphetamine in Respondent's urine sample. 15.

On or

about April

23,

2010, Serenity Healthcare notified

Respondent that her drug test had returned positive for amphetamine and

methamphetaniine, and she was terminated. 16.

On or about June 16, 2010, the Department attempted

to notify

Respondent, by letter sent to her address of record with the Department,

of her positive drug test and

give her the opportunity to produce a lawful

prescription for substances that would test positive for amphetamine and metharnphetamine, but the letter was returned to the Department in the

original envelope stamped "Return to Sender" by the post office. 17.

Respondent did not provide

a

prescription for amphetamine

and methamphetamine, or any other substance that might test positive for

Department of Health v. Patricia Case Number 2010-0838g

E.

Humphrey Kelly, R.N.

Casey\Drafted ACs\Crirnes, Drugs, IPN\KeIIy, Patricia (RN, positive test).dx

55447

4

I

amphetamine and methamphetamine; and she did not have a legitimate medical reason for using amphetamine and methamphetamine. 18.

Section 456.072(1)(aa), Florida Statutes (2009), subjects

a

licensee to discipline for testing positive for any drug, as defined in Section

112.0455, on any confirmed

or employer-ordered drug

screening when the practitioner does not have a Lawful prescription and

legitimate medical reason for using the drug. 19.

Respondent

is

licensed

pursuant to Chapter 464,

Florida

Statutes, and is a health care practitioner as defined in Section 456.001(4), Florida Statutes (2009).

20.

As

set

forth

above,

Respondent

tested

positive

for

amphetamine and methamphetamine on a reasonable suspicion employerordered drug

test.

Respondent did

not provide

prescription for

a

amphetamine and methamphetamine, or any other substance that might test positive for amphetamine and methamphetamine, and she did not have

a

legitimate

medical

reason

for

using

amphetamine

and

metharnphetamine. 21.

Based

on

the

foregoing,

Respondent

456..072(1)(aa), Florida Statutes (2009), subjects

a

licensee

DepartrTlent of Health v. Patricia E. Humphrey Kelly, R.N. Case Number 201D-08389

Dntgs,

55448

violated

Patricia (RN, positive test).doc

Section

b discipline for

I

testing positive for any drug,

2S

defined in Section 112.0455, on any

confirmed pre-employment or employer-ordered drug screening when the

practitioner does not have

a

lawful prescription and legitimate medical

reason for using the drug.

Health v. Patricia Case Number 2010-08389

E.

Humphrey Keriy, R.N. 6

ACs\Crimes, Drugs, IPN\KeIIy,

55449

(RN, po5ttive test).doc

___________(date)

WHEREFORE, the Petitioner respectfully requests

I

that the Board of

Nursing enter an order imposing one or more of the

penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fIne, issuance of a reprimand,

placement of the Respondent

on probation, corrective action, refund

of

fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

JJ

day of Ana

A

I

Viamonte Rose, M.D., M.P.H. State Surgeon General

•

FILED,

M.

Casey Assistant General DOH

/CLH Reviewed and approved by: PCP: PCP Members: Department of Health

Number

Services Unit

4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0035536 (850) 245-4640 Telephone (850) 245-4683 Facsimile

DATE

Case

*

v. Patricia E. ZO1O-083B9

(initials)

7/22/Jo C.

&

.S.

Humphrey Kelly, R•N.

Casey\Drafted ACS\Crimes, Drugs, IPI'J\XeIly, Patricia (RN, positive test).doc

55450

7

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be. conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requesteri. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of

a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

PdtrlcIa E. Humphrey Kelly, FIN. Case Number 2010-08359

Casey\Drafted ACS\Ciimes, Dwgs,

55451

LPN\Kelly, Patric;a (RN, positive

test)4oc

I

TO:

Cassandra G. Pasley, BSN, JD, Chief Bureau of Health Care Practitioner Regulation

FROM:

Joe Baker, Jr., Executive Director Florida Board of Nursing

DATE:

December 22, 2010

RE:

Delegation of Authority

During my absence on Thursday, December 23, 2010 through Monday, January 3, 2011, the following managers are delegated authority for the board office: 12/23 12/27-1/3

William Spooner Robert Johnson

Program Ops Administrator Program Ops Administrator

Best wishes for a meaningful holiday season!!

JBjr/ms

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

05:28

INDUSTIES 3 18504880796

ND.

DasSee Community Health Systems 800 Akel Street St. George Island, FL 323238 August 5,

RE:

3

,

Letter of Reference for

.

Patricia Kelly, RN

¶4 Whom It May Concern:

Ms. Patricia Kelly, R..N had been employed with DasSee Community Health System for a period of six (6) years. During her tenure at the George E. Weems Florida she had perfotmed the duties of Memorial Hospital, in Director of Nursing Services..

for their In my 40 plus years in Healthcare Administration, some people stand out great qualities and Ms. Kelly is one of those people. She is well known for her personality qualities, intelligence, work ethic, positive attitude and leadership. She was wefl respected throughout the facility as the go to person for getting things done. On countless occasions, she was able to teach and perform excellent clinical skills, while increasing the quality of care performed at Weems Hospital.

Throughout the time I have known her, she has shown me time and again she is a positive, motivated leader with great potential.

would in summation, due to her great attitude, dedication, and excellent potential, I heartily recommend Ms. Kelly for reinstatement of her license. I am sure that her problems from the past are behind her and never to be repeated again.

Michael C. Lake President and C.E.O

558

P03

19:32

HUMPHREY I NDUSTI ES 3

18504880796

NO. 579

Ms. Williams, You ask me to submit a re-entry plan.

When the suspension is lifted of my license plan to look in work back In the nursing field. No planning on being very picky about what type job it is as long as can work back as a nurse. I live in a rural area so jobs are not that plentiful. I

I

will always continue to do my support groups and meetings. have only be in IPN since June of 2013, hut for the 2 years that my license was suspended have beert in outpatient treatment and under the care of a Board Certified Psychiatrist who treats people with addictions, and attending regular meetings. iplan to do whatever must to continue my soberly. I

I

1

I

Thank You,

Patricia Kelly License

RN22215902

Case 4 201008389

C02

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

of all

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H Vision: To

be the Healthiest State in the Nation

NOTICE OF HEARING

November 13, 2013 Case #2010-08389 To:

Patricia Kelly 347 Mossie Rd Wewahitchika, FL 32465

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, August

Time:

8:30 AM or thereafter

Type:

RN Reinstatement and Compliance Issues

Re:

Patricia Kelly

Place:

1,

2013

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Attendance Requirement: Respondents are not required to attend unless otherwise indicated on this notice. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in. Reinstatement and Compliance Issues, Motion to Vacate, Recommended Orders, Petitions for Hearing/Modification, Petitions for Declaratory Statement and other items for Board consideration are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance

Board of Nursing

4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE: 850/245-4125 FAX 850! 245-4172

www.FloridasNursing.gov T\NITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

M.OEIDA DEPAfl}AENT OF

HEALT Charlie Crist Governor

Ana M. Viamonte Ros, M.D., MPH. State Surgeon General

MEMORANDUM TO: FROM: RE:

Joe Baker, Jr., Executive Director, Florida Board Casey L. Cowan, PSU Attorney

SUBJECT:

DOH v. Patricia E. Humphrey Kelly DOH Case Number 20 10-08389

DATE:

September 7, 2010

of Nursing

Informal Waiver Hearing

Enclosed you will find materials in the above-referenced case to be placed on the Informal Waiver agenda for final agency action for the December 2010 meeting of the board. The following information is provided in this regard. Subject: Patricia E. Humphrey Kelly 114 Fieldstone Lane Wewahitchka, FL 32465 Enforcement Address: 114 Fieldstone Road Wewahitchka, FL 32465

Subject's License No: Licensure File No:

2215902

Initial Licensure Date:

4/15/199 1

Required to Appear:

No

Prior Discipline: Probable Cause Panel:

4050, DOH-07-1060-S July 22, 2010 Home and Bowen

Complainant/Address:

Serenity Healthcare 220 9th Street The Bridge at Bay St. Joe Port St. Joe, FL 32456 Memorandum to the Board Motion for Final Order Administrative Complaint Motion to Assess Costs Board Affidavit Clerk Affidavit Settlement Agreement Packet

Materials Submitted:

Rank: R.N.

108093

PCP Memo

COMPAS Screen ESO 4052 Bald Cypress Way

*

Bin C-65 * Tallahassee, FL 32399-3265

________________________________________________________I FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK DATE

STATEOFFLORIDA

'4a.

0f tOotiJo /

DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

•Petitioner, v.

CASE NO.

Patricia

E.

2010-08389

Humphrey Kelly, R.N., Respondent.

MOTION FOR FINAL ORDER AFTER HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACTS AND DETERMINATION OF RESPONDENT'S WAIVER OF RIGHT TO REQUEST A FORMAL HEARING COMES NOW, the Petitioner, by and through its undersigned counsel, and moves the Board of Nursing for entry of a Final Order in the above-

styled cause on a date and time that has been determined and noticed by

the Board. As grounds therefore, the Petitioner states: 1.

Petitioner previously iled an Administrative Complaint against

Respondent alleging that Respondent had violated the provisions of Florida

Statutes, as set forth therein. The Department, by filing the Administrative

Complaint, seeks to discipline Respondent's certification to practice nursing,

thereby affecting the Respondent's substantial interests.

2.

On or about August 9, 2010, Petitioner served Respondent with

the Administrative Complaint via Certified Mail at 114 Fieldstone Road, Wewahitchka, FL 32465.

By serving Respondent with the Administrative

Complaint, the Department provided the Respondent written notice of its decision to seek discipline of the Respondent's certification to practice Nursing. 3.

Rule 28-106.111(2), F.A.C., provides in pertinent part that:

persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 4.

Rule 28.106.111(4), F.A.C., provides in pertinent part that:

any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

The Respondent failed to file a written request for

a

hearing on

the Administrative Complaint within twenty-one (21) days of receipt of the Administrative Complaint. 6.

The Respondent has waived his/her right to request

on the Administrative Complaint.

a

hearing

7.

There are no disputed issues of material fact to be resolved by

the Board. 8.

Respondent has been advised, by a copy of this Motion, that a

copy of the investigative file in this case shall be furnished to the Board to establish a prima facie case regarding the violations as set forth in the

Administrative Complaint. WHEREFORE the Petitioner requests that, after allowing the Respondent the opportunity to present oral and/or written evidence in

mitigation of the Administrative Complaint, the Board of Nursing enter

a

Final Order imposing such discipline upon the Respondent's license as the

Board deems appropriate.

Respectfully submitted,

Casey L. Cbwan Assistant General Counsel Department of Health Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65

Tallahassee, FL 32399-3265 (850) 245-4640 telephone (850) 245-4683 facsimile Florida Bar No. 0035536

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that foregoing

has

been

-

true and correct copy of the above and provided by U.S. mail this day of 2010, to: Patricia E. Humphrey Kelly, R.N., a

114 Fieldstóne Road, Wewahitchka, FL 32465.

Casey L. Cg4van Assistant General Counsel

STATE OF FLORIDA

DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, v.

CASE NO.

PATRICIA

E.

2010-08389

HUMPHREY KELLY, R.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Patricia E. Humphrey Kelly,

and in support 1.

thereof alleges:

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to this Administrative

Complaint,

Respondent was a licensed registered nurse (R.N.) within •the state of Florida, having been issued license number RN 2215902.

Respondent's address

3.

of record

is

Post Office

Box

1461,

Wewahitchika, Florida 32465. On or about April 6, 2010,

4.

Serenity Heatthcare,

Respondent was required by

skilled nursing facility in Port St. Joe, Florida, to

a

submit to an employer-ordered reasonable suspicion urine drug screen

after it was suspected that she was diverting medication. On or about April 6, 2010, Respondent provided a urine sample

5.

for use

in a

drug screen requested by her employer. The collector sealed

the sample, prepared

a

chain of custody form, and sent the sample to

LabCorp in Research Triangle Park, North Carolina. 6.

The sample arrived at LabCorp on or about April 8, 2010.

7.

On or about April 8, 2010, scientists at LabCorp performed an

initial drug screen of the sample using an enzyme immunoassay technique

with an automated analyzer. 8.

Immunoassay

the presence of drugs

is a

in

drug testing method used for determining human

biological

fluids

such

as

urine.

Imnmunoassay measures the presence of drugs by adding to the specimen

specific antibodies that bind with the drug being measured, enabling the

a

Department of Health v. E. Humphrey Kelly, RN. 2010-08389 J:\PSU\Nursing\Hagen, Casey\Drafted ACS\Crimnes, Drugs, IPN\KeIiy, Patilda (RN, positive test).doc Case Number

2

scientist to determine the presence and amount of drug

sample was determined to

Respondent's

9.

in

the specimen. be

positive for

amphetamine and methamphetamine. 10. is a

and

According to Section 893.03(2), Florida Statutes, amphetamine

Schedule

I controlled substance that has

high potential for abuse

a

has a currently accepted but severely restricted

treatment

in the United States, and abuse

medical use in

of amphetamine may lead to

severe psychological or physical dependence. to

According

11.

metharnphetarnine

is a

Section

893.03(2),

Florida

Statutes,

Schedule II controlled substance that has

a

high

potential for abuse and has a currently accepted but severely restricted medical

use

in

treatment

methamphetamine

may

in

lead

the to

United

severe

States,

and

psychological

abuse or

of

physical

dependence. 12.

On or about Aprfl 8, 2010, LabCorp conducted a

test of the initial positive screen using

a

confirmation

gas chromatography/mass

spectrometry test (GC/MS). 13.

GC/MS is

a

drug testing method that

principle than the immunoassay method. Department of Health v. Pabida E. Humphrey Kefly, RN. Case Number 2010-08389 J:\PSU\Nursing\Hagen, Casey\Drafted ACs\Crimes, Drugs,

is

different

in

scientific

A special instrument, the gas 3

JPN\lKeIly, Pafricia (RN, positive

test).doc

amphetamine and methamphetamine; and she did not have

a

legitimate

medical reason for using amphetamine and methamphetamine. 18.

Section 456.072(1)(aa), Florida Statutes (2009), subjects

a

licensee to discipline for testing positive for any drug, as defined in Section

112.0455, on any confirmed pre-employment or employer-ordered drug screening when the practitioner does not have

a

lawful prescription and

legitimate medical reason for using the drug. 19.

Respondent

Statutes, and is

a

is

licensed

pursuant to Chapter 464,

Florida

health care practitioner as defined in Section 456.001(4),

Florida Statutes (2009).

20.

set

As

forth

above,

Respondent

amphetamine and methamphetamine on ordered

drug

test.

Respondent did

a

tested

positive

for

reasonable suspicion employer-

not provide

a

prescription for

amphetamine and methamphetamine, or any other substance that might test positive for amphetamine and methamphetamine, and she did not have

a

legitimate

medical

reason

for

using

amphetamine

and

methamphetamine. 21.

Based

on

the

foregoing,

Respondent

456.072(1)(aa), Florida Statutes (2009), subjects

a

Section

licensee to discipline for

DepartrTlent of Health v. Patricia E. Humphrey Kelly, R.N. Case Number 201D—08389

J:\PSU\Nursing\Hagen, Casey\Drafted

violated

Drugs, IPN\Keily, Patricia (RN, positive test).doc

5

testing positive for any drug,

as

defined in Section 112.0455, on any

confirmed pre-employment or employer-ordered drug screening when the

practitioner does not have

a

lawful prescription and legitimate medical

reason for using the drug.

Department of Health v. Patricia E. Humphrey Kelly, RN. Case Number 20 10-08389 3:\PSU\Nursing\Hagen, Casey\Drafted ACs\Crimes, Drugs, JPN\KelIy, Patricia (RN, positive test).doc

6

_______ _______(initials) __________(date)

WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penafties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of

a

reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

day of Ana

,

2o.S..

Viamonte Rose, M.D., M.P.H. State Surgeon General M.

Casey

L

Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0035536 (850) 245-4640 Telephone (850) 245-4683 Facsimile

C LE RK

/CLH Reviewed and approved by: POP: PCP Members:

7/22/ic) &

Department of Health v. Patricia E. Humphrey Kelly, RN. Case Number 2010-08389 J:\PSU\Nursing\Elagerj, Casey\Drafted ACs\Crimes, Drugs, IPN\KeIiy, Patricia

7 (RN, positive test),doc

NOTICE OF RIGHTS

Respondent has the right to

request a hearing to be conducted in accordance with Section 120.569 and 120.57, florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Paticia

E.

Humphrey Kelly, R.N.

Case Number 2010-05389

J:\PSU\Nursing\Hagen Casey\Drafted ACs\Crimes, Drugs, IPN\Kelly,

ia

8

(RN, positive test)doc

2.

Section 456.072(4), Florida Statutes (2005),1 states:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel. costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

. 3.

The investigation

and

prosecution of this case has

resulted in costs in the total amount of $2,562.63 based on the

following itemized statement of costs:

,.

Ch. 2003-416, § 19, Laws of effective September 15, 2005, amended Section Statutes (2003), to include the underlined language. 1

(4),

Florida

2

Cost to Date

I

Hours

011

Complaint: jinvestigation:.

1

22.8OjL [

1

Costs

*****e****!

$764541

**********

[

.

Expenses to Date:

ITotal Costs to Date:

L

$250.00

.

1

,562.63j

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $2,562.63, as evidenced in the

attached affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to

be assessed based

upon its consideration of the affidavit attached as Exhibit A. and any

timely-filed written objections.

3

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY

that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day of 2010, to: Patricia E. Humphrey Kelly, R.N., 114 Fieldstone Road, Wewahitchka, FL 32465.

Casey

L.

towan

Assistant General Counsel

5

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared JULIE M. WEEKS who was sworn and states as follows: 1) My

name is Julie M. Weeks.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DON. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida

I

I

I

.275.

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2010-08389 (Department of Health v. PATRICIA E.

HUMPHREY KELLY, R.N.) are TWO THOUSAND FIVE HUNDRED SIXTY-TWO DOLLARS AND SIXTY-THREE CENTS ($2,562.63). 6) The costs for DOH case numbers 201 0-08389 (Department of Health v. PATRICIA E. HUMPHREY, R.N.) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case numbers 2010-08389 (Department of Health v. PATRICIA E. HUMPHREY KELLY, R.N.) are

detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DON employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

1

of2

I-

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Julie M. Weeks, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of her knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

M.

Weeks, Affiant

State of Florida County of Leon Sworn to and subscribed before me

day

of Notary Printed Stamp Commissioned Name of Notary Public:

of 2

Staff Rate

0.30 0.10

0.40

Sub Total

0.80

Sub Total

$61.04

$29.93 $32.13

Florida Department of l-Jealth

1.00

2.00

C150

150

1.50

0.10 2.00

0.50

1.20 1.00 1.10 1.00

2.00

1.00

0.50

10

1.00 1.00 1.00

150 150 150

C150

150 150

CI5O

SO

150 150 150 150 150

O SO $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23

ILNVESTIGATIVE SERVICES UNIT

0.80

O3

ICONSUMER SERVICES UNIT

13

1C20

COMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours Cost

Activity Date

$65.23 $65.23 $65.23 $71.75 $32.62 $65.23 $130.46 $78.28 $65.23 $71.75 $65.23 $32.62 $97.85 $6.52 $130.46 $65.23 $130.46

$48.83

$48.83

512.19

$8.98 $3.21

—

100 4 4

4

U

4

4 76

4

76 58 4 4 58

4

78

116 116

Activity Description

WORK WORK

WORK WORK

I

-

itemizedcost

WORK SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE ROUTINE INVESTIGATIVE

INVESTIGATIVE

TRAVELTIME ROUTINE INVESTIGATIVE ROUTINE INVESTIGATIVE TRAVEL TIME ROUTINE INVESTIGATIVE ROUTINE INVESTIGATIVE REPORT PREPARATION

REPORT PREPARATION

ROUTINE INVESTIGATIVE

ITIALREVIEWANDANALYSISOFCOMPLAINT

ROUTINE COMPLIANCE MONITORING

FOR INTERNAL USE ONLY

05/03/2010 05/04/2010 05/07/2010 05/17/2010 05/17/20 10 05/18/2010 05/18/2010 05/26/2010 05/27/2010 05/27/2010 06/01/2010 06/04/20 10 06/04/2010 06/07/20 10 06/07/2010 06/10/2010 06/10/2010

04/26/2010

07/06/2010 07/08/2010

Activity Code

201008389

MQL Complaint

Time Tracking System Itemized Cost by Complaint

Report Date 09/07/20 10

***CONFJDENTJAL***

Medical Quolily Msutance

Olvkk,.n of

1.00

HLL67A HLL67A HLL67A HLL67A HLL67A -ILL67A

6.80

Sub Total

Florida Department of Health

0.30 0.30

1.00

0.50 0.30 0.30

1.00 1.50

0.60

ULL67A HLL67A HLL67A

l-ILL4B

22.80

Sub Total

1.50

0.40

0.50 0.20 0.40 0.80

152 152 152

C152

145

C145

Stafl'Code Activity Hours

Report Date 09/07/20 10

MQA

Medical Quclily Asst'tance

Diviskin ci

$112.43 $112.43 $112.43 $112.43 $112.43 $112.43 $112.43 $112.43 $112.43 $112.43

$65.23 $65.23 $65.23 $65.23 $65.23 $65.23

Staff Rate

$764.54

$112.43 $67.46 $112.43 $168.65 $56.22 $33.73 $33.73 $112.43 $33.73 $33.73

$1,487.26

$32.62 $13.05 $26.09 $52.18 $97.85 $26.09

Cost

28 89 63

81

81

81 81

25 26 25

58 4

6

4

6

58

Activity Code

Activity Description

.

Page 2 of3

itemizedcost

PROBABLE CAUSE PREPARATION PRESENTATION OF CASES TO PROBABLE CAUSE PANEL

PREPAREORREVISEADMINISTRATIVECOMPLAINT

REVIEW CASE FILE ESO/ERO ESO/ERO ESO/ERO ESO/ERO

IGATION

201008389

TRAVEL TIME SUPPLEMENTAL INVESTIGATION ROUTINE INVESTIGATIVE WORK SUPPLEMENTAL TRAVEL TIME ROUTINE INVESTIGATIVE WORK

- FOR INTERNAL USE ONLY -

06/15/2010 06/15/2010 06/22/2010 06/22/2010 06/29/2010 06/29/2010 07/07/2010 07/09/2010 07/21/20 10 07/22/2010

07/07/2010 07/07/20 10 07/12/2010 07/12/2010 07/14/2010 07/14/2010

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

***CONF}DENTIAL***

I

Florida Depai-trnent of Health

Staff Code Activity Hours

Report Date 09/07/20 10

QA

Modicol Quality Assutance

Division of

Staff Rate Cost

- FOR INTERNAL USE ONLY -

Activity Date Activity Code

Complaint 201008389

Activity Description

Time Tracking System Itemized Cost by Complaint

***CONFJDENTIAL***

itemizedcost

Page3of3

OMsion ol

$250.00

$250.00

Total Expenses

$250.00

Expense Amount

SubTotal

07/02/2010

Florida Department of Health

SS

ICONSUMER SERVICES UNIT

Stall Code

Date

Expense

Report Date: 09/07/2010

I\/IL

Medical Qualtty Assurance

PAYMENT FOR INFORMATION AND EVIDENCE

Expense Code Description

- FOR INTERNAL USE ONLY -

497000

Expense Code

Complaint 201008389

Itemized Expense by Complaint

ON F IDE N TI AL Time Tracking System

C

1

I

oft

itemizedexpense

Page

FLORIDA DEPARTMENT OF

lie

HEALT

Christ

Ma

Governor

MPH.

State Surgeon General

I,

Joe Baker. Jr

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure

of

M. Viamonte Ros,

/8/2010

iles that the Board of Nursing

,

has no evidence of an Election

as

of Rights form or

other responsive pleading requesting a hearing prior to any agency action regarding

PATRICIA E. HUMPHREY KELLY,

2010-08389 which would affect the Subject's substantial

CASE NUMBER

interests or rights.

of Florida Board of Nursth4 Before me, personally appeared

identity is known to me

Joe Baker, Jr.

Dersonally

(type

whose

,

of identification)

who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this

8

day of

September

C

Notary

SHIRLEY HAMILTON Commission # DD 876511 Expires April 1, 2013 BoSed 1).u ioy

Department of Health Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 850-245-4444

,

2010.

and

Charlie

at

Ana M. Viamonte Ros, M.D., M.P.N. State Surgeon General

Governor

jCF

AFFIDAVIT

I,

't'eo,'

Clerk's

Officj'hereby certify

.

,

Deputy Clerk for the Department

in my official capacity as custodian

for the

Department Clerk's records, that the Department Clerk's Office has not

,

received an Election of Rights form or other responsive pleading, which

requests a hearing prior to any Department action regarding PATRICIA E.

HUMPHREY KELLY,

CASE NUMBER

whIch would

affect the Respondent's substantial interests or rights.

Before me, personally appeared

.

—

,

whose identity

to me by Dersonallv knowwftype of identification) and who,

is known

under oath, acknowledges that his/her signature appears Sw

n

t

and

subscribed

before

me

this

Notary Public My Commission Expires: ATLAFJnC

a

of

VILQ 3901 9849 0035 0414

ft SENDER:

•

(

REFERENCE:

PS Form 3800, January 2005

RETURN RECEIPT SERVICE

A CICt

t.JL)

Postage Certified Fee

Return Receipt Fee Restricted Delivery Tetal Postage & Fees

US

POSTMARK OR DATE

SeSco

Receipt for

Certified Mail •

No Insurance CCVeT2ge Provided Do Net ties br Intemalianel Mall

2. Article Number

ceived by (Please Print clearly) je

0.

C.digna

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IU

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deliJry It YES.

enter daivery

CERTIFIED MAIL.

4. RestrIcted Delivery? (Extra

I.

D.

Article Addressed to:

Lives

I

PS Form 3811. January 2005

Domestic Return Receipt

Iriiient addrtekw

1?

ate

Delve

Charlie Cost Governor

August

Ana M. Viarnonte Ros, M.D., MPH. State Surgeon General

3, 2010

teititied krlitle

Patricia E. Humphrey Kelly 114 Fieldstone Road Wewahitchka, Fl 32465 RE:

7160 3901 9849 0035 0414

Case Name: Patricia E. Humphrey Kelly, R.N Case Number: 2010-08389

Dear Ms. Kelly: Enclosed please find a copy of an Administrative Complaint which has beenfuied against your license by the Department of Health. An Election of Rights and an Explanation of Rights forms are also provided.

I have also enclosed an Agreement for settlement of this matter with terms which we believe will be acceptable but is subject to final approval by both the Department Chief and then the Board of Nursing. The costs of investigation and prosecution (currendy about $2,458.44) are included, but will likely increase by the time the case is heard at the Board meeting. However, the Agreement limits the costs to $3,458.44. The remaining settlement terms are set forth on pages 1-6. If the terms are acceptable, sign the Agreement before a notary. NOTE, you must read the nurse practice provisions of the Florida Statutes and the Board Rules before signing the Agreement. Please refer to the following websites: www.leg.state.fl.us and httD://fac.dos.state.f].us or consult your attorney for this information.

The Agreement would be sent to the next Board of Nursing meeting for its consideration. Your attendance at this meeting would be required. Meeting details would be sent to you once scheduled. If the Board accepts the Settlement Agreement, then the terms become the final resolution of the case. If the Board does not accept the Settlement Agreement, then your election will determine whether the case proceeds as either an informal or formal hearing.

.

You must sign the Election of Rights form, with your signature notarized, and return the form to my office within twenty-one (21) days of the date you received it. Failure to return this form within twenty-one days may result in the entry of a default judgment against you without hearing your side of the

' General

CLH/alt

Prosecution Services Unit • 4052 Bald Cypress Way, Bin # C-65 • Tallahassee, FL 32399-3265 Telephone (850) 245-4640 • Telefax (850) 245-4683

-

-C

&

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—4

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"

4052 Bald Cypress Way, Bin #C65 Tallahassee, Florida 32399-3265

Prosecution Services Unit

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RETURN RECEIPT REQUESTED

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Slip PACK SENDER:

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REFERENCE:

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RETURN SE

•

.

2005

WEVVAHflC.Hq C)

rflit-4-

VIA US Mail H

Ms. Jodi Ann Johnson, Esq. Department of Health, Bin C-65 4052 Bald Cypress Way

Tallahassee, Florida 32399-7017 Re:

Representation of Stacie Hanmiann

Dear Ms. Johnson:

Good afternoon. I hope this e-mail finds you well. Please find attached the executed Acknowledgment of and Agreement to Maintain Patient Confidentiality. I understand the attached entitles me to receive/review the investigative files. Upon receipt of the files, I will respond in a timely manner on behalf of my client.

Thank you for your time in this matter, Best,

Jo Ann

alchak Attorn 'for Ms. Stack Hamaim

JAP/vmc

WASHINGTON, CC

NEW YORK

TAMPA

BALTIMORE

_______ __________

.

I

RlckScott

Mission:

o pad, piamas & bi,pxova the health state,

S

blE

John H. Armstrong, MD, FACS Gesez& &

HEALTH

To be the

Iest

GOVOMOI

I

lbridá

Fólda%-oughbtgrated

Up op

Seaaiy

I

State hi eta P4sficn

DOH v. Stade D. Hamann, L.P.N. 1948 Case No. Page 3

Acknowledgement of and Agreement to Maintain Patient Confidentiality

Si. c

C

tk

C)

am the Subject of an Investigation by the Department of Health.

As the Subject of such an investigation,

I

am entitled to inspect or receive a copy of the investigative

report, including any expert witness report or patient records connected with the investigation pursuatt2 to Section 456.073(10), Florida Statutes, if

I

agree in wilting to maintain the confidentiality of any

Information received under this provision, until 10 days after probable cause Is found and to maintain the confidentiality of patient records pursuant to Section 456.057, Fonda Statutes.

understand the cost associated with duplicating x-rays and I want () do not want a copy of any x-rays that are contained within the investigative file. I

day of

SIGNED

'

to receive

2013.

:4

SIGNED this

( )

L

0. Hamann, L.P.N. 2012-11948

day of

.

2013 on behalf of Stacie 0. Hamann,

L.P.N.

ak, Esquire

Counsel

of Health Of

aithe

Genfl Ccwis& • P,cseai5on SeMen Unit

4052 BakJ Cypress Way. Ski C-65 Express mail 2585 Merthanls Row— PHONE: 850,245-4444 • FAX 1245-4683

sdin

Fl. 32299-1701 105

wwwSborfdasH eaith..com

oKFtflepertitettzfltaTh YOUThBE Mob

____________

,

Rick Scott

Mission: To protect promote

improve the health

&

Florida

U

HEALTH Vision: To be the Healthiest

John H. Armstrong,

State Surgeon General

&

Governor

Secretary

State in the Nation

April 24, 2013

lchak, Esquire Zuckerman Spaeder, LLP 101 East Kennedy Boulevard, Suite 1200, Tampa, Florida 33602 Jo Ann

Re:

'Stacie

Complaint No. 2012-11948 D. Hamann, L.P.N.

Dear Ms. Palchak:

Pursuant to section 456.073(10), Florida Statutes, you requested a copy of the Departments investigative file prior to the submission of this matter to the probable cause panel. Section 456.073(10), Florida Statutes, provides in part: The complaint and all information obtained pursuant to the investigation by the department are confidential and exempt from s. 119.07(1) until 10 days after probable cause has been found to exist by the probable cause panel or by the department, or until the regulated professional or subject of the investigation waives his or her privilege of confidentiality, whichever occurs first. Upon completion of the a recommendation by the department to find probable cause, and pursuant to a written request by the subject or the subject's attorney, the department shall provide the subject an opportunity to inspect the investigative file or, at the subject's expense, forward to the subject a copy of the investigative file. Notwithstanding s. 456.057, the subject may inspect or receive a copy of any expert witness report or patient record connected with the investigation if the subject agrees in writing to maintain the confidentiality of any information received under this subsection until 10 days after probable cause is found and to maintain the confidentiality of patient records pursuant to s. 456.057.

Attached for your review is an Acknowledgement of and Agreement to Maintain Patient Confidentiality. Please sign and return the enclosed form to my office as soon as possible. The signed confidentiality agreement will be placedin our file. Upon receipt of this form, and a determination by the Department to recommend that an Administrative Complaint be filed, a copy of the investigative file, including any expert witness report or patient record, will be forwarded to you for review. Our office will not make duplicates of any x-rays contained within the investigative file unless specifically requested to do so. You will have twenty (20) days from the date of mailing to file your response with the Department, unless an extension. is granted by the attorney handling this matter.

Florida Department of Health

1

Office of the General Counsel' Seivices Unit 4052 Bald Cypress Bin C.65 • Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 8501245-4444' FAX 850/245.4553

www.FlorldasHealth.com

"

F

FACEBQOKFLDe' rtrnetofH alth 11

BE fi

______ Mission:

Rick Scott

I

To protect promote & improve the health all people in Flodda through integrated state, county 8 community effortt

lóüda

I

John H. Armstrong, MD, FACS State Surgeon General

HEALTH Vision: To be

Governor

I I

&

Seaetary

I

the Healthiest State in the Nation

DOH v. Stacie D. l-iamann, L.P.N. Case No. 2012-11948

Page

2

However, please note that the Department is only required to provide a copy of the investigative file after the investigation has been completed and only if the Department is recommending an Administrative Complaint. A copy of the file will not be provided if the Oepartment recommends closure of the complaint. If you have any questions, please give me a call at (850) 245-4444 extension 8113.

Respectfully,

V.

Assistant General Counsel

JAVJ/pb Enclosure:

Confidentiality Agreement

,

Florida Department of Health

ls

Office of the General Counsel Proseaithn Services Unli FL 32399-1701 4052 Bald Cypress Way, Bin C-65 . Express mail address: 2585 Row —Suite 105 PHONE: 8501245-4444• FAX 8501245-4683

I I

I

I

ldasHealth.com

lHealth

TWITTER:HealthyFLA YOUTIJBE: ftdoh

_____________________________ ____ ____________________, /

1

Mission: promote & improve the health olali people in Florida through integrated state, county & community efforts.

To

Rick Scott

ida

I

I

i

Vision: To be the

Healthiest State

John H. Armstrong, MD, FACS

I

State Sumeon General & Secretary

HEALTH

I

Governor

I

I

in the

NMon

DOH v. Stacie D. Hamann, L.P.N. Case No. 2012-11948 Page 3

Acknowledgement of and Agreement to Maintain Patient Confidentiality am the Subject of an investigation by the Department of Health.

As the Subject of such an investigation,

I

am entitled to inspect or receive a copy of the investigative

report, including any expert witness report or patient records connected with the investigation pursuant to Section 456.073(10), Florida Statutes, if

I

agree in writing to maintain the confidentiality of any

information received under this provision, until 10 days after probable cause is found and to maintain the confidentiality of patient records pursuant to Section 456.057, Florida Statutes.

I

a

understand the cost associated with duplicating x-rays and

I

want

( )

do not want

( )

to receive

copy of any x-rays that are contained within the investigative file. SIGNED this

day of

2013.

-

Stacie 0. Hamann, L.P.N, 201 2-11948

SIGNED this

day of

2013 on behalf of Stacie D. Hamann,

L.P.N.

0 Ann Palehak,

Esquire Counsel of Record 201 2-11948

Florida Department of Health Office of the General Counsel • ProsecuUon Services Unit 4052 Bald Cypress Way, Bin 0-65 Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row —Suite 105 PHONE: 850/245-4444 'FAX 850/245-4683

www.FloridasHealth.com I1TER:HealthyFLA

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FAX Cover Sheet April 4, 2013

2

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CLIENT/MATTER

Ms. Jodi Ann Johnson, Esg.

850-245-4683

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Thank you fbr taking the time to speak me othei This letter notia the Department ofHealf.h that we represent Mg Stacte Hamanix in reference-to any rnveshgation dothplSt. utiderway at the Departmettt. AcsGrdingly, we. arc rtquestthg that all tb.Ms. .Hathajn he sent to atteñtioñ at sheWe tho cc-py of any-and all mvesttgative files of curretidy open Upon

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CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

:

December 4-6, 2013 Florida Board of Nursing Meeting

Full Board RN

Endorsement Request for Modification to Previous Conditional Order

Livingston, Alexandra Paula; 1701/456545 5060

Sw th

Gainesville,

Date

of

:

Lane

FL 32607

October 23, 2013

The initial application for Ms. Livingston was denied at the December 2012 meeting and subsequently approved with conditions at the February 2013 Board meeting. July 15, 2013, Board staff received a memo confirming Ms. Livingston's active IPN participation.

October 23, 2013, Board staff received a request from Ms. Livingston asking for the Board to allow her to start practicing nursing.

Supplemental

Request to Address the Board Board Order(s) IPN Memos Previously Viewed Material from the December 2012 Agenda Correspondence Report Prepared By: Vickie Boyd

CONFIDENTIAL AND EXEMPT MATERIALS

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/

Final Order No,

DATE

-N1QA

-FEBZ jttlealth

STATE OF FLORIDA

BOARDOFNURSING

IN RE APPLICATION FOR

LICENSURE OF

ALEXANDRA LIVINGSTON

FINAL ORDER This mailer appeared before the Board of Nursing at meeting on February 7, 2013

in

a

duly-noticed public

Panama City, Florida, for a hearing not involving

disputed issues of material fact pursuant to Sections 120.569 and 120.57(2), Florida

Statutes, pursuant to Respondent's request. The applicant, ALEXANDRA LIVINGSTON,

applied for licensure as

a

registered. A Notice of Intent to Deny was filed on December

17, 2012. Respondent was present and was represented by Adam Bushnell, Esquire.

FINDINGS OF FACT 1.

On November 18, 2010, the Board suspended the applicant's license until she

submitted to

a

psychological evaluation coordinated by the Intervention Project for

Nurses. 2. The applicant's license subsequently became null and void. 3. On

August 29, 2012,

a

judgment was entered against the applicant for the

unlicensed practice of a health care profession in violation of Section 456. 065(2)(d)3., Florida Statutes. 4. The

applicant has been diagnosed with

a

condition that, untreated, would

impair her ability to practice nursing with reasonable skill and safety.

1

2013

5. The

applicant has demonstrated that she is currently under treatment and her

condition is currently stable. 6. In

order to ensure that the applicant remains safe to practice, the Board finds

a

necessary to require monitoring by the Intervention Project for Nurses. 7. The Board is empowered by Sections 464.01 8(2) and

456072(2), Florida

Statutes, to deny or place conditions on the license.

Therefore, the application of ALEXANDRA LIVINGSTON is approved under the following conditions: A license shall not be issued until the applicant has entered into a monitoring

agreement with the Intervention Project for Nurses (IPN). It is the duty of the licensee to

contact the IPN at P.O. Box 49130, Jacksonville Beach, Florida 32240-9130, (904) 2701620 within 30 days.

Upon notice to the Board of the applicant's entry into IPN, the

license shall be issued in a suspended status. The suspension shall be stayed while she is compliant with the terms of her monitoring agreement. If she does not comply with all

conditions of the

1PM

Advocacy Contract, she will be in violation of the Board Order,

Termination from IPN shall result in the immediate lifting of the stay of suspension. Reinstatement will require compliance with all terms and conditions set forth in this and any previous Board Order, and the licensee's appearance before the Board to

demonstrate her present ability to engage in the safe practice of nursing. The Board reserves the right to impose reasonable conditions of reinstatement at the time of

appearance before the Board to demonstrate present ability to engage in the safe practice of nursing.

2

This Final Order shalt become effective upon filing with the Clerk of the

Department of Health. DONE AND ORDERED

of•

,

2013.

BOARD OF NURSING

ExecUe ftrector for Ann-Lynn Denker, PhD. ARNP, Chair NOTICE OF APPEAL RIGHTS

Pursuant to Section 120.569, Florida Statutes, the parties are hereby notified that they may appeal this Final Order by filing one copy of a notice of appeal with the clerk of

the department and by filing a filing fee and one copy of

a

notice of appeal with the

District Court of Appeal within thirty days of the date this Final Order is filed.

CERTIFICATE OF SERVICE I

HEREBY CERTIFY that a true and correct copy of the foregoing has been

furnished by U.S. Mail to ALEXANDRA LIVINGSTON

do Adam Bushnell, Esquire,

Office

of Criminal Conflict, 235 North Main Street, Suite 205, Gainesville FL 32601 and by interoffice mail to Board of Nursing, 4052 Bald Cypress Way, Bin C02, Tallahassee,

'

Florida 32399-3252 and Lee Ann Gustafson, Assistant Attorney General, PL-01, The

Capitol, Tallahassee, Florida 32399-1050 on this — day of

L

2013.

Deputy Agency Clerk

FILED DEPARTMENT OF HEALTH DEPUTY CLERK

'...RK

STATE OF FLORIDA BOARD OF NURSING

DATE

Angel Sanders DEC

1

7 2012

IN RE THE APPLICATION FOR

LICENSURE OF:

ALEXANDRA LIViNGSTON File No. 1701/456545

NOTICE OF INTENT TO DENY

ALEXANDRA LIVINGSTON has applied for licensure by endorsement as a registered nurse. The application came before the Board of Nursing at a duly-noticed public meeting on December 6, 2012, in Sarasota, Florida. On November 18, 2010, the Board suspended the applicant's license until she

submitted to a psychological evaluation coordinated by the Intervention Project for

.,

Nurses. Subsequently, the Michigan Board of Nursing suspended the applicant's license.

On August 29, 2012, a Judgement was entered against the applicant on four

counts of the unlicensed practice of a health care profession in violation of Section Florida Statutes.

The applicant is in violation of Sections 464.018(1 )(c), Florida Statutes, being

convicted or found guilty of, or entering a plea of

adjudication,

a

nob

contendere to, regardless of

crime in any jurisdiction which directly relates to the practice of nursing

or to the ability to practice nursing, and 456.072(1 )(f), Florida Statutes, having a license to practice a health care profession suspended by any jurisdiction.

I

Based on the foregoing, the Board may refuse to certify an applicant for licensure, or restrict the practice of the licensee, or impose conditions, pursuant to

Sections 464.018(2) and 456.072(2), Florida Statutes. It is

therefore ORDERED that the application for certification to be licensed of

ALEXANDRA LIVINGSTON is hereby DENIED. DONE AND ORDERED this

day of

2012. BOARD OF NURSING

Joe Ba er, Jr. Execu Director for Ann-Lynn Denker, ARNP, PhD, Chair .

NOTICE OF HEARING RIGHTS You may seek review of this Order, pursuant to Sections 120.569 and 120.57,

Florida Statutes, by filing a petition with the Executive Director of the Board, 4052 Bald

Cypress Way, Bin 002, Tallahassee, Florida 32399-3252, within 21 days of receipt of this Order. If you dispute any material fact upon which the Board's decision is based, you may request a hearing before an administrative law judge pursuant to Section

120.57(1), Florida Statutes; your petition must contain the information required by Rule

26-106.201, Florida Administrative Code, including a statement of the material facts

which are in dispute. If you do not dispute any material fact, you may request

a

hearing before the Board pursuant to Section 120.57(2), Florida Statutes; your petition must include the information required by Rule 28-106.301, Florida Administrative Code.

2

Pursuant to Section 120.573, Florida Statutes, you are hereby notified that mediation pursuant to that section is not available.

CERTIFICATE OF SERVICE I

HEREBY CERTIFY that a true and correct copy of the foregoing has been

furnished by certified mail, return receipt requested, to ALEXANDRA LIVINGSTON, 5060

Sw th Lane, Gainesville

I

FL 32607, and by interoffice mail to Board of Nursing,

4052 Bald Cypress way, Bin C02, Tallahassee, Florida 32399-3252 and Lee Ann Gustafson, Senior Assistant Attorney General, Department of Legal Affairs, Capitol, Tallahassee FL 32399-1050 this

of

D*aQ.

erqbir

2012.

Deputy Agency Clerk

fl

7012 1010 0002 2381 3423 &nflJ

—

—

3

The

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

::

December 5-7, 2012 Florida Board of Nursing Meeting

Credentials

RN Endorsement Applicant applying under Section 464.009(1)(b), Discipline, Criminal, and Health History Listed on AppJication

with

Livingston, Alexandra Paula; 17011456545 5060 SW 9th Lane Gainesville, FL 32607

Date of

11/05/2012

Applicant is seeking licensure by endorsement as a registered nurse under Section 464.009 (1)(b), F.S. that states: (1) The department shall issue the appropriate license by endorsement to practice professional or practical nursing to an applicant, who upon applying to the department and remitting a fee set by the board not to exceed $100, demonstrates to the board that he or she: (b) Meets the qualifications for licensure in Section 464.008, F.S. and has successfully completed a state, regional, or national examination which is substantially equivalent to or more stringent than the examination given by the department.

Licensure History: State

Lf!pnda Michigan

:

Basis Exam Endorsement

Issue Date 04/17/2001 04/08/2011

Expiry Date 07/3112010 03/31/2013

Status Suspended

Nursing Employment in last 5 years: None

Discipline: November 2010, Ms. Livingston's license was reprimanded and suspended, due to her criminal charges, until she personally appears and can demonstrate her present ability to engage in the safe practice of nursing. Ms. Livingston was ordered to pay an investigative fine of $4,054.78 and undergo an in-depth psychological evaluation coordinated throough IPN, with an MMPI or other appropriate testing from a licensed mental health counselor, psychiatrist, or psychologist.

:: :

Ms. Livingston's RN license was suspended based on the administrative actions taken by the state of Florida and on her fialure to report said action to the Michigan Board of Nursing.

Date of Offense: Offense: Level of Offense: Pleading Type: Adjudication: Confinement: Probation: Cost & Fines: Notes:

Health

Not Eligible.

Applicant

—

Misdemeanor Nob Contendre Withheld 30 days (credit for time served) 30 days $1230.00 Community Service

:

History question 118 on application,

Section 456.0635, F.S.

is listed on

Supplemental

03/31/2011 Unlicensed Practice Healthcare 456.065(2)(d)(3) - 4 counts

the U.S. Department of Health & Human Services Exclusion List.

Application Application Updates Self Explanation (Confidential) Employment Verification Florida Board Order Michigan Board Order Court Documents Health History Documents (Confidential) Letters of Recommendation Correspondence Previously Viewed Documents (October 2010) Report Prepared By: Alison Harte

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

APPLICATION

NURSING LICENSURE BY ENDORSEMENT

APPUCATIONS ARE PROCESSED IN DATE ORDER RECEIVED. PLEASE TYPE OR PRINT IN BLUE OR

INK

(FOR REVENUE RECEIPTING ONLY)

DEPARTMENT OF HEALTH MEDICAL QUALITY ASSURANCE FLORIDA BOARD OF NURSING

-

-

Post Office Box 6330

lahassee, FL 32314 (850) 245-4125

FAILURE TO SUBMIT FEES (SEE INSTRUCTIONS), TO COMPLETE ThIS APPLICATION, OR TO ATTACH ANY REQUIRED DOCUMENTATION WILL RESULT IN AN INCOMPLETE APPUCATION. YOUR APPLICATION WILL NOT BE CONSIDERED FOR EXAM APPROVAL UNTIL IT IS COMPLETE.

APPLICATION TYPE: (Check one only) Indicate below the type of license you wish to use to qualify for licensure in the State of Florida. See instructions for eligibility requirements.

LI 1.

5

lot—

PERSONAL INFORMATION

NAME; LasUSurrlame

MAILING ADDRESS:

Gcu

PHYSICAL

Q

t)

Middle

First

0

03 / 03/

DATE OF BIRTH

City

Endorsement (1701) $218.00 Endorsement (1702) $21800

Registered Nurse (RN) License Practical Nurse (LPN)

E-MAIL

ADDRESS._______________________________ Apt.

it

State

1&

Zip

3o? olYl

Country

LOCATION:________________________________________________

(Required if mailing address is

a

.O.

3'fl

—

t

C4+')

7

LkaJ

Country

Zip

State

PLACE OF BIRTft

Apt. No.

Box-See Checklist)

City

HOME TELEPHONE;

No._______________

.

WORK TELEPHONE:

MOTHER'S MAIDEN NAME:

R9Y,'inO

EQUAL OPPORTUNITY DATA: We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2. Uniform Qutdelrnes on Employee Seleclion Procedure (1978)43 CFR38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure. Other HispanIc Asian/Pacific Islander Slack RACE: White Female Mate SEX:

0

0

0

0

0

18 DH-MQA 1095, 06/12, Rule 64B9-3.008 Page 9

2012

NAME NURSING EDUCATION HISTORY

2.

A. NURSING SCHOOL ATTENDED:

nt Zip________ Country_________________________

B. Type of Program (LPN, DIPL, ADN, BSN)

0.

C. Date Graduated or Anticipated Graduation

I

:5

ADDITIONAL NURSING PROGRAM ATTENDED:

E. Type

ci Program

3.

APPLICANT BACKGROUND

(LPN, DIPL, ADN, BSN)

F.

Dale Graduated or Anticipated Graduation

Attach additional sheets, If necessary

Lmnjr&

A. List any other name(s) by which you have been known in the

B.

What name(s) did you use when you received your nursing education?

C.

What name did you use when you were first licensed?

L

Have you ever applied for RN licensure by examination in Florida?

D.

Yes

No

E.

Yes

No

Date___________

Have you ever applied for LPN licensure by examination in Florida?

F.

0

Yes

No

Date___________

Have you ever applied for RN licensure by endorsement in Florida?

G.

a

Yes

No

Date___________

Have you ever applied for LPN licensure by endorsement in Florida?

Yes

No

Yes

No

H.

0

1.

Have you ever been licensed in Florida as an

Date___________

RN'

Have you ever been licensed in Florida as an LPN?

(active, inactive or lapsed). Submit a License Verificati on Form to your onginal and an active state of licensure. (ATTACH ADDITIONAL SHEET, IF NECESSARY) J. List all nursing licenses

State/Country

License No.

RN or LPN

Date Of Licensure

If no longer licensed, state why & when

.SS K.

0

Yes

T

No

Have you ever been denied or is there now any proceeding to deny your application for any healthcare license to practcce in Florida or any other state, jurisdiction or country?

U(2hJP.

ayi

JI

ncvb

MANDATORY CONTINUING EDUCATION REQUIREMENT 4. Completion of a two-hour course on Prevention of Medical Errors is required prior to licensure. This course must be from an approved Florida Board of Nursing provider.

attest have completed a 2 hour course in the Prevention of Medical Errors as required by Florida Statute. I

LI

I

I have NOT completed a 2 hour course in the Prevention of Medical Errors as required by Florida Statute and I understand that will not receive my license until I submit proof of completion. I

Note: Additional continuing education requirements affect your renewal. See Chapter 64B9-5, F.A.C.

DH-MQA 1095, 06/12, Rule 64B9-3.008 FAC

Page

10

NAME 5.

CRIMINAL HISTORY

A.

Yes

No

J

(Review Questions & Answers section in instructions)

Have you EVER been convicted of, or entered a plea of guilty, nob contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld. Driving under the influence (DUI) or driving while impaired (DWI) is not a minor

traffic offense for purposes of this question. If you answered "YES", you are required to send a letter in your own words describing in detail the circumstances surrounding each offense; including dates, city and state, charges and final results. You must documentation for the of Courts in the juasdiction (state/county) in which the offense records results. Your application will not be considered occurred ing you must obtain a letter of their unavailability from the county Clerk of the Court.

.

Please review the questions regarding criminal historycarefully. If you are unable to determine how to answer the questions you will need to review the court documents from the Clerk of the Court. If you no longer have them from the Clerk of the Court in the county in whichjj3,e copies of the court documents, offense(s)

•

6.

A.

Attach additiOnal sheets, if

DISCIPLINARY HISTORY

Yes

D

No

Have you ever had disciplinary action taken against your license to practice any healthcare related profession by the licensing authorfty in Florida or in any other state,

jurisdiction or B.

Yes

E

No

.ssaly

country?I

Have you ever surrendered a ncense to practice any healthcare re'ated profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you?

1U,

C.

Yes

No

Do you have any disciplinary action pending against your license?

If you answered "Yes" to any of the above questions, please send a written letter of self explanation. in the State(s) in which you were disciplined. You must request official You must contact the copies of the Administrative Complaint and Final Order be sent directly to the Ftorida Board of Nursing.

DH-MQA 1095, 06/12, Rule 64B9-3.008 FAC Page

ii

NAME

CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS

7.

IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be excluded from licensure, certification or registration if their felony conviction falls into certain timeframes as established in Section 456.0635(2), Florida Statutes. If you answer "YES" to any of the following questions, please provide a written explanation for each question including the county and state of each termination or conviction, date of each termination or conviction, and copies of supporting documentation to the address below. Supporting documentation includes court dispositions or agency orders where applicable. No

Have you been convicted of, or entered a plea of guilty or nob contendere, regardless of adjudication, to a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893. F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction? (If you responded "No", skip to #2.)

a. El Yes

0 No

If "Yes" to 1, for the felonies of the first or second degree, has it been more than 15 years from the date of the plea, sentence and completion of any subsequent probation?

b. El Yes

El No

If "Yes" to 1 for the felonies of the third degree, has it been more than 10 years from the date of the plea, sentence and completion of any subsequent probation? (This question does not apply to felonies of the third degree under Section 893.13(6)(a), Florida Statutes).

Yes

1.

c. El

Yes

No

d. El

Yes

El No

2. El Yes

a.

3.

0

0

Yes

Yes

a. El Yes

No

El No

No

0 No

If to 1, for the felonies of the third degree under Section 893.1 3(6)(a), Florida Statutes, has it been more than 5 years from the date of the plea, sentence and completion of any subsequent probation?

If "Yes" to 1, have you successfully completed a drug court program that resulted in the plea for the felony offense being withdrawn or the charges dismissed? (If "Yes", please provide supporting documentation).

Have you been convicted of, or entered a plea of guilty or nob contendere to, regardless of adjudication, to a felony under 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. to public health, welfare, Medicare and Medicaid issues)? (if you responded "No", skip to #3.)

If "Yes" to 2, has it been more than 15 years before the date of application since the sentence and any subsequent period of probation for such conviction or plea ended? Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes? (If you responded "No", skip to #4.) If you have been terminated but reinstated, have you been in good standing with the Florida Medicaid Program for the most recent five years?

OH-MQA 1095, 06/12, Rule 64B9-3.008 FAC Page 12

NAME

4.

0

No

Have you ever been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program? (If you responded "No", skip to #5.)

Yes

No

Have you been in good standing with a state Medicaid program for the most recent five years?

b, D Yes

0 No

Did the termination occur at least 20 years before

a.

Yes

J

the date of this application?

5.

0

Yes

EJ No

Are you currently listed on the United States Department of Health and Human Services Office of Inspector General's List of Excluded Individuals and Entities?

6.

0

Yes

0 No

If "Yes" to any of the questions I through 5 above, on or before July 1, 2009, were you enrolled in an educational or training program in the profession in which you are seeking licensure that was recognized by this profession's licensing board or the Department of Health? (If "Yes", please provide official documentation verifying your enrollment status,)

DH-MQA 1095, 05/12, Rule 64B9-3.008 FAC Page 13

8.

ADDITIONAL INFORMATION

Availability for Disaster:

Yes No Will you be available to provide health care services in special needs shelters or to help staff disaster medical assistance teams during times of emergency or major disaster?

Do you want to donate to the Florida Center for Nursing? (You will find directions in the application instructions on how to do so.)

DR-MQA 1095, 06/12, Rule 6489-3.008 FAC Page 14

El Yes

No

12.

APPLICANT SIGNATURE

1,

the undersigned, state that I am the person referred to

I

recognize that providing false information may result in disciplinary action against my license or criminal penalties pursuant

in

this application for licensure in the State of Florida.

to Sections 456.067, 775.083 and 775.084, Florida Statutes. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind. Should I furnish any false information in this application I hereby agree that such act shall constitute cause for denial, suspension or revocation of my license to practice as a Registered Nurse or Licensed Practical Nurse in the State of Florida,

have read and understand Chapter 464, Florida Statutes, and Rule Chapter 6489, Florida I further state that Administrative Code as they pertain to the practice of nursing (Note: A current copy of Ch 464 and Rule Chapter 64B9 may be obtained via the internet at http://www.doh.state.fLus/mqalnursing). I

Florida Law requires you to immediately inform the Board of any material change in any circumstances or condition stated in the application which takes place between the initial filing and the final granting or denial of the license and to supplement the information on this application as needed. I

will comply with all requirements for liceasure renewal including continuing education credits.

Applicant's

Date

DH-MQA 1095, 06/12, Rule 64B9-3008 FAC Page 17

i

I

01

NAME NURSING EDUCATION HISTORY

2.

P

A. NURSING SCHOOL ATTENDED:

Parr Country_______________________ B. Type of Program (LPN, DIPL, ADN, BSN)

C.

Date Graduated or Anticipated

ADDITIONAL NURSiNG PROGRAM ATTENDED:

D.

of Program (LPN, DIPL, AUN, BSN)

E. Type

APPLICANT BACKGROUND

3.

F. Date

Graduated or Anticipated Graduation_______________

Attach additional sheets, if necessary

A. List any other name(s) by which you h ave been known in the pest.

What name(s) did you use when you received your nursing education?

B.

I

CL 0

Y31

:C yfr&.

C. What name did you use when you were first licensed?

Yes

D.

EIIJ

Have you ever applied for RN licensure by examination in Florida?

No

Yes

No

Date___________

Have you ever applied for LPN licensure by examination in Florida?

F,

Yes

No

Date___________

Have you ever applied for RN licensure by endorsement in Florida?

0.

Yes

No

Date___________

Have you ever applied for LPN licensure by endorsement in Florida?

H.

Yes

D

E.

0

I.

0

Yes

Have you ever been licensed in Florida as an RN?

No No

Have you ever been licensed in Florida as an LPN?

Date___________

(active, inactive or lapsed). Submit a License Verificati on Form to your original and an active state ollicensure. (ATTACH ADDITIONAL SHEET, IF NECESSARY) J. List all nursing licenses

State/Country s

K.

0

Yes

License No. 3

No

If no longer licensed, state why & when

Date Of Licensure

RN or LPN

gN

bJee4s

Have you ever been denied or is there now any proceeding to deny your aeplication in Florida or any other state, jurisdiction or country?

for any heaithcare license to practice

U2tiJP.

iT

i-

51

had

nob

Aiv

MANDATORY CONTINUING EDUCATION REQUIREMENT 4. Completion of a two-hour course on Prevention of Medical Errors is required prior to licensure. This course must be from an approved Florida Board of Nursing provider.

attest have completed a 2 hour course Statute. I

fl

I

in

the Prevention of Medical Errors as required by Florida

I have NOT completed a 2 hour course in the Prevention of Medical Errors as required by Florida Statute and I understand that I will not receive my license until I submit proof of completion.

Note: Additional continuing education requirements affect your renewal. See Chapter 64B9-5, F.A.C.

DH-MQA 1095. 06(12, Rule 6489-3.008 FAC Page 10

-k

+.'

NAME

4.

Yes

No

Have you ever been terminated for cause, pursuant to the appeals procedures established by the state from any other state Medicaid program? (If you responded "No", skip to #5.)

a.

Yes

11 No

Have you been in good standing with a state Medicaid program for the most recent five years?

b.

Yes

11 No

Did the termination occur at least 20 years before to the date of this application?

Yes

No

Are you currently listed on the United States Department of Health and Human Services Office of Inspector Generals List of Excluded Individuals and Entities?

6.11 Yes

11 No

5.

0

lf"Yes"to any of the questions I through

5 above, on or before July 1,2009, were you enrolled in an educational or training program in the profession in which you are seeking licerisure that was recognized by this profession's licensing board or the Department of please provide official documentation verifying your enrollment Health? status.)

1095, 06/12, Rule 64B9-3,008 FAC

Page 13

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Ave Lake City,

FL

32056

PROFESSIONAL STAFFING, INC.

October 12, 2012 Florida Board of Nursing 4052 Bald Cypress Way Bin #C02 Tallahassee, FL 32399-3252

Re: Alexandra_Livingston

To Whom It May Concern:

Alexandra Livingston worked as an RN Independent Contractor with CMS Professional Staffing, Inc. in October 2008 for a total of 50.75 hrs. Ms. Livingston is not eligible for rehire at this time. Please let me know if I can be of further assistance. Thank you,

Kathy Godwln Finance Manager

I

JC!

5

k

?

of

pflone 386.7529440

•

1

.866.DIAL,CMS

•

386.758.9047

www.cmsprostaffcom

STATE OFFLORJ.DA

•

DEPARTMENT OF KEALTh.

•

DEPARTMENT OF HEALTH, PETITIONER,

v..

2010-00522 2010-03725

CASENO

ALEXANDRA LIVINGSTON, R.N., RESPONDENTS

—j COMPLAINT by and

through its

ffles this Administrative Complaint

before the

COMES NOW, Petitioner, Department of •

undersigned counsel, and

against Respondent, Alexandra LMngsbn, R.:N., and in

Board of

support thereof alleges: 1.

petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

materia'

to this Administrative Complaint,

Respondent was a bcensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9177360.

64347

3.

Respondent's

address of

record', is

5060

SW

th

Lane,

Gainesville, Florida 32607-3867,

4.

On or about November 12, 2009, the University

Police Department (UFPD) received a cafl from

a

security officer at Shands

Healthcare at the University of Florida (Sliands).

reported that

a susptcious

person, identflled

of F'orida

The security

as Respondent, had been

harassing the doctárs of the second floor of the Shands Medical Plaza.

Respondent was informed that she was trespassing. 5.

On Or about November 12, 2009, the Director

for

and Recruitment at Shands contacted the UFPD and reported

had been showing up at

Respondent, a former employment

various Shands dinics baking for employment, despite being not meet the

stay away from the

that

she did

to be hired. The Director had asked Respondent to Respondent had continued to vistt

Shands clinics,

Shands seeking employment, having been seen three times at different clinics during the period of November 6, 2009, through November

12,.

2009. 6.

On or about December 8, 2009, in the course of

business, Respondent antacted

Numbec 201

64348

1.

.

for information aboutthe location of 2

an assisted

living

fadilty.

of home care and

.

1.

Respondent began discussing the topic

mentioned he was loOking for assistance with his

care on the weekends.

Respondent informed

registered nurse and expressed interest

in

that she was a

providing assistance to

They agreed to meet at or about 4:00 p.m. to discuss the topic further. 7.

t. is an

adult quadriplegic person who is gainfully employed

and lives with his mother,

8.

On or

;

provides support and assistance to

about December 8, 2009, at or about 4:45 p.m.,

Respondent arrived at about

who

.'s office, Respondent asked multiple questions

health history, medications, routines, and

the extent of his

physical abilities. Respondent provided

with a copy of her nursing

license and resume. Respondent asked

if he had any questiqns and

rephed that he left the tough questions for

"You've gotta pass the Mom test because 9.

On or about

Respondent contacted

it is her

mother stating,

house and her rules."

December 8, 2009, at or about 8:00 p.m., .

by phone with additional questions about his

medications. Respondent stated that she was worried about the dosage of

R.N.

64349

3

one be taken with •

mentioned arid stated that the medication shduld not

1

10.

On

other prescribed rnedicatbn.

.

1

or about December

Respondent by phone regarding

on the weekends.

I

.,

B,

her

's mother,

2009,

.,

interest in providing services to M.M.

wrote a statement about the conversation which

stated in part: she informed me that based Very shortly into the on "research" she had.done on his medications that he was taking two medications which should never be taken together.

She stated she felt he was overmedicated and sedated when she had seen him earlier that day. (The first and only time she had ever seen him.) She asked his physician was aware he was taking the two medications together. I informed her that the physician was fully aware of his medications, and indeed was the prescribing physician. She persisted and strongly urged me to have my son discuss the issue with the physician. "Maybe one of the prescriptions.is an old one and the physician has forgotten about it," she saki I informed her again that the physician was fully aware and also that I had overseen and managed the administration of my son's medications for more than 25 years and both were very, comfortable with the

arrangement. 11.

E.M.

.

-

discussed with Respondent the assistance

.

getting out of bed. Respondent asked about using a Mayer

that helps

lift disabled persons out

o(bed by use of a sling.

needed for

Uft.. F

a device

informed

Respondent that a Hoyer Lift would not work because there was no way to of

v.

Uvthgstcn, RN. A

64350

4

remove the sling out from under

once he. was in the wheelchair.

Respondent insisted that a Iloyer lift should be

as described

written statement:

She replied that she could roll him from side to side in the chair and remove the sling. I told her a sliding board works best with him and I am not certain if she heard me, or if she did hear, that she knew what .a sliding board was. She kept insisting she wou'd use a Hayer] Lift until I said a firm "No! That will not happen for the reasons I just stated." 12.

On or about December 8, 2009, despite having numerous

reservations about hiring R.espóndent to assist in her son's an interview with Respondent for on or about December 12, 2009, at 10:30a.m.

13.

On or about December

Respondent came back to had papers

.1.1,

's place

of

2009, at or about 2:00 business. Respondent stated she

to sigrL Respondent presented a notebook paper to

for

with the following handwritten

near Dr.

PG.],

I am a registered nurse providing care to your patient, M.M.J. Could you kindly provide a copy of his medica' chart and converse with me regarding his care? His signature on this letter indicates his cbnsent

v. A

64351

ACS\LMngSWfl.

Thank you. Alexandra Livingston, Registered Nurse 14. 15.

signed the statement at that time.

On or about

Respondent went to

2009,

11,

the

Southeastern Integrated Medical, Dr. P.G.'s office, and

handwritten note to the clinic staff. Respondent stated she needed

's

The staff. informed Respondent that the

medical records Immediately.

to

records. would: not be processed immediately and Respondent

argue, stating they had to hurry tecause she had better things to do. The

Office Manager recognized Respondent as she had previously brought a sithilar note on another patient in the clinic. The Office Manager asked the Risk Manager for direction. The Risk Manager advised to tell Respondent

that requests for medical records were processed they were received.

in the

order

which

to

The Office Manager relayed that

Respondent, who left the office. 16.

The

Risk

Respondent attempted

Manager

to

contacted

obtain

s

.

and

records.

explained

that

informed

Southeastern integrated Medical that Respondent was not employed by them and that

if

Case NumbeT 2010-00522,

64352

's records

should not be released to her. 6

17.

On or

about December 11, 2009, at or about 2:45 p.m.,

Southeastern Integrated Medical contacted

Respondent attempted to obtain

reported that they contacted

.M.

arid

him that

medical records.

The Risk Manager

directed them not to r&ease his

records. 18.

with

On or

1.,

1.

about December 11, 2009, after discussing

agreed that his

informed the

Risk Manager

that

to

records should not be

contacted

Respondent.

matter

Integrated

SoLttheastera

Medical

and

he wanted to revoke his release to give his

records to Respondent. signed the following written statement:

19.

had earlier signed a release of medical records authorizing Alexandra Livingston to obtain my medical records froin Dr. {P.G.Ts office. Upon further reflection., I have decided.to withdraw my consent for release of those records, effective December 11, 2009. This withdrawal of consent shall apply to any/all doctors and medical records I have throughout Southeastern Integrated Medicine. Please disregard any form or statement that is in contradiction to this statement.

I

20.

Onor about December

Ii, 2009, after

to give his medical records to Respondent, the

revoked his release

RiSk Manager learned

Respondent was back at Southeastern Jnteg rated Medical. of

V.

20100372S ACS

64353

that

The Risk

Manager went

to the front check-in window where Respondent was

speaking very loudly and also speaking on the phone.

attempting to reach the

physkcian covering for Dr. P.G.

Manager advised Respondent that

believe

.

The Risk

had revoked his release to provide

medical records. Respondent became argumentative, stating

her with she had

Respondent was

a

"

written 'etter signed

by

the patient and that she

not

The Risk Manager explained that she had just gotten off the

who reported that Respondent had not been hired iand he

phone with

Respondent grew louder and began talking about

revoked his release.

personal

health

information

and

her

concerns

about

his

prescriptions while standing in the lobby. Respondent's statements about -

's

personal information were overheard by staff in the office and other

patients waiting in the lobby. The Risk Manager told Respondent -. 's records.

would not release

If

taking care of my patient.

Respondent stated she would pray building.

Dartmeilt Case

V.

R.N,

L

2D10-00522. 2010-02725 ACS

an RN,'

'm

you were licensed you would

repeated that

The Risk

Respondent stated,

that they

VL

had

rescinded

his

release.

the Risk Manager and left

the

On

21.

or about. December 11,

Respondent called the residence or

Southeastern Integrated Dr. L

Respondent told.

had been trying to obtain Respondent stated

......

that she was

a copy,

of

was not under the ;

tare of

treating nurse and she

s medical records for twø days.

to begin

morning. She stated that she had been

representative at Southeastern Integrated

a

practked at

she had been hired by the family and was

treating the patient the

told by

physidan who

Medical (Dr. .L). Dr. L.

or about 5:00 p.m.,

.2009, at

that

1t

would

be a few days before she could receive the records, but she needed them you think

immediately stating,

it

is my right as a treating nurse to

have the medical records?" Or. L informed Respondent that he

lnovi

or Respondent

and asked why she did not

not

just take a patient

history and follow the patient's desires. Respondent reported that she was very concerned about the dose of

's.

medications, that he waS '\fery

on the medications, and she thought he might be in danger. Dr. L. replied he

would contact the administrator on call to get back to her.

Respondent indicated that she was applying to medical school and knew

At that time

her rights. n umber.

Case

Dr.

L.

asked Respondent how she got his ;phone

Respondent stated she looked it up in the phone book.

Health v. Number 201

64.355

.

1)-0372$

Dr. L. 9

then

noticed the caller identification on

Respondent was cafling

from

his

phone

22.

•

of

•

why

.

that

lie asked where

Millennium 3ank.

Respondent was calling from. Respondent replied, "Millennium

that time, Dr. L

"

indicated

hung up the phone.

At

On or about December 12, 2009, Respondent called the home

and

speak to

asked

she attempted to obtain

spoke to her and asked

M..M.'s medical records.

Respondent

stated

she needed them "in order to formulate the best. nursing care p'an possible

•

for my patient."

stated,

"lie

is

not your patient, you have not been

hired, in fact you have not even been interviewed.b

Respondent stated,

"YoUr adult son hired me to manage his care, his activities of daily living] and his medications and I want to' do the best. job I can do.

•

permission to get copies of his medical records."

He 'gave me

informed

Respondent that she was not hired, that she would not be hired,' and that •

she needed to immediately stop her attempt to get

s records

or

there would be repercussions. 23.

On or about December 12, 2009, at or about .5:00 p.m.;

Respondent arrived at the door of' Dr. L's residence wearing

a lab

jacket.

Respondent had papers in her hands and handed Dr. L a copy of the ci

v.

Uvir)

.

on. R.N

Case Number 2Q10-0052Z

64356

•

•

handwritten note that she

had previously convinced

to sign,

discussed above in paragraph 12. - Respondent informed Dr. L.

needed to obtain

him. Dr.

the

L.

police.

copy of

medical records so

I

advised. Respondent

in

that

got into a taxi that was

the driveway.

On or

about January

2010, a representative frOm the

19,

University of Florida Clinical and Translational Science Institute,,

oriented research center, contacted the

their office

had been

.

to

treat

she

toget off his property or he would contact

Respondent left the doorway

waiting for her 24.

a

she

become a patient

and

since

UFPD complaining

a

patient-

that

about March of 2009, initially trying

later attempting

to

gain

employment.

Respondent was directed to contact Human Resources for employment

questions, but since-that time, Respondent had been repeatedly calling the j

-

25.

On or about February 4, 2010, a representative from Shands

Hospital contacted the UFPD and complained that Respondent was trespassing on their property. 26.

On or

about February 4, 2010, at or about 2:25 p.m.,

officer was dispatched to Shands Department of Health v. Case

64357

a UFPD

Hospital and contacted Respondent, who

201003fl5

\U

.

was outside of patient, invited, there by

.;

Respondent stated that she had been

room.

Respondent was wearing a white tab

name and

nurse" written on the coat.

coat with her:

Respondert was

arrested for trespassing. Pursuant to her arrest, Respondent's duffel bag was searched and secured. The duffel bag contained medical

including two envelopes containing

equipment

patient medical records, surgical

protective masks, a blood pressure cuff, a. stethoscope, Diastix urinalysis

strips, a 2009-2010 Atachua County Physician Directory, cotton swabs,

latex gloves,

a

professional scale,

a

glucose testing meter, bandages., and

Found with her possessions was

rubbing alcohol.

a

patient information

release form permitting Respondent to obtain medical records

different patient, patient Avenue clinic, '27.

a

for

patient of the Family Medicine at

a

th

'Shands.

clinic

On or about February 5, 2010, a UFPD Officer interviewed the

Nurse Manager on the

th

floor of Shands

where Patient

room was located. The Nurse Manager stated that .Respondent had been trying to gain employment at Shands since about October of 2008. The Director of Employment and Recruitment at Shands had sent out an e-mail

at that 'time indicating that Respondent had been visiting various Shands Rig.

Health v. Number

643 58

2010-

departments and dinics seeking information about employment.

The e-

mail directed managers to direct Respondent to contact Human Resources

with her questions. in or

aboUt July

of

2009, a follow-up e-mail was sent

out directing managers and employees of Shands to contact tiospital security to initiate a trespass warning if Respondent was seen visiting Shands. 28.

With regard to.

f., the Nurse Manager

stated that

admission, Respondent had been visiling him constantly. Manager

SiflCe his

The Nurse

was informed by staff members that they had observed

Respondent conducting blood pressure checks, blood glucose checks, and

urine dip stick checks using her own equipment.

Respondent was not

under any Shands contract and was not under any direction from a Shands

physidan to perform these procedures

on..

.

while he was under the

care of Shands physicians and nurses. 29.

A blood glucose check involves pricking a finger using

and placing a drop of blood on a strip

that

needle

is placed into a glucose meter

which reads the glucose level in the blood;

30.

On or about February 5, 2010, the UFPD Officer

a

had seen patient care assistant working at Shànds who stated she Departrnento( I4eaIt'1 Case

64359

R.N.

Piexandra

201003725 ACS

.

Respondent conduct a blood pressure prick

equipment 31.

I.

finger for

and also observed

check

check using her .own

a

and On or about

February 5, 2010, the

UFPE)

registered nurse who observed Respondent in.

identified herself

s nurse.

as

a

podiatrist, indicating

s

she was working

room.

Respondent

attempted to give the.

Respondent

registered nurse orders regarding the care of

Officer intervIewed a

and made

references to

under his direction.

On or about February 5, 2010, the UFPL) Officer interviewed

32. who

stated that he met Respondent through his church.

His

grandmother had been on the bulletin prayer list because she was. ill and Respondent contacted his grandmother offering her services as a nurse.

stated that

Respondent, she determined he needed her

when he

more for a wound on his foot. Respondent changed his dressings,.. thecked his biood pressure, checked

urine using

his

a dip stick.

could not care for him as and

that

a

his blood glucose levels, and checked

The Officer Informed

.

that Respbndent

nurse whRe he was under the care of Shands

Respondent had trespassed and would not be able to visit

expressed that he

Case

Hea!th V. Number 2010-30522 20100372$

64360

14

.any Shands medical

equipment or administer any medications from

Shands, but did maintain

Officer asked Respondent

records on her if

The UFPD

was against hospital pohcy, or a conflict

of

Respondent answered that it was not because she still had to bill

interest.

the patients' insurance providers for the

she provided

The

detective then informed Respondent that she was given a trespass Warning to stay away

Campus

and

from all Shands properties, and from the University of aU

of

its properties. Respondent stated she was not

the trespass warning and asked how to get it lifted. The UFPD Officer repeated that Respondent could be

arrested if she goes to Shands

or UF properties again. 35.

On or about February 9, 2010, a UFPD Officer met with

Inciudedin the meeting

UFPD

Respondent

an

Officer frorri the Gainesville Police Department (GPI)) and an Officer from

-,

the Alathua County Sheriff's Office.

Respondent was given a

warning to stay away from every Shands property in the dty and in

the

the county of Atachua. Respondent was given

trespass

Shands property in

201

RN.

letter explaining

the letter was the location of every

Respondent read the

the

v.

Case Number

Atl:ached to

a

of Gainesville

and stated she

.

.

2010-03725 A

64362

.

I

understood the warning. At that time, the medicai

UFPD.

released

Respondent's

equipment back to her. The UFPD Officer asked Respondent who

she was working for. •Respondent would not say, but did state that she was under orders from a podiatrist to treat On or about February 10, 2010, the UFPD Officer went to the

36.

with

podiatrist's dinic and inteMewed the podiatrist about his The podiatrist stated that he

Respondent.

permitting Respondent to treat

.

did write orders

with minor procedures such as

changing dressings and checking blood pressure, but this was belore he realized

that Respondent

working, technically, sl,e n-iet

as a home

at church."

have mental issues and that she wasn't nurse and that she was just 'finding people

The podiatrist stated that Respondent

and

harassed him constantly, almost to the point of stalking."

On or about February 10, 2010, the UFPD Officer traveled to

37.

•

of the the church Respondent attended and spoke with an administrator church.

The administrator reported that

been looking

at

she learned that Respondent had

the prayer lIst for ill church members in

the

and

had been calling the people listed after looking up their phone numbers

v. Case

Number 2010-00S22,

64363

£Mflgston PJI

kn

17

the phone book. This became such

a

problem that the ill member list 'had

to be removed from the church bulletin.

38:

On or about February 18, .20.10,

reported a theft. .1

.

A GPO

/. contacted the GPD and

Officer was dispatched to

where

explained that he was disabled and he met Respondent at church and

she befriended him. In or about January of 2010,

1.

was hospitalized

for a foot amputation and Respondent was often at the hospital

assistance.

After his discharge, the supplies he needed to care for the

surgical site were to be sent to his home by mail. Respondent

to his home 'and change his dressings. Respondent sent

to send.

a

come

For reasons. unknown

-

form to the medic& supply cornpa'ny and directed them

supplies

to Respondent's home.

Respondent contacted

and told him to obtain copies of his medicai records from Shands Fiospital and copies of his medical records from his treating physidans and

forward those medical records

her.

Respondent stated she would return directed

.. J. te have no

.

Department of Case Number

64364

Once she received the records,

his medical supplies. The GPO

further contact with Respondent and to

at his home.

v.

-

2010-03725

.

''

adoc

.

.

.

Officer

physician's license number for medical

demanded that she be.gtven

The office staff member would not release the number and

reasons.

again.

instructed Respondent not to

On

42.

or about

13,

a

who stated that his grandmother was II and 'isted on the

interviewec

stated

prayer Ust in the church buUetin. caRs

Department investigator

he started

getting phone

through the

from Respondent who stated she had been

and offered to assist his grandmother. Through the conversation,

informed Respondent that 'he had a wound on his foot. He stated, started 'coming to see me and changing the dressing on my foot. At'

She would call me every day every

some point she became

hour on the hour."

explained

'

that when

Respondent would visit him in the

he was hospitalized,

and dieck his blood pressure

arid do glucose checks. After he was discharged Respondent

continued to

and then "she started having my medical supplies sent to her

see

home and

I

asked for her to return my medical supplies.

going to give them back to me until I signed some

contac±ed the GPD who directed him not

retrieved his supplies from Respondent. ,

LW

Health v. Case Nijmbe

64366

not

At' that time

sign anything and who also explained

that 20

'

AC

'

She

,

Respondent was taking care of his neighbor's mother and the doctor's

office told the mother that she needed to Obtain

.a

continued to receive help from Respondent.

.

mother sent Respondent on her way.

She did

different doctor if she stated,

not want to change her

doctor."

43.

On

or about May 13,

2010,.

Respondent

Southeastern Urology office, located at 1179 NW FloiicIa.

entered

the

th Terrace, Gaidesville,

Southeastern Urobgy is a division of Southeastern integrated

MedicaL.

44.

Respondent previously was issued a trespass warning for all

Southeastern Integrated Medic& faciHties.

45.

Respondent approached the front desk staff and asked to

speak with the facility's physicians. could not speak directly to the

The staff informed Respondent she but she could speak with the

office manager.

46.

Respondent

that she did not want to speak with the

office manager, and she needed to hand deliver documents to the

physicians and did not want to give them to. the office manager.

tçarvnent

64367

2)

v.

2010413725

47.

informed

Respondent

stated she previously cafled the office and was

they were hiring. The office was not hiring at this time.

48.

Respondent eventually talked to the

informed himthat she had three letters

she wanted

office manager 'and

to personally deliver to

the physicians at the facility.

49.

The office manager informed Respondent that hiring

of new

employees was handled through the company's main office. The office

manager gave Respondent instructions on how to contact the human resources department at the company's main office. 50..

Respondent gave the office manager her business card and

asked that he give the card to each physician to see if they would be able

to schedule

a

time to meet with' Respondent Respondent then heft

the

facility. 51.

On

Southeastern

or about Urology

May

14,

2010, •Resporident

entered the

office and, approached the front desk staff.

Respondent met with a clinic assistant and asked in speak with the

facility's physicians so she could deliver letters to the physicians. Respondent informed the clinic assistant that she 'previously

spoke with the

office

manager the previous day and the physicians were 22

of Case Number

64368

AC

not available. The clinic assistant informed Respondent that she would not be perrnitted.to speak with the physidaris. 53.

Resoondent informed the clinic assistant

that

she would mail

the letters to the physicians and she left the facility. 54.

Section

,018(1)(j), department

pertinent part,

in'

Florida Statutes (2009, 2010), shaH

have, upon a finding of

State

Surgeon General or the State Surgeon Gener&'s designee that probab'e

cause exists to believe that the licensee

unable to

nursing

because of the reasons stated in this paragraph, the authority to issue an

order to compel a licensee to submit to

a mental

or physical examination

by physidans designated by the department." 55.

On

or about June 17, 2009, the Department, through :the an

designee of the State Surgeon General, issued an Order

Examination to Respondent and scheduled a mental/physical evaluation for

July 7, 201G. 56.

On

or about

22, 2010, Department investigators

visited

address of record to serve the Order Compelling

an

Examination..

Case

of Health v. A'exandra 2010-03725

64369'

'•'

23

57.. No

one in the residence. responded

Department

to the

investigator. Department investigators left a business card wedged In the door.

.

..

On or about June

58.

.

29,..

.

2010, Department

Respondent's address of record to serve the Order

an

Examination.

Respondent's mother,

59.

answered

door and infdrmed

investigators that Respondent was residing residence.

at the

.

accepted service of the Order Compelling an Examination.

50. 61.

Respondent never contacted the Dépaitment investigator.:

62.

Respondent failed to attend the' mental/physical evaluation

scheduled for July 7, 63.

.

.

Section 4,56..072(lXa), I9orida Statutes (2009), subjects

a

to disdpline, induding suspension, for making misleading,

licensee

deceptive, or fraudulent representations in or related to the practice licensee's profession. 64.

Respondent

.

made

of the

.

misleading,

deceptive,

frauduent

or

representations in or related to the practice of nursing by stating to the Health Case Number

64370

.

RN,

.

24

staff at

;

physidan's office that

nurse when she attempted to obtain continued to attempt to

use

.

she had been hired by ;

records

release to obtarn

as a

Respondent

medica' records

after being Informed numerous times that the release had been rescinded.' Respondent has been making multiple misleading

to

and their hea)th care providers in attempts to provide care to patients and Respondent told

obtain patients' medica'

that she was

working through the church and attempted to get Dr. L to assist her in

obtaining

medical records by stating that

was sedated and in

danger. COUNT ONE

•

S

'65.

Petitioner realleges

through sixty-four (64), 66.

as

and incorporates paragraphs one

(1)

if fully set forth herein.

Section 464A318(1)(h), Florida Statutes (2009), provides that

unprofessional conduct

as

defined by board rule constitutes grounds for

disciplinary 67.

Rule 64B9-8.005(2), Florida Administrative code, provides that

unprofessional conduct includes misappropriating drugs, supplies or

equipment. of Case

-

Number

64371

,Alexandra

.N

25

68.

Respondent

have

misappropriated

.s

supplies by arranging to.

sent to her home. When

medical

asked for. the

Respondent refused to return

be

•

.

and

.•

:.

•

to manipulate

.. into releasing his medical records to Respondent in

exchange for the property that belonged to

•

69

the

on

Based

464,018(1)(h), Florida

conduct

foregoing,

Respondent

violated

Statutes (2009), by engaging

Section

unprofessional

as defined by Rule 64B9-8.005(2), Florida Administrative Code,

include acts of negligence either by

orr%ission

to

or commission.

COUNT TWO

•

and incorporates paragraphs one (.1)

Petitioner reafleges

70.

through sixty-four (64), as if fully set forth herein. Seclion 456.072(1)(q),. Florida Statutes

71.

(0lO), provides that

violating a lawful order of the. department or the board, or failing to comply

with a lawfully

issued

subpoena of the department, constitUtes grounds for

disciplinary action. 72.

.

Respondent

Statutes, and Florida

64372

licensed

to Chapter 464k Florida

health care practitiüner as defined in Section 456.001(4), -.-.

v.

Case NUmber

is a

IS

Livingsten,

-

.

..•

.

•

26

-

73.

Respondent violated

a

lawful order of the Department by

violating the Order Compelling AnExarninatian isstied,by the Department

to Respondent when

she faded to attend the scheduled examination on

July 7, 2010. 74.

Based

on

the

foregoing,

Respondent

456.072(1)(q), Florida Statutes (2010), by violating

violated

a lawful

department or the board, or failing to comply with

a

Section

order

the

lawfully

subpoena of the department. COUNT THREE

75.

Petitioner realleges and incorporates paragraphs

one (1)

through sixty4our (64), as if fully set forth herein. 76.

Section 464M18(1Xj), Florida Statutes (2010), provides

that

being unable to practice nursing with reasonable skill and safety to patients -by reason of illness

or use of alcohol, drugs, narcotics, or chemicaLs or any

other type of material or

as a result

of any mental or physical condition

constitutes grounds for disciplinary action. 77.

Respondent is unable to practice nursing with reasonable skill

patients by reason

and safety

of illness or use of

alcohol, drugs,

narcotics, or chemicals or any other type of material or as a result of any of

v.

A

64373

s mental

or

condition

physical

as

demonstrated

by

her

behavior..

that she actively seeks out dl patents,

behavior

attempts to become their: nurse,

attempts to

oljtain their medical records, and if allowed to provide any becomes possessive and harasses the patients, harasses their health care

providers, and disrupts the care the patients receive from their health care

providers. Respondeflt continued to show up at Sharids properties despite

multiple warnings to stay away and continued to attempt to get patient medical records, after being told by clinic staff, patients, patient family

members, 'and physicians to cease. Her behavior is disruptive and bizarre.. 78.

Based on the foregoing,

Respondent has violated Section

4&4.018(1)(j), Rorida Statutes (2010), by being unable to practice nursing

with reasonable skill and safety to patients by reason of illness or use of •akxhol, drugs, narcotics, or cherrucals or any other type of material or as

a

result of any mental or physical condition.

28

R.I'L

Case Number 201 D-OOS2Z 201 fr037Z5 A

64374

-

WHEREFORE, the Pebtioner respectfully requests that

the Board of

Nursing enter an order irnposin9 one or more of the following penalties or suspension of Respondent's license; restriction of

permanent

practice, Imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other rellef

the

Board deems appropriate.

,

clay of

SiGNED this

Ma

20112..

M. \/iamonte Rose, M.D.,

Assistant General Coun

J

DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida BarNumber 0011265 - 4640 Telephone (850) - 4683 Facsimile (850)

•

/MGL

PCP Members:

Depwtrneflt of Case Number

64375

29

V

ACS

NOTICE OF RIGHTS

'

1

be '..,Respofldent has the right to.. request, a hearing conducted in accordance with Section 120.569 and. 110.57, Florida Statutes; to be represented by cOunsel or other qualified' representative, to present, evidence and argument, to call and 1

withesses and, to have subpoena and subpoena duces tecum issued on'hls or her behalf if a hearing is

crossexamine

NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter Pursuant to SeCtion 456;072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which' may include attorney hours and costs, on the Respondent in addition to any other disciplineimposed.

of health v Number 201D-00S22

64376

.doc

STATE

DEPARTMENT OF ',.LTH.,

Petitioner, Case No.:

vs.

2010-03725 2010-00522

License

i

No.: RN 917731

ALEXANDRA LIVINGSTON,

Respondent.

FINAL ORDER

This matter

noticed public meeting on

for

duly-

appeared before the Board of Nursing .Octobe.r 8,

a hearing not involving

2010 in Orlando,

disputed issues of material tact

120.57(2)

pursuant to Sections 120.569 and

Petitioner has filed an Administrative Complaint

disciplinary action against the license.

1

Florida Statutes.

A copy

of the

Administrative Complaint is attached to and made a part of this Final Order. Service of the Administrative Complaint was made

upon Respondent by certified mail, return receipt requested. Respondent has not filed an Election of Rights. filed a Motion for Determination of Waiver and Order. Petitioner

'was

represented

Petitioner has

Entry of

Final

by William Miller, Assistant

General Counsel, Florida Department of Health. Respondent was not present.

1

Case

201Th-03725 &

PINDINGS OF FACT

Since the licensee has not replied to the

Complaint

nor contested the factual allegations,

the prosecuting

attorney offered the investigative file to prove the facts as alleged.

and

The investigative file was received into

the Board finds the uncontested facts adequately .support:the allegations..

Therefore,

the facts

forth

facts

the Board adopts as its

in the Administrative Complaint.

CONCLUSIONS OF LAW

the

Based upon the Findings of Fact, the Board licensee has violated Section 464.018(1) (h). 456.072(1)

(q).,

(j)

and

Florida Statutes.

The Board is empowered by Sections 464.018(2) and

456.072(2)1 Florida Statut:eS, to impose a penalty against the licensee.

Therefore it is ORDERED that:

The license of ALEXANDRA LIVINGSTON

hereby

The licensee must. pay investigative costa of $4

Payment

to reinstatement of her license.

Board of Nursing and Bin C76, P.O. Box

mailed

63.204

to,

shall

prior

be made to the

DOE-Compliance Management Unit,

TallahaSsee, Florida 32314-6320,

Attention; Nursing Compliance Officer. The license of ALEXANDRA LIVINGSTON is suspended until

personally

appears before the Board and can demonstrate her

present ability to engage in the safe practice of nursing. 2

Case No.

she

&

That

demonstration shall include at least an in-depth p.sycholbgical evaluation coordinated through the Intervention Project or

other

appropriate testing from

a:

psychiatrist, psychologist or other licensed mental The

counselor experienced in the treatment of addiction. licensee shall supply a copy of this

to the evaluator.

evaluation must contain evidence that the evaluator knows

reason for referral.

0-f

The the

iise this in the safe

The evaluator must specifically

Board that the licensee is presently able to engage

practice of nursing or recommend the conditions under which safe practice could be

The licensee must also submit prior

and

to appearance before the Board proof of continued

counseling if recommended in the psychological evaluation and a reentry plan. The Board reserves the right to impose reasonable conditions of reinstatement at the time the licensee appears in

before the Board to demonstrate the present ability to the safe practice of nursing.

to the

Within 30 days, the licensee shall return her

board bffice., 4052 Bald Cypress Way, Bin

C02,

Tallahassee,

Florida 32399-3252 or shall surrender the license to an

Investigator of the Department of Flealth.

The

employer shall immediately be informed of the

in

writing from the licensee with a copy to the Board office. This Final Order shall become effective upon 3

Case No.

2010-03725 & 201.0-00522

with the

Clerk of the Department of Health. DONE

AND

this

1—

day

of

2010.

BOARD OF NURSING

JOE R. B KER, JR. Execu iv Director Jessie Cohn, RN,

CHAIR

NOTICE OF APPEAL RIGHTS

Pursuant to Section 120.569, Florida Statutes, the $rties are hereby notified that they may appeal this Final Orde± by filing one copy of a notice of appeal with the clerk of

department and by filing a filing fee and one copy of a notice of

appeal with the District Court of Appeal within thirty

of

the date this Final Order is filed.

CERTIFXCATE OF SERVICE

,

HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Mail and certified I

LIVINGSTON, 5D60

return receipt requested to

Lane., Gainesville, FL 32607—3867 and Jean DrAprix, IPN

th

P.O.

Box

Jacksonville Beach, Florida 32240-9130; by interoffice mail to Lee Ann Gustaf son, Assistant Attorney General, -Ol, The Miller, Capitol, Tallahassee, Florida 32399-1050; and 49130.,

Assistant General Counsel, Department of Health, 4052 Bald Cypress Way, Bin # .6S., Tallahassee, Florida 32399-3.265 on this

day

701)9

,

2010.

3410 0001 45&1 p371

4

Case No.

2010-03725

&

2010-00522

Discipline Case Summary Report Printed for FLORIDA INDIVIDUAL: DOB:

SSN:

10074208

NCSBN ID:

RESTRICTED

Name:

LIVINGSTON, ALEXANDRA PAULA

Gender:

RESTRICTED

LICENSES DISCIPLINED: MICHIGAN

RN

I

4704255808

GENERAL CASE INFORMATION: Case Number:

664135

Jurisdiction:

MiCHIGAN

Date Action Was Taken:

08116/2011

General Case Comments:

VIOLATIONS (BASIS FOR ACTION): Violation Code:

39

LICENSE REVOCATION, SUSPENSION OR OTHER DISCIPLINARY ACTION TAKEN BY A FEDERAL, STATE OR

LOCAL LICENSING AUTHORITY

HIPOB Narrative (Comments):

INITIAL ACTIONS: 09/15/2011 - INDEFINITE/UNSPECIFIED

Duration:

Stayed:

1135- SUSPENSION OF LICENSE

Initial Code:

Appeal - Date:

NO

UNKNOWN

HIPOB Narrative (Comments): Ms. Livingston's license to practice as a registered nurse In the state of Michigan was suspended for a minimum period of six months and one day. This action was based on Ms. Livingston's final adverse administrative action taken by the state of Florida, and on her

failure to report said action to the state of Michigan.

REVISION ACTIONS: There are no revisions for this Discipline Case

JURISDICTION DISCIPLINE NOTICE HISTORY: Notice Date:

1010512011 01

Recipients:

FL

-

N

S

13

N

PM

Case Action: CREATED

Sender:

BSCHIMKEM LDELETED

Disc/p/The Case Summary Report - Page 1 Printed By: AL/SON HARTS

Printed On: 10(0212012 930AM

STATE OF MICHIGAN

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

RiCK SNYDER GOVERNOR

BUREAU OF HEALTH PROFESSIONS

H. HILFINGER DIRECTOR

STEVEN

RAE RAMSDELL 1RECTOR

October 15, 2012

Board of Nursing Florida Department of Health Attn: Alison Harte 4052 Bald Cypress Way, Bin C02 Tallahassee, FL 32399-3252

Request — Alexandra Paula Livingston, License No. — 47-04-255808, Suspended FOIA

RE:

R.N.

Dear Ms. Harte: In response to a request received October 9, 2011, from Alexandra Livingston, and in accordance with the Freedom of Information Act (FOIA), 1976 P.A. 442, as amended,

please find enclosed 1)

2)

a

certified copy of the following:

Final Order dated August 16, 2011; Administrative Complaint dated May 10, 2011 with attachments.

certify that the attached documents are true copies taken from the master file maintained by the Michigan Department of Licensing & Regulatory Affairs Health, Bureau of Health Professions. I

ation Section

Bureau of Health Professions

kdf Enclosures cc: Alexandra P. Livingston th Lane 5060 SW Gainesville, FL 32607 LARA is an equal opportunity employer. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. 611 W. OTTAWA ST. • P.O. BOX 30670 • LANSING, MICHIGAN 48909 www.michigan.govfhealthlicense • (517) 335-0918

STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF HEALTH PROFESSIONS BOARD OF NURSiNG DISCIPLINARY SUBCOMMITTEE In

the Matter of

ALEXANDRA PAULA

R.N.

LIcense Number: 47-04-255808

4740-118703

File FINAL ORDER

On May 10, 2011, the Department of Licensing and Regulatory Affairs,

Bureau of Health Professions, hereafter Department, filed an Administrative

Complaint, with the Disciplinary Subcommittee of the Michigan Board of Nursing,

hereafter Disciplinary Subcommittee, charging Alexandra Paula Livingston, R. N., hereafter

.

Respondent, with having violated sections 16221 (b)(x) and 16221(1) of the Public Health

Code, 1978 PA 368, as amended; MCL 333.1101 et

,

The Complaint notified Respondent that, pursuant to sections 16231(7) and 16231(8) of the Public Health Code,

Respondent's failure to respond to the

Complaintwithin 30 days from the date of receipt would be treated as an admission of the allegations contained in the Complaint and would result in transmittal of the Complaint

,

directly to the Disciplinary Subcommittee for imposition of an appropriate sanction.

Contrary to section 16231(7) of the Public Health Code,

Respondent

failed to provide a written response to the allegations set forth in the Complaint within 30 days from the date of receipt.

1 I

Ii

.

The Disciplinary Subcommittee, having read the Complaint, considered the

within matter at a regularly scheduled meeting held in Lansing, Michigan, on August

3,

2011, and imposed a sanction pursuant to section 16231(8) of the Public Health Code, Now, therefore,

FT

IS HEREBY

ORDERED that forthe violations of sections 16221(b)(x) and

I 622i(i) of the Public Health Code,

Respondent's license to practice as a registered

nurse in the state of Michigan is SUSPENDED for a minimum period of six months and one day, commencing on the effective date of this Order. Said periods of suspension shall run concurrently.

IT IS FURTHER ORDERED that reinstatement of a license which has been

suspended for more than six months is not automatic and, in the event Respondent applies

.

for reinstatement of the license, application for reinstatement may be made no sooner than 90 days prior to the end of the suspension period and shall be in accordance with sections

16245 and 16247 of the Public Health Code,

Further, in support of the application

for reinstatement, Respondent shall supply clear and convincing evidence to the Michigan Board of Nursing that Respondent is of good moral character, is able to practice the

profession with reasonable skill and safety, that it is in the public interest for Respondent to resume practice, and that Respondent has met the guidelines on reinstatement adopted by

the Department.

IT

VS

FURTHER ORDERED that in the event Respondent violates any

provision of this Order, and if such violation is deemed to constitute an independent .

2

.•

.

.

violation of the Public Health Code or the rules promulgated thereunder, the Disciplinary Subcommittee may proceed to take disciplinary action pursuant to 1996 AACS, R 338.1632 and section 16221(h) of the Public Health Code,

IT

JS

FURTHER ORDERED

that this Order shall be effective

the date signed by the Disciplinary

30 days from

Chairperson or authorized

representative, as set forth below.

Dated:

MICHIGAN BOARD OF NURSING SUBCOMMITTEE By:

Rae

Acting Director

Bureau of Health Professions This is the last and final page of a Final Order in the matter of Alexandra Paula Livingston, R.N., File Number 47-10-118703, before the Disciplinary Subcommittee of the Michigan Board of Nursing, consisting of three pages, this page included. WH

3

a

STATE OF MICHIGAN AND REGULATORY AFFAIRS LICENSING OF DEPARTMENT BUREAU OF HEALTH PROFESSIONS BOARD OF NURSING DISCIPLINARY SUBCOMMITTEE

In

the Matter of

,

ALEXANDRA PAULA LIVINGSTON, R.N.

File Number: 47-10-118703

License Number: 47-04-255808

ADMINISTRATIVE COMPLAINT NOW COMES the Michigan Department of Licensing and Regulatory Affairs,

hereafter Complainant, by Rae

Acting Director, Bureau of Health Professions,

and files this complaint against Alexandra Paula Livingston, R.N., hereafter Respondent, alleging upon information and belief as follows:

.

1.

,

The Michigan Board of Nursing, hereafter Board, is an administrative

agency established by the Public Health Code, 1978 PA 368, as amended; MCL 333.1101 et

Pursuant to section 16226 of the Public Health Code,

the Board's

Disciplinary Subcommittee is empowered to discipline licensees for violations of the Public

Health Code.

2.

Respondent is currently licensed to practice as a registered nurse

the state of Michigan.

in

Respondent has an address of record with Complainant of

Gainesville, Florida.

I A

3.

, 1

On November17, 2010, the Florida Board of Nursing, hereafter Florida

Board, issued a Final

practice as

a

by which Respondent was reprimanded; her license to

registered nurse was suspended until she personally appears before the

Florida Board and can demonstrate her ability to engage in the safe practice of nursing; and she was required to pay investigative costs of $4,054.78 prior to reinstatement of her

license. The demonstration to practice must minimally include an in-depth psychological evaluation by a

psychologist, or other licensed mental health counselor

experienced in the treatment of addiction.

The disciplinary action was based on

Respondent taking medical records and equipment of patients, as well as providing false information in order to coerce patients and medical personnel into hiring her so that she could bill Medicaid and charge patients for unsolicited medical care or services. A copy of

the disciplinary documents from the Florida Board, marked Exhibit A, is attached and incorporated.

4.

Respondent failed to notify Complainant of the disciplinary action

taken in the state of Florida on November 17, 2010, within 30 days of the date of action.

COUNT

I

The foregoing action in the state of Florida, as set forth above in paragraph 3, constitutes a final adverse administrative action by

.

a

licensure, registration, disciplinary, or

certification board involving the holder of, or an applicant for, a license or registration regulated by another state or a territory of the United States, in violation of section 16221(b)(x) of the Public Health Code,

2

COUNT

, .

I

Respondent's conduct, as set forth above in paragraph 4, evidences a failure

.

to notify Complainant of the disciplinary action in the state of Florida, as required by section

16222(3) of the Public Health Code,

Health Code,

in violation

of section

1)

of the Public

The within complaint is based upon files and records maintained by Complainant and the attached Affidavit of Tern

WHEREFORE, Complainant requests that the within complaint be served upon Respondent and that Respondent be offered an opportunity to show compliance with all lawful requirements for retention of the license.

.

tf compliance is not shown,

Complainant further requests that formal proceedings be commenced pursuant to the Public Health Code, rules promulgated thereunder, and the Administrative Procedures Act

of 1969, MCL24.201

,

RESPONDENT IS HEREBY NOTIFIED that, pursuantto section 16231(7) of the Public Health Code,

Respondent has 30 days from the date of receipt of this

complaint to submit a written response to the allegations contained herein. The written response shall be submitted to Complainant, Rae Ramsdell, Acting Director, Bureau of Health Professions, Department of Licensing and Regulatory Affairs, RD. Box 30670,

Lansing, MI 48909.

3

,

RESPONDENT IS FURTHER NOTIFIED that, pursuant to section 16231(8) of the Public Health Code,

Respondent's failure to submit a written response within

30 days, as noted above, shall be treated as an admission of the allegations contained herein and shall result in transmittal of this complaint directly to the Board's Disciplinary

Subcommittee for imposition of an appropriate sanction.

DATED:

Icj

Ramsdell, Acting Director Bureau of Health Professions Attachments This is the last and final page of an Administrative Complaint in the matter of Alexandra Paula Livingston, File Number 47-1 0-118703. before the Disciplinary Subcommittee of the Michigan Board of Nursing, consisting of four pages, this page included. PB

4

IN THE CIRCUiT COURT OF THE EIGHTh JUDICIAL CIRCUIT 1L AND FOR ALACHUA COUNTY FLORIDA

-.

Ccnwol Violator

Li

SEP 2

SEP

2012

24

L-

STATE OF FLORIDA

ALEXANORA P LMNGSTON Case:

Defendant

1 o

2012

01-201

JUDGMENT The defendant, ALEXANDRA P UVINGSTON, being personally before this court represented by ALAN BUSHNELL the attorney of HECHAVARRIA and record, and the state represented by

tied and tound guilty by jury/hy court of the JLi been entered plea of guilty the following crime(s) a plea of

U been

crime(s)

to

a

nob

contendere to the following crime(s)

in violation of probation at hearing

'

Count

(s)

t;

Degree of CIime

Offense Stjtut€

Crime

,

p

should not be adjudicated guilty, IT IS ORDERED THAT the defendant is hereby crime(s).

defendant U and no cause being shown why the above

ADJUDICATED GUILTY of the

good cause being shown; IT iS ORDERED THAT ADJUDICATION OF GUILT BE an FDLE-approved blood or biological specimen, F.S. )(b)(5) is required to The qualifying offender per FS. Q43.325(7). Unless the defendant has been declared indigent by the court, he/she shall pay the actual costs of coftecung the approved biological specimens required under F.S. g43.325.

DONE AND ORDERED

in Open

Filed in Open Court August

Court In Gainesville. Alachua County. Florida this

øf A

ust. 2012

D.C.

2Q12

HEREBY CERTIFY THAT A COPY OF THIS Judgment was furnished by US, Mail and/or hand delivery at the addresses of record to day of counsel for the state and defense/defendant pro se this

——

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BY Deputy

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County Court Clerk, in a true width may have in this

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02-11-008492

LiVINGSTON. ALEXANDRA P ADDRESS STREET. APARTMENT NUMBER.

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OF A HEALTH CARE PROFESSION WITHOUT A LICENSE 3RD 0

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named Alexandria P informed that on March 31, 2011 the DEF, a named Willie Lee Mobley. Livingston, passed herself off as a licensed nurse to a area of 100 East in the the RTS bus, on Livingston Kxzezevicb atated !4obley met a stethoscope University Avenue. Livingston was wearing a white doctors coat

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IAGREE AND PROMISE TO COMPLY BEAD ANSWER TO THE CHARGES AND INSTRUCTIONS SPECIFIED IN THIS NOTiCE TO APPEAR WILLFUL REFUSAL TO ACCEPT AND SIGN THIS NOTICT TO APPEAR MAY RESULT IN PHYSiCAL ARREST. WATBER OF MY RIOT-ITS I UNDERSTAND MY SIGNATURE IS NOT PR A-OMISSION OP GUILT OR SWOR

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10 RE VERSA AND ATTACHED

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MD STATEMENT.S ART

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STATE ATTORNEY

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if she was a doctor around her neck when øhe got on the bus. Mobley asked and she told him she was a registered nurse. Mobley told Livingston about a medical problem and said she could arrange for him to meet a doctor to aasist him. Mobley P office (915 NW 56th Terrace; 352-331-4333) Dr. Thomas R advised that they went to 0 and Dr. Berens set up a vascular test for Mobley at UP. The TJP vascular department S 431 Southwest 6th Terrace called at Dr the wrong location and actually E called C the vascular, test. about Mobley or know did not Behrns This Dr. (352-331-8382). U 7, 2011, Livingston located Mobley and gave him a handwritten itemized On I V bill E for, The bill has the dates of service $100.00, her assistance as a registered nurse. a business card, which attached LivingstOn 4/8/11, and 4/2/11, 4/3/11 as 3/31/11, S U Knezevich advised and a certified licensed (registered) nurse. her as identified M nurse was suspended on registered practice 88 a M verified that Livingstofla license to A she is illegally acting 2010 and on July 31, expired same license That 2010. July 22, Y in that medical capacity. On May 4, 2011, I contacted Mobley and he identified Livingston, from a 6 person photograph line-up, as the person he received the bill from, for her assistance as a C 0 nurse. Mobley further informed he paid Livingston the $100.00 fee on May 3, 2011. N T

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(RevIEed

COURT

STATE AflORNEY

OUGIYCCUI1

AGENCY

DEFENDANT

PAGE

2

JUDiCiAL CiRCUIT IN 141) FOR

IN THE CIRCUIT

FLORIDA

FLORIDA Division: P3

P UVINGSTON

ORDER ESTABLISHINO MONETARY SUMS The defendant shall pay the following sums

it checked:

X)COSTS.MANDATORY Laws of Fionda 94-4444. P.S. 3.00 CouxtCotClearingTrustFund. P.S. 938.01 50.00 Crimes Compensation mist Fun& P.S. 938.03 Local Law Training. P.S. 938.15 &A.C. Ord. 04-10 Ala. Co. Ord. 05-08 65.00 Ct. Facilities. LegaLAid. Law Ubrary. P.S. Co. Ord, 05-09 3.00 Teen Court. P.S. 938.19 Trust Fund. P.S. 939.06 20.00 Crime 100.00 State An.oniey Cost ofProsecuton, P.S. 246.00 3.0(1

$

5.

$

2.

(

PRO

)

AO

OS

P.S.

50.00 Crime Prevention 80CC Fund P.S. 775.083(2)

.

-

$275.80

DUI ADDITIONAL COSTS

3.

-

FELONY - MANDATORY

$135.00 DUlcoutCostEmezgency Medical. P.S. 938.07 04-10 15.00 State Court Faduilies Surcharge. P.S. 318.I8(13)(a) Costper P.S. 938.13) $1 50.00 (Does nor indude MM Substaisce Abuse

4. INDIGENCY APPLICATiON AND PUBLIC ASSISTANCE ATTORNEY FEES 3$_________ PUbIk Defender .Applicatien Pee. F.S. 27.52. ($50.00) . CF.AFATTY-X 3$________ Appointed Counsel Attorney Fee. P.S. 938.29 ($100.00)! Indigency Application Filed not Filed - CFAFAFNA-X 100.00 Appointed Counsel Attorney Fee. P.S. 938.29 ($1 00.00)1 idigency X] $ .

M1SDEMRANOPJCRIMD'lAL TRAFFIC - MANDATORY $ 60.00 Addiuonal Cowt Cost. P.S. 938.05(I)(b) 775.083(3) BOCC Fund 20.00 Cnme

S.

$80.00 6.

flU! ADDITIONAL COSTS - MISORMEANOR- MANDATORY $135.00 DUI Court Cost Emergency Medical. F.S. 938.07 15.00 LocalsubstanceAbuseProgtzfl Cost. P.S. 938.13 &.kC. OM.04.l0 15.00 Stare Court Facilities Surcharge. P.S. 319.18(13)(a) &Ord. 04-10 $ 165.00

3

7. STATUTE SPECiFIC- MANDATORY &.AIaCo, Ord. 04-10 $1 5.00 State Court Facilities Surcharge, F.S. 31 3.00 State Radio System Surcharge. P.S. 318.18(17) Chapter 316 Only ($3.00) P.S. 939.08 ($201.00) 201.00 939.085 (8151.00) P.S. Crisis Rape 151.00 3 151.00 CrimesAgainstMinors Cost P.S. 938.10 ($151.00) ] — Reiniburseinent (Sez Crimes). FS. 943. 3250 (iXa) 3 E2amination (Sea Crimes), F.S. 960.28 Forensic F.S. 316.192 EinergencyMedicalCowtCost $5.00

13)(a)

only ($15.00)

1

8. FINES

(3

Rne. F.S. '775.083

(

Fine. Fine, Fine. Fine.

)

1 3

P.S. 775.083(1) Fine imposed when Adjudication is P.S. 316.193(2)(a)4)(DUI) (istalin 500. 2nd mm 1000. 3rd F.S.

P.S. 893.135 Drug Trafficking (aim. amount P.S. 775.0835(1) (Result otinjury or Death)

.Total of Fines

Victim Surcharge.

5% Surcharge,

2000.5000 outside to yrs. 4thmin. 3000)

deteninned by subsection charged)

P.S. 938.04< Fine required)

Total Fines and 5% Surcharge

(3

3

Ala. Co. Ord 04.10 Flue reiuir€d County Alcohol Drug Abuse Trust Fund. P.S. 938.21 or 938.23 and (amount up to the authorized due amount) (Court Cost up to the Fine amount authorized) Alcohol & Drug Abuse Trust P.S. 938.21, 938.23,; .AIa.Co.Ord 94.29

se Nurnbet

P LIVINGSTON

-2011

9. RESTITUTION

The Court reserves jurisdiction to establish re

tion at hearing, after notice at

Ahearingts scheduled for

60 days, AM/PM.

See affached Civil Lien Order, which rs incorporated herein by reference plus $3.50 feeperpaymentRS. 28.24(26)(a). (Numberoftiens Orders

10.

DISCRETIONARY COSTS Outsrde Agency

3

P.S. 938.21

Eeinibwsementto

10000

assess require& P.S. 893.13) Florida Crimes Lab (FDLE Lab)pursuant to P.S. Medical Costain County Sail pursuanttc P.S. 951.032. Cost of collecting the DNA sample required by s. 943.325. Florida Statetes. GtMuested). State Attorney Worthless Check Fees pwroantto P.S.

1 3

's

TOTAL SUMS ORDERED SHALL BE PAID AS 1Ol.LOWS: probation officer in equal monthly ürttailmeuts in an amount guffident to pay the total rum in flu three months Through the end of the probationary penod.

.an.

Defendantrsentencodto Throughthe Clerk ofCouxtin 3 incarceration report the Alachna County Clerk of the Court's Office to mahe payment arrangements. to

If you cannot immediately pay all of the costs, fees andlor fines assessed by the court in this order, you are required by Section 28.246(4). including the $25 Florida Statutes, to enroll wub the Clerk of the Court in a payment plan. You are required to pay all costs, fees and payment plan fee, to the Clerk of Court the enlire amount due by the compliance date as specified in Ike You may pay weekly, bLweekly or monthly. If you have with the Court's order. compliance in not that you are Court the advise may Clerk Payment Ptan. the The Defendant may perfonn community service hours in lieu of court costs at a rate of

3

4'i..

hour.

Civil judgment(s) shall be entered for the ordered sums.

-

order ofprobarion. The foregoing costs are in addition to any costs of supervision the court may have ordered in separate

3 3

Driver's License Suspension!Revocaflofl (Drug Offenses) pursuant to

Driver's License Suspension/Revocation

ii). pursuant to

DONE AND ORDERED in Open Court in

F.S.

5. 322.055.

322.28

!dachua Comm

months.

29th ay

2012.

Filed in Open Court August 29, 2012 by Copies to: State Attorney. Defense Counsel, Wobation and Parole

Attachments (If applicable): Order Awarding Costs of Lien Order Civil

and Prosecution; Order Awarding Attorney's Fees and Costrof Defense;

STATE OFVFLORIDA OCT 092012

OF

yin

IN THE EIGHTH JUDICIAL CIRCUTT COURT, IN AND FOR

ALACHUA COUNTY

CASE

Defendant

ORDER

OF_________________________

This cause coming before the Court to be heard, and you, the defendant, being now present before the court, and you having

LI

entered a plea

of guilty to

been found guilty by jury verdict of

12'

entered a plea

of nob contendere to

been found guilty by the court trying the case without a jury of

Count

Count

_ j

Couni

—-

Count

)

Count

Count

Count__ Count

SECTION 1: JUDGMENT OF GUtLT

0

adjudges you to be guilty of the above offense(s),

The

you be placed Now, therefore, it is ordered and adjudged that the imposition of sentence is hereby withheld and that a period of__________________________ under the supervision of on the Department of Corrections, subject to Florida law.

SECTION 2: ORDER WiTHHOLDING ADJUDICATION Now therefore, it is ordered and adjudged that the adjudication of guilt is hereby

foraperiodof

epartment of

subject to Florida law.

and that you be placed on under the supervision of

Iyrp(e'bC&bff?hO

SECTION 3: INCARCERATiON DURING PORTION OF SUPERVISION SENTENCE ft is

Li

hereby ordered and adjudged that you be;

committed to the Department of Corrections — prison with credit for for a term of a period

]

of

1

o18

for jail time, law. Florida under the supervision of the Department of Corrections, subject to

or confined in the County Jail time. After you have served with credit for for a term of for a period of ALL of the term, you shall be placed on law. Florida to subject under the supervision of the Department of Corrections, or confined in the County Jail for a term of

Page

-

with credit for

jail time, as a special condition of supervision. Revised

IT IS FURTHER ORDERED that you shall comply with the following standard conditions of supervision as provided by florida law:

(1) You will report to the probation officer as directed, the (2) You will pay the State of Florida the amount of $____________________________ per month, as well as 4% surcharge, toward Statutes, Florida with compliance exempted in otherwise unless F.S., 948.09, with s. supervision accordance in cost of your (3) You will remain in a specified place. You will not change your residence or employment or leave the county without first procuring the consent of your officer.

of your residence

procuring the (4) You will not possess, carry or own any firearm. You will not possess, carry, or own any weapon without first consent of your officer. (5) You will live without violating any law. A conviction in a court of law is not necessary for such a violation violation of your probation, community control, or any other form of court ordered supervision.

of law to constitute a

(6) You will not associate with any person engaged in any cnminal activity. a physician. (7) You will not use intoxicants to excess or possess any drugs or narcotics unless prescribed by or used. dispensed unlawfully sold, are substances dangerous other places where ineoxicants, drugs or

Nor will you visit

status, and support any dependents to the (8) You will work diligently at a lawful occupation, advise your employer of your probation officer. your directed by as best of your ability, or the officer, and allow your officer to visit in (9) You will promptly and truthflully answer all inquiries directed to you by the court your officer may give you. instructions with all your home, at your employment site or elsewhere, and you will comply

conditions imposed or in accordance with the attached (I 0)You will pay restitution, court costs, andlor fees in accordance with special orders. (1

the treatment center where you are l)You will submit to random testing as directed by your officer or the professional staff of substances. controlled alcohol or of or use presence receiving treatment to determine the

prescribed in sa. 943.325 and 948.014. F.S. (12) You will submit a DNA sample, as directed by your officer, for DNA analysis as This photograph may be displayed on the (13)You will submit to the taking of a digitized photograph by the department. requirements of s. 119.07, F.S. department's website while you are on supervision, unless exempt from disclosure due to

.

incarceration to the probalion ofticc in ALACFLL3A County, (14)You will report in person within 72 hours of your release from applies only if section 3 on the previous page is Florida, unless otherwise instructed by the court or department. (This condition at 215 SE located office probation the to immediately checked.) Otherwise, you must report

Page2of8

Revised07-Ol-ll

SPECIAL CONDITIONS You must undergo a Drug and Alcohol evaluation and, if treatment is deemed necessary, you must successfully complete the treatment, and be responsible for the payment of any costs incurred while receiving said evaluation and treatment, unless waived by the court. Additional instructions ordered:

LI

1.

0

You will make restitution to the following victim(s), as directed by the court, until the obligation is paid in full: NAME: TOTAL AMOUNT: $____________________ Additional instructions ordered, including specific monthly amount, begin date, due date, or joint & several: 2.

NAME: TOTAL AMOUNT: $__________________ Additional instructions ordered, including specific monthly amount, begin date, due date, or joint & several:

You will be required to pay for drug testing unless exempt by the court. You will enter the Department of Corrections Non-Secure Drug Treatment Program or other residential treatment program/Probation and Restitution Center for a period of successful completion as approved by your officer. You are to of remain until you successfully complete said Program and Afiercare. You are to comply with all Rules and Regulations in the jail, confined are if you program, and said in placement until jail the county in confined be shall Program. You the the Sheriff will transport you to said program.

LI

3.

4.

anyone who is You will abstain entirely from the use of alcohol and/or illegal drugs, and you will not associate with alcohol. illegally using drugs or consuming 5.

basis to determine the presence of alcohol or illegal drugs. You will You will submit to urinalysis testing on a court, the by exempt unless tests for the be required to pay

LI

6

D

7.

LI

8.

o

9.

o

You will submit to electronic monitoring, follow the rules of electronic monitoring, and pay for the cost of the electronic monitoring service.

You will not visit any establishment where the primary business is the sale and dispensing hours

You will successfully complete work Site approved by your officer. Additional instructions ordered:

of alcoholic beverages.

of community service at a rate of

unless otherwise directed by the You will remain at your residence between 10 p.m. and 6 am. due to a curfew imposed, court. 10.

o o

per month

during the period of supervision.

11.

You will not associate with

12.

during the period of supervision. You will have no contact (direct or indirect) with the victim or the victim's family

13. You will have no contact (direct or

indirect) with

during the period of supervision.

school full time or a combination 14. You will maintain full time employment or attend school./vocational

during the term of your supervision.

of school/work

literacy skills or a high school equivalency You will make a good faith effort toward completing basic or functional diploma. Restitution Program, abiding by all rules and regulations. 16. You will successfully complete the Probation & 15.

o Page

at a

3

of 8

Revised 07-01 -11

0

17.

,

You will attend a support group with a focus on

the court.

at least

.

monthly, unless otherwise directed by

and be responsible for the payment of any costs incurred while 18. You must successfully complete receiving treatment, unless waived. If convicted of a Domestic Violence offense, as defined in s. 741.28,' F.S., you must attend and successfully complete a Batterer's Intervention Program, unless otherwise directed by the court, Additional instructions ordered:

O

19. You will attend an HIV/AIDS Awareness Program consistingofa class (4) hours in length, the cost for which will be paid by you.

0

of not less than two (2) hours or more than four

If you have been found to have committed a crime on or after October 1, 2008 for the purpose of benefitting, promoting, or furthering the interests of a criminal gang, you are prohibited from knowingly associating with other criminal by law enforcement officials, prosecutorial authorities, or the court, for gang members or associates, except as the purpose of aiding in the investigation of criminal activity. 21. You will successfully complete a Post-adjudicatory treatment-based drug court program, as provided in S. 397.334(3), 20.

O

22 Other:

LV

Pier

23. Other:

24. Other:

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25. Other:

fl

26. Other:

t1?

27. Other:

0

28. Other:

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29.

Other:

h

6

,

YOU WILL COMPLY WITH THE FOLLOWING CONDITION AND, IF PLACED ON DRUG OFFENDER OF SUPERViSION iN ADDITION TO THE STANDARD CONDITIONS LISTED ABOVE AND ANY OTHER SPECIAL CONDITIONS ORDERED BY THE COURT:

recommended by the (15) You will participate in a specialized drug treatment program, either as an in-patient or out patient, as will comply treatment provider. You will attend all counseling sessions, submit to random urinalysis arid, if an in-patient, you treatment with associated all costs for will pay You facility. treatment of the with all operating rules, regulations and procedures directed. otherwise unless testing and Additional instructions ordered:

U

o

,

(16) You will remain at your residence between otherwise directed by the court.

p.m. and

—

am. due to a curfew imposed, unless

as provided in s. 397.334(3), (17) You will successfully complete a Post-adjudicatory treatment-based drug court program, F.S.

YOU WILL COMPLY WITH THE FOLLOWING CONDITIONS, IN ABOVE AND ANY OTHER SPECIAL CONDITIONS LISTED ADDITION TO THE STANDARD CONDITIONS COURT: THE ORDERED BY AND, IF PLACED ON COMMUNITY

have written consent otherwise. (15) You will report to your officer as directed, at least one time a week, unless you and after your approved empLoyment, (16) You will remain confined to your approved residence except for one half hour before your officer. by approved activities special other or any public service work, Page 4 of 8

Revised 07-01-Il

.

submit to your officer on request. (17) You will maintain an hourly accounting of all your activities on a daily log, which you will

(18)You will successfully complete approved by your officer. Additional instructions ordered:

1

,

-

hours

of community service at a rate of

at a

-

(19) You will submit to electronic monitoring, follow the rules month for the cost of the electronic monitoring service.

of electronic monitoring, and pay

work site

per

pRovmED IN CHAPTER AND, IF PLACED ON PROBATiON OR COMMUNITY CONTROL FOR A SEX WILL 1. OCTOBER AFTER OR ON COMMITTED 847.0145, or s. s. 847.013 s. IN ADDITION TO THE STANDAJU) CONDITIONS, OFFENDER SEX STANDARD FOLLOWING THE WITH COMPLY THE COURT: CONDiTIONS LISTED ABOVE AND ANY OTHER SPECIAL CONDITIONS ORDERED BY another 8-hour period if the offender's employment (15) A mandatory curfew from 10 p.m. to 6 a.m. The court may designate Department of Corrections. If the court determines the by recommended is alternative precludes the above specified time, and the alternative sanctions. that imposing a curfew would endanger the victim, the court may consider 1,000 feet of a school, child care facility, park, playground, or (16) If the victim was under the age of 18, a prohibition on living within the court. The 1,000-foot distance shall be measured in a by where children regularly congregate, as prescribed other park, playground, place of residence to the nearest boundary line of the school, child care facihty, straight line from the route. automobile or route pedestrian a by or other place where children congregate. The distance may not be measured treatment program with qualified practitioners specifically (17) Active participation in and successful completion of a sex offender practitioner is not available within a 50-mite radius of qualified a If expense. own trained to treat sex offenders, at the offender's appropriate therapy. the offender's residence, the offender shall participate in other unless approved by the the victim, directly or indirectly, including through a third person, court. sentencing the and victim, a qualified practitioner in the sexual offender treatment program,

18)A prohibition on any contact with

in this prohibition on contact with a child under the age of 18 except as provided approval is based upon a if the 18 age of under the child with a contact paragraph. The court may approve supervised on a risk assessment. Further, recommendation for contact issued by a qualified practitioner who is basing the recommendation program. The court may not therapy offender a sex completed successfully the sex offender must be currently enrolled in or have by a qualified practitioner and may deny supervised grant supervised contact with a child if the contact is not recommended contact with a child at any time. volunteer at any place where children regularly (20)lf the victim was under age 18, a prohibition on working for pay or as a pet store, library, zoo, theme park, or playground, park, facilities, care congregate, including, but nOt limited to any school, child mall. practitioner in the sexual offender treatment program, a (2l)Unless otherwise indicated in the treatment plan provided by a qualified or sexually stimulating visual or auditory pornographic, obscene, prohibition on viewing, accessing, owning, or possessing any that are relevant to the offender's services computer or programs, computer media, material, including telephone, electronic deviant behavior pattern. Florida Department of Law Enforcement to be registered with the (22) A requirement that the offender submit a DNA sample to the DNA data bank.

(19)If the victim was under the age of 18,

a

the court under (23)A requirement that the offender make restitution to the victim, as ordered by care. psychological and psychiatric, physical, to relating and related professional services

s.

,

for all necessary medical

probation officer of the offender's person, residence, or vehicle. (24) Submission to a warrantless search by the community control or

CRIME WAS COMMITTED ON OR EFFECTIVE FOR PROBATIONER OR COMMUNITY CONTROLLEE WHOSE OR SEX OFFENDER CONTROL COMMUNITY ON PLACED AFTER OCTOBER 1. 1997. AND WHO IS IN ADDITION TO ANY OTHER s. s,847.0135(5)or 827.071, s. 800.04, s. CHAPTER FOR A VIOLATION OF OF SUPERVISION: CONDITIONS FOLLOWING THE WITH PROVISION OF THIS SECTION, YOU MUST COMPLY

TiON

Page 5 of8

Revised 07.01-11

of a treatment program, participation at least annually in polygraph examinations to obtain information necessary for risk management and treatment and to reduce the sex offender's denial mechanisms. A polygraph examination must be conducted by a polygrapher who is a member of a national or state polygraph association and who is certified as a postconvlction sex offender polygrapher, where available, and at the expense of the offender.

(25) As part

(26) Maintenance officer.

of a driving log and a prohibition against driving a motor vehicle alone without the prior approval of the supervising

(27)A prohibition against obtaining or using

a

post office box without the prior approval of the supervising officer.

(28) If there was sexual contact, a submission to, at the offender's expense, an HIV test with the results to be released to the victim and/or the victim's parent or guardian. (29) Electronic monitoring when deemed necessary by the probation officer and supervisor, and ordered by the court at the recommendation of the Department of Corrections, If you are placed on electronic monitoring, you must pay the department for the cost of the electronic monitoring service. (30) Effective for an offender whose crime was committed on or after July 1, 2005, and who are placed on supervision for violation of chapter 794,s. 800.04, s. 827.071, or a, 847.0145, a prohibition on accessing the Internet or other computer services until a qualified practitioner in the offender's sex offender treatment program, after a risk assessment is completed, approves and implements a safety plan for the offenders accessing or using the Internet or other computer services. (31) Effective for offenders whose crime was committed on or after September 1, 2005, there is hereby imposed, in addition to any other provision in this section, mandatory electronic monitoring as a condition of supervision for those who: unlawful Axe placed on supervision for a violation of chapter 794,s. 800.04(4), (5), or (6), s. 827.071, or s. 847.0145 and the sexual activity involved a victim IS years of age or younger and the offender is 18 years of age or older; or Are designated as a sexual predator pursuant to s. 775.21; or Has previously been convicted o fa violation of chapter 794, s. 800.04(4), (5), or(6), s. 827.071, or s. 847.0145 and the unlawful sexual activity involved a victim 15 years of age or younger and the offender is 18 years of age or older.

forth in You are hereby placed on notice that should you violate your probation or community control, and the conditions set shall be placed on you revoked, or not revoked control is community probation or your whether satisfied, or (2) are s. 948,063(1) electronic monitoring in accordance with F.S. 948.063. May 26, 2010, arid who (32) Effective for offenders who are subject to supervision for a crime that was committed on or after the criminal offenses commit, any of to conspiring or soliciting, attempting, committing, or has been convicted at any time of under the age of 18 at the listed in s. 943.0435(1 )(a) 1 .a.(l), or a similar offense in another jurisdiction, against a victim who was time of the offense; the following conditions are imposed in addition to all other conditions: approval from the offender's (a) A prohibition on visiting schools, child care facilities, parks, and playgrounds, without prior ordered under this prohibition The a victim. protect supervising officer. The court may also designate additional locations to the sole purpose of for playground or facility, park, care child school, a visiting from offender the paragraph does not prohibit children or grandchildren at a offenders the dropping off or attending a religious service as defined in s. 775.0861 or picking up child care facility or school. Claus costume, or other (b) A prohibition on distributing candy or other items to children on Halloween; wearing a Santa costume to appeal to other or costume, Bunny Easter wearing an Christmas; costume to appeal to children, on or preceding prior approval from the children, on or preceding Easter; entertaining at children's parties; or wearing a clown costume; without court.

modify any of the conditions of your YOU ARE HEREBY PLACED ON NOTICE that the court. may at any time rescind or from further supervision. If you violate you discharge or may law, by authorized probation as of probation, or may extend the period adjudicate you guilty probation, your any of the conditions of your probation, you may be arrested and the court may revoke placing you on probation or require before imposed have might it that adjudication of guilt was withheld, and impose any sentence sentence. the you to serve the balance of

probation, you shall be released from IT IS FURTHER ORDERED that when you have been instructed as to the conditions of discharged from liability. (This stand shall custody if you are in custody, and if you are at liberty on bond, the sureties thereon paragraph applies only if section or section 2 is checked.) I

if checked: IT IS FURTHER ORDERED that you pay the following charges/costs/fees Page 6 of 8

Revised 07-01-1

1

,

CHECK ALL THAT ARE ORDERED:

O LI

O

o o O

0 o O

FINES Total of tines assessed in sentence, pursuant to s. 775.083 (1)(a) through (g) or Chapter 316, P.S. Statutorily mandated 5% surcharge/cost if fine assessed (on first line) pursuant to a. 938.04, ES.

$225.00 $ 60.00 $ 50.00 $ 50.00 $ 3.00

MANDATORY COSTS IN ALL CASES Additional court cost for relony offense, pursuant to s. 938.05(1 )(a), ES. Additional court cost for misdemeanor or criminal traffic offense, pursuant to s. 938.OS(l)(b) or (c), F.S. Crimes Compensatioit Trust Fund pursuant to s. 938.03(1), F.S. County Crime Prevention Fund pursuant to s. 775.083(2), F.S. Additional Court Costs Clearing Trust Fund pursuant to s. 938.01(1), F.S.(Requires an adjudication except when adjudication

$20.00

withheld pursuant so s. 318.14(9) or (10), ES.) Prosecution Costs, pursuant to a. 938.27, ES. (Minimum of$1 00 Eelony/$50 Misdemeanor) Investigative Costs, pursuant to a. 938.27, P.S. (if applicable and requested) Crime Stoppers Trust Fund pursuant to s. 938.06(1), F.S.

MANDATORY COURT COSTS FOR COURT-APPOiNTED COUNSEL CASES 938.29, P.S. Public Defender/Appointed Counsel Application Fee, if not previously collected, pursuant to ss. 27.52 and s. (Minimum of$ 100 Public Defender/Appointed Counsel Fees and Costs, pursuant to a. 938.29, ES. as determined locally

O

o

Fclony/$50.O0 Misdemeanor).

O

$151.00

D

$201.00

O

$151.00

MANDATORY COSTS IN SPECIFIC TYPES OF 784.041, Rape Crisis Program Trust Fund, pursuant to s.938.085, F.S. for any violations of ss. 784.011,784.021,784,03, F.S. 794.011 or 784.085, 784.083, 784.082, 784.08, 784.08), 784.045, 784.048, 784.07, 784.03, 784.04 L, 784,045, Domestic Violence Trust Fund, pursuant los. 938.08, F.S. for any violations of ss. 784.011, 784.021, Violence described in s. 784.048, 784.07, 784,08, 784.081, 784.082, 784.083, 784.085, 794.011, or any offense of Domestic

.s.

741.28, F.S.

o O

$135.00 S 3.00

787, chapter 794, s. Certain Crimes Against Minors, pursuant to s. 938.10(1), F.S. for any violations ofs. 784.085, chapter 893.147(3), or a. s. 847.0138,s. 796.03, a. 796.035,s. 800.04, chapter 827, s. 847.0)2, s. 847.01 33, s. P.S. 943.0435. 847.0134, or s. 847.0125, s. s. 823.07, 775.21, s. of S. 985.701, or any offense in violation F.S. DU1 Court Costs, pursuant to s. 938.07, P.S. for any violations of as. 316.193 or 327.35, for any violations of offenses listed State Agency Law Enforcement Radio System Trust Fund, pursuant to s. 318.18(17), P.S. 316.067, 3)6.072(3), 316,192, 316.193, 893, as. chapter 316.1935,316.027,316.061,877.111, ins. 318.17 including ss, or any other offense in chapter 316 which is classified as a criminal violation.

135(5),

545(I),

Li U O

$_

D

$

El

Other:

El

Other:

LI

$_

1.00

o

MANDATORY COURT COSTS AUTHORIZED BY LOCAL GOVERNMENTAL ENTITlES Criminal Justice Education by Municipalities and Counties, pursuant tos. 938.15, ES. Additional court costs for local requirements and other county funded programs pursuant to Teen Court pursuant to

s.

s.

939.18S(t)(a), P.S.

938.19(2), P.S.

organization established for the sole purpose Per month during the term of supervision to the following nonprofit pursuant to s. 948.039(2), ES.: Corrections, of supplementing the rehabilitative efforts of the Department

DISCRETIONARY COSTS FOR.SPECIFIC TYPES OF CASES s. 938.23, F.S. for violations of a. 3)6.193, County Alcohol and Other Drug Abuse Trust Fund, pursuant to s. 938.21 and s.8S6.0 11, s. 856.015, or chapter 562, chapter 567, or chapter 568, ES. 893.13 offenses Operating Trust Fund of the FDLE, pursuant to s. 938.25. F. S. for violations of a.

TOTAL AMOUNT OF COURT COSTS ORDERED =

0TH ER OBLIGATIONS IMPOSED 2.00

X

$

o

Other:

El

Other:

Page 7

of 8

of

Per month for each month

of supervision for Training Trust Fund Surcharge, pursuant los. 948.09,

Revised

Il

P.S.

PAYMENT IS TO BE MADE THROUGH AND PAYABLE TO: X Department of Corrections

(if collected

0

by the Department

Clerk of Court

of Correcnons, a surcharge of 4% will be added to all payments ordered by the court, pursuant toe. 945.31,

Court Costs/Fines Waived

Court Costs/Fines converted to community service hours at

3

or

a

rate of

1.10

F.S,)

perhour.

Court Costs/Fines reduced to civil judgment

SPECIFIC INSTRUCTIONS FOR PAYMENT:

to the attached Order Establishing Monetary Sums

certified copies of same to IT IS FURTHER ORDERED that the clerk of this court file this order in the clerk's office and provide the officer for use in compliance with the requirements of law.

ORDERED, on

DONE NUNC PRO TUNC

Date:

Defendant

Instructed by: Supervising Officer

Page

8

of S

Revised 07-01-13

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

MAY E. MONTRICHARD, M.D. FAMILY MEDICINE, PA. 1216 NW22NDAVENUE GAINESVILLE, FL 32609 PHONE: (352) 378-2615 FAX: (352) 378-9194

February 1,2011 Re: Alexandra Livingston, RN (Board Certified in Michigan)

Letter of Appreciation To Whom It May Concern: Ms. Livingston participated. in our annual health fair event by assisting our staff with blood pressure screenings and providing patient education for hypertension. She was instrumental in facilitating the progression of forty-one patients from the Gainesville community at our health fair event. Ms. Livingston exceeded our expectations by interpreting the results and making specific recommendations with respect to medications. She also helped to facilitate blood sugar and cholesterol screenings. As a result of her professional contributions, our patients and the Gainesville community received health education to improve their health status.

Should you have any further questions please do not hesitate to contact my office. Sincerely,

May E. Montrichard MD Board Certified Family Physician

All Physical Medicine and Rehabilitation

.

Rehabililalion & Electrodiagnostic Medicine Spine, Joint and Muscle Pain interventional Management of

Voussef W. Wassef, MD, M.S Board

Physiatrist in Pain Medicine

May 20, 2011

Re: Alexandra P. Livingston, RN Letter of Recommendation

To Whom It May Concern: I have the pleasure writing this letter

of recommendation on behalf of Ms. Livingston.

at two Ms. Livingston had been at my office and observed while I performed procedures needs. patients' to attending and learning, observing, occasions. She showed much interest of knowledge and a desire of She is pleasant and ready to help, she showed good fund of medical gaining more experience and advanced career. registered nurse in Illinois licenses as a and Michigan Florida, Michigan, and Illinois. She recently renewed her Registered Nurse

had been licensed as a I had reviewed her resume which stated that she

Please call me at your convenience with any questions. Best e ards, 1'

Yo sse W. Wassef, M.D., M.S.

FL 32605 379-7707 Tel: (352) DO-REHAB (367-34221/ Fax: (352)

I

.

Re: Letter of Recommendaton for Alexandra Livingston, RN To Whom It May Concern:

Alexandra served as a volunteer for the American Cancer Society for two years. Her first year as a volunteer was spent working with the patients who are resident at Hope Lodge, a facility for cancer patients undergoing treatment.

1

The second year Alexandra worked as a volunteer in the department of Patient in support of an Services. In that capacity, in her work and meticulous was She outreach event. upcoming medical considerable saved me innumerable hours of work by using her expertise in the research.

Alexandra's other duties have included: Registering patients for ACS programs and services . Acting as liaison between staff and program facilitators . Interpreting ACS programs to patients Assisting with various patient projects in the office Alexandra is a detailed, conscientious and compassionate worker and will be a success at whatever she endeavors. Sincerely,

i&& Margaret Shaw, Area Patient Services Representative

North Central Area 2119 SW 16th Street GainesvUle, FL 32608 t) 352. 376.6866 t) 888. 295.6787 0 352. 336.3861 Cancer Informafion .800.ACS.2345 www.cancer.org 1

Rick Scott

John T Armstrong M D Stale Surgeon General

Governor

October 2, 2012 Alexandra Paula Livingston 5060 Sw 9th Lane Gainesville, FL 32607 Dear Ms. Livingston: The Board of Nursing has received your endorsement application for Registered Nurse licensure. Upon review of your file, it has been determined that the following information is incomplete:

Supporting documents are required regarding your "Yes" answer in the health history section of the application. Documents must include: - A

self explanation of your medical condition(s) or occurrence(s) and your current status

- A letter from a licensed medical professional summarizing your diagnosis,

treatment

and prognosis.

Documentation must be dated within the last year, but does not need to come from the original treating physician. You must submit all available court dispositions, regardless of adjudication, to show the final outcome of each case and all sentence requirements, including costs and fines. Court documents can be obtained from the Clerk of the Court in the jurisdiction where the offense occurred. If documents are not available due to record retention policies, have the Clerk of Court provide you with a letter, on letterhead, stating there is no information available > The Board office has received the Judgment documents that list the charges, plea, and adjudication in formation.

Provide written documentation that you have completed your sentence requirements. You may obtain a copy of this documentation by contacting the Department of Corrections. The report must include the start date, end date and indicate that all conditions were met.

We have not received your fingerprint cards. All applicants must complete two (2) fingerprint cards, per Florida Statutes 464.009(3). When you contact your local law enforcement agency, confirm that they have the FD-258 fingerprint card available. Your local law enforcement agency will roll your fingerprints and may charge you a fee. If the fingerprint cards are unavailable at your local law enforcement agency, please visit www.fldoh.sofn.net, fill out the demographic questionnaire, print the bar code sheet and request the cards. When they have been completed please send them to the address indicated on the bar code sheet. Instructions for filling out the fingerprint cards are available on the SOFN website. If your background check returns with an undisclosed charge(s), the Board office will notify you if any additional information is required. FLORIDA BOARD OF NURSING 4052 Bald Cypress Way, Bin C02 Tallahassee, FL 32399-3252

/www.doh.state.fl.us Created on 10/2/2012 9:53 AM

OF

Rick Scott Governor

John F! Armstiong M D State Surgeon General

If you have worked as a nurse during the last 5 years, have your employer submit the employment verification information as stated in the application packet. You can find the employment verification requirements in the endorsement application on our website at:

ing/ap_endorsernent-RN-LPN.pdf

If you have NOT worked as a nurse in the last 5 years, your file will be presented to the Board for review at the next available Board meeting. Please include with your application a letter of self explanation of your career path since you last practiced as a licensed nurse. You can find our Board meeting dates on our website at http://www.doh state.fl. us/rn qa/nursing/nur_meeting .htm I

.

Request that the Board(s) in the state(s) (Michigan) where you were discipUned send official copies of the administrative complaint and final order to the Florida Board of Nursing. Submit a self explanation in regards to the action(s) taken against your license(s). There were unanswered question(s) on your application, the required pagaes have been included with this letter. Return the completed questions to the Board. You can now follow the progress of your application through our website at: Once there, select your profession and enter your md passwon to check your application status. if we require further usernam. your application, this will also be viewabie. You must check this documentattonor information to website every 30 days or until your application is approved for updates on the status.

Please ensure that the deficiencies listed above are forwarded to the address listed below. If you have additional questions, you may contact the board office at the address below or by e-mail at

mqa_nursingappstatus©doh.state.fl.us. As a reminder to all applicants, please understand that Chapter 456.013(1)(a), Florida Statutes, provides that an incomplete application shall expire one-year after initial filing with the department. Sincerely,

Alison Rarte Board Staff

Profession: 1701

Applicant ID: 456545

FLORIDA BOARD OF NURSING 4052 Bald Cypress Way, Bin C02 Tallahassee, FL 32399-3252 http://www.doh.state.fl.us Created on 10/2/2012 9:53AM

I

Armstrong M D State Surgeon General

Rick Scott

John

Governor

October 9, 2012

Alexandra Paula Livingston 5060 SW 9th Lane Gainesville, FL 32607 Dear Ms. Livingston:

Attached with this letter is a copy of the Important Notice for Initial Licensure Applicants and Renewals, as well as the Section 456.0635 from the 2012 Florida Statutes. The web links have also been provided within the letter so that you may view them online as well. Please review the documentation provided and contact the Board office once you have completed the review and have determined how you wish to proceed with your file. If you have any questions, please do not hesitate to contact this office at the address below, by telephone (850) 245-4125 or e-mail: MQA_Nursing_Appstatus©doh.state.fLus.

Sincerely,

Atison Harte Regulatory Specialist

FLORIDA BOARD OF NURSING 4052 Bald Cypress Way, Bin C02 Tallahassee, FL 32399-3252 http :flwww.d oh state us Created on 10/9/2012 3:36 PM

l

II

Rick scott Governor

John H Armstrong M r)

State Surgeon General

October 16, 2012 Alexandra Paula Livingston 5060 SW 9th Lane Gainesville, FL 32607 Dear Ms. Livingston:

The Board of Nursing has received your endorsement application for Registered Nurse licerisure. Upon an updated review of your file, it has been determined that the following information is incomplete: We have not received your fingerprint cards. All applicants must complete two (2) fingerprint cards, per Florida Statutes 464.009(3). When you contact your local law enforcement agency, confirm that they have the FD-258 fingerprint card available. Your local law enforcement agency will roll your fingerprints and may charge you a fee. If the fingerprint cards are unavailable at your local law enforcement agency, please visit www.fldohsofn.net, fill out the demographic questionnaire, print the bar code sheet and request the cards. When they have been completed please send them to the address indicated on the bar code sheet. Instructions for filling out the fingerprint cards are available on the SOFN website.

background check returns with an undisclosed charge(s), the Board office will notify you if any additional information is required. If your

You can now follow the progress of your application through our website at: http://ww2.doh,state.fl.us/mgaservicesllogin.a3P Once there, select your profession and enter your o check your application status. If we require further password username documentation or information to process your application, this will also be viewable. You must check this website every 30 days or until your application is approved for updates on the status.

Please ensure that the deficiencies listed above are forwarded to the address listed below. If you have additional questions, you may contact the board office at the address below or by e-mail at As a reminder to all applicants, please understand that Chapter 456.013(1 )(a), Florida Statutes, provides that an incomplete application shall expire one-year after initial filing with the department.

Sincerely,

Alison Harte Board Staff

Profession: 1701

Applicant ID: 456545 FLORIDA BOARD OF NURSING 4052 Bald Cypress Way, Bin C02 Tallahassee, FL 32399-3252 http:l/www.doh.state.fl.uS Created on 10/16/2012 1:41 PM

FLORIDA

OF

HEALT Ana M. Viamonte Ros, M.D., MPH. State Surgeon General

Charlie Crist Governor

MEMORANDUM Joe Baker, Jr., Executive Director, FROM:• RE: SUBJECT: DATE:

Florida.. Board

Michael Lawrence Jr., Senior. Attorney

of Nursing

I

tmal Waiver Hearing

DOH v. Alexandra Livingston DOH Case Number 2010-03725 & 2010-00522 August 18, 2010

Enclosed you will find materials in the above-referenced case to be placed on the

Informal Waiver Hearing agenda for final agency action for the October 2610 meeting provided in this regard. Alexandra Livingston

of the board. The following information

Subject:

is

5060 Sw 9th Lane Gainesville, FL 32607-3867

Enforcement Address:

5060 Sw 9th Lane Gainesville, FL 32607-3867

Rank:

Subject's License No: 9177360 262595 Licensure File No: Initial Licensure Date: 4/17/2001 Board Certification: Required to Appear:

.

RN

No

Current PRN Contract: Allegation(s): Prior Discipline: Probable Cause Panel:

Complainant/Address:

August 2, 2010 Home & Bowen University Of Florida Pd 132 Museum Rd Box 112150

0

Gainesville, FL 32611

Materials Submitted:

Memorandum to the Board Administrative Complaint Motion for Final Order Motion to Assess Costs with Attachments Affidavit of Non-Receipt - Board Office Affidavit of Non-Receipt - Agency Clerk's Office -

4052 Bald Cypress Way

*

Bin C-65 * Tallahassee, FL 32399-3265

Settlement Package PCP Memo pkg_enl_rpt_psu.pdxpDl 8L: 08/18/2010 11:35:47

4052 Bald Cypress Way

*

Bin C-65

*

Tallahassee, FL 32399-3265

STATE OFFLORIDA DEPARTMENT OF HEALTH

CLERK

DEPARTMENT OF HEALTH,

Petitioner,

•

v.

CASE NO.

•

ALEXANDRA LIVINGSTON,

N.,.

2010-00522 & 2010-03725

Respondent. MOTION FOR FINAL ORDER AFTER HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACTS AND bETERMINATION OF RESPONDENT'S WAIVER OF RIGHT TO REOUEST A FORMAL HEARING

-.

COMES NOW, the Petitioner, by and through its undersigned counsel, and moves the Board of Nursing for entry of a Final Order in the

styled cause on October 8, 2010 at 8:30

Petitioner states: 1.

As grounds therefore, the

-

Petitioner previously filed an Administrative Complaint against

Respondent alleging that Respondent had violated the provisions of Florida

Statutes, as set forth therein. The Department, by filing the Administrative

Complaint, seeks to discipline Respondent's certificationto practicenursing,

thereby affecting the Respondent's substantial interests.

•

There are no disputed issues of material fact to be resolved by

7.

the Board. Respondent has. been advised, by a.copy of this Motion, that a

8.

copyof the investigative file establish

a

in this case shall be furnished

to the Board to

prima :facie case regarding the violations as set forth in the

Administrative Complaint. WHEREFORE the

Petitioner requests that; after allowing• the

Respondent the opportunity to present oral and/or written evidence in

mitigation of the Administrative Complaint, the Board of Nursing enter a Final Order imposing such discipline upon the Respondent's license as the

Board deems appropriate.

JR.

Assistant General Department of Health Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 (850) 245-4640 telephone (850). 245-4683 facsimile Florida Bar No. 0011265

.

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of thq abpve and 2.Q±Q foregoing been provided by U.S. mail this day of 2010, to: Alexandra Livingston, 5060 SW gth Lane, FL

Assistant General Couns

I

STATE OFFLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

CASENO.

v.

2010-00522

-03725

ALEXANDRA LIVINGSTON, R.N.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT by arid through its COMES NOW, Petitioner, Department of Health,

undersigned counsel,

the and files this Administrative Complaint before

Alexandra Livingston, R.N., and in Board of Nursing against Respondent, support thereof alleges:

i.

Petitioner

is the state

department charged with regulating the

Florida Statutes; Chapter practice of nursing pursuant to Section 20.43,

Statutes. 456, Florida Statutes; and Chapter 464, Florida 2.

At

all

times

material

to

this• Administrative

Complaint,

(R.N.) within the state of Respondent was a licensed registered nurse

number RN 9177360. Florida, having been issued license

3.

of

Respondent's address

record, is

5060

SW

gth

Gainesville, Florida 32607-3867

4.

On or about November 12, 2009, the University of Florida

Police Department (UFPD) received

a

call from a security officer at Shands

Healthcare at the University Qf Florida (Shands).

reported that

a

The security officer

suspicious person, identified as Respondent, had been

Plaza. harassing the doctors of the secOnd floor of the Shands Medical

Respondent was informed that she was trespassing. 5.

and

On Or about November 12, 2009, the Director

for Employment

Recruitment at Shands contacted the UFPD and reported that

up at Respondent, a former employment applicant, had been showing

told she did various Shands clinics looking for employment, despite being Respondent to not meet the standards to be hired. The Director had asked had continued to visit stay away from the Shands clinics, but Respondent

'

times at different Sharids seeking employment, having been seen three

.,

through November 12, clinics during the period of November 6, 2009, 2009. 6.

course of M.M.'s On or about December 8, 2009, in the

business, Respondent contacted M.M. for information Department of health v. Alexandra Livingston, 2010-03725 Case Number 3: \PSU\NurSing\M ichael\ACS\Drafted

RN.

'

Alexandra .doc

the location of 2

an assisted living facility. M.M. and Respondent began discussing the topic

of home

care and

KM. mentioned he was looking for assistance with

care on the weekends.

Respondent informed M.M. that she was

registered nurse and expressed interest

they

agreed to meet 7.

at or about

M.M. is an

and lives with

his

in

a

providing assistance to M.M.

4:00 p.m. to discuss the topic further.

adult quadriplegic person who

is gainfully employed

his

mother, E.M., who provides support and assistance to

On or

about December 8, 2009, at or about 4:45 p.m.,

M.M. 8.

Respondent arrived at M.M.'s office. Respondent asked multiple questions

about M.M.'s health history, medications, routines, and the extent of his physical abilities. Respondent provided M.M. with

a

copy of her nursing

license and resume. Respondent asked M.M. if he had any questions and

M.M: replied that he left the tough questions for his mother stating, "You've gotta 9.

pass

the Mom test because it is her house and her rules."

On or about December 8, 2009, at or about 8:00

p.m.,

Respondent contacted M.M. by phone with additional questions about his

medications. Respondent stated that she was worried about the dosage of

Department of Health v. Alegandra Livingston, Case Number 2010-00522, 2010-03725

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3

one medication M.M. mentioned and stated that the medication should not be taken with M.M.'s other prescribed medication. On or

10.

about December

8,

2009, M.M.'s mother, F.M., contacted

Respondent by phone regarding her interest in providing services to M.M.

on the weekends.

E.M. wrote

a

statement about the conversation which

stated in part: Very shortly into the conversation she informed me that based on "research" she had done on his medications that he was taking two medications which should never be taken together. She stated she felt he was overrnedicated and sedated when she had seen him earlier that day. (The first and only time she had ever seen him.) She asked if his physician was aware he was taking :the two medications together. I informed her that the physician was fully aware of his medications, and indeed was the prescribing physician. She persisted and strongly urged me to have my son discuss the issue with the physician. "Maybe one of the prescriptions is an old one and the physician has forgotten about it," she said. I informed her again that the physician was fully aware and also that I had ovirseen and managed the administration of my son's medications for more than 25 years and both were very, comfortable with the

arrangement. 11.

.

F.M. discussed with Respondent the assistance M.M. needed for

getting out of bed.

Respondent asked about using

that helps lift disabled persons out of bed by use of

a

a

Hoyer Lift, a device sling. F.M. informed

Respondent that a -foyer Lift would not work because there was no way to

Department of Health

v.

Alexandra Livingston, RN.

Case Number 2010-00522, 2010-03725

ACs\ACs\Livingston Alexandra.doc

4

remove the sling out from under M.M. once he. was in the wheelchair.

Respondent insisted that

a

Hoyer lift should be used as described in E.M.'s

written statement: She replied that she could roll him from side to side in the chair and remove the sling. I told her a sliding board works best with him and I am not certain if she heard me, or if she did hear, that she knew what a sliding board was. She kept

insisting she would use a Hoyer] Lift until I said a firm "No! That will not happen for the reasons I just stated." 12.

On or about December 8, 2009, despite having numerous

reservations about hiring Respondent to assist .

in her son's care,

E.M.

scheduled an interview with Respondent for on or about December 12, 2009, at 10:30 13.

am.

On or about December

i,

2009, at or about 2:00 p.m.,

Respondent came back to M.M.'s place of business. Respondent stated she had papers for M.M. to sign. M.M.

Respondent presented

a

notebook paper to

with the following handwritten statement; Dear Dr. P.G.],

I am a registered

nurse providing care to your patient, M.M.J. Could you kindly provide a copy of his medical chart and converse with me regarding his care? His signature on this

letter indicates his cOnsent.

Department of Health v. Alexandra Livingston, RN. Case

Nunter 2010-00522, 2010-03725 ACs\ACs\Livingston

5

Thank you, Alexandra Livingston, Registered Nurse 14.

M.M. signed the statement at that time.

15.

On

or about

December

11,

Southeastern Integrated Medical, Dr.

2009,

P.G.'S

Respondent

went to

office, and presented the

handwritten note to the clinic staff. Respondent stated she needed M.M.'s medical records immediately.

The staff. informed Respondent that the

records would not be processed immediately and Respondent began to

argue, stating they had to hurry because she had better things to do. The

Office Manager recognized Respondent as she had previously brought

a

similar note on another patient in the clinic. The Office Manager asked the Risk Manager for direction. The Risk Manager advised to tell Respondent

that requests for medical records were processed they were received.

in the

order in which

The Office Manager relayed that information to

Respondent, who left the office. 16.

The

Respondent

Risk

attempted

Manager

to

contacted

obtain

M.M.'s

E.M.

and

records.

explained E:M.

that

informed

Southeastern Integrated Medical that Respondent was not employed by them and that M.M.'s records should not be released to her. Department of Health v. Alexandra Livingston, RN. Case Number 2010-03725 J:\PSU\Nursinq\Michael\ACs\Drafted

6

Alexandridoc

17..

On or

about December 11, 2009, at or about 2:45 p.m.,

Southeastern Integrated Medical contacted M.M. and informed him that

Respondent attempted to obtain

his

medical records.

The Risk Manager

reported that they contacted E.M. who directed them not to release his records. 18.

with EM.,

On or

about December 11, 2009, after discussing the matter

M.M. agreed

Respondent.

M.M.

that his medical records should not be released to

contacted Southeastern Integrated Medical

and

informed the Risk Manager that he wanted to revoke his release to give his records to Respondent. 19.

M.M. signed

the following written statement:

I

had earlier signed a release of medical records authorizing Alexandra Uvingston to obtain my medical records from Dr. P.G.]'s office. Upon further reflection, I have decided to withdraw my consent for release of those records, effective December 11, 2009. This withdrawal of consent shall apply to any/all doctors and medical records I have throughout Southeastern Integrated Medicine. Please disregard any form or statement that is in contradiction to this statement.

20.

Onor about December

11,

2009, after M.M. revoked his release

to give his medical records to Respondent, the Risk Manager learned that Respondent was back at Southeastern Integrated Medical. Department of Health v. Alexandra Livingston, RN. Case Number 20i0-00522, 2010-03725 3: \PSU\N ursing\MichaeMtCs\Drafted ACs\ACS\LiviflgStOn, Alexandra.doc

.

.

The Risk

7

Manager went

to the front check-in window where Respondent was

speaking very loudly and also speaking on the phone.

Respondent was

attempting to reach the on-call physician covering for Dr.. P.C

The Risk

Manager advised Respondent that M.M. had revoked his release to provide

her with his medical records. Respondent became argumentative, stating she had a written letter signed by

the patient and that she "could not

believe it." The Risk Manager explained that she had just gotten

off the

phone with N.M. who reported that Respondent had not been hired and he revoked his release. M.M.'s

personal

Respondent grew louder and began talking about

health

information

and

prescriptions while standing in the lobby.

her

concerns

about

his

Respondent's statements about

M.M.'s personal information were overheard by staff in the office and other

patients waiting in the lobby. The Risk Manager toid Respondent that they

would not release M.M.'s records.

taking care of my patient.

The Risk Manager

Respondent stated, "I'm an RN, I'm

If you were licensed you would understand."

repeated that M.M.

had

rescinded

his

release.

Respondent stated she would pray for the Risk Manager and left the

building.

Department of Health v. Alexandra Livingston, R.N Case Number 2010-00522, 2010-03725 J:\PSU\Nursing\Mithael\ACs\Drafted ACs\ACs\Livingston Alexandndoc

.

21.

On or about December 11, 2009, at or about 5:00 p.m.,

Respondent called the residence of another physician who practiced at

Southeastern Integrated Medical (Dr. L.). M.M. was not under the care of Dr.

L.

Respondent told

Dr. L.

had been trying to obtain

a

that she was M.M.'s treating nurse and she

copy of M.M.'s medical records for two days.

Respondent stated she had been hired by the family and was to begin

treating the patient the following morning. She stated that she had been told by

a

representative at Southeastern Integrated Medical that it would

be a few days before she could receive the records, but she needed them

immediately stating, "Don't you think it have the medical records?" Dr.

L.

is my

right as

a

treating nurse to

informed Respondent that he did not

know N.M. or Respondent and asked why she did not just take a patient

history and follow the patient's desires. Respondent reported that she Was very concerned about the dose of M.M.'s. medications, that he was "very sedated" on the medications, and she thought he might be in danger. Dr. L. replied he would contact the administrator on call to get back to her.

Respondent indicated that she was applying to medical school and knew her rights.

number.

At that time

Dr.

L.

asked Respondent how she got his phone

Respondent stated she looked it up in the phone book.

Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 J:\PSU\Nursing\MiChaeI\AC5\Drafted ACS\ACS\Livingston, Alexandra.doc

Dr. L.

9

then

noticed

the

caller

identification

Respondent was calling from Respondent was calling from.

that time, Dr. 22.

L.

on

Millennium

his

phone

Bank.

indicated that asked

He

where

Respondent replied, "Millennium Bank." At

hung up the phone.

On or about December 12, 2009, Respondent called the home

of EM. and M.M. and asked to speak to M.M.

spoke to her and asked

why she attempted to obtain M.M.'s medical records.

Respondent stated

she needed them "in order to formulate the best, nursing care plan possible

for my patient."

E.M. stated,

"He

is

not your patient, 'you have not been

hired, in fact you have not even been interviewed'."

Respondent stated,

"Your adult son hired me to manage his care, his activities of daily living] and his medications and I want to do the best, job I can do.

'permission to get coØies of his medical records."

He gave me

E.M.

informed

Respondent that she was not hired, that she would not be hired; and that she needed to immediately stop her attempts to get M.M.'s records or

there would be repercussions.

23.

On or about December 12, 2009, at or about 5:00

Respondent arrived at the door of

Dr. L.'s residence wearing a lab

Respondent had papers in her hands and handed Dr. Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 J:\PSIJ\Nursing\Michael\ACs\Drafted

Alexandradoc

L. a

jacket.

copy of the

was outside of patient A.W.'s room. Respondent stated that she had been

invited there by A.W.

Respondent was Wearing

a

white lab coat with her

name and "registered nurse" written on the coat.

arrested for trespassing.

Respondent was

Pursuant to her arrest, Respondent's duffel bag

was searched and secured. The duffel bag contained medical equipment

b

including two

envelopes containing

patient medical records, surgical

protective masks, a blood pressure cuff, a stethoscope, Diastix urinalysis strips,

a

latex gloves,

a

Alachua County Physician Directory, cotton swabs,

professional scale,

rubbing alcohol.

a

glucose testing meter, bandages, and

Found with her possessions was

release form permitting Respondent to obtain

different patient, patient AM.,

a

a

patient information

medicS records for a

patient of the Family Medicine at

th

Avenue clinic, a clinic affiliated with Shands. 27.

On or

about February

Nurse Manager on the

room was located.

th

5,

2010, a UFPD Officer interviewed the

floor of Shands Hospital, where Patient A.W.'s

The Nurse Manager Stated that Respondent had been

trying to gain employment at Shands since about October of 2008.

The

Director of Employment and Recruitment at Shands had sent out an e-mail

at that time indica5ng that Respondent had been visiting various Shands Departrnentof Health v. Alexandra ingston, RN. 2010-00522, 2010-03725 J:\P5U\Nursing\MictiaeMCs\Drafted

12

Case Number

Alexandradoc

departments and clinics seeking information about employment.

The e-

mail directed managers to direct Respondent to contact Human Resources

with her questions. In or about July

of

2009, a follow-up e-mail was sent

out directing managers and employees of Shands to contact hospital security to initiate

a trespass

warning if Respondent was seen visiting

Shands. 28.

With regard to A.W., the Nurse Manager stated that since his

admission, Respondent had been visiting him constantly. Manager

was

informed

by

The Nurse

staff members that they had observed

Respondent conducting blood pressure checks, blood glucose checks, and urine dip stick checks using her own equipment.

Respondent was not

under any Shands contract and was not under any direction from physician

to perform these procedures on A.W. while

he was

a

Shands

under the

care of Shands physicians and nurses.

29.

A blood glucose check involves pricking

and placing a drop of blood on a strip

that

a

is placed

finger using into

a

a

needle

glucose meter

which reads the glucose level in the blood

30.

patient

On or about February 5, 2010, the UFPD Officer interviewed

a

assistant working at Shands who stated she had seen

Department of Health v. Alexandra Livingston, R.N. Case Number 2010-00522, 2010-03725 3;\P5IJ\Nursing\MidlaeI\ACS\Drafted ACS\ACS\LiVingstofl, Alexandra.doc

13

Respondent conduct

a

blood pressure check on A.W. and also observed

Respondent prick A.W.'s finger for

a

glucose check using

her own

equipment and meter. 31.

On or about February 5, 2010, the UFPD Officer interviewed a

registered nurse who observed Respondent

identified herself

as A.W.'s

nurse.

in A.W.'s room.

Respondent

Respondent attempted to give the

registered nurse orders regarding the care of A.W. and made references to a

podiatrist, indicating she was working under his direction. 32.

A.W.

On or about February 5, 2010, the UFPD Officer interviewed

who stated that

he

met Respondent through his church.

1

His

grandmother had been on the bulletin prayer list because she was

D

Respondent contacted his grandmother offering her services as

nurse.

A.W. stated that when he met

services more for

a

a

and

she determined he needed her

wound on his foot. Respondent changed his dressings,.

checked his blood pressure, checked his blood glucose levels, his

urine using

a dip stick.

The Officer informed A.W. that Respondent

could not care for him as a nurse while he was under the care of Shands and A.VV.

that

Respondent had trespassed and would not be able to visit

hint

expressed that he i4

Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 Alexandradoc

33.

about February

On or

Family Medicine on

th

5,

2010, the UFPD Officer went to the

Avenue clinic arid interviewed the Clinic Manager.

The Clinic Manager reported that Respondent had been to the clinic many

times and had purported to

be the

nurse of two clinic patients; patient

A.W. and patient A.N., often accompanying the patients during their clinic

visits.

Respondent's behavior at the clinic was generally disruptive and

aggressive.

The

Clinic Manager stated that Respondent carried

a

dilapidated purse filled with gloves and other supplies that were generauy disheveled. 34.

On or

about February

6,

2010, Respondent went to the UFPD

station and stated that two detectives had taken possession of her medical bag and its contents.

Respondent stated she was informed that she could

retrieve her property at any time

and

that she needed her medical bag and

its contents to successfully -conduct her job.

The UFPD Officer at the

station asked Respondent why she visited Shands. Respondent stated that she had to go to Shands to continue the medical care she provided to her

patients. Respondent stated she

was

not employed by Shands, but stated

she still needed to go to the hbspital to conduct the necessary medical

follow-up she felt her patients needed. Respondent stated she did not use Department àf Health v. Alexandra Livingston, RN. Case Nuniber 2010-00522, 2010-03725 3 :\P$U\Nu sinq\Midiael\ACs\Drafted ACs\ACs\LMnqston, Alexandradoc

15

any Shands

medical equipment or administer any medications from

Shands, but did maintain medical records on her patiehts.

The UFPD

Officer asked Respondent if this was against hospital policy, or a conflict of interest. Respondent answered that it was not because she still had to bill

the patients' insurance providers for the services she provided.

The

detective then informed Respondent that she was given a trespass warning to stay away from all Shands properties, and from the University of Florida Campus and all its properties.

Respondent stated she was not aware of

the trespass warning and asked how to get it lifted. The UFPD Officer repeated that Respondent could be

arrested if she goes to Shands

properties, or UF properties again. 35.

On or about February 9,

Respondent

atthe

2010,

UFPD policé'station.

a

met with

UFPD Officer

Included in the meeting was an

Officer froth the Gainesville Police Department (GPD) and an Officer from the Alachua County Sheriff's Office.

Respondent was given

a

trespass

warning to stay away from every Shands property in the city of Gainesville and in the

county of Alachua. Respondent was given

the trespass warning.

a

letter explaining

Attached to the letter was the location

of every

Shands property in the county. Respondent read the letter and stated she Department of Flesith v. A'exandra Livingston, RN. Case Number 2010-00522, 2010-03725 ACS\ACs\L;vingston, Aiexandra.doc

16

understood the warning.

At that time, the UFPD released Respondent's

medical equipment back to her. The UFPD Officer asked Respondent who she was

working for. Respondent would not say, but did state that she

was under orders from 36.

a

podiatrist to treat A.W.

On or about February 10, 2010, the UFPD Officer went to the

podiatrist's clinic and interviewed the podiatrist about his interactions with Respondent.

The podiatrist stated that he initially did write orders

permitting Respondent to treat A.W. with minor procedures such as changing dressings and checking blood pressure, but this was before he realized that Respondent "may have mental issues and that she wasn't

working, technically,

as a home

nurse and that she was just finding people

she met at church." The podiatrist stated that Respondent "called and

harassed him constantly, almost to the point of stalking." 37.

On or about February 10, 2010, the UFPD Officer traveled to

the church Respondent attended and spoke with an administrator of the

church. The administrator reported that she learned that Respondent had been looking at the prayer

Fist

for.ill church members in the bulletin and

had been calling the people listed after looking up their phone numbers in

Department of Health v. Alexandra ingston, RN. Case Number 2010-00522, 2010-03725 3: \PSIJ\Nursirlg\MIchaBMCS\Drafted ACs\ACs\Livingston, Alexandradoc

17

the phone book. This became such

a

problem that the ill member list had

to be removed from the church bulletin. 38.

reported

On or about a

theft.

February

A GPD

18, 2010, A.W.

contacted the GPD and

Officer was dispatched to A.W.'s home where

A.W. explained that he was disabled and he met Respondent at church and she befriended him.

for

a

In or about January of 2010, A.W. was hospitalized

foot amputation and Respondent was often at the hospital providing

assistance.

After his discharge, the supplies he needed to care for the

surgical site were to be sent to his home by mail. Respondent would come to his home and change his dressings.

Respondent sent

a

FQr

reasons unknown to A.W.,

form to the medical supply compahyand directed them

to send A.W.'s supplies to Respondent's home.

Respondent contacted

A.W. and told him to obtain copies of his medical' records from Shands

Hospital and copies of his medical records from his treating physicians and

forward those medical records to Respondent stated she would return

her.

Once she received the records,

his medical

supplies. The GPD Officer

directed A.W. to have no further contact with Respondent and to call the GPD

if she showed

up at his

home.

Department of Health V. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 J:\PSU\Nursinq\MichaeMCS\Drafted ACs\ACS\Livingston, Aiexandra.doc

18

39.

On or

about February

2010, the GPD Officer contacted A.W.

21,

regarding his medical sUpplies. A.W. informed the Officer that Respondent

had called him asking him about the status of his medical records, stating she needed them so she could bill Medicaid for her services.

The GPD

Officer went to Respondent's home and directed her to release A.W.'s medical supplies; Respondent released A.W.'s supplies to the GPD Officer •

who returned them to A.W. 40.

On or

about March

1,

2010, Respondent went to patient A.N.'s

and left paperwork in three envelopes at his

physician's residence

residence. The envelopes contained several pages of diagnosis evaluations

and treatment options suggested

the documents was

a

by Respondent

for A.N. Also included in

Medicare form completed by Respondent with a

request for A.N.'s physician to sign the Medicare form.

not sign the form, but contacted the 41.

On or

about March

A.NL'S

physician did

GPD.

3, 2010, A.N.'s physician was

notified by his

office that Respondent had contacted the office and asked for the physician's license number to add to

a

document that she was preparing.

The office staff member refused to release that information to Respondent and ended the call.

A few minutes later, Respondent called again and

Department of Health v. lexandra Livingston, RN. Case Number 2010-00522, 2010-03725 2:\PSU\Nursthg\M1Cb3eMCS\Drafted ACs\ACS'\LiVingStOn, Alexandra.doc

19

demanded that she be given A.N.'s physician's license number for medical reasons.

The office staff member would not, release the number and

instructed Respondent not to call again. 42.

On

or about April

13,

2013,

a

Department investigator

interviewed A.W. who stated that his grandmother was ill and listed on the prayer list in the church bulletin.

A.W. stated he started getting phone

through the

calls from Respondent who stated she had been "working

church" and offered to assist his grandmother. Through the conversation,

kW. informed Respondent thathe had

a

wound on his foot.

He stated,

"She started coming to see me and changing the dressing on my foot. At some point she became possessive.

hour on the hour."

She would call me every day every

A.W. explained

that when he was hospitalized,

Respondent would visit him in the hospital and check his blood pressure• and do glucose checks. After he was

see A.W. and

discharged Respondent continued to

then "she started having my medical supplies sent to her

hone and' I asked for her to return my medical supplies.

She was not

going to give them back to me until I signed some paper."

At that time

A.W. contacted the GPD who directed him not to sign anything and who

retrieved

his

supplies from Respondent.

Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 \Nursing\Micbael\ACS\Drafted ACS\ACS\Livingstofl, Alexandra.doc '

A.W.

also explained

that 20

Respondent was taking care of his neighbor's mother and the doctor's office told the mother that she needed to obtain

continued to receive help from Respondent. mother sent Respondent on her way.

a

AAW.

different doctor if she stated, "My neighbor's

She did not want to change her

doctor." 43.

On

or

about

May

2010,

13,

Respondent

Southeastern Urology office, located at 1179 NW Southeastern Urobgy is

Florida.

a

entered

the

th Terrace, Gainesville,

division of Southeastern Integrated

Medical..

44.

Respondent previously was issued

a

trespass warning for all

Southeastern Integrated Medical 45.

Respondent approached the front desk staff and. asked to

speak with •the facility's physicians.

The staff informed Respondent she

could• not speak directly to the physicians but she could speak with the

office manager.

46. office

Respondent indicated that she did not want to speak with the

manager, and she, needed to hand deliver documents to the

physicians and did not want to give them to the office manager.

Department of Health v. Alexandra Uvingston, RN. Cas& Number J

2010-00522, 2010-03725 ACs\ACs\Uvingston, Aiexandra.doc

21

47.

Respondent stated she previously called the office and was

informed they were hiring. The office was not hiring at this time. 48.

Respondent eventually talked to the

informed him that

she had

office manager and

three letters she wanted to personally deliver to

the physicians at the facility. 49.

The office manager informed Respondent that hiring of new

employees was handled through the company's main office.

The office

manager gave Respondent instructions on how to contact the human resources department at the company's main office. Respondent gave the office manager her business card and

50.

asked that

he give the card

to schedule

a

to each physician to see if they would be able

time to meet with Respondent.

Respondent then left the

facility. 51.

On

or

about

May

Southeastern Urology office

Respondent met with

facility's physicians 52.

a

so she

14,

2010,

Respondent

and approached

entered

the

the front desk staff.

clinic assistant and asked to speak with the could deliver letters to the physicians.

Respondent informed the clinic assistant that she previously

spoke with the office manager the previous day and the physicians were Department of Health v. Alexandra LMngston, RN. Case Number 2010-00522, 2010-03725 ACs\ACs\Livingston, Alexandra.doc

22

No

57.

investigator.

one

in

the

residence

responded

Department investigators left

a

to the

Department

business card wedged in the

door.

On or about June 29, 2010, Department investigators visited

58.

Respondent's

address of record to

serve the Order Compelling an

Examination.

Respondent's mother, P.L., answered the door and informed

59.

the Department's

investigators that Respondent was residing

at the

residence. 60.

P.L. accepted service of the Order Compefling an Examination.

61.

Respondent never contacted the Department investigator.

62.

Respondent failed to attend the mental/physical evaluation

scheduled for July 7, 2010. 63. licensee

Section 456.072(1)(a), Florida Statutes (2009), subjects

to discipline, including suspension,

for

making

a

misleading,

deceptive, or fraudulent representations in or related to the practice of the licensee's profession. 64.

Respondent

made

deceptive,

or

fraudulent

representations in or related to the practice of nursing by stating to the Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 J:\PSU\Nursing\MichaeMCs\Drafted ACs\ACs\LMngston, Alexandra.doc

24

staff at M.M.'s

physician's office that she had been hired

by M.M.

as a

nurse when she attempted to obtain M.M.'s medical records. RespondentS

continued to attempt to use

M M 's

release to obtain his medical records

after being informed numerous times that the release had been rescinded. Respondent has been making multiple misleading stitements to patients and their health care providers in attempts to provide care to patients and

obtain patients' medical records. IflJI

Fhrru LI

%.II

I

tho rht.rrh LI P... II..II I ¼.d

%..I

.nrl

LII

Respondent told A.W. that she was LIatcftin-.ntaA

11.4

fn

d-

flr

I

f-n

kar I

I

obtaining M.M.'s medical records by stating that M.M. was sedated and in danger. COUNT ONE

•

Petitioner realieges

through sixty-four (64), 66.

and incorporates

paragraphs one (1)

if fully set forth herein.

as

Section 464.018(1)(h), Florida Statutes (2009), provides that

unprofessional conduct

as

defined by board rule constitutes grounds for

disciplinary action. 67.

Rule 64B9-8.005(2), Florida Administrative Code, provides that

unprofessional

conduct

includes

misappropriating

drugs,

supplies

or

equipment; Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 2010-03725 J:\RSU\Nursirig\Midiael\ACS\Drafted

25

Alexandr&doc

68.

Respondent misappropriated A.W.'s supplies by arranging to

have A W

's

medical supplies sent to her home

When A W asked for the

to be returned, Respondent refused to return Them and attempted

to manipulate A.W. into releasing

his medical

records to Respondent in

exchange for the property that belonged to A.W. 69

the

on

Based

464.0 18(1)(h), Florida conduct

foregoing,

Respondent

Statutes (2009),

by

violated

engaging

as deflned by Rule 64B9-8.0O5(2), Florida

Section

unprofessional

Administrative Code, to

include acts of negligence either by omission or commission. COUNT TWO 70.

Petitioner

réalleges and incorporates paragraphs one (1)

through sixty-four (64), as if fully set forth herein. 71.

violating

Section

456.072(1)(q), florida Statutes (2010), provides that

lawful order of

a

with a lawfully

the board, or failing to comply

issued subpoena of the department, constitutes grounds

for

disciplinary aclion. -

72.

.

Respondent

Statutes, and

is a

is

licensed pursuant to Chapter 464k

Florida

health care practitioner as defined in Section 456.001(4),

Florida Statutes(2010).: Department of Health v. Alexandra Livingston, Case Number 2010-00522, 2010-03725

-

RN.

ACs\ACs\Livingston, Afexandradoc

..

.

-

..

26

-

73.

Respondent violated

a

lawful order of the Department by

violating the Order Compelling An Examination issUed by the Department

to Respondent when she failed to attend the scheduled examination on July 7, 2010. 74.

Based

on

the

foregoing,

Respondent

456.072(1)(q), Florida Statutes (2010), by violating

a

department or the board, or failing to comply with

violated

Section

lawful order of the a

lawfully issued

subpoena of the department. COUNT THREE

75.

paragraphs one

(1)

Section 464.018(1)Q), Florida Statutes (2010), provides

that

Petitioner réalleges and incorporates

through sixty-four (64), as if fully set forth herein. 76.

being unable to practice nursing with reasonable skill and safety to patients

by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any

other type of material or

as a result

of any mental or physical condition

constitutes grounds for disciplinary action. 77.

Respondent is unable to practice nursing with reasonable skill

and safety to patients by reason of illness or use of alcohol, drugs,

narcotics, or chemicals or any other type of material or as a result of any Department of Hea'th v lexandra Livingston, R.N Case Number 2010-00522 2010-03725 3: \PS!J\N ursing\Michael\ACS\Drafted ACs\ACS\LiVinQStOn, Alexandradoc

27

mental, or

physical

condition

as

demonstrated

by

her

behavior.

Respondent's behavior indicates that she actively seeks out ill patients,

attempts to become their nurse, aggréssivthly attempts to obtain their medical records, and if allowed to provide any assistance, becomes possessive and harasses the patients, harasses their health care

providers, and disrupts tha care the patients receive from their health care providers. Respondent continued to show up at Shands properties despite

multiple warnings to stay away and continued to attempt to get patient medical records, after being told by clinic staff, patients, patient family

members, and physicians to cease. Her behavior is disruptive and bizarre. 78.

'

Based on the foregoing,

Respondent has violated Section

4&4.018(1)(j), Florida Statutes (2010), by being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of •alcohol, drugs, narcotics, or chemicals or any other type of material or as

a

result of any mental or physical condition.

,

Department of Health v. Alexandra Livingston, RN. Case Number 2010-00522, 201 0-03725 3: \'PSU\Nursing\Michael\ACs\Drafted

28 Alexandra.doc

WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties

permanent revocation or suspension of Respondent's license; restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

day

201Q.

A

Ana M. Viamonte Rose, M.D., M.P.H.

Assistant General Coun el

K.

S

DOH Prosecution Services Unit 4052 Bald Cypress Way, $in C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0011265 (850)245 - 4640 Telephone (850) 245 - 4683 Facsimile

/MGL PCP: PCP

Members:

Department of Health v. lexandra Livingston, Ri1. Case

Number 2010-00522, 2010-03725

I :\P5U\Nursing\MichaeMCS\Drafted ACs\ACs\Livingston, Alexandra.doc

-

29

NoTIcE OF RIGHTS has the right to requestS,

'.Responde a hearing to conducted in accordance with.: Section 120.569 and. Florida Statutes; to be represented by counsel or other qualified representative, to present evidence and argument, to call and witnesses and, to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which' may include attorney hours and costs, on the Respondent in addition to any other disciplineimposed.

Department of Health 'i. Alexandra Livin9ston, RN. Case Number 2010-00522 2010-0372S J

\PSU\Nursing\Mithaei\ACS\Drafted ACs\ACS\Livinqston, Alexandradoc

30

FILED

DEPARTMENT OF HEALTh

STATE OF FLORIDA DEPARTMENT OF HEALTH

CLERK:

DATE_________

DEPARTMENT OF HEALTH,

Petitioner

-

)

CASE NO. 20 10-00522 &

v.

ALEXANDRA LIVINGSTON, R.N.,

Respondent

2010-03725

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW the Department of Health,

by and

through

undersigned counsel, and moves the Board of Nursing for the entry

of

a

Final Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes (2003). As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter

a

Hnal Order therein.

Section 456.072(4), Florida Statutes (2003),1 states as

2.

follows:

-

3.

In addition to any pther discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or discipline imposed through final order, or 2001, for a citation, entered on or after July violation Of any practice act, the board, or the department when there is •not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries, and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amountof costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

. The

..

investigation and

prosecution of this case, has

resulted in costs in the total amount of $4,054.78, based on the

following itemized statement of costs:

Ch, 2003-416, § 19, Laws ofFla., effective September 15. 2003, amended Section 456.072(4), Florida Statutes (2003), to include the underlined language.

2

Complaint Cost Summary Cost to Date *****

•

!ComplaiUt:

$164.81

Legal:

r

1

j to

Therefore, the Petitioner seeKs an assessment of costs against the Respondent in the amount of $4,054.78 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, withinten (10) days

ofthe date

Of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-flied written objections.

3

5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $4,054.78 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes (2003). WHEREFORE, the Department of Health requests

Board of Nursing enter

a Final

that the

Order assessing costs against the

Respondent in the amount of $4,054.78.

DATED this

-

day

of

I

,

2010.

Respectfully submitted,

I

EL G. LAWRENCE,

R.

Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0011265 (850) 245-4640 Telephone (850) 245-4683 Facsimile

4

CERTIFICATE OF SERVICE

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

S

Motion to Assess Costs has been provided by U.S. Mail this day of

20

2910, to: Alexandra Livingston 5060 SW

Lane, Gainesville, FL 32607.

th

Michael G. rence, Jr. Assistant General Counsel

5

AFFIbAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared JULIE M. WEEKS who was sworn and states as follows: 1) My

name is Julie M. Weeks.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for theConsumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health .care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee Florida 32399-3275.

I

I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida. health care licensees: 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 0-00522 & 2010-03725 (Department of Health v. Alexandra Livingston, R.N.) are FOUR THOUSAND FIFTY-FOUR

HUNDRED DOLLARS AND SEVENTY-EIGHT CENTS ($4,054.78). 6) The costs for DOH case numbers 2010-00522 & 201 0-03725

(Department of Health v. Alexandra Livingston, RN.) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case numbers 2010-00522 & 2010-03725 (Department of Health v. Alexandra Livingston, R.N..) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

I

of2

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Julie M. Weeks, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of her knowledge and belief. FURTHER AFFIANT SAYETI-I NOT.

Weeks, Afffant State of Florida County of Leon

Sworn to and subscribed before me this______ day of by Julie M. Weeks, who is personally tà me.

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

2010,

Page

1

of!.

Complaint Cost Summary Complaint Number: 201000522

Complainant's

SO1.JTHEASTERN INTEGRATED Name: MEDICAL. PL Subject's Name: LIVINGSTON. ALEXANDRA Cost to Date *****

J

Hours•

I

Costs

Investigation: Legal: Compliance:

18.4011

[

1

ISub Total:

lExpenses to Date: Prior Amount: (Total Costs to Date:

11

$73.25]

J

29.8011

.

I

$1,200.301

( l1 1

$2,090.70J

.

8/19/2010

Division rA

Staff Rate

0.10

(1.40

Sub Total

1.20

Sub Total

$6! .04 $61.04

$29.93 $32.13

0.30

0.50

Florida Department of Health

6124 6124 0124

.

1.00

124

0.30 0.50

GI24

124

0124

124

0.70 0.30 0.60 0.20 0.30 0.50 0.30 0.50 0.50 0.50 .1.00

0124 0124 0124 6124 6124 0124 0124

:

.

$65.23

$65.23

$65.23 $65.23 $65.23 $65.23 $65.23

$65.23

$65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23

IINVESTEGATIVE SERVICES UNIT

0.20

1.00

103

HA 103

ICONSUMER SERVICES UNIT

030

I-1C22

HCI3

ICOMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date 08/19/20 10

MQA

Medical Quolily Assurance

$19.57

$65.23 $65.23 $19.57 $32.62 $32.62

$19.57 $32.62 $19.57 $32.62 $32.62 $32.62

$45.66 $19.57 $39.14

573.25

$61.04 $12.21

$12.19

$8.98 $3.2!

Cost

.

.

..

.

4

4

76 76 4 4

4

4

4

76

4

4

4 4 4

4

78 25

116 116

Activity Description

INVESTIGATIVE WORK INVESTIGATIVE WORK INVESTIGATIVE INVESTIGATIVE WORK

.

K ROUTINE ROUTINE ROUTINE ROUTINE

.

INITIAL REVIEW AND ANALYSIS OF REVIEW CASE FILE

.

ROUTINE MONITORING ROUTINECOMPLIANCEMONITOPJNG

201000522

ROUTINE INVESTIGATIVE REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK

Activity Code

- FOR INTERNAL USE ONLY -

02/10/2010 02/10/2010 02/24/2010 03/11/2010 03/15/2010 03/17/2010 03/18/2010 03/29/2010 04/05/2010 04/09/2010 04/12/2010 04/13/2010 04/13/2010 04/22/2010 04/30/20 10 05/03/2010

01/12/2010 02/05/2010

07/22/2010 07/23/2010

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

Co NE IDE NT IAL

.•

.

.

itemizedcost

.

.

.

I

I

.

18.40

$65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23

Staff Rate

1.40

1-ILOIN

IN

Florida Department of Health

HLL38B HLL38B HLL56A

1-ILO

HLL52A

I-ILL56A HLOIN

2.30

HLOIN

0.30 0.10 0.10 0.80 0.10 0.60 0.70 0.50

:1.60

OIN $50.00 $50.00 $50.00 $112.43 $112.43 $50.00 $114.59 $50.00 $112.43 $112.43 $112.43

IE'ROSECUTION SERVICES UNIT

1.20

0.50 0.20

1.00

0.70

1.60

0.20 0.60

1.20

Sub Total

•

0.30

.

•

0.50 0.30 0.70 0.20 0.70 0.10 0.40

flours

0124 0124 0124 0124 0124 0124 0124 0124 0124 0124

129

Gl24 0124 Gl24 0124 0124 0129

Staff Code

Report Date 08/i9/2010

ol MedlcW QualUy As5urunce

$80.00 $115.00 $70.00 $33.73 $11.24 $5.00 $91.67 $5.00 $67.46 $78.70 $56.22

$1,200.30

$45.66• $6.52 $26.09 $78.28 $13.05 $39.14 $104.37 $45.66 $65.23 $32.62 $13.05 $78.28 $19.57

13.Q5

s32:62 $19.57 $45.66

Cost

b

81

81

25 64 25

•

201000522

Activity Description

-

Page 2 of

3

-

ESO/ERO ESO/ERO ESO/ERO TELEPHONECALLS ESO/ERO ESO/ERO REVIEW CASE FILE LEGAL ADVICE/DISCUSSION REVIEW CASE FILE ESO/ERO ESO/ERO

-

itemizedeost

BOARD OFFICE,DEPT STAFF OR ATFY GEN OFF:

I

REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION SUPPLEMENTAL INVESTIGATION ROUTINE INVESTIGATIVE WORK TRAVEL TIME SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE WORK SUPPLEMENTAL INVESTiGATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE TRAVEL TIME SUPPLEMENTAL INVESTIGATION REPORTPREPARATION REPORT PREPARATION

Complaint

-- FOR INTERNAL USE ONLY

06/15/2010 06/16/2010 07/12/2010 07/13/2010

81 81

35

06/08/2010 06/09/2010

81

81

81

06/08/201Q

06/02/2010 06/03/2010 06/05/2010

76 76

6

100 58

6

6 76

4

100

58

6 4

76 4 4 76

Activity Date Activity Code 05/03/2010 05/04/2010 05/04/2010 05/04/2010 06/18/2010 06/22/2010 06/22/2010 06/22/20 10 06/24/2010 06/30/2010 06/30/2010 07/22/2010 07/23/2010 07/23/2010 07/23/2010 07/26/2010 07/27/2010

FIDE NT IAL

Time Tracking System Itemized Cost by Complaint

C ON

—

Assurance

.

$112.43 $112.43 $112.43 $112.43 $112.43 $112.43

0.10 0.20 0.30 0.30 0.30 0.10

10.20

$112.43

Staff Rate

0.40

Florida Department ol Health

Total Cost

Sub Total

HLL38B

HLL4B HLL38B

SB SB

I-ILL56A HLL56A

Stall Code Activity flours

ReportDate 08/19/2010

M

uy

$2,090.89

$805.15

533.73 533.73 $11.24•

$44.97 $11.24 $22.49

Cost

ON F IDE NT IA L

TELEPHONECALLS

90

28

28

81

POST PROBABLE CAUSE PROCESSING

IVECOMPLAINT

ESO/ERO ESO/ERO

ESO/ERO

81

81

Activity Description

INT

201000522

35

- FOR INTERNAL USE ONLY -

07/14/2010 07/14/2010 07/20/2010 07/22/2010 07/26/2010 07/26/2010 08/04/2010

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

C

ilemizecicost

-

.

Page3of3

i

Total Expenses

SubTotal

Expense Date

08/19/2010

Florida Department of Health

Staff Code

Report Date:

MA

Medical Quality

DMsion

mount

Expense

—

Expense Code Description

- FOR iNTERNAL USE ONLY

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

CO NF ID ENT I AL

itemizedexpense

Page 1 of

1

Complaint Cost Summary Complaint Number: 201003725

Complainant's• TJNIVERTSTY OF FLORIDA PD

Name: Suhject's Name: LIVINGSTON, ALEXANDRA ***¼* Cost to Date ***t*fl Costs Fours i .50k

111

Investigation:

21.900

Compliance:

-to

$91.56]

S1,428.6j) S434.92j $9.00I

II

Sub Total:

1

.6011

$1,964.08 $0.00

Date:

IPrior Amount: I

OTIMETRAK!CSDETL.ASP

$1,964.08)

8/19/2010

Staff Rate

1.50

Sub Total

UNIT $61.04

$29.93

0.50 0.50

1.00

0.30

1.00 1.00

0.70 0.40 0.10 0.50 0.20 0.50 0.70 0.50 0.30 0.80 0.50 0.50

Florida Department of Health

124

0124 0124 0124 0124

124 124

0124 0124

G124

0124 0124 0124 0124

124 124

0124

124 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23

1GATIVE SERVICES UNIT

1.50

O3

ES

0.30

Sub Total

ICONSUMER

030

HC22

1ANCE MANAGEMENT UNIT

Stall Code Activity Hours

Report Date 08/19/20 10

MQ

Medicol Quality Assurance

Division

.

.

$45.66 $26.09 $6.52 $32.62 $13.05 $32.62 $45.66 $32.62 $19.57 $52.18 $32.62 $32.62 $65.23 $65.23 $19.57 $65.23 $32.62 $32.62

$91.56

$91.56

$8.98

$8.98

Cost .

.

4 .

04/30/2010

.

201003725

Activity Description

-

RATION

ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINEINVESTIGATIVE WORK WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINEINVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE 1NVESTIGATIVE WORK REPORT ROUTINE INVESTIGATIVE WORK ROUTINE N VESTIGATIVE WORK REPORT PREPARATION ROUTINE.INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK

.

INITIAL REVIEW AND ANALYSIS OF COMPLAINT

.

.

ROUTINE COMPLIANCE MONITORING

.

-- FOR INTERNAL USE ONLY

4

76 4

4

4 4

4

4

76

4

4 4

4

4

4

78

76 4

.

.

116

Activity Code

03/10/2010 03/11/2010 03/15/20 10 03/18/2010 03/29/2010 03/31/2010 03/31/2010 04/05/2010 04/09/2010 04/12/2010 04/13/2010 04/13/2010 04/13/2010 04/21/2010

10

03/05/2010 03/08/2010

03/01/2010

07/22/2010

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

.

.

itemizedeost

..

.

.

I

I

•

21.90

0.30

1.20

.

865.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23

i

$65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23 $65.23

Stall Rate

0.10 0.10 0.20 0.70 0.20

1.40

2.40

1.60

0.40

Florida Department of Health

HLL38B HLL38B HLL38B

HLO IN

HLOIN

IN OIN IN OIN $50.00 $50.00 $50.00 $50.00 $50.00 $50.00 $112.43 $112.43 $112.43

IPROSECUTLON SERVICES UNiT

Sub Total

0124 0124

0.50 0.20

1.00

G124

0.70

0124 0124

0.60

124

•

0.20

.0.50 1.00

1.60

.

•

1.20

040

0.30 0.50 0.70 0.20 0.70 0.10

Activity Hours

0124

124

0124 0124 0124 0124 0124 0129 GI29 0124 0124 0127 0127

lCode

Report Date 08/I 9/2010

MQA

ci Medical Guolily Ass•j,ance

$20.00 $80.00 $120.00 $70.00 $5.00 $5.00 $22.49 $78.70 $22.49

$1,428.60

$19.57 $32.62 $45.66 $13.05 $45.66 $6.52 $26.09 $78.28 $13.05 $32.62 $65.23 $39.14 $104.37 $45.66 $65.23 $32.62 $13.05 $78.28 $19.57

Cost

-

05/26/2010 06/02/2010 06/03/2010 06/05/2010 06/09/2010 06/10/2010 07/08/2010 07/12/2010 07/20/2010

!

81

64 25

81

81

81

1

25

76 76

6

100 58

6

76

6

100

58

4

4 58 100

6

76

4

4 76

Activity Code

201003725

Activity Description

Page 2

of 3

-

lemizedcost

ESO/ERO ESO/ERO ESO/EKO ESO/ERO LEGAL ADVICE/DISCUSSION - BOARD OFFICE,DEPT STAFF OR REVIEW CASE FILE ESO/ERO ESO/ERO

REVIEWCASEFJLE

nY GEN oFF:

I

WORK REPORT PREPARATION ROUTINE INVESTIGATIVEWORK REPORT PREPARATION SUPPLEMENTAL INVESTIGATION ROUTINE INVESTIGATIVE WORK TRAVEL TIME SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE WORK TRAVEL TIME SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASF SUPPLEMENTAL INVESTIGATION REPORTPREPARATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE TRAVEL TIME SUPPLEMENTAL INVESTIGATION REPORT PREPARATION REPORT PREPARATION

IVE

INTERNAL USE ONLY

05/03/2010 05/03/2010 05/04/2010 05/04/2010 06/18/2010 06/22/2010 06/22/2010 06/22/2010 06/24/2010 06/29/2010. 06/29/2010 06/30/2010 06/30/2010 07/22/2010 07/23/2010 07/23/2010 07/23/2010 07/26/2010 07/27/2010

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

•

7.20

0.10

Florida Department of Health

Sub Total

HLL3SB

Stall Code Activity Hours

Report Date 08/19/2010

MQA

Medical Quolily Msmance

OMsion ci

$112.43

Staff Rate

$434.92

$11.24

Cost

ON FIDE

TIAL

201003725

-

STIPULATION

Complaint

-- FOR INTERNAL USE ONLY

.

79

Activity Date Activity Code 08/05/2010

N

Activity Description

Time Tracking System Itemized Cost by Complaint

C

itemizedcost

Total Expenses

SubTotal

Expense Date

Florida Department of Health

Stall Code

Amount

Expense

-

l

-

Expense Code Description

INTERNAL USE ONLY

Expense Code

MQA

Report Date: 08/19/2010

Time Tracking System Itemized Expense byComplaint Complaint

***CONFIDENTIAL***

Divsion Medical Qualily A,surance

.

ilernizedexpense

Aim M. Viaznonte Ros, M.D., M.P.H.

Charlie Crist Governor

State Surgeon General

,,

AFFIDAVIT

I,

Deputy

for

Clerk

the

Department Clerk's Office, hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive

pleading, which requests

regarding Alexandra

& 2010-03725

me,

hearing pr!or to any Department action CASE NUMBERS

2010-00522

.which would affect the Respondent's substantial interests

or rights.

Before

a

personafly

appeared

.

fñid

A

,

whose

identity is known to me by personally known (type of identification) and who, under oath, acknowledges that his/her signature appears above. Sworn

o

and

subscribed

before

me

this

Notary Public

EXPIRES 911/2013 eONDEDmRU

Prosecution Services Unit

.

4052 Bald Cypress Way! Bin C-65

•

Tallahassee, FL 32399-3265

day

of

Charlie Crist

Ana M. Viamonte Ros, M.D., MPH State Surgeon General

Governor

I,

Joe Baker. Jr.

.

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure. files that the Board of Nursing as

/20

of

has no evidence of an Election of Rights form or

10

other responsive pleading requesting a hearing prior to any agency action regarding Alexandra

& 2010-03725

Livingston, R.N., CASE NUMBERS

which would affect the Subject's substantial interests or rights.

of Record4j Florida Board of Nursing Before me, personally appeared

identity

is known

Joe Baker.

.

whose

to me personally (type of identification) and who, under, oath,

acknowledges that his/her signature appears above. •Sworn to and subscribed

is

18

day of

August

,

2010.

Notary Public

I

Prosecution Services

.

4052 Bald Cypress Way, Bin C-65

. Tallahassee,

EL

32399-3265

I

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Ana M. Viarnonte Ros, M.D.,

Charlie Crist Governor

MPH.

State Surgeon General

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health/ESO —A1A-(ML)

FROM:

Board of Nursing! Central Probable Cause Panel

SUBJECT:

ALEXANDRALIVINOSTON, RN

DATE OF PROBABLE CAUSE MEETING:

This matter was brought before

a

CASE NO.: 2010-00522 & 2010-03725

AUGUST

2,

2010

Probable Cause Panel composed of:

CLAYDELL HORNE, CHAIR and STEPHEN BOWEN, CONSUMER

on the date set forth above! The panel, having received the investigative report and supplemental

materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that: X

Probable cause exists herein that the Subject violated the following statutes/rules: FS 2009 by rule 64B9-8.005(2) FAC CT-2 456.072(1)(q) FS 2010 CT-3 464.018(1)0) ES 2010

CT-i 464.01 8(1)(H)

The panel suggests imposing the following penalty: Reprimand, Costs! V2

Probable cause does not exist and the case should be closed with the following closure code: finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question: lieu of

a

The panel has requested supplemental or additional information on the following:

Prosecution Services unft • 4052 Bald Cypress Way, Bin # C-65 • Tallahassee, FL 32399-3265 Telephone (850) 245-4640 • Telefax (850) 245-4683

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CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

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CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

No ëcehTed For Scanning/Imaging Image

4

Rick Scott

Mission:

e

Governor

To protect, promote & improve the health

ofaflpeopieinflohdalhroughhitegrated

John H. Armstrong, MD,

State Surgeon General & Secretaiy

IIEAJ.i11 Vision: To be the

Healthiest State

in the Naflon

NOTICE OF HEARING

November 8, 2013 Case#: 201206792 To:

IVON M PEREZ

29525 DELAWARE RD HOMESTEAD, FL 33033, FL YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

4401/201206792

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

.

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under sIPlacefl If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Fiorida Department of Hoaith Division ol Medical Quality Assurance • Board of Nursing 4052 Baid Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 850/ 245-4125 • FAX 8501245-4172

www.FiorldasHeaith.gov TWiTTER:HealthyFLA FACE600K:FLDepartmentof Health yOuTuBE: fldoh

-

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

John H. Annstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be The

lthiest State in the Nation

MEMOR AND UM FROM:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Judson Searcy, Assistant General Counsel

RE:

Determination of Waiver

SUBJECT:

DOH v.

TO:

lyon

M

9

Perez, C.N.A.

.

DOH Case Number 2012-06792

DATE:

.

.

.

SeDtember 16, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5,2013rneeting of the board. The following information is provided in this regard.

Subject: Subject's Address of Record: Enforcement Address:

lyon

M Perez 29525 Delaware Rd Homestead, FL 33033

Subject's License No: Licensure File No:

29525 Delaware Rd Homestead, FL 33033 39657 Rank: CNA 355090

Initial Licensure Date:

3/12/2004

Board Certification: Required toAppear: Current IPN/PRN Contract:

No

Allegation(s):

464.204(1)(b), 456.072(1)(ii),

Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

Florida Department of Health Unit Office of the General Counsel Prosecution 4052 Bald Cypress Way. Bin C-65 • Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Sufte 105 PHONE: 8501245-4444 • FAX 8501245-4683

No No FS FS

(2012). (2012)

None May 31, 2013; Home & Bryant Pro Se

Department Of Health/Consumer Services Unit

www.FloridasHealth.com TWIflER:HealthyFLA FACEBOOK:FLDepartmentof Health VOUTUBE: fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, CASE NO.

v.

2012-06792

IVON M. PEREZ, C.N.A.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

31, 2013.

An Administrative Complaint was filed against Respondent on May

A copy of said

is

attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified. US mail on June 19, 2013

(7196 9008 9111 8826 9045). A copy of the certified

mail receipt is attached as Petitioner's Exhibit B.

3.

Rule

28-106.111(2),

Florida

Administrative Code,

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received, written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights. form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C and D. 6.

Based upon the foregoing, Respondent has waived the. right to

dispute ahy materials facts contained within the Administrative Complaint.

Therefore, there are. no disputed issues of material fact to be resolved by the .

Board. 7.

.

.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final Order imposing

whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

sistant General Counsel Fla. Bar No. 0098772 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 xSlOO Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

-

I HEREBY CERTIFY that foregoing

has

been

true and correct copy of the above and by± U.S. mail clay of 2013, to lyon M. Perez, 29525 Delaware Road, a

FL 33033.

Searcy Athistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH.

DEPARTMENT OF HEALTH,

PETITIONER, CASE NO.

2012-06792

M. PEREZ, C.N.A.,

RESPONDENT.

/ ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and flies this Administrative Complaint before the Board of Nursing against Respondent, lyon N. Perez, C.N.A., and in

support thereof alleges: Petitioner is the state agency charged with regulating the

1.

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

-

At

air

Respondent was

a

material

to

this

Administrative

Complaint,

certified nursing assistant (C.N.A.) within the state of

Florida, having been issued license number CNA 39657.

3.

of

Respondent's address

record is 29525

Delaware Road,

Homestead, Florida 33033. 4.

On or about January 24, 2013, in the United States District

Court of the Southern District of Florida, in case number 12-20291-CR,

Respondent entered a plea of guilty to one (1) count of Conspiracy to Receive and Pay Health Care Kickbacks relating to the Medicaid Program,

violation of 18 U.S.C. 5.

Section

in'

371.

464.204(1)(b),

Florida

Statutes

(2012),

provides

intentionally violating any provision of chapter 464, chapter 456, or the rules adopted by the board, constitutes grounds 6.

f& disciplinary action.

Section 456.072(fl(ii), Florida Statutes, (2012), provides that

being convicted of, or entering a plea of guilty or

nob

contendere to, any

misdemeanor or felony, regardless of adjudication, under 18 U.S.C.

§ 371

relating to the Medicaid Program, constitutes grounds for, disciplinary action. Respondent entered

a

plea of guilty to Conspiracy toReceive

and Pay Health Care Kickbacks relating to the Medicaid Program, a violation

of 18 U.S.C.

§

371, on or about January 24, 2013.

Departiicsjt of Health V. Ivan Case Number 20 12-06792

I. Perez, C,N.A.

2

Based

8.

the

on

foregoing,

Respondent

violated

Section

464.204(1)(b), Florida Statutes (2012), by intentionally violating Section 456.072(1)(ii), Florida Statutes, (2012), by being convicted of, Or entering a

plea

of guilty or

nob

contendere to, any misdemeanor or felony,

regardless of adjudication, under 18

.C.

§

371 relating to the Medicaid

Program.

Department of v. yon M. Perez, Case Number 2012-06792

,A.

3

WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of .a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief

that the

Board deems appropriate.

SIGNED

this S Li+ day of John

_, FiLED

DEPARTMENT OF HEALTh DEPUTY CLERK

,

2013.

Armstrong, MD, FACS State Surgeon General and Secretary of Health H.

IN

SE.4RCY

;istant General Counsel Fla. Bar No. 0098772 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 ex. 8100 Facsimile: (850) 245-4683 Email: [email protected]

PCP:

PCP

Members:

Departnent or Healthy. lyon Case Number 2012-06792

lvi.

1-

C.N.A.

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be: conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine withesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOflCEREGARDING ASSESSM.ENTOFcogrs Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Healthy.

an M. Perez, C.NA.

Case Number 2012-06792

7196 9008 9111 8826 9045 TO:

lyon M. Perez, CNA 20 12-06792 ab-Stip Pk Sent 6/12/13

REFERENCE:

.

lyon M. Perez 29526 Delaware Road: Homestead, FL 33033

POSTMARK OR DATE

Receipt for

Certified Mair No Insurance Covarage Pravided Do NN Use tar Inhemelionel Mail

..

2. Article Number

I

I i If!

i

Received by (I-lease Print Clearly)

II

--7196 9fl0& 9111 8826 9045 3. Service Type

CERTIFIED MAILIM

Lives

Fee) 1.

Article Addressed to

-

-

L

;-ç?,ifl

)

wirc Road

115

fL

—

3

N PS Form 3811 January 2005

Domestic Return Receipt

t,

Rick

Governor

Mission: To protect promote & improve the hea'th

state,

John H. *nnstrong,

State Surgeon Genetal

efforts.

&

FACS

& Secretary

HEALTH Vision: To be the Heaitlüest State in the Naten

,

Affidavit of Non-Receipt

William Spooner

I,

,

hereby certify in my official capacity as

that the Board, as of custodian for the Board of Nursing's licensure files 9/17/2013

,

has no

evidence of an Election of Rights form or other

agency action regarding responsive pleading requesting a hearing prior to any

Perez. C.N.A.: rights.

yon M.

or which would affect the Subject's substantial interests

Custodian of Reedrds

Florida Board of Nursing Before me, personally appeared

William SpoOner

,

whose identity is

that his/her signature known to me personally and who, under, oath, acknowledges appears. above.

Sworn to and subscribed before me this

17

day of

September ,2013.

Notary Public Signature My commission expires:

rida D.part.nsnt of Hnlth

Olfrce of the GenerS

services unk

ICH

_____________________

Minion:

y

Rick Scott Governor

To protect promote & improve the heald, of all peope in through integrated state, county & effort.

John H. Annetrong, MD, FACS

,

State Surgeon General & Secretary

HEALTH

Vision: To be he Health jest State

In

the Nation

AFFIDAVIT

ñrcd

%ncW

Office,

Deputy Clerk for the Department

Clerk's

certi& in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has Pot received an Election of Rights fonn or other responsive pleading, which requests a hearing prior- to any Department action regarding lyon M. Perez, C.N.A.;

substantial interests or rights.

which would affect the Respondent's

Custodia Record Department Clerk's Office Before me, personally appeared known to me personally and who,

,

1

whose

is

oath, acknowledges that his/her signature

appears above,

Sworn to and subscribed before me this

.2013.

L2iaaga Notary Public ANGELA BAATON

My Commission Expires: \04

Commussioti

0

FE

-

—

49339

BaC$1Ivm#NtaWJSSC

Floulda Department of Health

1

Office of the General Counsel' Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 'Tallahassee FL PHONE: 85012454444 'FAX 850/2454683

EXHIBIT

STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO.. 2012-06792

v. IVON M. PEREZ, C.N.A., Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW the

Department of Health, by and through

undersigned counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petiticner states the following.: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter a Final Order therein. 2.

.

.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

,

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to but the_investigation and prosecution are not limited to. salaries and benefits of personnel. costs related to the time spent by the attorney and other personnel working on the any other expenses incurred by the department for the case. The board, or the deDartment when there is no board, shall determine the amount of costs to be assessed after its consideration 'of an affidavit of itemized costs and any written obiections

3.

.

The investigation and

prosecution of this case has

resulted in costs in the total amount of $2,288.22, based on the

following itemized statement of costs:

***** Hours

laint: Investigation:

Sub Total:

Expenses to Date:

Cost to Date

1 1 I

1

Costs $122.96J

$1,060. $1,084.83

0.05

$1.67

29.45

$2,269.60 $18 62 •

Prior Amount:

to

$0.00

$2,288.22

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $1,203.39 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs; within ten (10) days of the

of this

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

,

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $1,203.39 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section

Florida Statutes.

WHEREFORE, the Department of Health requests that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $1,203.39.

3

DATED

thislt)kilday of Respectfully

s

bmitted,

.$4son Searcy General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0098772 (850) 245-4444 x8100 Telephone (850) 245-4683 Fax

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY

that

a

true and correct copy of the

foregoing Motion to Assess Costs has been prOvided by U.S. Mail this day of

2013, to lyon Perez, 29525

Delaware Road, Homestead, FL 33033.

Searcy General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared SCOTT FLOWERS who was sworn and states as follows: 1)

My name is Scott Flowers.

2)

of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Senior Management Analyst II (SMAll) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

am over the

I

I

I

4) As SMAll of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs

i

regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH

case number(s) 2012-06792 (Department of Health v. IVON M. PEREZ) are TWO THOUSAND TWO HUNDRED EIGHTY-EIGHT DOLLARS AND TWENTY-TWO CENTS ($2,288.22).

6) The costs for DOH case number(s) 2012-06792 (Department of Health v. IVON M. PEREZ) are summarized in Exhibit 1 (Cost Summary - Report), which is attached to this document. 7) The itemized costs and expenses for DOH case number(s) 201206792 (Department of Health v. WON M. PEREZ) are detailed in

Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

8) The itemized costs as reflected in Exhibit 2 are

I

of2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into.the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9)

Scott Flowers, first being duly sworn, states that he has read the foregoing Affidavit and its attachments and the statements contained therein-are-true-and- correct to--the-best-cf-her-knowledge

FURTHERAFFIANT SAYETH NOT.

Scott Flowers, Aftiant.

State of Florida County of Leon

-

-

day of Sworn to and subscribed before me this t'R by Scott Flowers, who- is personally known to me.

Notary Signature

Name of Notary Frinted

-

Stamp Commissioned Name of Notary Public:

2

of 2

2013,

Page

1

of

1

Cost Summary Complaint Num her... 201 PEREZ. 1VON M

Subject's Name:

***** Cost

to Date

1

lours

.

Costs

!

SI 22.961

Si. ,060.i.4

investigation: Legal:

,05

[

51.67

**********

H Sub Total: Expenses to Date;

Prior Amount: Total Costs to Date:

S2,269.60

[

)

1 .22 $18.62

.

1

EXHIBIT

i http://mqaapps.doh.state.fl.us/IRMO0TIMETRAK/CSDETL.ASP

9(16/2013

oF

I

196

1.10

1.70

2.70

0.90

2.10

0.90 0.40

Florida Department of Health

Ml 196

M

Mi28 $63.98 $63.98 $63.98 $63.98 $63.98

$63.98 $63.98

ENVESTIGATIVE SERVICES UNIT $57.58 $25.59 $134.36 $57.58 $172.75 $108.77 $70.38

$325.76

144

/25/2013

5.80

144

01/09/2013 .

$10.98 $21.96

$54.90

$54.90

Sub Total

HA73

1/08/2012

6 58

76

4

58 4 4

201206792

,

Activity Description

TRAVEL TIME ROUTINE NVESTIGATIVE WORK. ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION SUPPLEMENTAL INVESTIGATION TRAVEL TIME

.

REPORTPREPARATLON PREPARATION OF DESK INVESTIGATION SYNOPSIS CSU INVESTIGATIVE WORK CSU INVESTIGATIVE WORK

PRELIMINARY INVESTIGATION ROUTINE NVESTIGATLVE WORK REVIEW CASE FILE PRELIMINARY INVESTIGATION PRELIMINARY INVESTIGATION CSU INVESTIGATIVE.WORK CSU INVESTIGATIVE WORK OSU INVESTIGATIVE WORK

.

ICENSESTATUSCI-IANGE

- FOR INTERNAL USE ONLY--

05/01/2013 05/01/2013 05/0 1/20 13 05/02/2013 05/02/2013 05/17/20 13 05/28/2013

0

I

$49.41

144

144

144

7

7

4 25

7

$54.90

.

125

Activity Code

76 77

05/03/2012 05/04/20 12 06/13/2012 09/28/20 12 09/28/2012 10/05/2012 10/23/20 12 11/01/2012

05/I5120l3

.

Activity Date

II/02/20l2

1A73

0.50 0.30 0.50 0.80

SI 1.52

$11.52 $17.29

$28.81

$1.67

81.67

Cost

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFIDENTIAL***

¶57.62 $28.81 $16.47 $27.45 $43.92

0.90 0.20 0.40

HA73 HA73 HA73 UA73

1A57 1A73

1-IA57

1.00

$57.62 $57.62 $57.62 $57.62 $57.62 $54.90 $54.90 $54.90

0.20 0.30 0.20

.

HA23

1A57

$57.62

0.50

IT

$33.33

I-1A57

SERVICES

0.05

Sub Total

ER

0.05

1C27

iT

Staff Rate

COMPLIANCE MANAGEMENT

Staff Code Activity Hours

Report Date 09/16/2013

MQA

MedIcol Quolily &ssurance

I

.

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EXHIBIT

,

Page

.

13.40

0.20

1.20

0.20 0.30 0.40 0.50 0.60 0.60 0.10 0.40 0.20 0.30 0.90 0.40 0.30 0.50

0.20 0.20

Florida Department of Health

ILL96B

I-ILL96B I-ILL96B HLL96B

1-ILL96B

I-ILL96B HLL96B FILL9OA HLL96B FILL96B EILL96B

ILL96B

.

0.40

HLL96B I-ILL96B HLL96B HLL96B

I-ILL96B HLL96B

$106.35

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FILL96B

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

$106.35

5106.35 5106.35 $106.35 $106.35

0.30 0.20 0.40

0.30

-ILOIN HLOIN HLL96B HLL96B HLL96B

0.40 .

$108.77

$63.98 $63.98

25 25

04/02/2013 04/03/2013 04/03/2013 04/03/2013 04/03/2013 04/23/2013

ESO/ERO ESO/ERO REVIEW CASE FILE PREPARE OR REVISE ADMINISTRATIVE COMPLAINT PREPARE OR REVISE ADMINISTRAT1VE COMPLAINT

- FOR INTERNAL USE ONLY

28 28

25

81

81

6

25 64

64

25

103

6

60 25

ION

60 115

11/29/2012 01/09/2013

$21.27 $42.54 $53.18 $42.54 $21.27 $21.27 $21.27 $31.91 $42.54 $53.18 $63.81 $63.81 $10.64 $42.54 $21.27 $31.91 $95.72 $42.54 $31.91 $53.18 $127.62

04/30/2013 05/07/2013 05/07/2013 05/08/2013 05/08/2013 05/08/2013 05/08/2013 05/08/2013 05/09/2013 05/16/2013 05/16/2013 05/17/2013

PREPAREORREVISEMEMORANDUM INITIAL REVIEW AND ANALYSIS OF COMPLAINT

78

11/19/2012

$31.91

itemizedcost

CONTACT WITH INVESTIGATQRS REVIEW CASE FILE REVIEW CASE FILE MISCELLANEOUS LEGAL ADVICE/DISCUSSION - BOARD OFFICE,DEPT STAFF OR ATTY GEN OFF. SUPPLEMENTAL INVESTIGATION MISCELLANEOUS REVIEW CASE FILE SUPPLEMENTAL INVESTIGATION REVIEW SUPPLEMENTAL REPORT REVIEW•CASE FILE -BOARD OFFICE,DEPT STAFF OR ATTY GEN OFF LEGAL RE VIEW CASE FILE LEGALADVICE/DISCUSSION- BOARDOFFICE,DEPTSTAFFORATTYGENOFF SUPPLEMENTAL INVESTiGATION

REVIEW CASE FILE

26

I

TRAVEL TIME SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE REPORT PREPARATION

25

60 64 6

Page 2 of 3

SER VICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE

Activity Description

11/15/2012

76

100

58

100

Activity Code

201206792

11/15/2012

06/03/2013 06/12/2013

05/28/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

CONE ID E NT IAL

$31.91

$42.54

5857.34

$12.80

Cost

$63.98

Staff Rate

IF'ROSECUTION SERVICES UNIT

Sub Total

M1196

1196

196

Staff Code Activity Hours

Report Date 09/16/2013

Quolfty t..ssu,ance

ol

10.20

Sub Total

Florida Department of Health

Total Cost

-ILL96B

0.10 0.30

ILL96B

Staff Code Activity Hours

Report Date 09/16/2013

Medicul Ouolity Assurance

DVISIOO ol

$106.35 $106.35

Staff Rate 63

05/31/2013 06/06/2013

$10.64 $31.91

$2,269.60

ID E

NT IA L

201206792

Activity Description

.

Page3of3

itemizedoost

PRESENTATION OF CASES TO PROBABLE CAUSE PANEL MISCELLANEOUS

Complaint

- FOR INTERNAL USE ONLY

60

Activity Code

Activity Date

Cost

S1,084.83

NF

Time Tracking System Itemized Cost by Complaint

CO

Assurance

Expense Date

09/16/2013

$18.62

Total Expenses

862

$18.62

SI

Amount

Expense

SubTotal

05/28/20 13

Florida Department of Health

ILL96B

PROSECUTION SERVICES UNIT

Staff Code

Report Date:

MO

Mecikot

Divicionc4

LEGAL & OFFICLAL ADVERTISEMENTS

Expense Code Description

Complaint 201206792

- FOR INTERNAL USE ONLY -

133100

Expense Code

0NFIDENTIAL

Time Tracking System Itemized Expense by Complaint

xxx C

.

1

of I

izedexpense

Page

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Rick Scott

Mission: -

To protect, promote & improve the health of all people in Rorida through integrated

-:'-.

-r

Govemor

-

John H. Armstrong, MD, FACS

slate, county & community efforts.

State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest State in the Nation

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO: Department of Health FROM: Board of Nursing, Special Probable Cause Panel SUBJECT:

Ivan

M. Perez, C.N.A. CASE NO.: 2012-06792

DATE OF PROBABLE CAUSE MEETING: May 31, 2013

This matter was brought before

a

Probable Cause Panel composed of:

Claydell Hot-ne, RN &

ody Newman

Bryant, EdD, EdS

A-3 (3 S)

The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that:

Probablecause exists herein that the Subject violated the following statutes/rules: Section ,204(1)(b), Florida Statutes (2012), by violating Section 456.072(1)(ii), Florida Statutes (2012)

The panel suggests imposing the following penalty: VS

_Probable

cause does not exist and the case should be closed with the following closure code:

_In lieu of a finding of probable cause, the above named licensee shall be issued

a

letter of guidance to

address the conduct in question:

The panel has requested supplemental or addftional information on the following:

Other___________________________

L,&L/

i

CHAIRPERSON, PROBABLE CAUcE PAN EL BOARD OF NURSING

Florida Department of Health Office of the General Counsel • Prosecution Services Unit 4052 Bald Cypress Way, Bin 0-65 • Tallahassee, FL 32399-1701 Express maH address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 ext 8103• FAX 850/245-4683

www.FioridasHeaith.com TWI1TER:HealthyFLA YOUTUBE: fldoh

—

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

PLORIDA DEPARrMENT OF

IHEALT

INVESTIGATIVE REPORT Office:

CONSUMER SERVICES

Date of Complaint: November 1, 2012

Case Number:

CNA 2012-06792

Subject:

Source:

IVON Ni. PEREZ, CNA

CONSUMER SERVICES UNIT 4052 BALD CYPRESS WAY, BIN #C-75 TALLAHASSEE, FLORIDA 32399-3265 (850) 245-4339

29526 Delaware Road

Homestead, FL 33033 (305) 248-5046 License #:

Prefix:

: CNA

39657

Profession:

Board:

Report Date:

Certified Nursing

Nursing

November 8, 2012

Assistant

eriod of Investigation:

Type of Report:

November 2, 2012 through November 8, 2012

FINAL

Alleged Violation: Possible violation of 55. 456.072(1)(c)(dd)(ii)(Il) 464.018(1)(c)(o) 464.204(1)(b), F.S. 42 U.S.C. ss. 1320a-7b(b)(1) conviction of a crime; violating statute/rule; guilty plea for 42 U.S.C. ss.1320a-7b relating to Medicaid; gully plea for health care fraud This investigation is predicated from CONSUMER SERVICES UNIT providing US Department of ,.Justice News Release titled "Fifty-nine South Florida Residents Charged as Part of Nationwide Coordinated Takedown by Medicare Fraud Strike Force Operations. PEREZ charged with conspiracy to receive and pay health care kickbacks in exchange for referring Medicare beneficiaries to Health Care Solutions Network (HCSN). On October 26, 2012 PEREZ entered a guilty plea forfederal health care fraud. (Ex. #1) PEREZ was notified of this complaint by certified letter dated November 2, 2012 sent to PEREZ'S address of record by INVESTIGATOR SHONDRA WATSON. (Ex. #2) Forwarded with this letter was a copy of the UCF and the initiating documents including a copy of the Plea Agreement from the United States District Court, Southern District of Florida. (Ex. #1) DOH computer information reflects the status of PEREZ'S license to practice as the State of Florida is Clear and Active.

a

Certified Nursing Assistant in

No patient identified in criminal case, therefore patient notification was not required.

PEREZ is not known to be represented.

PEREZ response will be forwarded to the Prosecution Services Unit upon receipt. (Ex. #3)

Related Case:

,$igator/Date: Shondra A. Watson, Government Analyst, Distribution:

Approved By/Date:

I

-73)

Nicole Singleton, OMC Manager

Prosecution Services Unit/Consumer Services Unit

:j

1)

:

2)

Copy of Notification letter

DOH INVESTIGATIVE REPORT

CASE NUMBER CNA 2012-06792

TABLE OF CONTENTS

I.

INVESTIGATIVE REPORT COVER PAGE

TABLE OF CONTENTS II.

III.

1

2

INVESTIGATIVE DETAILS

Summary of Records

3

Statement of PEREZ(Subject)

3

EXHIBITS

Complaint Form and attachments

4-27 28-29

DOH INVESTIGATIVE REPORT

CASE NUMBER CNA 201 2-06792

INVESTIGATIVE DETAILS SUMMARY OF RECORDS Exhibit #1 contains:

• • •

A Uniform Complaint Formsigned by INVESTIGATOR WATSON on November 2, 2012. Complaint from Consumer Services Unit Media Analyst dated May 3, 2012. Copy of Plea Agreement entered on Docket on October 26, 2012 and received November

1,2012. Exhibit #2 contains: •

Copy of certified letter dated November 2, 2012 from INVESTIGATOR WATSON sent to PEREZ'S address of record.

STATEMENT OF IVON M. PEREZ, CNA- Subject Mailing Address on Correspondence: 29526 Delaware Road Homestead, FL 33033 PEREZ'S response will be forwarded to the Prosecution Services Unit upon receipt.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

em

cfQ

et\

Rick Scott

Mission: To protect, promote of at

&

improve the healTh

in Hodda

through integrated

Governor

John

L11I Vision:

To be the Healthiest State

H.

Annstrong, MD, FACS

State Surgeon General & Secretary

in The

Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201302958 To:

NIKITA NICHOLLE GOODSON 519W NOBLE AVE BUSHNELL, FL 33513. FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

4401/201302958

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materiars to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health

/

Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 8501 245-4125 • FAX 245-4172

www.FiorldasHeaith.gov TWIITER:HealthyFLA

oepartmentofHealth YOUTUBE: fldoh

____________

Rick Scott

Mission: To protect promote & improve the health through integrated of all people in state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General

HEALTH Vision:

&

Secretary

To be the Healthiest State in the Nation

flE MORAN D U M TO: FROM:

Joe Baker, Jr., Executive Director, Certified Nursing Assistants Kristal Beharry, Assistant General Counsel n.j

RE:

Determination of Waiver

SUBJECT:

DOH v. Nikita Nicholle Goodson, C.N.A. DOH Case Number 2013-02958

DATE:

October 14, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Subject: Nikita Nicholle Goodson, C.N.A. Subject's Address of 519 W Noble Ave. Record: Bushnell, FL 33513 Enforcement Address 519 W Noble Ave Bushnell, FL 33513

Subject's License No: Licensure File No:

159138

Initial Licensure Date:

11/20/2007

Board Certification: Required to Appear: Current IPN/PRN Contract:

None

Allegation(s):

Count 1: Section 464.204(1)(b), ES. (2012), by

Rank: CNA

434483

No

None

intentionally violating Section 456.072(1)(c), F.S. (2012); Count 2: Section 464.204(1)(b), F.S. (2012), by intentionally violating Section 456.072(1)(x), F.S. (2012).

Prior Discipline: Probable Cause Panel

None

June 28, 2013 Home & Newman

Subject's Attorney:

Pro Se

Complainant/Address:

Visiting Angels Home Health Care Attn: Ruth Bridger 1009 East Avenue

Fiortda Dopsrtment of Health Office ci the General Counsel • Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row— Suite 105 PHONE: )245-4444 • FAX 850/245-4683

www.FiorldasHeaith.com TWITTER:HeaIthyFLA FACEBOOK:FLDepartmentofl-iealth YOUTUSE: fldch

Clermont, FL 34711

_________________________________________________________I

STATE OF FLORIDA

BOARD OF NURSING DEPARTMENT OF HEALTH, Petitioner,

CASE NO.

v.

2013-02958

NIKITA NICHOLE GOODSON, C.N.A., Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

An Administrative Complaint was filed against Respondent on July 1,

2013. A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were sent to Respondent via certified US mail on:

July 3, 2013 ( Have

questions? We're here to help.

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10/2/2013

Rick Scott

Mission

Governor

To protect, promote & improve the health of all in Florida Through integrated state, county & community efforts.

John H. Armstrong, MD, FACS

UCt HEALTh Vision: To be

State Surgeon General & Secretary

the Healthiest State in the Nation

AFFIDAVIT OF SERVICE

ida Department of Health Petitioner vs

Lone Ann ASIFOR-TUOVO, Respondent

.

Case No.201301.204

COMES NOW) the affiant, who first being duly sworn, deposes and states: 1) Affiant is an Investigator/Inspector employed by the DEPARTMENT OF HEALTH, State of Florida. 2) That on date) 08/28/2013 Affiant made a diligent effort to locate Respondent, to serve, to servex Administrative Complaint and related papers; — Order compelling examination(s); order; to cease and desist; ESO/ERO and related papers. 3) Check applicable answer below:

made. personal service on Respondent or on some person at Respondent's usual place of abode over the age of 15 residing there) on (date)

0

Affiant was unable to make service after searching for Respondent at: (a) all addresses for Respondent shown in the DOH investigation of the case; (b) all official addresses for Respondent shown in his licensing records on the computer terminal or Board office; (c) Local telephone company for the last area Respondent was known to frequent; and (e) Utilities (electric, cable, etc.); any others:

Affiant State Of Florida County Of Leon Before me, personally appeared Sherri Cannon whose identity is known to me by personally (type of identification) and who, acknowledges that his/her signature appears above.

Sworn to or affirmed by

a

P

I

efore me this

blic-State of Florida

Type or Print Name

28

day of

Auaust

201

3_.

My Commission Expires

L KENNEDY Commission # EE 052342 -P ExpiresJanuary 16 2015 J.

So,WS

4052 Bald Cypress Way, Bin C-70 'Tafahassee, FL 32399-1 700 PHONE: 850/413-0023 FAX 850/413-9718

--

liru

lth VOUTUSE: fldoh

Mission:

John H.

Joe Baker, Jr

,

Governor

MD, FACS

State Surgeon General& Sectetary

HEALTH

Vision: To bethe Healthiest

I'

r

, .

the health To protect promote & of all people in Flerida through integrated & community efforts. slate,

Rick Scott

State in the Nathn

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure files that the Board of Nursing as

9/30/2013

of

has no evidence of an Election of Rights form or

other responsive pleading requesting. regarding

NUMBER Or

rights.

Case

a

LORIE ANN

R.N.. CASE

which would affect the Subject's substantial interests

Flori

Before me, personally appeared

identity is known to me

hearing prior to any agency. action

a

of Records Board of Nursin whose

Joe Baker, Jr (type

oersonallv

of

identification)

and

who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this

30

day of

SeDtember

2013.

Notary Public

.com

Florida Department of Health Counsel • Prosecuflon Servoes Unit Office of the 4052 Bald Cypress Way, Bin C-65 - Tailehassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PRONE: 850/245-4441 • FAX 850/245-4683

TWFITER:HeaIthyFLA FACEBOOK:FLfleparUnentofl-lealth VOUTUBE: fldoh

EXHIBIT

—

Rick Scott

I

Minion: To protect, promote & improve the health of all people in Flodda through integrated & community efforts. state,

Governor

John H. Annetrong, MD, FACS State Surgeon General & Secreta'y

HEALTH

—

Vision: To be the

Healthiest State in the

AFFIDAVIT Deputy Clerk for the Department Clerk's

I,

certify in my official capacity as custodian for the Department Clerk's of Rights form records, that the Department Clerk's Office has not received an Election Department action or other responsive pleading, which requests a hearing prior to any Office,

2013regarding Case Name, LORIE ANN ASIFOR-TUOYO, R.N., Case Number 01204, which would affect the Respondent's substantial interests or rights.

Custodian of Record Department Clerk's Office

Before me, personally appeared

identity is known to

-

me by personally known (type of identification) and who, under oath, acknowledges

that his/her signature appears above. Sworn to and subscribed before me this

day

of______

Notary Public I' RENADACONr RedO-) of Stat. N*Vy Public

My Commission -Expires:

My Comm.

Ejpltfl Nov 9. 2016k # U fl4542 p

CommIutlon

Florida Department of Health Office of the General Counsel • Prosecuthn Services Una 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL Express mail address: 2585 Merchants Row— Suite 105 F&X 850/245-4683 PHONE:

.1701

T

www.FiorIdasliealth.cOm

:HealthyF entoiHealth

LA

VOUTUBE: fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner,

) CASE NO.

v.

LQRIE ANN ASIFOR-TUOYO, R.N.,

Respondent.

2013-01204

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, by and through the

.

undersigned counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent

the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter 2.

a

Final Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through linal order, or.citation, entered on or after July 1, 2001, pursuant.to this section or discipline imposed through final Order, or citation, entered on or after July. 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to. salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board. shall determine the amount of costs to be assessed after its consideration of an. affidavit of itemized costs and any written obiections

3.

.

.

.

The investigation and

prosecution of this case has

the

resulted in costs in the total amount of $910.26, based

following itemized statement of costs: *****CostthDath*****

.

[

Hours

laint: Investigation: Legal:

f

COStS

1 .

[ j

.

.

sub Total:

3.30

$350.98J

0.05

1.611

12.35

$910.26

Expenses to Date:

$ 0 00

Prior Amount:

$0.00

$910.26 I

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of. $559.28 as evidenced in the attached

affidavit. (Exhibit A). 4.

...

.

.

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,.

specifying the grounds for the objections and the specific elements of

the costs to which the object bns arEmade, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $559.28 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $559.28.

3

DATED this

day of

6a4cv

,

2013.

Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

li-Ann V. Jofrmnsonl ;sistant Genthral CqLinsel H Prosecution'sefvices Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar #0073525 (850) 245-4444 telephone (850). 245-4683 facsimile

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this

of

2013, to: Lone Ann Asifor-Tuoyo, R.N.,

8669 Alexandrite Court, Tallahassee, Florida 32309.

Jodi-Ann V. John on Assistant G er Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTYOF LEON:

BEFORE ME, the undersigned authority, personally appeared ELISA FLOYD who was sworn and states as follows: 1) My

NI.

name is Elisa M. Floyd.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am a Regulatory Program Administrator (RPA) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for address is 4052 Bald Cypress Way, more than one year. My Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As a RPA of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees.

today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-01204 (Department of Health v. LORIE ANN ASIFOR-TUOYO, RN) are NINE HUNDRED TEN DOLLARS AND TWENTY-SIX CENTS ($91026)

1) As of

2) The costs for DOH case numbers 201 3-01 204 (Department of Health v. LORIE ANN ASIFOR-TUOYO, RN) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document.

3) The itemized costs and expenses for DON case numbers 201 3-01 204 (Department of Health v. LORIE ANN ASIFOR-TUOYO, RN) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 4) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH erhployees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators •

I

of2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Bpard of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses.are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report)

thatshe-has read the— foregoing Affidavit and its attachmenth and the statements contained therein are true and correctto the best of her knowledge and- belief.

.Elisa

FURTHER AFFIANT SAYETH NOL

lLth

Elisa M. Floyd, Affiant State of Florida County of Leon Sworn to and subscribed before me this_____ day of by Elisa M. Floyd, who is personally known to me.

Notary Signature

Name of Notary Printed Stamp

Name of Notary Public: HAYEFI

/g .I

Commission#EE838344 Expfres September 25, 2016 Boildod

Troy

lr,ac.800-3e5.701g

2

12

Lp K

,

2013,

Page

lof I

Complaint Cost Summary Complaint Number: 201301204

Subject's Name:

ASIFOR-'I'UOYO, LORIE ANN

1

Hours {

Investigation: Legal: Compliance:

H [

Costs 1.00

8.00

$502.77

3.30

$350.98]

0.05,

$1.61

****k*****F(

Sub Total: Expenses to Date: Prior Amount: ITotal Costs to Date:

____________

[

[

[

l 1

$91

(BT OOTIMETRAKICSDETL.ASP

10/1/2013

10/01/2013

Staff Rate

0.05

Sub Total

2.00

Sub Total

$54.90 $54.90

$32.13

7.00

0.50 0.80 0.70 0.70 0.70 0.30 0.50 0.80 0.10 0.70 0.60 0.40 0.20

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

Florida Department of Health

IPROSECUTION SERVICES UNIT

Sub Total

C150 CI5O

150

CI5O

CISO

CI5O

O O O 145

CJ5O

150 150

IINVESTIGATIVE SERVICES UNIT

1.00 1.00

I-1A107 11A107

ICONSUMER SERVICES UNIT

0.05

HC27

ICOMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date

MULL

Medicol Quoldy Assurance

Division of

$447.87

$51.18 $6.40 $44.79 $38.39 $25.59 $12.80

$3 1.99

$19.19

$4439

$31.99 $51.18 $44.79 $44.79

$109.80

$54.90 $54.90

51.61

$1.61

Cost

6 6

6 6

6 6

6

4 58

6 6 100 58

.

78 77

137

Activity Code

201301204

Activity Description

1

of2

.

Page

I

I

iternizedcost

F

EXHIBIT

ROUTINE INVESTIGATIVE WORK TRAVEL TIME SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE TRAVEL TIME 4

INITIAL REVIEW AND ANALYSIS OF COMPLAINT PREPARATION OF DESK INVESTIGATION SYNOPSIS

PRIORITY DOWNGRADES/UPGRADES

- FOR INTERNAL USE ONLY -

07/29/2013 07/30/2013 07/3012013 07/3 1/20 13 08/01/2013 08/06/2013 08/07/2013 08/09/2013 08/27/2013 08/27/2013 08/28/2013 08/28/2013 08/28/2013

01/1612013 01/16/2013

01/29/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

IAL***

of

10/01/2013

3.30

Sub Total

Florida Department of Health

Total Cost

0.20 0.30 0.20 0.30 0.10 0.20

0.40 0.30

10

HLL95A HLL95A HLL95A HLL95A HLL79A HLL79A HLL79A HLL79A HLL79A HLL97A HLL97A HLL79A

0.60 0.40 0.20

Staff Code Activity Hours

Report Date

MOA

Medical QuolLly Assurance

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

Staff Rate

$910.26

$350.98

$63.81 $42.54 $21.27 $10.64 $42.54 $31.91 $21.27 $31.91 $21.27 $31.91 $10.64 $21.27

Cost

35

28 28 64 79 79 35 25 25 25 35

81

Activity Code

201301204

Activity Description

Page 2 of 2

iteriiizedcost

ESO/ERO PREPARE OR REVISE ADMINISTRATIVE COMPLAINT PREPARE OR REVISE ADMINISTRATIVE COMPLAINT LEGAL ADVICE/DISCUSSION -BOARD OFFICE,DEPTSTAFF ORATTY GEN OFF STIPULATION 1 STIPULATION TELEPHONE CALLS REVIEW CASE FILE REVJEWCASE FILE REVIEW CASE FILE TELEPHONE CALLS TELEPHONE CALLS

- FOR INTERNAL USE ONLY -

01/29/2013 02/01/2013 02/04/2013 02/15/2013 03120/2013 03/25/2013 04/10/2013 06/10/2013 09/04/2013 09/17/2013 09/17/2013 09/18/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

4

Total Expenses

SubTotal

Expense Date

10/01/2013

Florida Department of Health

j

Staff Code

Report Date:

OMsion Medical Quclily Assurance

Expense Amount Expense Code Description

- FOR INTERNAL USE ONLY -

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

***CONFIDENTIAL***

.

1

.

of

1

itemizedexpense

Page

Rick Scott Mission:

Govemcr

To protect promote & iniprovethe health of aft people in Fioiida through inte9rated state, county & communfty efforts,

Armstrong, MD, FACS

John

Stats Surgeon General & Secretary

HEALTH Vision: To be the

Healthiest State in the Naflon

. MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS

i

TO:

Department or Health

FROM:

Board of Nursing, North Probable Cause Panel

SUBJEa:

Lone Ann Asifor-Tuoyo,

DATE OF PROBABLE CAUSE MEETING:

This matter was brought before

a

H 2

AC-07 (MD)

CASE NC.:

,

2013-01204

15, 2013

Probable Cause Panel composed of:

Lavigne Kirkpatrick. and Mary Jane Herrera forth above. The panel, having received the investigative report and supplemental niaterials, having having carefully reviewed said documentation and the recommendation of the agency/department, that: finds of counsel, hadthe opportunity to inquire

On the date set

•

n

Probable cause exists herein that the Subject violated the following statutes/rules x Count I Section 464 018(1)(c), Florida Statutes ( 2011) tountii:Sedion 464.018(1)ffl florida Statues (2011) 456072(1)(x), Florida Statutes (2011) Count

n:

The panel suggests imposing the following penalty: VS Probable cause does not exist and the case should be dosed with the flowing closure code:

In lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question: The panel has requested supplemental oradditional information on the following: Other

'

Florida Department of Hosith Proseoubon Services Unit Office of the General 4052 SaId Cypress Way, Bin C65 lahassee, FL 32399-1701 P1-lONE: 850/245-4444' FAX 850/2454663

www.Fiorjdasfleaitfl.com

HeaIthyFLA

FACESOOK:FLDeparbnentoflealth YCUTUBE: fldoh

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE NO.

V.

2013-01204

LORIE ANN ASIFOR-TUOVO, A.R.N.P. RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Lone Ann Asifor-Tuoyo, A.R.N.P., and in support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint

(Complaint), Respondent was an advanced registered nurse practitioner

(A.R.N.P) within the state of Florida, having been issued license number ARNP 2981202. 3.

Respondent's address of record is 8669 Alexandrite Court,

Tallahassee, Florida 32309. 4.

On or about March 8, 2012, in case number 2011-CF-34-A, in

the Circuit Court for the Second Judicial Circuit in and for Leon County, Florida, Respondent entered a plea of

nob

contendere to one count of

Trafficking in Oxycodone/Hydrocodone, a first-degree felony in violation of Section 893.135(1)(c)1, Florida Statutes, and one count of Obtaining or

Attempting to Obtain

a

Controlled Substance by Forgery, a Third-Degree

felony in violation of Section 893.13(7)(a)9, Florida Statutes. 5.

Oxycodone is commonly prescribed to treat pain. According to

Section 893.03(2), Florida Statutes, oxycodone is a Schedule

II controlled

substance that has a high potential for abuse and has a currently accepted

but severely restricted medical use in treatment in the United States. Abuse

of oxycodone may lead to severe psychological or physical dependence. 6.

Hydrocodone is commonly prescribed to treat pain.

to Section 893.03(2), Florida Statutes, hydrocodone is controlled substance that has

a high

a

According

Schedule

potential for abuse and has

a

II

currently

accepted but severely restricted medical use in treatment in the United Department of Health v, Lone Ann Aslfor-Tuoyo, A.R.N.P. Case No. 2013-01204

Asifor-Tuoyo, Lone Mn (ARNP, drug trafficking)

2

States. Abuse of hydrocodone may lead to severe psychological or physical

dependence. 7.

Respondent self-reported her crime to the Board of Nursing,

writing, on or about January 16, 2013. COUNT ONE 8.

Petitioner

realleges

and

incorporates

paragraphs one (1)

through seven (7), as if fully set forth herein. 9.

Section 464.018(1)(c), Florida Statutes (2011), provides that

being convicted or found guilty of, or entering a plea of

nob

contendere to,

regardless of adjudication, a crime in any jurisdiction which directly relates

to the practice of nursing or to the ability to practice nursing is grounds for discipline. 10.

Respondent

is

licensed

pursuant to Chapter 464, Florida

Statutes, and is a health care practitioner as defined in Section 456.001(4), Florida Statutes (2012). 11.

As set

forth above, on or about March 8, 2012, in case number

201 1-CF-34-A, in the Circuit Court for the Second Judicial Circuit in and for

Leon County, Florida, Respondent entered a plea of nob

count of Trafficking in Oxycodone/Hydrocodone, Department of Health v. Lode Ann Asifor-Tuoyo, Lode Ann (ARNP, drug trafficking)

a

contendere to one

first-degree felony in

count of Obtaining or Attempting to Obtain

a

Controlled Substance by

Forgery. 16.

Based on the foregoing,

Respondent has violated Section

Florida Statutes (2011), by engaging or attempting to

engage in the possession, sale, or distribution of controlled substances as set forth in chapter 893, for any other than legitimate purposes. COUNT THREE 17.

Petitioner realleges

incorporates paragraphs one (1)

and

through seven (7), as if fully set forth herein. 18.

Section 456.072(1)(x), Florida Statutes (2011), provides that

failing to report to the board, or the department if there is no board,

in

writing within 30 days after the licensee has been convicted or found guilty of, or entered a plea of

nob

contendere to, regardless of adjudication,

a

crime in any jurisdiction, is grounds for discipline. 19.

As set forth above, on or about March 8, 2012, in case number

2011-CF-34-A, in the Circuit Court for the Second Judicial Circuit in and for Leon County, Florida, Respondent entered a plea

of

nob

count of Trafficking in Oxycodone/Hydrocodone, Obtaining or Attempting to Obtain

Deparfrnent of Health v. Case No.

brie Ann Aslfor-Tuoyo,

2013-01204

Asifor-Tuoyo, Lode Ann (ARNP, drug trafficking)

A.R.N.P.

a

contendere to one

and

one count

of

Controlled Substance by Forgery.

5

______

Respondent did not report her plea, in writing, to the Board of Nursing

within 30 days of entering the plea. 20.

Based

072(1)(x),

on

the

foregoing,

Respondent

violated

Section

Florida Statutes (2011), by failing to report to the board, or

the department if there is no board, in writing within 30 days after the licensee has been convicted or found guilty of, or entered a plea of

contendere to, regardless of adjudication,

a

nob

crime in any jurisdiction,

is

grounds for discipline. WHEREFORE,

Petitioner respectfully requests that the Board of

Nursing enter an Order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

day of John

2013.

Armstrong, MD, FACS State Surgeon General and Secretary of Health

Department of Health V. Lone Ann Asifor-Tuoyo, A.R.N.P. Case No. 2013-01204 Asifor-Tuoyo, Lode Ann (ARNP, drug trafficking)

H.

6

Melissa E. Dinwoodie Assistant General Counsel Fla. Bar No. 76466 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65

Tallahassee, FL 32399-3265 Telephone: (850) 245-1111 ext. 8174 Facsimile: (850) 245-4683 Email:

@doh.state.fl.

us

/MED PCP:

a' Members:

Deparfrnent of Health v. Lade Ann Asifor-Tuoyo, A.R.N.P. Case No. 2013-01204 Asifor-Tuoyo, Lade Ann (ARNP, drug Irafflddng)

7

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTIcE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

,

Deparbnent of Health v. Lone Ann Asifor-Tuoyo, A.R.N.P, Case No. 20i3-01204 Lode Mn (ARNP, drug frafficking)

8

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FLORDA DEPARTMENT

INVESTIGATIVE REPORT Office:

Date of Complaint:

CONSUMER SERVICES

January

161

Case Number:

2013

201301204

Subject:

Source:

LORIE ANN ASIFOR-TUOVO 8669 Alexandrite Ct. Tallahassee, FL 32309

LORIE ANN ASIFOR-TUOVO 8669 Alexandrite Ct Tallahassee, FL 32309

(850) 727-7663

(850) 727-7663

:

#:

Prefix:

License

ARNP

2981202

Profession:

Mv Registered

Nurse

Practitioner

Board:

Report Date:

Nursing

1/16/13

Period of Investigation:

Type of Report

1/16/13-1/16/13

FINAL

Alleged Violation: SS. 456.072(1)(c)(dd); 464.016(1)(c)(o); Having been convicted or found guilty in a court of this state or other jurisdiction, of a crime which directly relates to the ability to practice of nursing.

1

This investigation is predicated on a self report from ASIFOR-TUOYO stating on 3/8/12 ASIFORTUOVO was convicted in Leon County, FL, of Trafficking in Oxycodone/Hydrocodone (893.135(1 )(c)1.] and Fraudulently Obtain Controlled Substance 893.13(7)(a)9.]. Adjudicated Sentenced to Leon County Jail for 11 months and put on probation. Court Documents attached. (EXHI BIT #1)

ASIFOR-TUOYO was notified of this complaint by certified letter, dated 1/16/13. The notification was sent to the address of record. Forwarded with this letter were copies of the UCF and the initiating documents. (EXHIBIT #2) DOH licensure information was reviewed on 1/16/13. It reflected ASIFOR-TUOYO's license was in Suspended, Active status (EXHIBIT #3) No patient(s) was/were identified, thus patient notification was not required.

ASIFOR-TUOVO does not appear to be represented by counsel in this matter as of the date of this

report.

ASIFOR-TUOYO has not responded as of the date of this report. Related Case: Investigator/Date:

Approved By/Date:

Leo Paulson (HA1O7) 1/16/13

Shane Walters, OMC Manager

'JAN

1

Distribution: Prosecution Services Unit/Consumer Services Unit

7 2013 1

U

DOH INVESTIGATIVE REPORT

CASE NUMBER 201301202

TABLE OF CONTENTS I.

INVESTIGATIVE REPORT COVER PAGE

I

TABLE OF CONTENTS II.

2

INVESTIGATIVE DETAILS Summary of Records Interview/Statement of Department of Health

II.

3

3

ITS 1)

Uniform Complaint Form, Initiating Documents & Copies of Court Documents

2)

SUBJECT's Notification Letter

4-12 13-14

Page 2

DOH INVESTIGATIVE REPORT

CASE NUMBER 201301202 INVESTIGATIVE DETAILS

SUMMARY OF RECORDS There were no authorizations, medical records, or Verification of Completeness of Record forms at issue in this matter. Exhibit #1 contains the following: Copies of Court Documents from Leon County Circuit Court, Florida, ASIFOR-TUOYO was convicted in Leon County, FL, of Trafficking in Oxycodone/Hydrocodone 893.135(1)(c)1.] and Fraudulently Obtain Controlled Substance 893.13(7)(a)9.J. Adjudicated Guilty, Sentenced to Leon County Jail for 11 months and put on probation.

INTERVIEW/STATEMENT OF THE FLORIDA DEPARTMENT OF HEALTH

Source

On 1/1 6/1 3, Investigator PAULSON received a self report from ASIFOR-TUOYO stating on 3/8/12 ASIFOR-TUOYO was convicted in Leon County, FL, of Trafficking in Oxycodone/Hydrocodone 893.135(1)(c)1.] and Fraudulently Obtain Controlled Substance 893.13(7)(a)9.]. Adjudicated Sentenced to Leon County Jail for 11 months and put on probation.

Page

3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

John H.

January

mstrong,

MD, FACS

16, 2013

CONFIDENTIAL Lone Ann Asifor-Tuoyo, RN 8669 Alexandrite Court Tallahassee, FL 32309

Complaint #: 201301204 Dear Ms. Asifor-Tuoyo:

The Consumer Services Unit has received the enclosed complaint against you. We reviewed the complaint or report and determined that the Nursing Practice Act may have been violated. Therefore, we have opened an investigation into this matter. Please submit a written response to this complaint within 20 days of receipt of this letter. You may make a written request for a copy of the investigative file. This complaint and all investigative information will remain confidential until 10 days after the probable cause panel has determined that a violation has occurred or you give up the right to confidentiality.

i

The mission of the Department of Health is to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts. If you have any questions, please call the Consumer Services Unit at (650) 245-4339. In addition, if you have any concerns or suggestions about our complaint process, please fill out our Customer Concerns or Suggestions form at www.floridashealth.comlmga/survey.

.

Sincerely,

Leo W. Paulson

Government Analyst

I

LWP/tb Enclosure Certified mail: 7011 2970 0003 6945 2006

Division of Medical Quality Assurance 4052 Bald Cypress Way, Bin C-75 Tallahassee, FL 32399-3275 Telephone Number (850) 245-4339 • Fax (850)488-0796- http://www.floridasheaIth.com

REPORT

"'1i

!T#

U.S. Postal -D

C C

1r.,

CERTIFIED Domestic

RECEIPT

Insurance Coverage Provided)

For4eliv.eryjnformatjon visit our r

Postago

4

1:'

$

Codified Fee Petum Receipt Fee (Endorsement ReqUired)

Rost,lcted DoIWecy Fee (Eadorsemeni

sent

To

CONFIDENTIAL Lone Ann Asifor-Tuoyo, RN 8669 iexandrite Court Taflahassee FL 32309 201301204 ha 107 .

-

-

-

m

UIJiLdbJ

1

REPORT

EXH!Bir#

L.

Rick Scott

Minion:

Governor

To protect, promote & improve the health of all people in Florida ilirough integrated

John H. Annstrong, MD, FACS

slate, county & community efforts.

State Surgeon General & Secretauy

Vision: To be the

Healthiest State

in

the Nation

NOTICE OF HEARING November 8, 2013 Case#: 201301204 To:

LORIE ANN ASIFOR-TUOYO 8669 ALEXANDRITE COURT TALLAHASSEE, FL 32309, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201301204

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Health DMsion of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 850/ 245-4125 • FAX 85012454172

www.FiorldasHeaith.gov TWITTER:HealthyFLA

oepartmentofHealth YOIjTUBE: fldoh

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK DATE OCT 2 2013

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH, Petit loner, vs.

Case No.: 2012-14411 License No.: RN 3269332

NANCY MARIE GALATI, Respondent.

/ ORDER GRANTING CONTINUANCE This matter appeared before the Board of Nursing at a duly-noticed public meeting on October 3, 2013,

in Naples, Florida, for a hearing not involving disputed

issues of material fact pursuant to Sections 120.569 and 120.57(2), Florida Statutes.

Respondent made a timely request for a continuance. Good cause for a continuance having been demonstrated, the request is GRANTED.

Therefore it is ORDERED that the hearing on this matter is continued to the next regularly scheduled Board meeting. DONE AND ORDERED this

day of

2013.

BOARD OF NURSING

Lavigne Ann Kirkpatrick, BS, RN, Chair

1

CERTIFICATE OF SERVICE I

HEREBY CERTIFY that a true and correct copy of the foregoing has been

furnished by certified mail to NANCY MARIE GALATI, 2311 Ulmerton Road, Clearwater FL 33762, and by interoffice mail to

and Yolanda Green, Assistant General Counsel,

Department of Health, 4052 Bald Cypress Way, Bin # C-65, Tallahassee, Florida 32399-3265, this

dayof

2013.

Deputy Agency Clerk

3050 0002 388w 0488

2

I

I

To protect, promote & improve the health of all people in Flohda through integrated state, county & community efforts.

Governor

j

Flat

I

HEALTH

I

Vision: To be the Healthiest State

.,

I

John H. Annstrong,

FACS

State Surgeon General & Secretary I

in the Nation

MEMO RAN

FROM:

Executive Director, Florida Board of Nursing Joe Baker, Kristal Beharry, Assistant General Counsel

RE:

Determination of Waiver

SUBJECT:

DOH v. Nancy Marie Galati, R.N. DOH Case Number 2012-14411

DATE:

October 17, 2013

TO:

,

Rick Sco2t

Mission:

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard: Subject: Nancy Marie Galati, RN. Subject's Address of 2311 Ulmerton Road

Record: Enforcement Address:

Clearwater, FL 33762 2311 Ulmerton Road Clearwater, FL 33762

Subject's License No: Licensure File No:

3269332

Initial Licensure Date:

4/16/1998

Board Certification: Required to Appear: Current IPN/PRN Contract:

None

Allegation(s):

Section 464.018(1)Q), F.S. (2012)

Prior Discipline: Probable Cause Panel:

None May 8, 2013

Rank: R.N.

192106

No

None

Kirkpatrick & Herrera

Subject's Attorney:

Complainant/Address:

Pro Se

Deborah Anne Worsham St. Petersburg General Hospital 6500 38th Ave N. St Petersburg, FL 33710

Fiorida Department of Health Office of the General Counsel • Prosecution Seivices Unt 4052 Bald Cypress Way, Bin C-65 'Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 'FAX 850/245-4683

.aith.com TWI1TER:HealthflLA

FA C E BOO K: FL Dep artmentofH ea Ith

YOUTUBE: fldoh

,

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

v.

CASE NO.

2012-14411

NANCY MARIE GALATI, R.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

8, 2013.

An Administrative Complaint was filed against Respondent on May A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on: May 18, 2013 (7196 9008 9111 8827

mail receipt is attached as Petftioner's

4155). A copy of the certified

,

3. Thereafter, Petitioner requested personal service on Respondent, which

was completed on June 19, 2013. The affidavit of personal service is attached as Petitioner's Exhibit C. 4.

Rule

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 5.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits D &

E.

7.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint. Therefore, there are no disputed issues of material fad to be resolved by the Board. 8.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima fade case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find

that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final Order imposing

whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Kristal Beharry Assistant General Counsel Fla. Bar No.

0078070

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 ext. 8218 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of the and foregoing Ahas provided by U.S. mail this day of 2013, to: Nancy Marie GalaU, 2311 Ulmerton Road, Clearwater, FL 33762.

Kristal Beharry Assistant General Counsel

________________I.

,

STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

ts

CASE

NANCY MARIE GALATI, R.F4.,

,

RESPONDENt ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Nancy Marie Galati, R.N., and in

support thereof alleges: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

registered nurse (R.N.) within the state of license number RN 3269332.

F

EXHIan-

lorida, having been

a

issued

3.

Respondents address

of

record

is

2311

Ulmerton

1

Clearwater, florida 33762. 4.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was licensed to prathce as a registered nurse in the State of Florida pursuant 5.

to Chapter 464, Florida Statutes (2012).

On or about September 7, 2012, while working as a registered

nurse at St.

Petersburg

General

Hospital

("SPGH"),

located in St.

Petersburg, Florida, Respondent was observed by another nurse to be

working extremely slow in a fast paced area known as the "holding area." 6.

Patient

S.

stated that on or about September 7, 2012,

Respondent appeared very distracted and failed to provide her with requested medication.

PatIent

S.

a

had to ask someone else for the

medication. 7.

On or about September 7, 2012, Respondent was observed by

her immediate supervisor to be sleeping at a patIent's bedside. 8.

Respondent explained to her supervisor that she had not slept

in two days due

to family issues. Respondent was subsequently sent home

by her supervisor.

Departnent of He&th v. Nancy Marie Galati, LW. Case Number: 2012-14411

2

9.

On or about September 8, 2012, Respondent was on call for

the post-anesthesia care unit (PACU) and was instructed to arrive at work between 7:00 a.m. and 7:15

an.

because there were scheduled surgeries

that morning. 10.

On or about September 8, 2012, Respondent failed to timely

report to work, and multiple attempts to contact Respondent by SPGH staff were unsuccessful. 11.

On or about September 8, 2012, at approximately 8:00 a.m.,

Respondent telephoned SPGH and stated that she had overslept. 12.

Subsequently, the SPGH Director of Surgical Services reviewed

pharmacy records and discovered that two (2) doses of Versed were taken

out for the same patient five (5) minutes apart and there was no accompanying documentation that the medication was given or wasted. One of the doses of Versed was signed out by Respondent and the other

dose was signed out by another nurse. 13.

Versed is the brand name for the drug midazolam, a sedative

commonly prescribed to provide sedation prior to a medical procedure. According to Section 893.03(4), florida Statutes (2012), midazolam is Schedule IV controlled substance that has

Depafti,ent of Health v. Nancy Marie GalaU, R.N, Case Number: 2012-14411

a

a

low potential for abuse relative

3

to the substances in Schedule

Ill and has a

currently accepted medical use

in treatment in the United States, and abuse of midazolam may lead to

limited physical or psychological dependence relative to the substances in Schedule

lL On or about September 13, 2012, Respondent was asked to

14.

submit to

a

drug screen when she presented to SPGH. Respondent's drug

screen returned with negative results. 15.

On or about November 5, 2012,

Department that she is under

a

lot

medical conditions, having to live

Respondent advised the

of stress at home

in

due to her husband's

a hotel, financial troubles, and having

no vehicle. 16.

Respondent stated that at the time of the incident she was

extremely tired and had not slept in two days due to staying up and taking care of her husband. 17.

Respondent denies that she was asleep at work. Respondent

stated that she became tearful due to stress and closed her eyes so no one could witness her breaking down.

of Health v. Nancy Marie Galati, R.N. Case Number;

2012-14411

4

18.

Respondent stated that she did give the Versed to the patient

and made mistakes using the Electronic Medication Administration Record (eMAR.) system because she never

19.

received eMAR training.

Respondent stated that she is under the care of a physidan for

pain management due to an automobile accident. 20.

Respondent's pharmacy profile shows that she is currently

prescribed multiple controlled substances. 21.

On or about December

12, 2012, the Department ordered

Respondent to submit to a mental and physical examination to determine her ability to practice nursing with reasonable skill and safety. 22.

On or about January 14, 2013, Respondent submitted to the

compelled mental and physical examination conducted by Dr D.B., a

spedalist in addiction medicine. 23.

workplace

Dr. D.B.

are

noted that the record of discrepandes at Respondent's

consistent with aberrant

behavior and are strongly

suggestive of inappropriate substance use. 24.

Dr. D.B.

administered

part of the examination.

a

urine drug screen to Respondent as

Respondent's specimen

tested positive for

Deparfrnent of Health v. Nancy Marie Galati, RN. Case

Number: 2012-14411

5

oxycodone at a level of 18291 ng/mI, and oxymorphone at a level of 21149

ng/rnl. 25. •

Dr. D.B. noted

that the levels of oxycodone and Its metaboliths

detected in Respondent's urine drug screen are clearly extremely high and

definitely not compatible with the doses of this medication that Respondent reports taking. 26.

Oxycodone is commonly prescribed to treat pain. According to

Section 893.03(2),

Ida

controlled substance that has

a high

potential for abuse and has

a

I

ly

Statutes (2012), oxycodone is a Schedule

accepted but severely restricted medical use in treatment in the United

States, and abuse of oxycodone may lead to severe psychological or physical dependence. 27.

oxycodone.

Oxymorphone is prescribed to treat pain and

is a

metabolite of

According to Section 893.03(2), Florida Statutes (2012),

oxymorphone is a Schedule II controlled substance that has potential for abuse and has

a

a

high

currently accepted but severely restiicted

medical use in treatment in the United States, and abuse of oxymorphone may lead to severe psychological or physical dependence.

Department of Health v. Nancy Marie Case Number: 2012-14411

FtN.

6

•

28.

D.B.

Dr.

Respondent,

.

stated that functional impairment is apparent in

who is

having

difficulty with documentation, securing

controlled substances, and falling to have Witnesses for use of controlled substances. Dr. D.B. added that falling asleep in the midst of a busy work area supports serious functional

29.

Dr. D.B.

opined that Respondent is not safe to practice nursing

with reasonable skill and safety at this time. 30.

Section 464.018(1)0), Florida

Statutes (2012),

subjects

a

licensee to discipline, including suspension, for being unable to practice

nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcolics,

material, or as 31.

a

or chemicals, or any other type of

result of any mental or physical condition.

As set forth above, Respondent is unable to

practice nursing

with rtasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as

a

result of any mental or physical condition. On or about January 14, 2013, a

specialist in addiction medicine determined that Respondent is not safe to

practice

DeparuTlent of Case

nursing with reasonable skill and

lth

v. Nancy Marie Galati,

Numbe 2012-1441.1

due

to functional

tN. 7

impairment and behavior that

is

strongly suggestive of inappropriate

substance use. 32.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)0), Rorida Statutes (2012), by being unable to practice nursing

with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals, or any other type of material, or as a

result of any mental or physical condition. WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of

a

reprimand,

placement of the Respondent or probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

Departnia,t cf

v. Nancy Marie Galat, Case Number: 20L2-144U

tN. 8

SIGNED

this

day of I

—

.

John N. Armstrong, MD, FACS State Surgeon General and

Secretary of Health

FILED DEPARTMENT OF HEALTH DEPUTY CLERK

CLERK 0

82013

PCP: PCP Member

:

Department of Health v, Nancy Marie Galati, R.N. Case Numbe- 2012-14411

Kristal Beharry Assistant General Counsel DON Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65

Tallahassee, Florida 32399-3265 Florida Bar # 0078070 Telephone: (850) Facsimile: (850) 245-4683

m4

Re

9

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and Florida Statutes, to be represented by counsel or other 120.57, qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

ion

Respondent is placed on notice that Petitioner has incurreci costs related to the investigation and of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Nancy Marie Galatj, R.N. Case Number: 2012-14411

10

7196 9005 9111 8827 415S TO:

Slip Pack

Date Mailed 5/15/2013

-14411 SENDER:

REFERENCaaIau, Nancy PS Form 3800 Janus

.

RETURN RECEIPT SERVICE

2005

Postage

Certified Fee Return Receipt Fee

Restricted Delive, Total

Postage

& Fees

Receipt for

Certified I

3. Service Type

Mar

No Inswance Coverage Do Not Use for

CERTIFIED

POSTMARK OR DATE

Mt

MAIL"'

4. Restricted Delivery? (Extra Fee) I. Article Addressed to:

Nancy Marie Galati, RN 2311

Clearwater, Florida 33762

EXHIBIT

I

5

___________ ______________ ________________________ ________ _________Final

________Affiant

___________

Rick Scott

I

Mlsslan To protect, promote

&

Governor

Fftr

improve the health

John K. Armstrong, MD, FAC$ Stale Surpeon General

HEALTH Vision: To be the

&

Healthiest State in the Nation

AFFIDAVIT OF SERVICE OR DILIGENT SEARCH DEPARTMENT OF HEALTH_________ Petitioner vs NANCY MARIE GALATI, RN Respondent

Case

No.______________ 2012-14411

COMES NOW, the affi ant, who first being duty sworn, deposes and states: 1) Affiant is an Investigator/Inspector employed by the DEPARTMENT OF HEALTH, State of Florida! 2) That on (date) 06/19/2013

Complaint and related papers; Notice to cease and desist;

,

diligent effort to loôate Respondent, to serve Subpoena(s); ESO/ERO and related papers.

Affiant made

a

— Order compelling examination(s);

X_ Administrative order;

3) Check applicable answer below:

X Afflant made personal service on Respondent, or on some person at Respondent's usual place of abode over the age of 15 residing there, on (date) 06/19/2013 was unable to make service after searching for Respondent at: (a) all addresses for Respondent shown in The DON investigation of the case; (b) all official addresses for Respondent shown in his licensing records on the computer terminal or Board office; (c) Local telephone company for the last area Respondent was known to frequent; (d) Division of Drivers Licenses: and (e) Utilities (electric, cable, etc.); any others: MQdcnc Toledo

772 t/t,ø'

N

C

-r

Afflant State Of Florida County Of

/

Before me, personally appeared

Marlene Toledo whose identity

is

known to me and who, acknowledges that his/her

signature. appears above. Sworn to oraffirrned b

Notary

7)q-vit q: Type or Print Name NV FORM 321

ffi nt before me this

o Florida

19th

day of

June

T

2013.

My Commission Expires

1 1

1.?

S

I WytiI

D

,J. HAYDEN

# EE 142141 Expires October 27,2015 eoss Thy, Tray Fa,

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Floilda through integrated state, counly & communhy efforts.

I,

the

Board

Joe

of

8/20/2013

,

,

John H. Armstrong,

HEALTH Vision: To be the

Jr

Nursing's ,

D, FACS

State Surgeon General & Secretary

Healthiest Staten the Nation

hereby certify in my official capacity as custodian for files

licensure

that

the

Board

of

Nursing

as

of

has no evidence of an Election of Rights form or other responsive

pleading requesting a hearing prior to any agency action regarding CASE

Nancy Marie

RN., CASE NUMRER: 2012-14411 which

/

the Subject's substantial

would affect

(Cybtodian of Records/\ 'Ft6rida Board of Before me, personally appeared

to me

personally

Joe Baker, Jr.

whose identity is known

(type of identification) and who, under, oath, acknowledges

that his/her signature appears above. Sworn to and subscribed this

20

day of

August

2013.

Notary Public

VAN ESSA RtSCH ExpiXeS July emltd

Tey

22,2016 banga

Florida Department of Health • Prosecution Services Unit 4052 Bald Cypress Way, BinC-65 • Tallahassee, FL 32399-1701 Express mail address: 2565 Merchants Row — Suite 105 PHONE: 8501245-4444 • FAX 8501245-4683

lth

www.FloridnsHealth.com

)thyFLA

Office of the General Counsel

i

VOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health

ida

through integrated of all people in state, county & community efforts.

,

John H. Annetrong, MD, FACS State Surgeon General & Secretary

HEA<H Vision: To be the Healthiest

State in the Nation

AFFIDAVIT

Deputy Clerk for the Department Clerk's Office,

hereby certify in my official capacity as custodian for the Department Clerk's records, that the

Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests

a

hearing prior to any Department action regarding Case Name:

Nancy Marie Galati, R.N., Case Plo: substantial interests or rights.

which would affect the Respondent's

Custodian of Record Department Clerk's Office

identity is known to me by

Before me, personally appeared Dersonallv known (type of identifica

that his/her

d who, under oath, acknowledges

J

signature appears above. Sworn to and subscribed before me this

i

g

day of

2013.

Notary Public My Commission Expires:

1

ANGELA BARTON NOTARY

pusLrc.

STATE

Of

COMM BS ION # 0D922154 EXPIRES 9/1/2013 8CNDEP THRu

Florida Department of Health Office of the General CounselS Servces Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245.4444 • FAX 8501245.4683

.com lealth TWITTER:HealthyFLA

FACE BOOK

id

VOUTUBE: fldoh

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF

9

v.

)

CASE NO. 2012-14411

NANCY MARIE GALATI,

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW

the

Department

of

Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of a Final Order assessing costs against the Respondent for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter

a

2.

Final Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $3,850.57 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $3,850.57 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline

imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter

a

Final Order assessing costs against the Respondent in the

amount of $3,850.57.

3

________________,2013.

DATEDth1S

2i%yof

,2013. Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Kristal Beharry

0

Assistant General Counsel Fla. Bar No.

0078070

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: Kristal [email protected]

CERTIFICATE OF SERVICE I HEREBY CERTIFY that

a

true and correct copy of the foregoing

Motion to Assess Costs has been furnished via U.S. mail to Nancy Marie Galati, R.N., at 2311 Ulmerton Road, Clearwater,

FL

33762, on this

Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

am over the age of 18, competent to $stify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs

regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 2-14411 (Department of Health v. NANCY MARIE

GALATI, R.N.) are FOUR THOUSAND FIVE HUNDRED FIFTY-TWO DOLLARS AND FIFTEEN CENTS ($4,552.15). 6) The costs for DOH case numbers 201 2-14411 (Department of Health v. NANCY MARIE GALATI, R.N.) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case numbers 2012-14411 (Department of Health v. NANCY MARIE GALATI, R.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

I

of 2

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the tithe worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9)

Share Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon Sworn to and subscribed before me this_____ day by Shane Walters, who is perisonally known to me.

\ Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

2013,

Complaint Cost Summary Complaint Number: 201214411 Subject's Name:

GALATI. NANCY MARIE Cost to Date

l&nt: Jnvestigataoan:

1 1

Hours I

I

Legal: 1

Costs $40.33j

51,850.01

6.60

5701.58

0.05

$1.61 [

sub Total:

l

[

lExpenses to Date:

Prflor Amount:

Costs to Date:

37.15

52,593.53 [

H [

$1,958.62 $0.00

$4,552.15

EXHIBIT

hap //mqaapps doh state 11 us/IRMOOTIMETRAKJCSDETL ASP

8/19/2013

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

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One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

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One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

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One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

/

Mission: To protect, promote & improve the health

1

Rick Scoff Governor

riuriu

I Vision: To be

John H. Annstrong, MD, FACS State Surgeon General & Secretary

the Healthiest State in the Nation

NOTICE OF HEARING November 8, 2013 Case#: 201214411 To:

NANCY MARIE GALATI 2311 ULMERTON RD CLEARWATER, FL 33762, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201214411

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board.

Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (650) 412-2206. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any further

Fiorida Department of Hesith Division of Medicai Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 950/ 2454125 • FAX 950/ 2454172

www.FiorldasHesith.gov TWIUER:HealthyFLA

oepatmentoftlealth VOUTUBE: fidoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county community e 0

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be the

Healthiest State

in the Nation

NOTICE OF HEARING November 8, 2013 Case #201214411 To:

DEBORAH ANNE WORSHAM ST PETERSBURG GENERAL HOSPITAL 6500 38TH AVE N ST PETERSBURG, FL 33710

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December 5,

Time:

8:30AM

Type:

Determination of Waiver

Re:

NANCY MARIE GALATI/201214411

letree by Hilton

Place:

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

This notice is to inform you, as an involved party or complainant, that the above listed case is scheduled to go before the Board of Nursing. While you are not required to attend, the meeting is open to the public. There is no action needed on your part at this time,

After the conclusion of the meeting, the Board file will file a final order stating the facts of the case and the Board's decision. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. This information will also be available on the Department of Health's website at: www.flhealthsource.com. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at [email protected].

Florida Department of Health

/

Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE: • FAX 8501 245.4172

lng.gov

TWITTER:HealthyFLA

lepartmentofrlealth VOUTUBE: fldoh

Rick Scott

Minion:

overnor

To proteci, promole & improve the health state, county

John H. Armstrong, MD, FACS

efforts.

State Surgeon General & Secretary

HEALTH Vision: To

be the

Iest

State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201307474 To:

CAROLYN JEAN EDDY 5441 GROVE MNR LADY LAKE, FL 32159, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201307474

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in,

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Departm•nt of

Hnlth

DWision of Medical Quality Assurance • Board of Nursing

4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 650/ 245-4125 • FAX 650/ 245.4172

,gov TWFTTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

STATE OF FLORIDA BOARD OF PHARMACY

DEPARTMENT OF HEALTH,

Petitioner, CASE NO.

v.

2013-07474

CAROLYN JEAN EDDY, L.P.N.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER BY HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT Petitioner, Department pf Health, by and through counsel, moves the Board of Nursing to find that Respondent has waived her right to elect a

method of disposition of the pending Administrative Complaint, to determine

that no material facts are in dispute, to conduct

a

hearing not involving

disputed issues of material face, and to enter a Final Order.

As grounds

therefore, Petitioner states: 1.

An Administrative Complaint was filed against Respondent on

August 23, 2013. A copy of said Administrative Complaint is attached hereto as Petitioner's Exhibit A.

l

DOI-i v. Cesar

Armando Raniirez, M.D.

Case Number 2012-16914

2.

Copies of the Administrative Complaint, Election of Rights form,

and Explanation of Rights form were sent to Respondent, via certified US mail delivery, on September 13, 2013, (article number 7196 9008 9111 8827

9730). A green card receipt was returned as "Signed by Carolyn Jean Eddy". A copy of said green card receipt is attached hereto as Petitioner's Exhibit B. 3.

Respondent has not filed with either the Department of Health or

the Board of Nursing, an Election of Rights form or other responsive pleading in this case within the required

twenty-one (21) day period to dispute the

allegations contained in the Administrative Complaint.

Copies of affidavits

supporting same are attached hereto as Petitioner's Exhibits C and D. 4.

Respondent has been advised, by a copy of this motion sent to

her address of record that a copy of the investigative file in this case shall be furnished to the Board to establish a prima

fade case regarding the

violations as set forth in the Administrative Complaint. 5.

The Department requests that this Motion and a hearing be

placed on the agenda for the next meeting of the Board of Nursing to be held on December 4-6, 2013, in Deeruield Beach, Florida. WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived her right to elect a method of resolution of this DOH v. Carolyn Jean Eddy, L.P.N. DOH Case Number 2013-07474

2

WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived her right to elect a method of resolution of this

matter, find that there are no material facts in dispute, hold

a

hearing not

involving material issues of disputed fact based on the information contained in the investigative file, find

that Respondent violated Chapters 456 and 465,

Florida Statutes, as alleged in the Administrative Complaint, impose discipline in accordance

with the disciplinary guidelines, and enter

DATED this

a Final

day of

Order. ,

2013.

Respectfully Submitted,

Louise Wilhite-St Laurent, Esq. Florida Bar No. 0091244 Assistant General Counsel Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 (P) 850-245-4444, extension 8331 (F) 850-245-4662 (E) Louise_StLaurent@3doh .state.fl .us

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion for Determination of Waiver and for Final Order by Hearing not Involving Disputed Issues of Material Fact has been

I

v. Carolyn Jean Eddy, 1.P.N. Case Number 2013-07474

3

provided by U.S. certified Mail to Respondent, Carolyn Jean Eddy, L.P.N., 5441 Grove Manor, Lady Lake, Florida 32159, this

day of

2013.

I

Wilhite-St. Laurent Assistant General Counsel LSL/mla

ll

DOH v. Carolyn Jean Eddy, L.P.N. Case Number 2013-07474

4

3.

of record

Respondent's address

is 5441 Grove Manor, Lady

Lake, Florida 32159. 4.

On or about April 13, 2010, Respondent pleaded guilty to the

charge of Driving Under the Influence, Second Offense, in Marion County Case Number 42-2010-CF-O0 1377.

Respondent was adjudicated guilty of

the charge of DrMng Under the Influence on the same date. 5.

Respondent failed to report her conviction in Marion County

Case Number 42-2010-CF-001377 to the Board

of Nursing in writing within

thirty days after her conviction. 6.

On or about May 26, 2011, Respondent pleaded guilty to, and

was adjudicated guilty of, the charge of Violation of Probation in Marion

County Case Number 42-2010-CF-001377. 7.

Respondent failed to report her conviction of the Violation of

Probation Charge in Marion County Case Number 42-2010-CF-001377 to

the Board of Nursing in writing within thirty days after her conviction. 8.

On

or about July

22,

2013,

Respondent

underwent a

Department-ordered evaluation with Dr. S.T., an addiction medicine specialist.

DOll v. Carolyn )ean Eddy, R.N. Case Numbe 2013-07474

DOF$

2

Respondent provide hair, urine and blood samples for drug

9.

testing.

Respondent's hair

and

urine

samples

were

positive for

hydrocodorie and Respondent's blood sample was positive for alcohol. Hydrocodone

10.

opiold-class medication.

is an

According to

Section 893.03(2), Florida Statutes (2013), hydrocodone is a Schedule

II

controlled substance. Dr. 5.1. diagnosed Respondent with alcohol dependence and

11.

poor coping skills. Dr. 5.1. opined that Respondent is not safe to practice nursing

12.

with reasonable skill and safety to patients.

I

COUNT Petitioner

13.

and

realleges

allegations in paragraphs

1

incorporates

by

reference

the

through 12, as if fully set forth herein.

Section 464.018(1)0), Florida Statutes (2013), subjects

14.

practical nurse to discipline for

bjeing

a

unable to practice hursing with

reasonable skill and safety to patients by reason of illness or use of alcohol,

drugs, narcotics, or chemicals or any other type of material or as

a

result of

any mental or physical condition."

Dolly. Carc4yn DOH

Jean Eddy, R.N.

Case Number

3

15.

Respondent violated Section 464.018(1)(j), Florida Statutes

(2013), by being unable to practice nursing with reasonable skill and safety

to patients due to her use of alcohol and/or opiates. 16.

Based

the

on

foregoing,

Respondent

violated

Section

464.018(1)Q), Florida Statutes (2013), by being unable to practice nursing

with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a

result of any mental or physical condition.

COUNT U 17.

Petitioner

realleges

allegatiOns in paragraphs 18.

1

and

incorporates

by

reference the

through 7, as if fully set forth herein.

Section 456.072(1)(x), Florida Statutes (2010-2011), subjects

practical nurse to discipline for

flailing

a

to report to the board... in writing

within 30 days after the licensee has been convicted or found guilty of, or entered a plea of

nob

contendere to, regardless of adjudication,

a

crime in

any jurisdiction." 19.

Respondent violated Section 456.072(1)(x), Florida Statutes

(2010-2011), by failing to report her conviction for Driving Under the Influence and/or Violation of Probation in Marion County Case Number 42OCH v, Carolyn Man Eddy, R.N. Case Number 2013-07474

oll

4

2010-CF-001377 to the Board of Nursing in writing within thirty days after Respondent's conviction for the offenses. 20.

Based

on

the

foregoing,

Respondent

violated

ion

456.072(1)(x), Florida Statutes (2010-2011), by failing to report to the Board of Nursing in writing within 30 days after Respondent was convicted

of

a

crime in any jurisdiction. WHEREFORE,

Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

,R.N. DOH Case Number

2013'07474

NOTICE OF RIGHTS Respondent has the right to request or petition for an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes. Respondent has the right to be represented by counsel or other qualified representative. Administrative hearings are governed by Rule 28-106, Florida Administrative Code. A request or petition for an administrative hearing must be in writing and must be received by the Agency Clerk within twenty-one (21) days from the day you received this Administrative Complaint. A request or petition for a hearing must be in conformance with Chapter 28-106.2015(5), Florida Administrative Code and must be sent to the Department at the following address:

Department of Health Prosecution Services Unit Attention: Louise Wilhite-St Laurent, Esquire 4052 Bald Cypress Way, Bin #C-65 Tallahassee, Florida 32399-3256 Mediation is not available as an alternative remedy.

Your failure to submit a petition or request for a formal hearing (Election of Rights) within 21 days from receipt of this Administrative Complaint will constitute a waiver of your right to a hearing, and this complaint will thereby become a final order of the Department.

II

DOH v, Carolyn Jean Eddy,

RN.

Case Number 2013-07474

7

7196 9008 9111 8827 9730 TO:

Carolyn 1 Eddy, LPN 5441 Grove Manor Lady Lake, Florida 32159 AC, ER, SA

Eddy 2013-07474 SENDER: REFERENCE:

PS Form 3800, January 2005

Postage

RETURN RECEIPT SERVICE

Certified Fee Return Receipt Fee

Restricted Delivery Total Postage

Fees

&

usps.

POSTMARK OR DATE

13

Receipt for Certified Mair No Insurance Coverage Pto'vlde,d Do Not br lntarnallon& Mea

.s

2.

Article Number

A.

B.

C

natur

llv

9/iila C

-

1111111

7196 9008 9111 8827 9730 3.

ServIce Type

CERTIFIED

4. Restricted Del ivory? (Extra Fee)

I. Atlicle Addressed

to:

I

D.

Is If

C Addresses C Yes C No

doliJery dlflarent from hem 1? YES, enter delivery address below:

C,

Yes

—

N)

Carolyn J. Eddy, LPN 5441 'Grove Manor Lady Lake, Florida 321S9

20

St.Lauwit N)

C PS Form 3811, January 2005

Domestic Return Receipt

EXHIBIT

I

Rick Scott

Mission:

Governor

proted. pmnzte & improve the health of aR peop'e in Fbr4a through integrated state, & oumunity elforta. To

John

H. Annetrong, MD, FACS State Surgeon General

Vision; To be the Healthiest Staten the

&

Secrelary

Nation

Affidavit of Non-Receipt

I,

Sherri Sutton-Johnson

,

hereby

in my official capacity as custodian

for the Board of Nursing's licensure files that the Board, as of

10/15/2013

has no evidence of an Election of Rights form or other responsive pleading requesting a

hearing prior to any agency action regarding Carolyn Jean Eddy. L.P.N.; 2013-07474 interests or rights. Custodian of Records Florida Board of Nursing Before me, personally appeared

Sherri Sutton-Johnson

,

whose

identity is known to me personally and who, under, oath, acknowledges that his/her

signature appears above. Sworn to and subscribed before me this

October

My commission expires:

Office of the General Ccuneel

day of

,2013.

Notary Public Signature

Floflds Dspartinsnt

15

ELZANA PLASKETT MYCOPQAISSIOW if EE 8S25n

u

EXPIRES: Febeuaiy 5,2C17

.f Health tJnft

Ncday

ldasHnlth.c.m 1TTER:HealthyFLA

EXHIBIT

iT I,

.

Deputy Clerk for the Department

Clerk's Office, hereby certify in my official capacity as custodian for the

Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Carolyn

)ean Eddy, L.P.N.; Case Number 2013-07474, which would affect the Respondent's substantial interests or rights.

Custodian of Record Department Clerk's Office STATE OF FLORIDA COUNTY OF

Leom

Before me, personally appeared is

'

whose identity

personally known to me or known to me by

(type of

identification) and who, under oath, acknowledges that his/her signature appears above. Sworn

to

and

.

subscribed

before

me

this

4 Notary Public

My Commission Expires:

EXHIBIT

day

of

STATE OF FLORIDA

DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, Petitioner,

)

CASE NO.

v. CAROLYN JEAN EDDY, L.P.N.,

Respondent.

2013-07474

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW the Department

of Health, by and through undersigned

counsel, and moves the Board of Nursing for the entry of a Final Order assessing

costs

against the

Respondent

for the

investigation

and

prosecution of this case in accordance with Section 456.072(4), Florida Statutes (2012). As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter

a Final

2.

Order therein.

Section 456.072(4), Florida Statutes (2012), states, in pertinent

part, as follows:

l

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

v. Carolyn Jean Eddy, L.P.N. DON Case Number 2013-07474

2001, under this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is no board, shall assess costs related to the investigation and prosecution of the case. The costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections thereto.... 3.

As

evidenced

in

attached affidavit

the

(Exhibit A), the

investigation and prosecution of this case has resulted in costs in the total

amount of $1, 407.31, based on the following itemized statement of costs:

Complaint Cost Summary Complaint Number: 201307474 Subject's Name:

EDDY, CAROLYN JEAN

***** Cost to Date Hours

__________________

Complaint: Investigation: Legal: Compliance: Sub Total: Expenses to Date: Prior Amount: Total Costs to Date:

DOH v. Carolyn Jean Eddy, L.P.N. DOH Case Number 2013-07474

1.00 I

1.50 15.60

.os

lis.is

7 9

Costs

$54.90

.67

**********

$1,387.93 $19.38 IIso.oo

I

I

I

2

4.

The attached affidavit reflects the Department's costs for

attorney time in this case as $595.59 (Exhibit A). The cost of obtaining an

affidavit from an outside attorney wiU be greater than $595.59. Therefore, the Department is not seeking costs for attorney time in this case. 5.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 6.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $1,407.31 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes (2012). WHEREFORE, the Department

of Health requests that the Board of

Nursing enter a Final Order assessing costs against the Respondent in the

amount of $1,407.31.

DOH v. Carolyn Jean Eddy, L.P.N. Case Number 2013-07474

oll

3

DATED this

day of

2013. Respectfully submitted, I

Louise Wilhite-St. Laurent Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0091244 Phone (850) 245-4444 x 8331 Fax (850) 245-4662

@doh.state.fl.us CERTIFICATE OF SERVICE I HEREBY CERTIFY that

a

true and correct copy of the foregoing

Motion to Assess Costs has been provided by U.S. Mail this

day of

2013 to Carolyn Jean Eddy, L.P.N., 5441 Grove Manor, Lady Lake, Florida 32159.

Louise Wilhite- St. Laurent Assistant General Counsel

LSL/mla

I

v Carolyn Jean Eddy, L.P.N. Case Number 2013-07474

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows: 1)

My name is Shane Walters.

2)

I

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at

the Florida Department of Health (DOH). 3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida

health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-07474 (Department of Health v. Carolyn Jean

Eddy, L.P.N.) are ONE THOUSAND FOUR HUNDRED SEVEN DOLLARS AND THIRTY ONE CENT ($1,407.31).

6) The costs for DOH case 201 3-07474 (Department of Health v.

Jean Eddy, L.P.N. are summarized in Exhibit Report), which is attached to this document.

1

Carolyn

(Cost Summary

7) The itemized costs and expenses for DOH case numbers 2013-07474 (Department of Health v. Carolyn Jean Eddy, L.P.N.) are detailed in

Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

EXHIBIT I

of 2

I

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the

foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of his knowledge and belief.

S 1t

FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiánt State of Florida County of Leon

Sworn to and subscribed before me this \Le day of nally known to me. by Shane Walters, who is

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

,

2013,

_l

Page

lof

1

Complaint Cost Summary Complaint Number: 201307474

Subject's Name:

EDDY, CAROLYN JEAN

fl

*****CosttoDate*****__I Hours

Complaint: investigation: Legal: 'Compliance:

l

Isub Total: Expenses to Date:

Prior Amount:

]

1

[

5.60

1

0.05 1.8.1

L

[

I

[

I

Costs to I)ate:

,doh.state.f1.us/IRMOOTIMETRAKICSDETL.ASP

Costs $54.90

1

5595.59

1

51,387.931

50.00

51,407.31

10/16/2013

i

1

Staff Rate

0.05

Sub Total

1.00

1.00

$54.90

$33.33

127

11.50

0.50

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

of Health

1.60

HLL 101 B

Florida

0.30

HLLIOIB

0.10

$106.35

$106.35 $106.35

IPROSECUTION SERVICES UNIT

IB

Sub Total

0127 0127 0127 0127

1.50

1.00

0.50 0.50 0.50

0127

127

127 127

1.00

0.50 3.00 2.00 0.50

0127

127

IENVESTIGATIVE SERVICES UNIT

Sub Total

O7

ICONSUMER SERVICES UNIT

0.05

1C27

COMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date 10/16/2013

Medical Quality Assurance

DivisiOn

$170.16

$31.91

$10.64

$735.77

$63.98 $31.99 $191.94 $L27.96 $31.99 $63.98 $31.99 $31.99 $31.99 $95.97 $31.99

$54.90

$54.90

$1.67

$1.67

Cost

-- FOR

05/13/2013 05/23/2013 05/29/20 13

05/17/2013 05/28/20 13 07/01/2013 07/08/2013 07/09/2013 08/20/2013 08/21/2013 08/22/2013

13

05/13/2013 05/15/2013

05/09/2013

08/15/2013

25 40

25

76

100

6

76

6

6

76 6

76

4

4

78

125

Activity Code

201307474

Activity Description

Page I

of 2

I

I

I

-

PREPARATION OF OR REVISION OF A PLEADING

REVIEWCASEFILE

REVIEW CASE FILE

I

L

EXHIBIT

I

ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE REPORT PREPARATION

JNITIALREVIEWANDANALYSISOFCOMPLAINT

LICENSE STATUS CHANGE

Complaint

INTERNAL USE ONLY

Activity Date

ONF IDE NT IAL

Time Tracking System Itemized Cost by Complaint

C

ot

$106.35 $106.35 $106.35 $106.35 $106.35 $L06.35 5106.35 $106.35 $106.35

0.20

0.60 0.10

5.60

0.20 0.L0 0.50 0.40 0.30

2.00

$106.35

Staff Rate

0.20

Florida Department of Health

Total Cost

Sub Total

HLLIO I B

OIB

HLLI 0 I B

IOIB

IB

HLLIOIB

IB

OIB

IO1B

HLLIOIB

Staff Code Activity Hours

Report Date 10/16/2013

l'vti

Medicol Quolily Assurance

$1,387.93

5595.59

$106.35 $21.27 $10.64 553.18 $42.54 $31.91

$63.81 $10.64

$21.27 $21.27

Cost

13

81

28

28 89

81

81

81

36

102

201307474

Activity Description

PROBABLECAIJSEPREPARATION PREPARE OR REVISE ADMINISTRATIVE COMPLAINT

ESO/ERO ESO/ERO ESO/ERO PREPARE OR REVISE ADMINISTRATIVE COMPLAINT

REVIEW EXPERT WITNESS REPORT PREPARATION OR REVISION OF LETTER

ESO/ERO

TELEPHONECALLS

- FOR INTERNAL USE ONLY -

08/22/2013 08/22/2013

13

08/02/2013 08/08/2013 08/08/2013 08/08/2013 08/09/2013 08/13/2013

35

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

CONFIDENTIAL ***

itemizedcost

Page 2

of 2

Expense Date

10/16/2013

$19.38 $19.38

Total Expenses

$19.38

Amount

Expense

SubTotal

09/25/2013

Florida Department of Health

FILLIO IS

IPROSECUTION SERVICES UNIT

Stall Code

Report Date:

Nit

Divisional Medical Quality Assurance

ON F IDE NT! AL

LEGAL & OFFICIAL ADVERTISEMENTS

Expense Code Description

Complaint 201307474

- FOR INTERNAL USE ONLY --

133100

Expense Code

C

Time Tracking System Itemized Expense by Complaint

***

of

I

I

—a

itemizedexpense

Page I

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Waiting on a Signed PCP Memo

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

STATE OF FLORIDA

DEPARTMENT OF HEALTH INVESTIGATIVE REPORT Alachua Date Subject: CAROLYN JEAN EDDY, LPN 5441 Grove Manor Lady Lake, FL 32159 (H) 352-350-4342 Office:

Prefix:

1PN

of Case:

February 22, 2013

2013-07474 Source: DEPARTMENT OF HEALTH CONSUMER SERVICES UNIT Case Number

License #:

Profession:

Board:

Report Date:

5178122

Licensed Practical Nurse

Nursing

05/17/2013

Period of Investigation:

Type of Report:

05/13/2013 to 05/17/2013

FINAL

Alleged Violation: Section(s) 456.072(1 )(c)(x)(z)(dd), 464.018(1 )(c)(j)(l)(o) FSS; Violate statuterules... Convicted of crime related to work... Failure to perform legal obligations... Impairment... Failure to report conviction... Synopsis: This investigation is predicated upon the receipt of an internally generated complaint (Case Summary and attachments, Exhibit #1), submitted by the Department of Health Consumer Services Unit, in regard to EDDY. It was discovered, following a review of FLCCIS court records that EDDY had been convicted of Driving Under the Influence, second offense. This conviction was not reported. EDDY may be impaired.

I

EDDY was notified of the investigation by letter (Exhibit #2), dated 05/13/2013 and was provided a copy of the Case Summary. (Exhibit #1). EDDY was contacted by phone on 05/13/2013 and agreed to accept this notification letter by mail. —a A check of DOH computer licensure records revealed EDDY is currently a licensed did not provide Investigator KNEZE a copy of her curficulum vitae.

-c

<

I'0 —

Patient Notification Letter(s) were deemed unnecessary by Investigator KNEZEVICH with inquiry.

m to CD

EDDY is not represented by an attorney.

2

Investigator KNEZEVICH spoke to EDDY on 05/13/2013, notifying her of this investigation. EDDY advised she had completed all court requirements regarding the criminal case and was curious as to how the administrative case was generated. EDDY advised she is currently not working in the healthcare field.

Related Case:

none

'5(2c( Michael Knezevich, Distribution:

HQ/ISU

-27

Received

William Schauer, Investigation

MAY 2

T-o.

1

1

DOH INVESTIGATIVE REPORT

CASiE NUMBER: 2013-07474

TABLE OF CONTENTS I.

II.

III.

:

INVESTIGATIVE REPORT COVER

1

TABLE OF CONTENTS

2

INVESTIGATIVE DETAILS Case Summary

3

Summary of Exhibits / Records I Documents

3

Interviews/ Carolyn Jean Eddy (subject)

3

Investigator Notes

a

IV.

*

EXHIBITS 1.

Case Summary and attachments

*

2. Copy of Notification letter, dated 05/13/2013

*

3. Court records from Marion County Clerk of the Court, case number

*

4. IPN program status request letter

*

5. IPN

47 8 1

0-CT-21 377

-16 17-18

program status response letter

19-20

*

EXHIBITS CONTAIN INFORMATION WHICH IDENTIFIES PATIENT(S) BY NAME AND ARE SEALED PURSUANT TO SECTION 456.057(lOfla), FLORIDA STATUTES

*

THESE RECORDS ARE SEALED PURSUANT TO SECTION 456.057(10)(a), Florida STATUTES AND COPIES OF SAME ARE NOT MAINTAINED IN THE ALACHUA INVESTIGATIVE OFFICE THIS EXHIBIT CONTAINS CONFIDENTIAL RECORDS CONCERNING REPORTS OF ABUSE, NEGLECT OR EXPLOITATION OF THE VULNERABLE ADULT, INCLUDING REPORTS MADE TO THE CENTRAL ABUSE HOTLINE, AND IS SEALED PURSUANT TO SECTION 415.107(1), FLORIDA STATUTES Page 2

DOH INVESTIGATIVE REPORT

CAbE NUMBER: 2013-07474

INVESTIGATIVE DETAIL CASE SUMMARY On 05/09/2013 the Florida Department of Health Consumer Services Unit received an anonymous complaint with regard to EDDY. Information was received which prompted a check of FLCCIS court records database, which showed EDDY had been convicted of Driving Under the Influence 04/13/2010. Records indicated EDDY failed to report this conviction and may possibly be impaired.

SUMMARY OF EXHIBITS I RECORDS I DOCUMENTS

Exhibit #1 is the Case Summary and attachments generated by the Florida Department of Health Consumer Services Unit on 05/09/2013. Included in this exhibit is a memorandum to open complaint dated 05/09/2013. Exhibit #2 is the notification letter dated 05/13/2013. Investigator KNEZEVICH sent this letter by US mail to EDDY. EDDY was contacted by phone on 05/13/2013 and agreed to accept the notification letter by mail.

)

Exhibit #3 is a copy of Marion County court records for case number 1O-CT-1377. Exhibit #4 is an IPN program status request letter dated, 05/17/2013. Exhibit #5is the IPN program status response letter received on 05/17/2013.

INTERVIEWS! STATEMENTS INTERVIEW OF CAROLYN JEAN EDDY PN 5178122

5441 Grove Manor Lady Lake, FL 32159 (H) 352-350-4342

Investigator KNEZEVICH contacted EDDY by phone on 05/13/2013 and notified her of this investigation. EDDY understood and made no comment regarding the conviction in Marion County in 2010. EDDY was curious as to how this case was initiated. Investigator KNEZEVICH advised it came from an anonymous email sent to the Consumer Services Unit EDDY stated she understood and advised she was not working in the healthcare field. INVESTIGATOR NOTES Marion County court records for the 2010 driving under the influence conviction are included as Exhibit #3. IRN was contacted. EDDY is not currently enrolled in an IPN program. Page 3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

-a

CD

clQ H

I

' CD

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county & community eFforts.

John H. Annstrong, MD, FACS

HEALTH

I

Vision:

State Surgeon General

& Secretary

To be the Healthiest State in the

NOTICE OF HEARING

November 8, 2013 Case#: 2013-06368 To:

MAYPETITE O'KELLEY SEGREE 496 AVE A, HOUSE B EASTPOINT, FL, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-06368

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way. Bin 0-02 Tallahassee, FL 32399-3252 PHONE: 850/ 245-4172

www.FlorldasHealth.gov TWITTER:HealthyFLA

lmentof}lealth VOUTUBE: fldoh

Rick Scott

Minion:

Governor

To protect, promote & improve the heatth of aU people in Floridathou hfritegrated

John H. Armstrong, MD, FACS Stale Surgeon General & Secretary

HEAL11—I Vision: To be

the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201306368 To:

MAYPETITE O'KELLEYSEGREE 206 WEST 3RD STREET CARRABELLE, FL 32322, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201306368

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

5,

2013

.

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412.2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florid. Department of Health Division of Medical Ouality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 P1-lONE:

85012454125 • FAX 65012454172

ld.sHealth.gov TWI1TER:HealthyFL.A

FAcEB00K:FLDeparmientotHealth VOUTUBE: lldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

John H.

HEALTH Vision; To be the Healthiest State

g, MD, FACS

State Surgecn General & Secretary in the Naflon

MEMORANDUM

H

FROM:

TO: Joe Baker, Jr., Executive Director, Florida Board of Nursing Jodi-Ann V. Johnson, Assistant General Counsel

RE:

Determination of Waiver

suBJEa:

DOH v. Maypetite O'Kelley Segree, L.P.N. DOH Case Number 2013-06368

DATE:

October 17, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 2013 meeting of the board. The following information is provided Subject: Maypetite O'Kelley Segree, L.P.N. Subject's Address of 496 Avenue A Rouse B Record: Eastpoint, FL 32328 Enforcement Address: 206 West 3rd Street Carrabelle, FL 32322

Subject's License No: Licensure File No:

70876

Initial Licensure Date:

12/2/1998

1330841

Rank:

PN

Board Certification: No Required to Appear' No Current IPN/PRN Contract: No

Allegation(s):

Section 456.072(1)(q), F.S. (2011-2012)

Prior Discipline:

None

Cause Panel:

Subject's Attorney: Complainant/Address:

September 5, 2013 Kirkpatrick and Rerrera Pro Se

,

Department of Health/Compliance Management Team

Fiorida Department of Health Office of the General Counsel • Prosecufion Services Unit 4052 Bald Cypress Way, Bin •Tallahassee. FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX 850/245.4683

www.FioddasHealth.com TWFfltR:HealthyFLA YOUTIJBE: lldoh

STATE OF FLORIDA

BOARDOFNURSING DEPARTMENT OFHEALTH,

4

Petitioner, v.

CASE NO.

2013-06368

MAYPETITE O'KELLEY SEGREE, L.P;N.,

,

Respondent.

I

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

Ptisi

the Florida Department of Health, by and through the

undersignedtounsel, hereby moves the Board of Nursing for entry of

a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states:

s 1.

An Administrative Complaint was flied against Respondent on

September 5, 2013. A copy of said Administrative Complaint is attached hereto as

2.

Exhibit A.

Copies of the Administrative Complaint,Explanation of Rights form,

and Election of US mail

were successfully served on Respondent via certified

on: September 13, 2013 (7196 9008 9111 1387 0582). Acopy of the

certified mail receipt is attached as Petitioner's Exhibit B.

3.

Rule

28-106.111(2),

Florida

Administrative

Code,

provides

in

pertinent part that: I

persons seeking a hearing on an agency decision which does or may determine their substantial interests. shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. •

4.

.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive, pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C and D. 6.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

7.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter a Final Order imposing whatever

disdpline upon Respondent's license that the Board deems appropriate.

Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

V.

.stant General H Prosecution Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar #0073525 (850) 245-4444 telephone (850) 245-4683 facsimile •

CERTIFICATE OF SERVICE

. HEREBY CERTIFY that foregoing has been provided by

a

true and correct copy of the above and

U.S. mail

to: Maypetite O'Kelley Segree, L.P.N., 206 West

of

C1:ltbo/

,

2013,

Street, carrabelle, Florida

32322 and Maypetite O'Kelley Segree, L.P.N., 496 Avenue A, House Eastpoint, Florida 32328.

nsel

B,

,

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

v.

I

CASE NO.

2013-06361

MAYPETITE O'KELLEY SEGREE, L.P.N.,

RESPONDENT.

/

ADMINISTRATIW COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through

Its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, O'KeIley Segree, LP.N., and in Support thereof alleges:

Ite

Petitioner is the state agency charged with regulating the practice of nursing assistance pursuant th Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Eloricia Statutes. 1.

2.

At

all

times

material

to this Administrative

Complaint,

Respondent was a licensed practical nurse (L.P.N.) within the state of Florida, having been issued license number PN 1330841.

3.

Respondent's address

of

record is 206 West

Street,

Carrabefle, Florida 32322. .4.

On or about March 28,

2012, the Department of Health filed

uniform non-disciplinary citation (citation) as

a

a

Final Order in case number

2012-00516. 5.

The Final Order required Respondent to complete and submit

certification for 2 hours in prevention of medical errors and 22 hours

in

general CME credits dated after January 12, 2012, and submitted before

July 12, 2012. 6.

.

Respondent failed to Submit certification

prevention of medical errors and

22

for 2 hours

in

hours in general CME credits dated

after January 12, 2012, and submitted before July 12, 2012. 7.

The Final Order required Respondent to pay a fine of $250.00

and costs in the amount of $122.00, within thirty (30) days of the date the

citation was filed as 3.

a Final

Order.

Respondent failed to pay a fine of $250.00 and costs in the

amount of $122.00, within thirty (30) days of the date the citation was filed as

a Final

,

Order.

Deparmient Health v. Maypetite O'KeIJey Segree, ,P.N. Case Number 2013-06368 Maypetite (LPN, CEs and $).doc

ley

2

9.

Section 56.072(1)(q), Florida Statutes (2011-2012), provides

that violating, a lawful order of the department or the board, or failing to comply with a lawfully issued subpoena

of the department constitutes

grounds for discipline. 10.

Respondent

is

licensed

pursuant to Chapter 464, Florida

Statutes, and is a health care practitioner as defined in Section 456.001(4), Florida Statutes (2011-2012). 11.

Respondent violated

a

lawful order of the Department of Health

by failing to do one or more of the following: a.

complete

and

prevention of medical

submit

certification

for

2

hours

in

and 22 hours in general CME

credits dated after January 12, 2012, and submitted before July 12, 2012; and b.

pay a fine of $250.00 and costs in the amount of

$122.00, within thirty (30) days of the date the citation was

12.

filed as

a Final Order.

Based

on the foregoing, Respondent has violated Section

56.072(1)(q), Florida Statutes (2011-2012), by violating Department of Health v. Maypctite O1(efley Segree, ,P.N. Number Segree, Maypeute O'KelIey (LPN, CEs arid $).doc Case

5368

a

lawful order of 3

______

the department or board, or failing to comply with a lawfully issued subpoena of the department. WHEREFORE, the Petitioner respectfully request-s

that the Board of

Nursing enter an order imposing one or more of the following penalties;

permanent revocation or suspension

of

restriction of

practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

day

ofi

I.

!t2C-r

D,

,

2013.

John Armstrong, FACS State Surgeon General and Secretary of Health

Ann V. Joh

nt FILED DEPAR1MENTOF

HEALTH

CLERK

fA

SEP 0 5 2073

Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0073525 (850) 245 - 4444 Telephone (850) 245 - 4683 Facsimile

/JvJ

3

PCP: PCP

Members:

e7vnc4

Departnent orflealth v. Maypetite

Case Number 2013-06368 Segree, Maypthte Okelley (t.Pr1,

LP.N. and $)doc

4

NOTIcE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by representative to present evidence counsel or other qualified and

to call and cross-e,camjne witnesses and to have subpoena and subpoena •duces tecum issued on his or her behalf if a hearing is NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the Investigation and pmsecuuon of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and of a disciplinary matter, which may incjude attorney hours and on the Respondent in addition to any other discipline imposed.

Depathnent of Health v. Maypetite OXeIley Segree, L.P.N. Case Number 2013.05368 Segreg, Maypetite OKeiley (LPN, cEs and $),doc

7196 9008 9111 1387 0582 *

*

TO:

STEP Pack

U,

—

Pauline/Johnson Date Mailed 9/6/2013

',

P'

CD

2013-06368 SENDER: REFERENCE:

00

—

D

D

PS Form 3800, January 2005

RETURN RECEIPT SERVICE

Postage

Certified Fee .

Return Receipt Fee

Restricted Delivery Total Postage & Fees

•

ISPS'

T

POSTMARK OR DATE

Receipt for Certified

No Insurance Coverage Provided International Mail Do Not Use

c

2. ArtIcle Number

IA, Received

or Delivery

by (Please Print Clearly)

1

7196 9008 9111 1387 0582

Is delivery adl(frhs different If YES,

Servtce Type

4.

Restricted Delivery? (Extra Fee)

—

lives

0

Segree 496 Avenue A

aC

13

3232

Pack

.

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CERTIFIED MAIL'

3.

PS Form

ttçffltem

Pa UikOcJJO}IttS OP

Domestic Return Receipt

January 2005

EXHIBIT

I

S

ma Scott Govemor

Mission: To protect promote & Improve the health

olall peo$e in state, county & community efforts.

,

.

H EALTH

Vistont To be the Healthiest

William Spooner

John H. Annetrong, MD, FACS State Surgeon General & Secretary

State in the Nathn

,

hereby certify in my official capacity as

,

Nursing as custodian for the Board of Nursing's licensure files that the Board of

of

10/16/2013

has no evidence

other responsive pleading requesting

of an Election of Rights form or

a hearing

prior to any agency action

regarding CASE NAME, MAYPETITE O'KELLEY

NUMBER or rights.

which would affect the Subject's substantial interests

Records Custodian Florida Board of Nursing

y

Before me, personally appeared

identity is known to me

L.P.N.C CASE

William Scooner

(type

of

l whose

identification)

and

who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this 16 day of

—

Notary Public

-

ton

Florida Department ot Health SoMoos Unit Office of the General Cypress Way, Bin C-65 • Tallahassee. FL 32399-1701 4052 Scpress mail address: 2585 Merthants Row Suite 105 PHONE: 850/245-4444 • FAX

-

T

October

h

2013.

ISth

SIthyFLA VOIJRJBE: fldoh

I

ion:

Rick Scott

To protect promote & improve the health of all people in Florida thmugh slate, county & efforts.

Governor

John H. Annatrong, MD, FACS

HEALTH Vision; To be the healthiest

State Surgeon General

&

Seaetary

Stats in the Nation

AFFIDAVIT

gctr\dely

Deputy Clerk for the Department Clerk's Office, hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case Name, MAYPE11TE O'KELLEY SEGREE, L.P.N., Case Number 2013-06368, which would affect the Respondent's substantial Interests or rights. ,

,

Custodian of Record Department Clerk's Office

Before me, personally appeared

I

whose identity is known to

me by personally known (type of identification) and who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this

!7rday of D@ 4nhgr

2013.

My Commission Expires: AlA?

L CAR RA

a tt Commissieji # DDWAY941828 Expires Januajy

Floulda Dopaitnont of Hosith

ls

t

Office of the General Counsel. Prosecution 4052 Bald Way, Bin C-65 . Tallahassee, Fl. 32399-1701 Express address; 2585 Row — Suite 105

eil

PhONE;

)2454444 •

850)2454683

,

EXHIBIT

m YOU11JBE; fidoft

STATE OF FLORIDA

BOARDOF NURSING DEPARTMENT OF HEALTH,

Petitioner, v.

) CASE NO.

MAYPETITE O'KELLEY SEGREE, L.P.N..,

Respondent.

.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, .by and through the undersigned counsel, and moves the Board of Nursing

of

a Final

for the entry

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section 456.072(4); Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition tp any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or discipline• imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case. and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

3.

.

The investigation and

prosecution of this case has

resulted in costs in the total amount of $329.19, based on the

following itemized statement of costs: [

Hours

Complaint:

investigation:

1 01

Costs

1

[

0.20 Sub Total:

1 6.67

4.20

Expensesto Date:

1 1 $6s.a8I

'

.

Prior Amount:

1otaelCoststo 1

2

Therefore, the Petitioner seeks an. assessment of. costs against the Respondent in the amount of $116.47 as evidenced in the attached

affidavit. (Exhibit A). 4.

should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit

as Exhibit A and any

timely-filed written objections. 5.

Petit!oner requests that the Board grant this motionS and

assess costs in the amount of $116.47 as supported by competertt,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and

is in

accordance with

Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter

a

Final Order assessing costs against the

Respondent in the amouñtof $116.47.

3

____________

day of

DATED this

-

.

2013.

Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

1

di-Ann V. Joh n sistant Gener Co sel OH Prosecution ices Unit 4052 Bald Cypress Way, Bin C-65 FL 32399-3265 Florida Bar #0073525 (850) 245-1111 telephone (850) 245-4683 facsimile J

,

I

CERTIFICATE OFSERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this

of 206 West

2013, to: Maypetite

rd Street, Carrabelle,

KelIey

Segree, L.P.N.,

Florida 32322 and Maypetite O'Kelley

Segree, L.P.N., 496 Avenue A, House B, Eastpoint, Florida 32328..

4/ 3

di-Ann v Joh'nso sistant unsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses,

I

I

respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System

and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 3-06368 (Department of Health v. MAYPETITE

O'KELLEY SEGREE, L.P.N.) are THREE HUNDRED THIRTY-NINE DOLLARS AND EIGHTY-THREE CENTS ($339.83). 6) The costs for DOH case numbers 201 3-06368 (Department of Health v. MAYPETITE O'KELLEY SEGREE, L.P.N.) are summarized in

Exhibit

1

(Cost Summary Report), which is attached to this document.

7) The itemized costs and expenses for DOH case numbers 201 3-06368 (Department of Health v. MAYPETITE O'KELLEY SEGREE, L.P.N.) are in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

determined by the following method: DOH employees who work on cases daily are to

8) The itemized costs as reflected in Exhibit 2 are

I

of 2

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report)

l

9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of his knowledge and belief. FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon Sworn to and subscribed before me this______ day of by Shane Walters, who is personally known to me.

ature

4'

.2013,

SCOTT D. FLOWERS

cS.

Notary PublicS State of Flotida

ComMulon

2017

# EE 862632

Bonded Through Nations Noisy Man,

Name of Notary Printed

I

Stamp Commissioned Name of Notary Public:

2

of 2

Page

1

of

1

Complaint Cost Summary Complaint Num her: 201306368

Subjeefs Name: SEGREE, MAYPETITE O'K JF.Y

*****

Cost to 1)ate

Hours

Complaint: investigation:

11

Legal:

1

1

Costs

.881 ¶43.92 ¶6.67

*********HI

1

SUI Total:

Expenses to Date: Prior Amount: Total Costs to Date:

¶339.83

.

¶339.831

E1

OTIMETRAKICSDETL.ASP

10/22/2013

10/22/2013

Staff Rate

0.20

0.20

2.00

Sub Total

$54.90 $54.90 $54.90 $54.90

$33.33

2.10

0.30 0.40 0.60 0.10 0.20 0.10 0.10 0.20 0.10

Florida Department of Health

Total Cost

Sub Total

-ILL79A

HLL9OB

HLL79A

HLL79A HLL79A I-ILL79A HLL79A

-ILL79A HLL79A

$106.35

$10635

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

PROSECUTION SERVICES UNIT

0.70 0.20 0.30 0.80

HA62 HA62 HA62 HA62

ICONSUMER SERVICES UNIT

Sub Total

I3

ICOMPI-JIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date

MQA

OMsion of Medical Quality AssI!rance

$339.83

$223.36

$31.91 $42.54 $63.81 $10.64 $21.27 $10.64 $10.64 $21.27 $10.64

$109.80

$38.43 $10.98 $16.47 $43.92

$6.67

$6.67

Cost

ON

201306368

25

35

35

25

79

62

28

25

25

76

TELEPHONE CALLS TELEPHONE cALLS REVIEWCASE FILE

.

.

Page

iteniizedcost

PREPAREORREVISEADMINISTRATIVECOMPLAINT REVIEWOFCASES FORPROBABLECAUSEPANEL STIPULATION REVIEWCASEFLLE

REVIEW CASE FILE REVIEWCASE FILE

REVIEW CASE FILE CSU INVESTIGATIVE WORK REPORT PREPARATION

144

INITIAL REVIEW AND ANALYSIS OF COMPLAINT

25

Activity Description

78

TELEPHONE CALLS

I

Complaint

- FOR INTERNAL USE ONLY --

10/02/2013 10/14/2013

10/0112013

07/05/2013 07/09/2013 07/09/2013 07/11/2013 09/05/2013 09/18/2013

.

04/23/2013 05/29/2013 06/20/2013 07/01/2013

35

Activity Date Activity Code

06/11/2013

NTIAL

Time Tracking System Itemized Cost by Complaint

C

I

of2

I

j

I

10/22/2013

Florida Department of Health

Staff Code Activity Hollrs

Report Date

Medical Ouo@y Assurance

Oivition of

Staff Rate Cost

Activity Code

- FOR INTERNAL USE ONLY -

Activity Date

Comptaint 201306368

Activity Description

Time Tracking System Itemized Cost by Complaint

x**CONFJDENTJAL***

itemizedcost

Page 2 of 2

oF

Total Expenses

SubTotat

Expense Date

10/22/2013

Florida Department of Health

Staff Code

Report Date:

.MQA

Medical Quality Assurance

Division

Amount

Expense

—

Expense Code Description

Complaint

- FOR INTERNAL USE ONLY

Expense Code

0 NF IDE NT IAL

Time Tracking System Itemized Expense by Complaint

C

itemizedexpense

.

Waiting on a Signed PCP Memo

_______________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

2013-06368

CASE

MAYPETITE O'KELLEY SEGREE, L.P.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Maypetite O'Kelley Segree, L.P.N., and in support thereof alleges: 1.

-

Petitioner is the state agency charged with regulating the

practice of nursing assistance pursuant to Section 20.43, Florida Statutes;

Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed practical nurse (L.RN.) within the state of Florida, having been issued license number PN 1330841.

3.

Respondent's address of record

Carrabelle, Florida 32322. 4.

On or about March 28, 2012,

uniform 2012-00516. 5.

The

l

is

Street,

206 West

l

the Department of Health filed a

citation (citation) as

a

case number

Order

Order required Respondent to complete and submit

certification for 2 hours in prevention of medical errors and 22 hours in general CME credits dated after January 12, 2012, and submitted before July 12, 2012. 6.

Respondent failed to submit certification for

2

hours in

prevention of medical errors and 22 hours in general CME credits dated

after January 12, 2012, and submitted before July 12, 2012. 7.

The Final Order required Respondent to pay

a

fine of $250.00

and costs in the amount of $122.00, within thirty (30) days of the date the

citation was filed as 8.

a Final

Order.

Respondent failed to pay a fine of $250.00 and costs in the

amount of $122.00, within thirty (30) days of the date the citation was filed as a Final Order.

Department of Health v. Maypetite O'Kelley Segree, L.P.N. Case Number 2013-06368 Segree, Maypetite OKelley (LPN, CEs and $)

2

9.

Section 456.072(1)(q), Florida Statutes (2011-2012), provides

that violating

a

lawful order of the department or the board, or failing to

comply with

a

lawfully issued subpoena of the department constitutes

grounds for 10.

Respondent is licensed

Statutes, and is

a

pursuant to Chapter 464,

Florida

health care practitioner as defined in Section 456.001(4),

Statutes (2011-2012). 11.

Respondent violated a lawful order of the Department of Health

by failing to do one or more of the following: a.

complete

and

submit certification

for

2

hours

in

prevention of medical errors and 22 hours in general CME credits dated after January 12, 2012, and submitted before July 12, 2012; and b.

pay a fine of $250.00

,

costs in the amount of

$122.00, within thirty (30) days of the date the citation was filed as 12.

a

Final Order.

Based on the foregoing,

Respondent has violated Section

456.072(1)(q), Florida Statutes (2011-2012), by violating Department of Health v. Maypetite O'KeIIey Segree, L.P.N. Case Number 2013-06368 Segree, O'KelIey (LPN, ca and $)

ite

a

lawful order of 3

______

1

the department or board, or failing to comply with subpoena of the

WHEREFORE, the Petitioner

ly

a

lawfully issued

requests that the Board of

Nursing enter an order imposing one or more of the

ies:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

p'acement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

day of

, 2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Jodi-Ann V. Johnson Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0073525 (850) 245 - 4444 Telephone (850) 245 - 4683 Facsimile

/JVJ PC P:

PCP

Members:

Department of Health v. Maypetite Q'KeIIey Segree, Case Number 2013-06368 Segree, Maypetite O'KeIIey (LPN, CEs and $)

,N.

4

NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Maypetite O'KeIIey Segree, L.P.N. Case Number 2013-06368 Segree, Maypetite OKelley (LPN, CEs and $)

5

FLORIDA DEPARTMENT

INVESTIGATIVE REPORT Office:

Date of Complaint:

Case Number:

CONSUMER SERVICES

4/22/13

LPN 201 3-06368 Source:

Subject:

4052 Bald Cypress Way

Street

206 West Carrabelle FL 32322

:

Tallahassee, FL 32399

Prefix:

License #:

Profession:

Board:

1702

1330841

Lic. Practical Nurse

Nursing

—

Report Date:

7/1/13

Type of Report:

Period of Investigation:

4/25/13

IT

DOH/COMPUANCE MANAGEMENT

MAYPETDTE SEGREE

FINAL

7/1/13

Alleged VioTation: 464.018 (1)(l)(o) F.S.

,072(1)(q)(k)(dd): Violating

statute/rule. Fail to perfomi legal obligation

a

Final Order of the Board, Violate

l)

This investigation is predicated on internally generated complaint and copies of final order dated 3/28/13, case 2012-00516. SEGREE has failed to submit proof of completion for 22 general CME credits and 2 hours prevention of medical errors by 7/12/12. SEGREE was initially notified of this complaint by letter dated 4/25/13 (Exhibit. #2). Forwarded with this letter were copies of the UCF and the complaint (Exhibit #1). A certified letter was mailed on 5/30/13. A check of DOH computer licensure records on 7/1/13 revealed that Clear/Active.

SEGREES licensure status

is currently

No patient(s) was/were identified thus patient notification was not required.

SEGREE does not appear to be represented by counsel as of the date of this report Investigator BATES has not received

Related Case:

a

response from SEGREE (Exhibit 3)

201200516

/Date:

Aed

Diane Bates (HA62) 7/1/13 Government Analyst

By Date:

Shane Walters, 0MG Manager JUL

2013

I

Distribution:

Legal/Consumer Services Unit

Pagel

. S 9,

I

:

CASE NUMBER 201 3-06368

DON INVESTIGATIVE REPORT

. II.

III.

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

TABLE OF CONTENTS

2

INVESTIGATIVE DETAILS Summary of Records

Statement of DEPARTMENT OF HEALTH(Source) Statement of SEGREE (Subject)

IV.

1

3

3

3

EXHIBITS 1)

UCF with attachments

4-9

2)

Copy of notification Letter

10-12

Page 2

DOH INVESTIGATIVE REPORT

CASE NUMBER 2013-06368 INVESTIGATIVE DETAILS

SUMMARY OF RECORDS Exhibit #1 is a Uniform Complaint Form, complaint from the Florida Department of Health/Compliance Management Unit

STATEMENT OF DEPARTMENT OF HEALTH/BON

- Source

On 4/22/13 Investigator BATES received internally generated complaint and copies of final

order dated 3/28/13, case 2012-00516. SEGREE has failed to submit proof of completion for 22 general CME credits and 2 hours prevention of medical errors by 7/12/12. (Exhibiti)

STATEMENT OF MAYPETITE SEGREE, LPN 206W. Carrabelle, FL 32322

—

Subject

A response has not been received from SEGREE. If

a

response is received

it

will be forwarded

to legal.

Page

3

CASE SUMMARY CONFIDENTIAL

Case No: 201306368 Please use this number

in all correspondence with the Department concerning this matter.

RESPONDENT INFORMATION 1330841 Maypetite O'kelley Segree 206 WEST 3RD STREET Carrabelle, FL 32322 Home Phone: (850) 843-1532

License No: Name: Address:

Profession: 1702 Licensed Practical Nurse

SOURCE OF INFORMATION Name:

Department Of Health/Compliance Management Team

Address: Home Phone:

REPORTED INFORMATION Receive Date: 04/22/2013 Responsible Party: ha62 Classification Code:

Source Code: 5 Status Code: 10 Incident Date: 03/28/2012

Form Code: Priority: 5

1

Patient Name: Possible Code(s): 15,

161

18

I

Summary: Possible violation s. 456.072(1)(q)(k)(dd), F.S., 464.018(1)(j)(o), F.S., Violate statute-rule and Violate order of the Board, fail to perform legal obligation Received internally generated complaint from Compliance Management Unit stating subject has violated terms of Final Order dated 3/28/1 2, case 2012-00516. Subject failed to submit proof of completion for 22 general CME credits and 2 hours prevention of medical errors by 7/12/12. A welcome letter was sent to the subject on 3/28/12. Attempting mediation of this case.

0

Rick Scott

Mission;

Govemor

To protect promote & improve the health of all people in Flodda through integrated

John H. Armstrong,

state, county & community efforts.

HEALTH Vision: To be the Healthiest State in the

D, FACS

State Surgeon General & Secretary

Nation

DEPARTMENT OF HEALTH UNIFORM REFERRAL FORM

I. /

Compliance Management Unit 4052 Bald Cypress Way, Bin C-76 Tallahassee, Florida 32399

/

/

/

SUBJECT OF REFERRAL Name:

Maypetite O'kelley Segree, LPN 206 West 3rd Street Carrabelle, FL 32322

LICENSE #:

1330841

rORNEY:

None on Record

CASE NO(S): DATE FILED:

201200516 March 28, 2012

FULL DETAILS OF REFERRAL: Maypetite OKelly Segree, license LPN 1330841 is required to complete and submit certification for (22) hours of General CME Credits and (2) hours in Prevention of Medical Errors. These courses were to be dated after January 12, 2012 and submitted before July 12, 2012. Ms. Segree is not in compliance with this final order. Please initiate a complaint based upon the above information.

April 19, 2013 Date Eric York Compliance Officer

Florida Department of Health Division of Medical Quality AssuranceS Bureau of Enforcement

4052 Bald Cypress Way! Bin C-76 . Tallahassee, FL 32399-325 1 PHONE: (850) 245-4268 • FAX: (850) 486.0796

FACE BOOK:

lth VOUTUBE: fldoh

Assurance

•

CMIU

COMPAS DataMart Reporting System Board Summary/Case File 201200516 Report April 19, 2013

Processed: 3:46:37PM

Page

1

of 2

Current Issue: Maypetite OKelly Segree, license LPN 1330841 is required to complete and submit certification for (22) hours of General CME Credits and (2) hours in Prevention of Medical Errors. These courses were to be dated after January 12, 2012 and submitted before July 12, 2012. Ms. Segree is not in compliance with this final order.

Otot Profession: Licensee:

Maypetite O'Kelley Segree

License Nbr:

1330841

License Status:

Clear/Active

Mailing Address:

206 West 3rd Street

Phone:

(850) 843-1532

Attorney:

None on Record

Monitor:

None on Record

Supervisor:

None on Record

Respondent:

Maypetite OKelley Segree

Address:

206 West 3rd Street Carrabelle, FL 32322

File Date:

3/28/2012

Disposition:

Non Disciplinary Citation Issued

Violation: Summary:

Continuing Education Violation

1702: Licensed Practical Nurse

File Nbr:

70876

Primary Location:

239 Crooked River Road Carrabelle, FL 32322

Appeal:

N

Info Package Mailed Date:

3/28/2012

Close 4084 Received an internally generated complaint alleging that the Subject failed to complete and submit certification for (22) hours of General CME Credits and (2) hours in Prevention of Medical Errors for license renewal for the biennium 8/1/09 to 7/31/11. The Subject is being issued a non-disciplinary citation.

Discipline Imposed:

Start Date 03/28/2012

End Date

Record Costs

Subject Area General

Prevention of Medical Errors

Comments

Due Date 04/28/2012 04/28/2012

Fine

Continuing Education:

lance

Carrabelle, FL 32322

Citation Issue

Compliance:

of

12

Due Dte

07/12/2012

CmpI Date 10/02/2012 10/02/2012

Req Hrs Credit Hrs 22.00 2.00

Amt Imposed 250.00 122.00

Crdt Dte

PAG

Ant Paid 250.00 122.00

Credit Desc

-

Activities:

Activity Date

Actv Code

Activity Description

03/28/2012 05/14/2012 05/14/2012 05/17/2012 09/10/2012 09/17/2012 09/18/2012 09/18/2012 09/26/2012 09/28/2012 10/01/2012 10/03/2012 10/09/2012 10/11/2012 10/11/2012 10/16/2012 10/23/2012 10/23/2012

901

Info pack mailed Collection Letter Sent Sent to Collections Referral to CSU

Contact History: Contact Date 03/28/2012 03/28/2012 05/14/2012 05/14/2012 05/17/2012 09/10/2012 10/02/2012

924 925 955 906

957

Warning Letter Returned Mail Mail Processed/Reviewed Mail Processed/Reviewed Respondent Contacted CO Respondent Contacted CO Mail Received in CMU Mail Received in CMU Returned Mail Mail Processed/Reviewed Mail Processed/Reviewed Mail Processed/Reviewed CO Contacted PSU PSU Contacted CO

Letter Code

Letter Description

NN157 NN179 NN174 NN174

CMU WELCOME LETTER

911

923 923 931 931

915 915 911

923 923 923 956

I NN91

NN152

INVOICE CMU COLLECTIONS LETTER CMU COLLECTIONS LETTER REFFERAL LETTER CMU -WARNING LETTER PAYMENT CMU RECEIPT LETTER

Attachments: Referral Form Summary 3. Final Order for Case 1.

2. Case

(rHBIT - J Florida Department of Health

—

FOR INTERNAL USE ONLY--

15:46;34 OND

_____

____________________

FILED DEPARTMENT OF HEALTH DEPUTy CLERK CLERK Angel DATE MAR 2 8 2012

Sanders

UNIFORM NON-DISCIPLINARY CITATION

Issued to:

BOARD OF NURSING Maypetite O'Kelley Segree,

LPN 206 West 3rd Street Carrabelle,_FL_32322 License Number LPN 1330841

Citation Number:

201200516

Date of Violation: Profession:

111 Nursing

Pursuant to Section 456.077 F.S., the undersigned hereby certifies that he/she has probable cause to believe that on July 31, 2011 the above referenced subject did violate the following P.S. 464.018(i)(i), F.A.C, 6489-5.002, provision(s) of law F.A.C. by commftting the following act(s); to complete and submit certification for Failure (22) hours Prevention of Medical Errors for license renewal of General CME Credits and (2) hours in for the biennium August 1, 2009 to July 31, 2011. Pursuant to Rule F.A.C. 64B9-8.003(4) Florida Administrative Code the Board/Departmer.g following penalties.for violation of the aforesaid has set the provision: e Fine of $250.00 plus costs in the amount of $122.00. amount due $372.00 You are required to complete and submit certification for (22) hours of General CME Credits and (2) hours in Prevention of Medical Errors. These must be dated after January 12, 2012 and submitted before July 12, 2012.

-5011(1)

l

On behalf of: State Surgeon General-Department of Health.

ISSUED this 12th day of January, 2012 by: Miles Hardison, Investigative Specialist

If you do not dispute the citation within, thirty (30) days of service, the citation will automatically be filed as a final order of the board but will not be considered

disciplinary action against your license, accept this citation, it will be filed as a final order If you and total payment of fine and cost is due thirty (30) days from the date the citation is filed and becomes a final order. In order to dispute this citation you must do so in writing. Send the written dispute and a copy of the citation by certified mail to the following address:

.

Department of Health, Consumer Services Unit 4052 Bald Cypress Way Bin C#75 Tallahassee Florida 32399-3275 You may elect to have these charges prosecljted as a disciplinary action according to section 456.073 Florida Statutes, rather than accept this In the event that you elect to have these charges prosecuted pursuant to section 456.073 Florida Statutes the case will be presented to probable cause panel or the Department for a the appropriate determination of probable cause. Please you choose this option, any penalties understand that if imposed by the board will be counted as discipline. PLEASE CHECK ONE OF THE FOLLOWING AND SIGN: (1) CHOOSE TO ACCEPT THE NON-DISCIPLINARY CITATION CHOOSE NOT TO ACCEPT THE NON-DISCIPLINARY CITATION AND WISH THIS CASE PROSECUTED UNDER SECTION. TO HAVE FLORIDA STATUTES. Signed: Date: PLEASE READ THE ON THE'REVERSE SIDE OF THIS FORM c-. i',...

)

I

I

,073,

s

Division of Medical Quality Msurance, consumer Services Unit 4052 Bald cypreis Way, Bin * Tallahassee FL 32399-3275 Telephone Number (850) 245-4339 Visit us online at corn j-

soume

____________________

IMPORTANT INFORMATION REGARDING COMPLIANCE WITH THIS CITATION the citation within thirty This citation automatically becomes a final order of the board If you do not dispute days from the date the thirty (30) due are costs (30) days of the date the citation was served. All fines and cashier's check or money with your of the citation citation becomes a final order. Please attach a copy shall be mailed to the Payment of Health. order. Payment should be made payable to the Department following address:

DOH/HMQACS/Coni pliance Management Unit-BIN C76 Post Office Box 5320 Tallahassee, Florida 32314-6320 citation and Any continuing education requirements shall be completed within the timeframe specified in the to: mailed must be completion Proof of Health. Department of with tbe proof of compliance documented

DOH/HMQACS Compliance Management Unit- Bin C76 4052 Bald Cypress Way Tallahassee, Florida 32399-3251 provide proof of After this citation becomes a final order, failure to pay the fine and costs specified and constitutes a violation of a final citation required continuing education within the timeframe specified on this agency. collection referral to a and order of the board, and may subject you to further disciplinary action

CERTIFICATE OF SERVICE (Initial service of citation offer) upon: HEREBY CERTIFY that a true and correct copy of the foregoing Citation has been served Scjrcc CY)(e iYlay petite

y

I

At

WesF

FL

Street

By Personal Service

94U.S. Certified Mail, Restricted Delivery Receipt Regular Mail

,20

day of

this Wes+

Mailing address verified as:

y ,1 .

3a3n

3rtl

Ft.

a

3aa

Consumer Services Unit Investigator CERTIFICATE OF SERVICE (Service of filed Final Order) I

been served by HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has

U.S. Mail upon:

this

of

Clerk

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Mission: To protect, promote & improve The health of all people in Florida through integrated

state, county & community efforts.

I

Vision: To be The

Healthiest State

Rick Scott Governor

John

I

in

D, FACS

H Armstrong, State Surgeon General

&

Secretary

the Nalion

NOTICE OF HEARING

November 8, 2013 Case#: 2012-18107 To:

LAURA ANN CLARK 3673 CATHEDRAL OAKS PL SOUTH JACKSONVILLE, FL 32217, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2012-18107

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place."

ov

further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Health Division of Medical Quality Assurance- Board of Nursing 4052 Bald cypress Way, Bin C-02 . Tallahassee, FL 32399-3252 PHONE: 8501 FAX 8501 245-4172

ITTER:HealthyFLA

VOUTUBE: fldoh

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Armstrong, MD, FACS

Fl

State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest State in

the Nation

NOTICE OF HEARING July 17, 2013 Case#: 201218107 To:

LAURAANN CLARK 3673 CATHEDRAL OAKS PL SOUTH JACKSONVILLE, FL 32217

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

10/3/2013

Time:

1:00 PM or soon thereafter

Type:

Determination Of Waiver

Re:

1701/201218107

Place:

Naples Beach Hotel 851 Gulf Shore Blvd N Naples, FL 34102

239-261-2222

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Fiorida Department of Heaith Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252

PHONE: 850/ 245-4125

•

FAX 850/ 245-4172

www.FioridasHeaith.gov TWITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Armstrong, MD, FACS

Fl

State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest State in

the Nation

NOTICE OF HEARING July 17, 2013 Case#: 201218107 To:

LAURAANN CLARK 3673 CATHEDRAL OAKS PL SOUTH JACKSONVILLE, FL 32217

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

10/3/2013

Time:

1:00 PM or soon thereafter

Type:

Determination Of Waiver

Re:

1701/201218107

Place:

Naples Beach Hotel 851 Gulf Shore Blvd N Naples, FL 34102

239-261-2222

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Fiorida Department of Heaith Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252

PHONE: 850/ 245-4125

•

FAX 850/ 245-4172

www.FioridasHeaith.gov TWITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Armstrong, MD, FACS

Fl

State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest State in

the Nation

NOTICE OF HEARING

September 9, 2013 Case #201218107 To:

CARESOUTH ATTN: JANICE PRICE, RN 570 MEMORIAL CIRCLE, SUITE 210 ORMOND BEACH, FL 32174-5063

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

10/3/2013

Time:

1:00 PM or soon thereafter

Type:

Determination of Waiver

Re:

LAURA ANN CLARK/201218107

Place:

Naples Beach Hotel 851 Gulf Shore Blvd N Naples, FL 34102

239-261-2222

This notice is to inform you, as an involved party or complainant, that the above listed case is scheduled to go before the Board of Nursing. While you are not required to attend, the meeting is open to the public. There is no action needed on your part at this time.

After the conclusion of the meeting, the Board file will file a final order stating the facts of the case and the Board's decision. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. This information will also be available on the Department of Health's website at: www.flhealthsource.com. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida

Board of Nursing office at (850) 245-4125 or via email at [email protected].

Fiorida Department of Heaith Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252

PHONE: 850/ 245-4125

•

FAX 850/ 245-4172

www.FioridasNursing.gov TWITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

_______________

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest State in

the Nation

MEMORANDUM TO: FROM: RE:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Jodi-Ann V. Johnson, Assistant General Counsel

SUBJECT:

DOH v. Laura Ann Clark, R.N.

Determination of Waiver DOH Case Number 2012-18107

DATE:

August 15, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the October 3, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of Record: Enforcement Address:

Laura Ann Clark, R.N. 3673 Cathedral Oaks Place South Jacksonville, Florida 32217

Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s):

9238235

3673 Cathedral Oaks Place South Jacksonville, Florida 32217

Rank:

RN

329925

10/13/2005 No No No

Section 464.018(1)(h), F.S. by Rule 64B9-8.005(6), F.A.C.

Prior Discipline: Probable Cause Panel:

None

Subject's Attorney:

Pro Se

ComplainantlAddress:

Caresouth 570 Memorial Circle, Suite 210 Attn: Janice Price, RN Ormond Beach, Florida 32 174-5063

May 8, 2013 Lavigne Kirkpatrick and Mary Jane Herrera

Florida Department of Health Office of the General Counsel• Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: FAX 850/245-4683

-4444•

www.FloridasHealth.com TWITTER:HealthyFLA FACEBOOK:FLDepartmentofHealth YOUTUBE: fldoh

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

,

_________________________________I

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

0

CASE

0

2012-18107

LAURA ANN CLARK, R.N.

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

8, 2013.

An Administrative Complaint was filed against Respondent on May A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were sent to Respondent via certified US mail on:

November 17, 2012 (7196 9008 9111 4171 4124).

Service on Respondent via certified mail was not successful.

A copy of the

certified mail receipt and envelope is attached as Petitioner's Exhibit

B.

3. Thereafter, Petitioner requested personal service on Respondent, which

was completed on July 16, 2013. The affidavfit of personal service is attached as

Petitioner's Exhibit B. 4.

Rule

Florida Administrative

Code, provides

in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 5.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits

C

and D.

7.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint. Therefore, there are no disputed issues of material fad to be resolved by the

Board. 8.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find

that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

di-Ann V. Joh on sistant Gene C nsel OH Prosecution ervices Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar #0073525 (850) 245-4444 telephone (850) 245-4683 facsimile J

I

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

a

,

true and correct copy of the above and day of

foregoing has been provided by U.S. mail this

2013,

to: Laura Ann Clark, R.N., 3673 Cathedral Oaks Place South, Jacksonville, Florida 32217.

V Jo i-Ann V. John n As istant Genera Co

l

2

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTh,

CASE NO.

201248107

LAURA ANN CLARI( R.N., RESPONDENT.

/

ADMINISTRATIVE CON PLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint befbre the Board of Nursing against Respondent, Laura Ann Clark, R.N., and in

support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, 2.

At

all

times

material to

Ida Statutes. this

Administrative Complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9238235.

3.

Respondent's address

South, Jacksonville, Florida 32217.

4.

At all

times

material

Respondent was employed by located in 5.

sonville,

,

of record is 3673 Cathedral Oaks

to this

south

ive

Place

Homecare Professionals (CHP),

Florida.

On or about October 30, 2012, patIent GE was hospitalized at

Memorial Hospital Jacksonville.

Patient GE remained

at MHJ until

November 6, 2012. 6.

or about November

On

3,

2012,

Respondent

submitted

documentation indicating she had conducted an in-home visit of patient GE on November 3, 2012.

7.

Patient GE was not at home on November 3, 2012.

8.

In

a

letter to the Department of Health, received January 11,

2013, Respondent admitted to writing Patient GE'S name in the signature

box of the in-home visit document, dated and submitted on November 3, 2012. 9.

Section 464.018(1)(h), Florida Statutes (2012), provIdes that

unprofessional conduct as defined by board rule constitutes grounds for disciplinary action. Department of Health v, Laura Ann Oark,

Case Number 20t-181O7 aan Laura Mn (RN, raJs4r?1ng

.

.

2

10.

Rule 64B9-8.005(6), Florida Administrative Code, provides that

unprofessional conduct includes falsifying or altering of patient records or nursing progress records, employrnent applications or time records.

,

Respondent engaged in unprofessional conduct by submitting

documentation of an in-home visit falsified patient 12.

's

Based

of patient

GE, on which Respondent

signature.

on

the

foregoing,

Respondent

violated

Section

464.018(1)(h), Florida Statutes (2012), by engaging in unprofessional conduct as defined by Rule 6489-8.005(6), Florida Administrative Code, to include falsifying or altering of patient records or nursing progress records,

employment applications or time records. WHEREFORE, the Petitioner respectfully requests that the Board

of

Nursing enter an order imposing one or more of the Ibliowing penalties:

permanent revocation or suspensiOn of Respondent's. license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

Departnent of Kea(th v, Laura Ann aadç RN. Case Numbec 201 2•18107 aark, Laura Ann (RN, reords)

.

3

SIGNED this

"

day of

.

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

di-Ann V. A sistant GeneraaLQbunsel a. Bar No, 0073525 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3255 Telephone: (850) 245-4640 Facsimile: (850) 245-4683 3

FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK .AngeCSandirs DATE MAY 0 8 1013

Email:

JVJ PCP: ¶3 PCP Members:•

Depaitnene or Health v. Laura Mn Cark, Case Numbs 2012-18107 Qarlç

Lain

Ann 1W, ralslMng reCords)

P.M.

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter, Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of V. ura Ann Oarlç RM. Case Number 2012-1t107 Oarlç Laura Am (RN, records)

.

____

______ ________________________ _____________ ____________

7196 9008 9111 8827 3639 TO:

STIP Pack

Pauline/Johnson Date Mailed 5/15/2013 2012-18107

N

•

SENDER: REFERENCE:

-

•

U

0

PS Form 3800, January 2005

en

Postage

RETURN RECEIPT SERVICE

Certified Fee Return Receipt Fee Resthcted Delivery Total Postage & Fees

•

USPS'

POSTMARK OR DATE

Receipt for Certif led Mar. No Insurance Coverage Provided Do Net Use Ice Int..naljonS Mel

111111

7196 9008 911.1 8827 3639 a. Service Type

CERTIFIED MAILTM

4. Restricted De!ivery? (Extra Fee) 1.

Article Addressed to:

Laura Ann Clark, R.N 3673 Carthedraj Oaks Place South

Jacksonville, Florida 32217

STIP Pack 2012-13107 Pauline/Johnson

I LREALI -ti -3265

Prosecution Services Unit 4052 Bald Cypress Way, Bin #C65 Tall a bass ee, Florida

FLORIDA

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//Ii/II//I/I// 1/11111

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Oaks Place South ida 32217

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1/111/1111111111111

15 2013 MAILEO FROM ZIPCODE 32301

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8/15/2013

______________ ________Affiant

________________________whose ___________________________ _____________Final _____________Notice

Rick Scott

Mission:

Governor

To protect, promote & mprove the health of all people in Florida through state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest

State in the Nalion

AFFIDAVIT OF SERVICE CR DILIGENT SEARCH Department of Health Petitioner vs

Case No.

2012-1 61 07

LAURA ANN CLARK, RN Respondent

,

COMES NOW, the affiant, who first being duly sworn, deposes and states: 1) Affiant is an Investigator/Inspector employedby the DEPARTMENT OF HEALTH, State of Florida.

Affiant made a diligent effort to locate Respondent, to serve XX papers; — Order compelling examination(s); Subpoena(s); orden and related papers. 2) That on July 16,

.

3) Check applicable answer below:

XXAffiant made personal service on Laura Ann Clark, Jacksonville, FL 32217 on July

i

,

Administrative Complaint and related to cease and desist;

at Respondent's address of record, 3673 Cathedral Oaks Place South,

was unable to make service after searching for Respondent at: (a) all addresses for Respondent shown in the DOH investigation of the case: (b) all official addresses for Respondent shown in his licensing records on the computer terminal or Board office; (c) Local telephone company for the last area Respondent was known to frequent; (d) Division of Drivers tnd,(e) Utilities ( e .); any others:

j

Affiant State Of Florida County Of Duval

Before me, personally appeared

William Pittman

Personal Knowledoe

identity is known to me by

(type of identification) and who, acknowledges that hisTher signature

appears above. before me this 16th Notary

Type or Print Name

Florida

C

day of

July

2013

My Commission Expires RYAN F. HEAL Commission # DD 926897 Expires Octobec8, 2013 Donded

lNv FORM 321

fluli

Fth

Rick Scott

Mission:

I

Governor

To piotect promote & imprtve the heatth of all people in orkia thm4J9h Integrated

, I,

I

John H. Armstrong, MD, FAGS SeSwgeonGenemi&Seaelaiy

Vision: To be the

Healthiest Stats in The Nation

Vickie Boyd

,

hereby certify in my official capacity as

,

custodian for the Board of Nursing's licensure files that the Board of Nursing as

of

/20

13

has no evidence of an Election of Rights form or

other responsive pleading requesting a hearing prior to any agency action regarding CASE NAME, LAURA ANN

R.N., CASE NUMBER

which would affect the Subject's substantial interests or rights.

Custodia of Records Florida Board of Nursing

Before me, personally appeared

identity is known to me

oersonally

Vickie Boyd

(type

whose

,

of identification)

and

who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this

VN4ESSARISCH Commission # EE 218427 Expiresjuiy 22 2016 BetS n,u tey rsi

.

15

day of

August

,

2013.

Notary Pubiic

Florida Department at Health Office at the General Counsel • Prosea,tion Unit 4052 Bald an Tallahassee. FL S2399-1?01 PHONE: 850/245-4444 ext FAX 850)245-4683

www.FloridasHnIth.con.

1eaIthyFLA

FACEBOOKFtheparUnenlolHealth VOUTUBE: fidoh

,

__________________ ___________________

Minion:

Rick Scott

f

To protect, promote & improve the health all people in Florida through integrated state, county & elfats.

I

I

John

HEALTH

I

Vision: To be the

1,

L

.

Governor

MD, FACS

State Surgeon General & secretary

Healthiest State in the Nation

AFFIDAVIT

Deputy Clerk for the Department Clerk's Office, hereby certify in my official capacity as custodian for the Department aerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case Name, Laura Ann Clark, RN., Case Number 2012-18107, which would affect the Respondent's substantial interests or rights.

Custodian of Record Department Clerk's Office

Before me, personally appeared

, —ca identity

me by personally known (type of iden'titication) and

that his/her signature appears above. Sworn to and subscribed before me this

of

is known

to

under oath, acknowledges

2013.

Notary Public

My Commission Expires:

ZI v

Pua

BARTON

EXPIRES 9/112013

Florida D.partm.nt of Hnith Clfice ot the General Counsel• Prosecution Services Unit 4052 Gatd Cypress Way, Gin C-65 -Tallahassee, FL Express mail address: 2585 Merchants Row— Suite 105 PHONE: 850/245-4444 • FAX 8501245-4683

-170

nlth.com

TWfl'TER:HealthyFLA

FACE BOOK: F Oe pa rtt ntoft-iea Its YDUTUBE: Ildoh

_____________________________________/

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE

LAURA ANN CLARK, R.N.,

Respondent.

0

2012-18107

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, by and through the undersigned counsel, and moves the Board of Nursing for the entry of a

Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the not board, shaH department when there assess costs related to the investigation and prosecution of the case. Such costs related to the i nvesticiation and orosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

3.

.

The investigation and prosecution of this case has resulted

in costs in the total amount

of $1,674.59, based on the following

itemized statement of costs:

***** Cost to Date ***** Hours Complaint: Investigation:

1

zo.soj

Legal:

3.OOj

Compliance:

0.00

Sub Total:

Expenses to Date:

Prior Amount: Total Coststo Date:

24.30

Costs

11 $43.92

l 0.00

$1,674.59 $0 00

674 59

2

Therefore, the Petitioner seeks an assessment of costs against

the Respondent

the amount of $1,355.51 as evidenced in the

attached affidavit. (Exhibit A). 4.

ld

the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $1,355.51 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and

is in

accordance with

Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $1,355.51.

3

flL4L4SY

of

DATED this

,

2013.

Respectfully Submitted,

John H.

mstrong, MD,

FACS

State Surgeon General and Secretary of Health

di-Ann V. Joh on A sistant Gener Co nsel H Prosecution rvices Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar #0073525 (850) 245-4444 telephone (850) 245-4683 facsimile 3

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this

10 day of

2013, to: Laura Ann Clark, R.N., 3673

Cathedral Oaks Place South, Jacksonville, Florida 32217.

di-Ann V. Jo so A sistant Gener C unsel 3

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

I

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at

the Florida Department of Health (DOH). 3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System

and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees.

DOll's total costs for investigating and prosecuting DOH case number(s) 2012-18107 (Department of Health v. LAURA ANN CLARK, R.N.) are ONE THOUSAND SIX HUNDRED SEVENTYFOUR DOLLARS AND FIFTY-NINE CENTS ($1,674.59).

5) As of today,

6) The costs for DOH case numbers 2012-13107 (Department of Health

LAURA ANN CLARK, R.N.) are summarized in Exhibit I (Cost Summary Report), which is attached to this document. v.

7) The itemized costs and expenses for DOH case numbers 201 2-18107

(Department of Health v. LAURA ANN CLARK, R.N.) are detailed Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the

following method: DOH employees who work on cases daily are to

I

of2

in

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the

foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief. FURTHER AFFIANT SAYETH NOT.

IflitTh

Shane Waiters, Affiant State of Florida County of Leon

Sworn to and subscribed before me this______ day of Walters, who is personally known to me.

signaturr

—..._-——N

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of2

2013,

Page

1

of

1

Compilaint Cost Summary Complaint Number: 201218H17 Subject's Name:

CLARK. LAURA ANN (

Cost to Date

L

Hours

l:

igation: 'Compliance:

j

0.80

Costs

1

$43.92

20.50

3.00

1lI 1 OMOJ

0.1)0

********** Sub Total:

Expenses to Date: Prior Amount: Total Costs to Date:

24.30 j_____________ I

I

OTIMETRAKJCSDETL.ASP

8/16/2013

ol

0.80

Sub Total

1.00

$63.98 $63.98 863.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

1.00

1.00

J187

187 187 187 187

20.50

1.50

0.50

Florida Department of Health

4OSECUTION SERVICES UNIT

Sub Total

1.50

187

1.00

1.50

2.00

JI87

1.00

1.00

1.00

0.50

1.00

$6198

$63.98 $63.98 $63.98

1.00

1.50 1.50

0.50 0.50

187 187 187 187 187 187 187 187 187

1187

187 187

JINVESTICATIVE SERVICES UNIT

0.80

HA52 $54.90

Staff Rate

ICONSUMER SERVICES UNIT

StafiCode Activity Hours

Report Date 08/16/2013

MQA

Medical Quolily

$1,311.59

$95.97

$3 1.99

$63.98 $31.99 $31.99 $63.98 $63.98 $63.98 $31.99 $63.98 $63.98 $63.98 $95.97 $95.97 $95.97 $127.96 $95.97 $63.98 $63.98

843.92

$43.92

Cost

100

4

100

76

76

76

76

4

4

4

4

4

4

4

4

4

4

4

4

78

Activity Code

201218107

Activity Description

E IVE

Page

I

of2

iteniizedcost

lb

I

L

EXHIBIT

ROUTINE INVESTIGATIVE WORK ROUTINEINVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK WORK ROUTINE ROUTINE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORTPREPARATION REPORTPREPARATION REPORT PREPARATION REPORTPREPAR.ATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE ROUTINE INVESTIGATIVE WORK SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE

INITIALREVIEWANDANALYSISOFCOMPLAINT

- FOR INTERNAL USE ONLY -

12/17/2012 12/27/2012 01/03/2013 01/07/2013 01/09/2013 01/10/20 13 01/14/2013 01/15/20 13 01/16/2013 01/22/2013 0 1/24/2013 0 1/28/2013 01/28/2013 01/29/2013 02/01/2013 03/04/2013 07/03/2013 07/15/2013 07/16/2013

12/11/2012

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFLDENTIAL***

i

3.00

Sub Total

Florida Department of Health

Total Cost

0.40 0.80 0.70 0.20 0.30 0.30 0.10 0.10 0.10

HLL79A HLL79A HLL79A HLL79A HLL79A HLL79A HLL79A HLL79A -ILL79A

Staff Code Activity Hours

Report Date 08/16/2013

Medical Quolily Asstaonce

Division

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

Staff Rate

$1,674.59

$319.08

$31.91 $31.91 $10.64 $10.64 $10.64

$74.45 $21.27

$85.08

$42.54

Cost 25 25 28 60 79 25 25 88 25

201218107

Activity Description

REVIEW CASE FILE PREPARE OR REVISE ADMINISTRATIVE COMPLAINT MISCELLANEOUS STIPULATION REVIEW CASE FILE REVIEW CASE FILE PROOFING AND SIGNING LETTERS REVIEW CASE FILE

REVIEWCASEFILE

- FOR INTERNAL USE ONLY --

03/13/2013 03/14/2013 03/14/2013 03/19/2013 05/14/2013 06/10/2013 06/27/2013 06/27/2013 07/23/2013

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

** itemizedcost

Page2of2

Total Expenses

SubTotal

Expense Date

O8/L6/2013

Florida Department of Health

Staff Code

Report Date:

M

Medicol Quolily Assurance

Diwision ol

Expense

Amount

Expense Code Description

- FOR INTERNAL USE ONLY -

Expense Code

Complaint

Time Tracking System Itemized Expense by ComplaEnt

***CONFIDENTIAL***

I

of I

itemizedexpense

Page

.

_____ ____ ______ _____

Mission: To prOteCt, piornote & improve the health

da

Rick Scott Governor

-

of all people in through integrated slate, county & community eftorts.

John H. AnnstTong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be the HealThiest

MEI4O*ANDJIM OF

Sbte

in the Nation

CAUSE PANEL FD1DING$

AC-02 (JV))

TO:

Department of Health

FROM:

Board

SUBJECT:

Laura Ann Clark, R.N.

of Nursing, North Probable Cause Panel

DATE OF PROBABLE CAUSE MEETING:

This matter was brought before

a

CASE NO.:

2012-18107

May 8, 2013

Probable Cause Panel composed of:

Lavigne Kirkpatrick and Mary Jane Herrera the date set forth above. The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that: On

,

Probable cause exisis herein that the Subject violated the following statutes/rules: Section

464.018(1)(h), Florida Statutes, by engaging in unprofessional conduct as defined by Rule 64B98-005(6), FAC

The panel suggests Imposing the following penalty: VS

Probable cause does not exist and the case should be closed with the flowing closure code:

In lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

__The

panel has requested supplemental or additional information on the following:

Other

BOARD

)IG

C)

Florida Department of Health of the General Counsel

Prosecution Services Unit 4052 Bald Cypress Way, Bin 0-65• Tallahassee, FL mail address: 25a5 Merchants Row -Suite 105 PHONE: (245-4444 FAX 850(245-4883 QtIICa

•

lth

lthyfL.A

-1701 .

VOUTUBE.

fl&h

_______________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE

v.

0

2012-18107

LAURA ANN CLARK, R.N.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Laura Ann Clark, R.N., and in

support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, florida Statutes. 2.

At

times

all

Respondent was

a

material

to

this

Administrative

Complaint,

licensed registered nurse (R.N.) within the state of

Florida, having been issued license number RN 9238235.

3.

RespondenU's address of record is 3673 Cathedral Oaks Place

South, Jacksonville, Florida 32217. 4.

At

all

times

to this

material

Administrative

Complaint,

Respondent was employed by CareSouth Homecare Professionals (CHP), located in JacksonvUle, Florida. 5.

Memorial

On or about October 30, 2012, patient GE was hospitalized at

Hospital Jacksonville.

Patient GE remained at

W

until

November 6, 2012. 6.

or about

On

November

3,

2012,

Respondent submitted

documentation indicating she had conducted an in-home visit of patient

GE

on November 3, 2012. 7.

Patient GE was not at home on November 3, 2012.

8.

In

a

letter to the Department of Health, received January 11,

2013, Respondent admitted to writing Patient GE's name in the signature box of the in-home visit document, dated and submitted on November 3,

2012. 9.

Section 464.018(1)(h), Florida Statutes (2012), provides, that

unprofessional conduct as defined by board rule constitutes grounds for

disciplinary action. Department of Health v. Laura Ann Clark, RN. Case Number 2012-18107 Clark, Laura Ann (RN, falsifying records)

2

10.

Rule 64B9-8.005(6), Florida Administrative Code, provides that

unprofessional conduct includes falsifying or altering of patient records or nursing progress records, employment applications or time records. 11.

Respondent engaged in unprofessional conduct by submitting

documentation of an in-home visit of patient GE, on which Respondent falsified patient GE's signature. 12.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(h), Florida Statutes (2012), by engaging in unprofessional conduct as defined by Rule 64B9-8.005(6), Florida Administrative Code, to include falsifying or altering of patient records or nursing progress records,

employment applications or time records. WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems apprcpriate.

Department of Health v. Laura Ann Clark, RN. Case Number 2012-18107 Clark, Laura Ann (RN, falsifying records)

3

SIGNED

day of John

2013.

Armstrong, MD, FACS State Surgeon General and Secretary of Health H.

Jodi-Ann V. Johnson Assistant General Counsel Fla. Bar No. 0073525 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4640 Facsimile: (850) 245-4683 Email: [email protected]

/JvJ

PCP: PCP

Members:

Department of Heafth v. Laura Ann Clark, RN. Case Number 2012-18107 CIarlç Laura Ann (RN, falsifying records)

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum iswed on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter Pursuant to SecUon 456.072(4), Florida Statutes, the Board shall assess costs r&ated to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Departhient of Health v. Laura Ann Clark, RN. Case Number 2012-18107 aark, Laura Ann (RN, falsifying records)

5

STATE OF FLORIDA

DEPARTMENT OF HEALTH INVESTIGATIVE REPORT Case Number: RN 2012-18107 Date of Case: 12-10-12 Office: Jacksonville Source: JANICE PRICE, RN Subject: LAURA ANN CLARK, RN C/O CareSoutli Homecare Professionals 3673 Cathedral Oaks Place South 6900 Southpoint Drive North Jacksonville, FL 32217 Jacksonville, FL 32216 (H) 904-716-2718 (W)_904-296-1913 Board: Report Date: Profession: License #: Prefix: 3-4-13 Nursing RegisteredNurse 9238235 RN Period of Investigation: 11-17-12 — 3-4-13

Type of Report: FINAL

,.

Alleged Violation: F,S. 456.072 (1 )(a)(l)(m)(dd) — (a) Making misleading, deceptive, or fraudulent representations... I) Making or filing a report which the licensee knows to be false... (m) Making deceptive, untrue, or fraudulent F.S. 464.018 (1 )ffl(h)(n)(o) —(0 Making or filing a representations.... (dd) Violating any provision of this false report or record.... (h) Unprofessional conduct... (n) Failing to meet minimal standards of acceptable and prevailing nursing practice... (o) Violating any provision of this chapter... Synopsis: This investigation is predicated upon receipt via mail on December 10, 2012, in DOH Consumer Services Unit (CSU) of a DOI-I Healthcare Practitioner Complaint Form, dated December 3, 2012, from JANICE PRICE, RN, Director of Operations, CareSouth Homecare Professionals, Jacksonville, FL, who alleges on November 3, 2012, CLARK submitted documentation of an in-home visit of patient GE when GE was a patient at Memorial Hospital Jacksonville. PRICE further alleges when she confronted CLARK she advised that she actually performed the visit on November 1, 2012. PRICE informed CLARK that patient GE was in the hospital on November 1, 2012, and CLARK informed her that her visit was actually on October 31, 2012. PRICE informed CLARK that patient GE was in the hospital on October 31, 2012 and CLARK admitted that she completed an electronic visit note in her handheld device for a visit that she did not perform. CLARK was terminated. (Exhibit 1)

CLARK was notified of the investigation by letters dated December 17, 2012 and January provided with a copy of the Department's Case Summary with attachments. (Exhibit 2)

10, 2013, and was

A check of DOH computer records on February 1, 2013, revealed CLARK is currently licensed Registered Nurse and holds a Clear, Active, license. CLARK was first licensed on October 13, 2005.

as a

A patient notification letter was not sent in this case.

CONTINUED NEXT PAGE... Related Complaint:

Investigator/Date: 3-4-13

Re

Approved By/Date: MAR

William J. Pittman Medical Malpractice Investigatoj Distribution:

ISU

DOH INV FORM 300 7/02

i 2913

Page

1

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 2012-18107

SYNOPSiS CONTINUATION

CLARK is not known to be represented by an Attorney in this matter. Tn

her written response, CLARK denied the allegations made against her in the complaint.

DOH FORM 300 07102

Page 2

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 201 2-181 07

TABLE OF CONTENTS

1.

II.

III.

INVESTIGATIVE REPORT COVER

.1-2

TABLE OF CONTENTS

3

INVESTIGATIVE DETAILS Summary of Exhibits/Records/Documents

4

Interviews/Statements JANICE PRICE, RN (Source) LAURA ANN CLARK, RN (Subject)

4-5 5-6

IV. EXHIBITS * 1.

Case Summary with Attachments

7-14

*2. Notification Letters with Attachments

15-29

*3 Copy *4•

,

of CareSouth's investigative file concerning this incident

30-45

Written response received from CLARK on January II, 2013

46-49

Copy of Complainant notification letter sent to JANICE PRiCE, RN

50-5 1

*6. Confidential Index

of Names

52

*EXHIBITS CONTAIN INFORMATION WHICH IDENTIFIES PATiENT(S) BY NAME AND ARE SEALED PURSUANT TO SECTION 456.057 (10) (a), FLORIDA STATUTES.

DOH FORM 300 07/02

Page 3

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 201 2-18107

INVESTIGATIVE DETAILS Summary of Exhibits/Records/Documents Exhibit 1 is a copy of our Case Summary; along, with a DOH Healthcare Practitioner Complaint Form dated December 3, 2012, received from JANICE PRICE, RN, Director of Operations, CareSouth Home Care Professionals, Jacksonville, FL. PRICE's complaint was summarized in the first paragraph of the synopsis section (page 1) of this Final Investigative Report. Exhibit 3 is a copy of CareSouth's investigative file sent to this Investigator by JANICE PRICE, RN and received on January 17, 2013. Documents of interest include the following:

•

o

• •

Visit Note Report dated November 3, 2012, for patient GE, submitted LAURA JAMES CLARK, RN. Report indicates CLARK's total in home time was one (1) hour and the form was signed by JAMES/CLARK and patient GE. (page 3 1-38) Memorial Hospital Jacksonville Admission Report dated October 30, 2012. Report indicates patient GE arrived Memorial by Fire Rescue at 12:55 on October 30, 2012 and was assigned bed 463A. (page 42) (According to this Investigator's interview with PRICE, she advised that patient GE was at Memorial until November 6, 2012) Physician Orders Form shows notes indicating GE received orders on November 3, 4, 5, 2012. (page 43) Request for consultation dated November 3, 2012. (page 44)

Exhibit 4 is a copy of CLARK's written response, received at DOH/MQA Jacksonville Investigative Services on January 11, 2013. CLARK failed to include two attachments she stated that were with her response. CLARK's response will be summarized under the INTERVIEWS/STATEMENTS section of this Final Investigative Report. Exhibit 5 is a copy of the complainant notification letter sent to JANICE PRICE, RN, on December 17, 2012.

INTERVIEW OF JANiCE PRICE, RN (Source/Complainant) Employment Director of Operations CareSouth Home Care Professionals 6900 Southpoint Drive North Jacksonville, FL 32216 (W) 904-296-1913 On January 7 & 28, 2013, this Investigator interviewed PRICE via telephone at the number shown above. PRICE reiterated her complaint against CLARK and stated that they received a call from the Discharge Planner at Memorial Hospital informing them that patient GE was admitted to Memorial

DOH FORM 300 07102

Page 4

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 2012-1 8107

INTERVIEW OF JANICE PRICE, RN (Continued) (Source/Complainant)

Hospital Jacksonville on October 30, 2012 and she was discharged on November 6, 2012. PRICE further stated that one of her staff members noted CLARK had submitted a completed nurse visit dated November 3, 2012, for patient GE. The visit was signed by CLARK and the patient. PRICE advised that she confronted CLARK with this information and she stated that this visit was actually performed on November 1, 2012. PRICE further advised that she informed CLARK that patient GE was in the hospital on November 1, 2012. PRICE stated that CLARK then advised her that she performed the visit on October 31, 2012. PRICE ftirther stated that she informed CLARK that patient GE was still in the hospital on October 31, 2012. PRICE stated that CLARK then admitted that she completed an electronic visit note for a visit on November 3, 2012, that she did not perform. PRICE advised that it would be easy for CLARK to forge patient GE's name on their hand held electronic device because you signed the device with your finger. PRICE further advised that CLARK was terminated.

STATEMENT OF LAURA ANN CLARK, RN (Subject) 3673 Cathedral Oaks Place South Jacksonville, FL 32217 (H) 904 -716-2718 On January 11, 2013, DOH/MQA Jacksonville Investigative Services received CLARK's written response. In her response, CLARK essentially stated the following:

• • • • • •

• •

• • •

•

have worked in the ICU/Critical Care since I graduated, until May of 2012, when I went into home health. My first and only home health agency was Alliance Care. We were later bought by CareSouth and we were told that all charting would be on a I

handheld device. If we had any problems with the device we were told to correspond via e-mail. The problem with that is that if you are in a patient's home, you can not wait for a return email. The patient in question was a wound care patient I saw on Monday October 29, in which I performed wound care. I charted it on my device and she signed the device with her finger. After a patient signs the device, there are two other questions you have to go to in order for it to be saved. I thought that it was saved, but found out later that week that it was not saved. After so many hours the patient moves to the very bottom of the screen, in which you have to scroll down to see. That week, due to all the nurses that left and the laying off of others, they were adding a lot of patients to my device without even asking me to see these patients. I was overwhelmed with charting at the end of the week.

DOH FORM 300 07102

Page 5

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 201 2-18107

STATEMENT OF LAURA ANN CLARK. RiM (Continued) Subject) •

• o

• • •

• • •

On Saturday when I noticed that the patient in question GE was at the bottom of my screen as late and not done since Monday, I charted on it and thought that I put in Monday's date, but obviously they are saying that I put the date I charted on it. I did put the patient's name in the signature box, but the patient had previously signed it. I didn't think it to be such a dangerous thing. Obviously in hindsight, I should have just not charted on it at all. When I was called to the office I did not know what it was about and I did not bring in any

of my paperwork. This was my first encounter with the new Director, JANICE. I began to try to explain to her that I saw the patient earlier that week and she cut me off and said answer this question "did you see this patient on Sat 11/6 th" I said no, I did not see her that day and tried to explain the device malfunctioning. She cut me off and said that I could no longer work there. I have enclosed the paper visit form seeing patient GE on that Monday along with the daily account record. (These items were not included with CLARK's response. This Investigator contacted CLARK and she stated that she would send these documents)

INVESTIGATOR NOTES: As of the report date, the documents CLARK advised this Investigator that she would send to DOHIMQA Jacksonville Investigative Services (paper visit form and the daily account record) have not been received.

Exhibit 6

is

the Confidential Index of Names.

DOH FORM 300 07/02

Page 6

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

crQ

_

E

C

C

L•I

Rick Scoff

Mission: To protect, promote & improve the health of all people in Flohda through integrated

John H. Annstrong, MD, FACS

state, oounty&communityefforts.

State Surgeon General & Secretary

Vision:

To be the Healthiest State in the Nation

NOTICE OF REARING

November 8, 2013 Case#: 201214824 To:

KEISHA MARIE SPARKS 218 E WHEELING ST LANCASTER, OH 43130, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201214624

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

5,

2013

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please

contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Fiends D.psrtmont of H.aith Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 850! 245-4125 • FAX 850! 245-4172

www.FlorldasH•sith.gov TWI1TER:HealthyFLA FACEBOOK:FLDepartnientofHeatth VOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect promote & improve the health

of all people in Florida through 3ntegrated state, county & community efforts.

John H. Armstrong, MD, FACS I

UM

Vision: To be the

TO: FROM: RE: SUBJECT:

State Surgeon General

Healthiest State in the Nation

Joe Baker, Jr., Executive Director, Florida Board of Nursing Michael Lawrence, Jr., Assistant General Counsel

.

Determination of Waiver DOH v. Keisha Marie Sparks, R.N. DOH Case Number 2012-14824

DATE:

& Secretary

.

April 22, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Keisha Marie Sparks Subject: 218 E Wheeling St Subject's Address of Lancaster, OH 43130 Record:

Enforcement Address: Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s): Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

Fiorida Department of Health Office of the GeneralCounsel •Proseáutibn Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105

PHONE: 850/245-4444

FAX 850/245.4683

218 E Wheeling St Lancaster, OH 43130 Rank: 9301462 399379

•RN

12/14/2009 No No No

464.018(1)(b),

FS

(2012)

None March 20, 2013; Habgood & Kemp Pro Se

Department of Health/ Board of Nursihg

www.FloridasHeaith.com TWITTER:HealthyFLA FACEBOOK:FLDepartmentotHealth YOUTUBE: fldoh

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner, v.

CASE NO.

2012-14824

KEISHA MARIE SPARKS, R.N.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER BY HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT Petitioner, Department of Health; by and through counsel, moves the Board of Nursing to find that Respondent has waived his/her right to elect a

method of disposition. of the pending Administrative Complaint, to determine that no material facts are in dispute, to conduct a hearing not involving disputed issues of material fact, and to enter a Final Order. As grounds• therefore,

Petitioner states: 1.

21, 2013.

An Administrative Complaint was filed against Respondent on March

A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights forms was sent to Respondent, via certified US mail

successfully, on March 30, 2013 (7196 9008 91118826 3920). A copy of the

certified mail receipt and envelope 3.

is

attached as Petitioner's Exhibit

B.

Respondent has not filed with either the Department of Health or the

Board of Nursing, an Election of Rights form or other responsive pleading in this case within the twenty-one (21) day period 'to dispute the allegations contained in

the Administrative Complaint. Copies ofaffidavits supporting the same are

attached hereto as Petitioner's Exhibits C and D. 4.

Rule

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 5.

Rule

28.106.111(4), Florida Administrative Code,

provides

in

pertinent part that: .person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 6.

Respondent has been advised, by a copy of this motion sent to

his/her address of record, that

a copy

furnished to the Board to establish

a

of the investigative file in this case shall be

prima fade case regarding the violations as

set forth in the Administrative Complaint.

7.

The Department has determined• that there are

io

material facts in

dispute and has concluded that Respondent has waived his/her right to elect the method of resolution. 8.

The Department requests that this Motion and a hearing be placed

on the agenda for the next meeting

of the

Board of Nursing.

WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived his/her right to elect

a

method of resolution of this

matter, find that there are no material facts in dispute, hold a hearing not involving material issues of disputed fact based on the information contained in

the investigative file, find that Respondent violated Chapters 456 and 464, Florida Statutes, as alleged in the Administrative Complaint, impose discipline in

accordance with the disciplinary guidelines, and enter

a Final

Order.

RespectfUlly submitted, John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Assistant General Counsel Florida Bar No. 0011265 Department of Health Prosecution Services Unit 4052 Bald Cypress Way Bin C-65 Tallahassee, Florida 32399-3265 Telephone: (850) 245-4444 x8199 Facsimile: (850) 245-4683 Email: michaél_lawrence@doh .state.fl .us

CERTIFICATE OF SERVICE I HEREBY CERTIFY

that

a

true and correct copy of the foregoing Motion

for Determination of Waiver and for Final Order by Hearing Not Involving Disputed Issues of Material Fact has been furnished via U.S. mail this day of

2013, to Keisha Sparks, 218 East Wheeling Street,

•Lancaster, Ohio 43130.

/

Michael C. LaWrence, Assistant General Counilel

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE 140.

2012-14824

KEISHA MARIE SPARKS, R.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through Its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Keisha Marie Sparks, R.N., and in

sUpport thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

R.espondent was a licensed registered nurse (R.N.) within the state of FLorida, having been issued license number RN 9301462.

14

EXHIBIT

•

3.

Respondent's address of record is 2t8 East Wheeling Street,

Lancaster, Ohio 43130.

4.

The Ohio Board of Nursing is the licensing authority of the

practice of nursing in the state of Ohio. 5.

Respondent's Ohio nursing.licenses are PN-117726 and RN-

327264. 6.

On or about September 21, .2012, the Ohio Board Of Nursing

entered into a Consent Agreement With Respondent.

7;

The Consent Agreement indefinitely suspended Respondent's

licenses to practice as a registered nurse and license practical nurse and placed Respondent's licenses on probation for

a

minimum of three (3)

years. 8.

The indefinite suspension was stayed as long as Respondent

met the probationary terms imposed by the Consent Agreement. 9.

Section 464.018(1)(b), Florida Statutes (2012), provides that

having a license tq practice nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action.

la

Departnent of Healthy. Case Number 201214824

Marie Sparks, R.N.

2

t

Respondent

10.

had

a

license

to practice

nursing, revoked,

another suspended, or otherwise acted against by the licensing authority of

indefinitely state, territory, or country by having her Ohio nursing licenses suspended and placed on probation for a minimum of three (3) years by

the Ohio Board of Nursing when it entered into the Consent Agreement on

oràbbut September 2-1, 2012. 11.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(b),. florida Statutes (2012), by having a license to practice nUrsing revoked, suspended, or otherwise acted against, Including the

denial of licensure, by the licensing authority of another state,

or

country. WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of

a

reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

DepaitneitdHealth Case Nuniber

y. Kaisha Marie Sparks, RN.

2012-14824

3

201j.

day of

John ft Armstrong, MD and Secretary of Health State Syrgpon

/

FILED DEPARTMENT OF HEALTH DEPUTY CLERK

CLERK Angel sanden DATE MAR 21 ?U13

MIC AE G. LAWREPICE, Assistant General Counsel Fla. Bar No. 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 rallahassee, FL 32399-3265 (850) 245-1111•EXT 8199 Facsimile: (850) 245-4683 Email: [email protected] -

/MGL PCP: PCP

Members:

March 20, 2013 Habgood & Kemp

Departnent of Health v. Kelstta Marie Sparks, R.N. Case Number 2012-14824

4

NOTICE OF RIGHTS

hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Stathtes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on.his or her behalf if a hearing is requested.

Respondent has the right to request

a

NOTICE REGARDINGASSESSMENTOFCOSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Boald shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

lsha

Department of Health V. Case Number 2012-14824

Marie Sparks, RN.

5

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FEATURES

Certfied Mail

1

7196 9008 9111 8826 3920 TO: Keisha Marie Sparks, RN

2012-14824

ab—StipPk Sent 3(26(13 SENDER: REFERENCE:

— •

Keisha Sparks 218 E. Wheeling Street Lancaster, OH 43130

USPS

POSTMARK OR DATE

Receipt for Certified

li"

lhleh

No Inswencs Coverage Pru.ided

Rick Scott

Mission: To protect promote & improve the health of all people in Florida through Integrated

John H. Armstrong, MD, FACS

state, counly& communIty efforts.

Slate Surgeon General & Secretary

HEALTH Vision; To be

the Healthiest State

In

the Nation

Affidavit of Non-Receipt

I,

Joe Baker.

.

,

hereby certify in my official capacity as custodian for

the Board of Nursing's licensure files that the Board, as of

4/22/2013

has no

evidence of an Election of Rights form or Other responsive pleading requesting a hearing prior to any agency action regarding Keisha M. Sparks, RN; affe

the Subject's sdt anti.a nterests or rights.

which would

Cust dia of Records Flori oard of Nursing

Before me, personally appeared

Joe Baker. Jr.

,,

whose identity is

known to me personally and who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

Ann!

22

day of

.2013

—

VWJESSARISCH Cormilssicn # EE 218427 Expires July 22, 2016

I

Notary Public Signature My commission expires

Florida Department of Health Office of the General Counsel • Prosecution Services Unt 4052 Bald Cypress Way, Bin C45 • Tallahassee, FL PHONE:

www.Fior

aith.coni

EXHIBIT

FACEBO

FAX

I

Rick Scott

Minion:

Governor

To protect prornole&improvethe health of all peopte in Flodda through Integrated effoit, & state,

John H. Annstrong, MD, FACS

,

State S'jigeon General 8

HEALTH

Vision: To be

the Healthiest State in the Naton

AFFIDAVIT

C

I,

Office, hereby

,

Deputy Clerk for the Department

Clerk'.s

in my official capacity as custodian for the Department Clerk's

received an Election of Rights form

reèords, that the Department Clerk's Office has

or other responsive pleading, which requests a hearing prior to any Department action regarding Keisha M. Sparks, RN; substantial interests or rights.

which would affect the Respondent's

nof Record

Before me, personally appeared

t

known to me personally and who,

Department Clerk's Office

\'LI

,

whose identity is

oath, acknowledges that his/her signature

appears above. Sworn to and subscribed before me

of

13.

Notary Public

My Commission Expires: LAWANDAMBELL tAt

I I

I Fioulda Department of Health Office of the General Counsel Prosecution Services Unit 4052 Bald Cypress Way Sin C-65 • Tallahass ee, FL 32399-1701

PHONE 850/2454444

www.FioridasHeaitli.com

STATE Ol FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2012-14824

v.

KEISHA MARIE SPARKS, R.N.,

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW the

Department of Health, by and through

undersigned counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Flohda Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter 2.

a Final

Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel workinci on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit• of itemized costs and any written objections

3..

.

The investigation

prosecution of this case

and

has

resulted in costs in the total amount of $277.28, based on the

following itemized statement of costs: Cost to Date

1

Complaint:

Investigation:

Hours

1

costs

I

1.00

Legal:.

1.50

.

0.00 Sub Total:

.

3.70]

Expenses to Date: Prior Amount:

*****

1 00

.

.

[

I

$0.00

costs to ]

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $117.98 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount

.

costs to be assessed based

upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $117.98 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

3

WHEREFORE, the Department of Health

Board of Nursing enter

a

requests that the

Final Order assessing costs against the

Respondent in the amount of $117.98. DATED this

•

2013.

Assistant General DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0011265 (850) 245-4444 x8199 Telephone (850) 245-4683

Fax

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY

that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day

of.

218 East Wheeling

&rII

2013, to Keisha M. Sparks,

Lancaster, Ohi 43130..

.

Michael L wrence,f Assistant General Counsel .

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared SI-lANE WALTERS who was sworn and states as follows: 1)

My name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

I

am the Operations and Management Consultant Manager (OFvICM) for the Consumer Services •and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors; dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As OMCM of the ConsumerServices and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida

health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH

case number(s) 2012-14824 (Department of Health v. KEISHA MARIE SPARKS) are TWO HUNDRED SEVENTY-SEVEN DOLLARS AND TWENTY-EIGHT CENTS ($277.28). 6) The costs for DOH case number(s) 2012-1 4824 (Department of Health

KEISHA MARIE SPARKS) are summarized in Exhibit Summary Report), which is attached to this document. v.

1

(Cost

7) The itemized costs and expenses for DOH case number(s) 2012-

14824 (Department of Health v. KEISHA MARIE SPARKS) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

EXHIBIT 1

of 2

and lawyers). A designated DOH employee in the' Consumer Services Unit, Legal Department, and in each area office, inputs the time' worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has, read the foregoing Affidavit and its attachments and the statements contained.

therein are true and correct to the best of her knowledge and belief. FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon

Sworn to and subscribed before me this day by'Shane'Walters, who is personally known to me.

•

Name of Notary

rinted of Notary Public:

JACQuELYNN MEI.NIrA KAMSTON

NOTARY PUBLIC STATE OF FLORIOA Commft EE027440 ,

Expires 1/15/2015

2

of 2

Fage I ot I

Complaint Cost Summary

:

Complaint Number: 201214824

Subject's Name:

SPARKS. KEISHA MARIE Cost to Date

.

Hours

complaint:

investigation: Legal:

I_________________________

suh Total:

Expenses to Date: Prnw Amount: Total Costs to Date:

Ir J

1

Costs

1.00

$62.85 $54.90

1.50

$159.53

0.00

$0.00

**.******** 3.70t-

H

]

I

1

$o.ooI

EXHIBIT

I

http://mqaapps.doh. state.fl.us/IRMOOTIMETRAKJCSDETL.ASP

4/23/2013

0.70 0.40 0.10

1.00

2.20

FIALO2

Sub Total

0.80 0.40 0.10 0.20

1.50

Sub Total

Ficrida Department of Health

Total Cost

I-ILL36B

SB

HLL38B

I-ILL38B

$106.35 $106.35 $106.35 $106.35

PROSECUTION SERVICES UNIT

I-1A102

HAIO2

$50.57 $54.90 $54.90 $54.90

Staff Rate

CONSUMER SERVICES UNIT

Staff Code Activity Hours

Report Date 04/23/20 13

MQA

Medicol Quolily Assurance

Division

$277.28

$159.53

$85.08 $42.54 $10.64 $21.27

$117.75

$35.40 $21.96 $5.49 $54.90

Cost

25 28 68 79

78 144 144 76

I

Activity Code

201214824

.

.

Page

1

of

.

I

.

SIGNING CLOSING ORDERS, ADMINISTRATIVE COMPLAINTS AND REASONAB STIPULATION

NISTRATIVECOMPLAINT

REVIEW CASE FILE

.

NT

Activity Description

INITIAL REVIEW AND ANALYSIS CSU INVESTiGATIVE WORK CSU INVESTIGATIVE WORK REPORT PREPARATION

- FOR INTERNAL USE ONLY -

02/05/2013 02/05/2013 03/20/2013 03/25/2013

10/09/2012 10/30/2012 12/19/2012 01/17/2013

.

Activity Date

Complaint

Time Trackiiig System Itemized Cost by Complaint

i

Health

TotalExpenses

bTotal

Expense Date

0 4/23/20 13

Assu,ance

rlor,Jj Department

Staff Code

Report Date:

Ps/t

Divhion ol

Expense Amount

.

CON F ID EN T IA L

.

Expense Code Description

Complaint

--FOR iNTERNAL USE ONLY--

Expense Code

w

Time Tracking System Itemized Expense by Complaint

w

Page 1

of

I

Rick Scott

i

impe all

Governor

the health.

pebplelnFtoddathroughintegrefed

state,

Florida

& community efforts,

John H. :A,in.trong,:MD,

HEALTH

I

FAGS

Surgeon Genetal & Secretary

Vision: To be thS Healthiest Stat.

in thàNai]on

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department.ofHeatth- A-I ML

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Keisha Marie Sparks, R.N.

CASE. NO.: 2012-14824

-DATE:

DATEtOF

March

This matter was brought before a Probable Causepanel composed

f

Batbara Kemp :andManjK. Habgood

On the date set forth above. The panel, having received the investigative report and Supplemental materials, having carefully reviewed said documentation. and the. recommendation of the inquire of counsel,: finds that: agency/department, and having had the

nity

x

Probable cause.exists herein that theSubject violated the following-statutes/rules:

464;ola{1)(b), F.S. (2012)

H :

.

.

The panel suggests imposing the following penalty:.

Costsand.V2

•

..

.,

.

cause:does .not:existand the case should be closed with the flOwing closure code: lieu of a finding of probable cause,. the above named licensee shall be issued .guidanceto address .the.conduct in question:

a letter of

The panel has requested supplemental or additional: information on the: following:

Florida Department of health. Office of the General Counsel • ProseoubOt+ SSMces Unit 4052 Bald Cypress Way, Bin 0-65 • Tallahassee; FL 32399-1701 PHONE' 8501245-4444 'FAX85012454683

TWFTTER:I-iealUiyFLA

F

VOUTUBE: ftdoh

____________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE NO.

2012-14824

KEISHA MARIE SPARKS, R.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the

RN; support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9301462.

3.

Respondent's address of record is 218 East Wheeling Street,

Lancaster, Ohio 43130. 4.

The Ohio Board of Nursing is the licensing authority of the

practice of nursing in the state of Ohio. 5.

Respondent's Ohio nursing licenses are PN-117726 and RN-

327264. 6.

On or about September 21, 2012, the Ohio Board of Nursing

entered into 7.

a

Consent Agreement with Respondent.

The Consent Agreement indefinitely suspended Respondent's

licenses to practice as a registered nurse and license practical nurse and placed Respondent's licenses on probation for a minimum of three (3)

years. 8.

The indefinite suspension was stayed as long as Respondent

met the probationary terms imposed by the Consent Agreement. 9.

Section 464.018(1)(b), Florida Statutes (2012), provides that

having a license to practice nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action.

Department of Health v. Keisha Marie Sparks, R.N. Case Number 2012-14824

2

10.

Respondent

had

a

license

to

practice

nursing

revoked,

suspended, or otherwise acted against by the licensing authority of another

state, territory, or country by having her Ohio nursing licenses indefinitely suspended and placed on probation for a minimum of three (3) years by

the Ohio Board of Nursing when it entered into the Consent Agreement on or about September 21, 2012. 11.

Based

on

the

foregoing,

Respondent

violated

Section

464.0 18( lj(b), Florida Statutes (2012), by having a license to practice nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state, territory, or

WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

Department of Health v. Keisha Marie Sparks, R.N Case Number 2012-14824

3

day of

SIGNED this

,

201

John H. Armstrong, MD State Surgeon General and Secretary of Health

MICHAEL G. LAWRENCE, JR. Assistant General Counsel Fla. Bar No. 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65

Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 EXT 8199 Facsimile: (850) 245-4683 Email: [email protected] /MGL PCP: PCP

Members:

Department of Health v. Keisha Marie Sparks, Case Number 2012-14824

RN.

4

NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Keisha Marie Sparks, R.N. Case Number 2012-14824

5

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FLORIDA

Da'Agrrve4r

INVESTIGATIVE REPORT Office: CONSUMER SERVICES

Date of Complaint: October 26, 2012

Subject:

KEISRA 1V1.RLE

Complainant/Source:

RN

Department of Health/Board of Nursing

218 E. Wheeling Street Lancaster, OH 43130 (740) 412-6679

Prefix: RN

License #: 9301462

Case Number: 20 12-14824

Profession: Registered Nurse

Period of Investigation: November 1,2012 through January 17, 2013

Board: Nursing

Report Date: January 17, 2013

Type of Report: FINAL

Alleged Violation: ss. 456.072(1)(f)(dd) and 464.018(1)(b)(o), P.S., Having a license orthe authority to practice any regulated profession revoked, suspended, Violating any provision of this chapter. This investigation is predicated by the Florida Department of Health/BOARD OF NURSING (Ex. #1), that SPARKS' RN license in Ohio was disciplined on 9/21/12 due to practicing beyond the scope. Alleged that on 6/20/11 SPARKS reported to the Ohio Board that she had entered inpatient treatment for suicidal thoughts and severe depression. SPARKS was self-medicating with Prozac, Ulfraxn, and Vicodin, all of which had not been prescribed to her. SPARKS also engaged in several incidents of improper narcotic administration, documentation in the MAR, withdrawing narcotics without a physician order and giving narcotics prior to the prescribed time. SPARKS has failed to report the discipline to the Board of Nursing.

SPARKS was therefore notified of this complaint by letters dated 11/1/12, via regular mail (Ex. #2), to the address on file with the Board including a copy of tb Case Summary and on 12/20/12, via Certified Mail, and signed by SPARKS on 12/24/12. DOR computer information obtained on 1/17/13 reflects SPARKS' license to practice as a Certified Nursing Assistant in the State of Florida is Delinquent/Active. No patient was identified, thus patient notification was not required.

SPARKS is not known to be represented at this time. ±{c response has been received by SPARKS. Any response received will be forwarded for review. Related Case: none

Approved By/DateS

Disthbution: PSU/CSU

DOH INVESTIGATWE REPORT

CASE NUMBER 2012-14824

TABLE OF CONTENTS

I.

INVESTIGATIVE REPORT COVER

I.

TABLEOFCONTENTS

ifi.

INVESTIGATIVE DETAILS

IV.

2

Summary of Records

3

Statement of KEISHA MARIE SPARKS, RN Subject

3

EXHIBITS

1)

Uniform Complaint Form and attachments

4-22

2)

Copy of Notification Letter wI attachments

23-26

DON INVESTIGATIVE REPORT

CASE NUMBER 2012-14824

INVESTIGATIVE DETAILS SUMMARY OF RECORDS Exhibit #1 includes a complaint initiated by the Florida Department of Health/BOARD OF NURSING (Ex. #1), that SPARKS' RN license in Ohio was disciplined on 9/21/12 due to practicing beyond the scope. Alleged that on 6/20/11 SPARKS reported to the Ohio Board that she had entered inpatient treatment for suicidal thoughts and severe depression. SPARKS was self-medicating with Prozac, Ultram, and Vicodin, all of which had not been prescribed to her. SPARKS also engaged in several incidents of improper narcotic administration, documentation in the MAR, withdrawing narcotics without a physician order and giving narcotics prior to the prescribed time. SPARKS has failed to report the discipline to the Board of Nursing Exhibit #2 includes the notification packages that were mailed to SPARKS, dated 11/1/12, via regular mail (Ex. #2), to the address on file with the Board including a copy of the Case Sumniaty and on 12120/12, via Certified Mail, and signed by SPARKS on 12/24/12.

RESPONSE FROM KEISRA MARIE SPARKS. RN. SUBJECT 218 E. Wheeling Street Lancaster, 011 43130 (740) 412-6679

No response has been received by SPARKS. Any response received will be forwarded for review.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

No DOcurne nt, ecch.ed For •

'S canning/Imaging

Image

4

Rick Scott

Mission: To protect, promote & improve the health

1

ot all people in Florida through integrated state county&community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H £4111—I Vision: To be

the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201217218 To:

SHELLY LEE ARNOLD 1034 TRI COUNTY RD GRACEVILLE, FL 32440, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201217218

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medicaU conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way! Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 850/2454125 • FAX 65W 245-4172

www.FlorldasHeslth.gov TWITTER:HeatthyELA FAcEB0OK:FLDepartmentofHeatth VOUTUBE: fldoh

I

Mission: To protect, prornote & improve the health a

Vision: To be

Rick Scott Governor

John H. Armstrong, MD, FACS State Surgeon General & Secretary

the Healthiest State in the Nation

NOTICE OF HEARING November 8, 2013 Case#: 2012-1 7218 To:

SHELLY LEE ARNOLD 352 SLOAN ROAD GRACEVILLE, FL 32440, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

/2012-17218

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

5,

2013

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

,

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must beaccompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 41 Please include your full name and contact information.

For questions regarding meeting location directions, contact the hotel at the number listed above under "Place.' If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality • Board of Nursing 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE:

www.FlorldasHealth.gov

I

ITTER:HealthyFLA FACEBOOlCFLDepartrnentofHealth .

JTUBE:

tldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida Through integrated state,

&

John H. Armstrong, MD, FACS

community efforts.

State Surgeon General & Secretary

HEAUH Vision: To be The Heaithiest State in

the Nation

MEMOR AND UM TO;

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM:

Judson Searcy, Assistant General Counsel

RE:

Determination of Waiver

SUBJECT:

DOH v. Shelly Lee Arnold, L.P.N. DOH Case Number 2012-17218

DATE;

•

.

September 13, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Subject: Shelly Lee Arnold Subject's Address of 1034 Tn County Rd Record: Graceville, FL 32440 1034 Tn County Rd Enforcement Address: Graceville, FL 32440 Subject's Additional 352 Sloan Road Address: Graceville, FL 32440 Rank: PN 5189617 Subject's License No: 138151 Licensure File .No:

Initial Licensure Date:

9/18/2009

Board Certification: Required to Appear:

No

Current IPN/PRN Contract: Allegation(s): Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

No

Fiorida Department of Heaith Office of the General Counsel Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701

Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX 850/245-4683

No

464.018(1)(b),

FS

(2012)

None May 20,2013; Habgood & Kemp

ProSe Department Of Health/Board Of Nursing 4052 Bald Cypress Way Bin C-02 Tallahassee, FL 32399

.aith.com ITTER:HealthyFLA

FACEBOOK:FLDepartmentoft-lealth YOUTUBE: fidoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, CASE NO.

v.

2012-17218

SHELLY LEE ARNOLD, L.P.N.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health,

•by

and through the

undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on

a

date and time that has been determined

and noticed by the Board. As grounds therefore Petitioner states: 1.

20, 2013.

An Administrative Complaint was filed against Respondent on May A copy

of said Administrative Complaint

is

attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on July 25, 2013 (7196 9008 9111 9326

mail receipt is attached as Petitioner's Exhibit B.

7272): A copy of the certified

3.

Thereafter, Petitioner requested personal service on Respondent, which

was completed on June 28, 2013. The affidavit of personal service is attached as Petitioner's Exhibit C.

4.

Rule

28-106.111(2),

Florida Administrative Code,

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days Of receipt of written notice of the decision. 5.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a the right to request a hearing within 21 days hearing on such matters. -

6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits D and 7.

E.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained. withi.n the Administrative Complaint.

Therefore, there are no disputed issues of- material fact to be resolved by the Board.

8.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

1

Final

Order imposing whatever

discipline upon Respondents license that the Board deems appropriate.

John H. MD, FACS State Surgeon General and Secretary of Health

t2' Searcy Msistant General Counsel Fla. Bar No. 0098772 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 x8100 Facsimile: (850) 245-4683 Email: [email protected]. us.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the above foregoing has been provided by U.S. mail this

and.:

day of

2013, to Shelly Arnold, 1034 Tn County Rd.,

Graceville, FL 32440, and to 352 Sloan Road, Graceville,

FL

32440.

sistant General Counsel

Respondent's address of

3.

record is 1034

n

County Road,

Graceville, Florida 32440.

The Alabama Board of Nursing is the licensing authority of the

4.

practice of nursing in the state of Alabama. 5.

Respondent's Alabama nursing license is 2-062590.

6.

On or about November

16,

2012, Respondent's voluntary

surrender of her Alabama nursing license was accepted by the Alabama

Boardof Nursing. Respondent's voluntary surrender was in response to the

7.

Alabama Board of Nursing's investigation of Respondent's license.

The Alabama Board of Nursing's acceptance of Respondent's

8.

voluntary surrender constitutes action taken, against her Alabama nursing license.

Section 464.018(1)(b), Florida Statutes (2012), provides that

9.

having

a

license to practice nursing revoked, suspended, or otherwise

acted against, including the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action.

DcparUrent or Health v. Case Number 2012-17218

,

Lee

LP.N.

2

10.

Respondent

had

a

license

to practice nursing revoked,

suspended, or otherwise acted against by the licensing authOrity of another state, territory, or country by voluntarily surrendering her Alabama nursing license to the Alabama Board of Nursing. 11.

Based

on

the

foregoing,

464.018(1)(b), Florida Statutes (2012),

Respondent

by

violated

Section

having a license to practice

nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state, territory, or country.

or heaTh v. Shelly Lee Case Number

2012-172t8

knold,

L.P.N.

3

WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one

ormore of the following penalties;

permanent revocation or suspension

of Respondent's

license, restriction of

practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the

Board deems appropriate.

SIGNED

this

day of

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

&L FILED DEPARTMENT OF HEALTH CLERK CLERK J4ngefsanters DATE MAY 2 0 2D13

UTY

PCP

Members:

Department of Health v. Case Number 2012-17218

SEAkCY C Assistant General Counsel Ha. Bar No. 0098772 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 ex. 8100 Facsimile: (850) 245-4683 Email: [email protected],fl.us

-f

Lee Arnold, L.P.N.

4

NOTICE CF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigatbn and prosecution of this matter. POrsuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Depathnent of Health v. Shelly Lee Arnold, L.P.N. Case Number 2012-17215

'

9008 9111 932h 7272 TO:

Shelly Lee Arnold, LPN

JS-ab/Stip Pk Sent 7/24/2913

Shelly Arnold 352 Sloan Road Graceville, FL 32440

SERVICE

I

Certified Fee.

I

Return Receipt Fee

Cted Delivery Total Postage & Fees

USFS'

POSTMARK OR DATE

Receipt for

ii

No Insurunce Coverap. ProviSO Do Not U.. for Irfl.rnetional

2. Article Number

COMPLETE THIS SECTION ON DELIVERY 3d

by (Pleese Print Clearly)

1

7196 9008 1111 9326 7272

?

3. Service Type 4. Restricted 1.

1FIED MAIL" (Extra Fee)

Article Addressed to:

Sriellv 352 Sloan Road 32440 Stip Pk—JS

PS Form 3511, January 2005

(0 —,

.

—.4

Mission: To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

John H.

Governor

MD, FACS

State Surgeon General & Secretary

HEALTh Vision: To be

,

Rick Scott

the Healthiest State

in

the Nation

AFFIDAVIT OF SERVICE DEPARTMENT OF HEALTH

.

,

Petitioner vs

Case No. PN 2012-1 7218

SH.ELLY LEE ARNOLD, LPN

Respondent

COMES NOW, the affiant, who first being duly swam, deposes and states: 1) Affiant is an Investigator/Inspector employed by the DEPARTMENT OF HEALTH, State of Florida.

.

Affiant made a diligent effort to locate Respondent, to serve )O(Administrative Complaint and related papers; — Order compelling examination(s); Subpoena(s); _Final order; _Notice to cease and desist; ESO/ERO and related papers. 2) That on

3) Check applicable answer below:

XX

Aff ant made personal service on Respondent, SHELLY

GRACE VILLE, FL, 32440 on

LEE ARNOLD, LPN at 352 SLOAN

ROAD,

was unable to make service after searching for Respondent at: (a) all addresses for Respondent shown off cial addresses for Respondent shown in his licensing records on the computer terminal or Board office; (c) Local telephone company for the last area Respondent was known to frequent; (d) Division of Ddvers in the DOH investigation of the case; (b) all

;;

and (e) Utilities

i

cable, etc.); any others:

Ft

State Of Florida County Of Escambia Before me, personally appeared Janie M. Shingles whose identity is known to me by personally known (type of

identification) and who, acknowledges that

S

o

to or affir e

Public-State of

,

lher signature appears above.

y Affiant before me this

of

June

LORA BOYD

CoinmSion # EE 869098 Expires JanuaTy 27,2017

My Commission Expires

Type or Print Name

— NV FORM 321

Exhibit

EXHIBIT

I

ZC./

Rick Scott

Mission:

I

Governor

To protect promote &impiove the health of all people in Florida through integrated

John H. Annstrong,

state, county & community efforts.

HEALTH Vision: To be the Healthiest State in

,

the Nabon

Affidavit of Non-Receipt

Robert Johnson

I,

PACS

State Surgeon General &

hereby certIfy in my official capacity as

custodian for the Board. of Nursing's licensure files that the Board, as of

1 3/20

13

-,

has no

evidence of an Election of Rights form or other

responsive pleading requesting a hearing prior to any agency action regarding Shelly

Lee ArnoLd, rights.

which would affect the Subject's substantial interests or

Cu to ian of Records

Florida Board of Nursing

Before me, personally appeared

Robert Johnson

whose identity is

known to me personally and who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

September

13:

Notary Public Signature My commission expires: Florida

ment of

Health

Office of the General Counsel • Prosecution Services Unit

13

dayof

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida throu9h integrated &cornniunity efforts. state,

John H. Armstrong, MD, FACS

,

Vision: To be the

,

13

State Surgeon General & Seaetary

HEALTh

Healthiest State

In

the Nation

AFFIDAVIT

'd

Clerk's

Deputy Clerk for the Department

Office, hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department. Clerk's Office has not received an Election of Rights form or other responsive pleadilig, which requests a hearing prior to—any Department action

regarding Shelly Lee Arnold, LPN: substantial interests or rights.

which would affect the Respondent's

Custodian oE*ecord Department Clerk's Office

-

Before me, personally appeared

j3

'JUC(et'

,

whose identity is

known to me personally and who, under oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

Notary Public

;jjy

her

ANGELA SARTON

My Commission Expires:

Notary Public . State at Flodda $17 My Comm. ExpIres Sip

,

0

Florida Dsp.rtmsnt of Office of the General Counsel • 4052 Bald Cypress Way, Bin

.2013.

sth

Services Unit • Tallahassee, FL 32399-1701

PHONE: 850/2454444' FAX 850/2454683

if 49330

www.F FACEB

iE

EXHIBIT

STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2012-17218

v. SHELLY LEE ARNOLD, L.P.N.,

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW the

Department of Health, by and through

undersigned counsel, and moves the Board of Nursing for

of

a

Final Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board

Nursing will take up for consideration the above-styled disciplinary

action and will enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

discipline imposed •through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to. salaries and benefits of personnel, costs related to the time scent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the deoartment when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

3.

.

The investigation and

prosecution of this case has

resulted in costs in the total amount of $1,037.35, based on the

following itemized statement of costs: L.

Cost to Date

JI Hours

11 11

IComplaint:

]I

Ilnvestigat!en: Legal:

o.oo]

Compliance: Sub Total:

Expenses to Date:

Costs

13.20

[

1 I

$192.15}

$281.51

$0.00]

$1,037.35 0 00

.

Prior Amount:

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $473.66 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the• objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the. affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $473.66 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and

is in accordance

with

Section 456.072(4), Florida Statutes.

3

WHEREFORE, the Department of Health requests that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $473.66.

of 3e

DATED

,

2013.

Respectfully submitted,

Searcy Msistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0098772 (850) 245-4444 x8100 Telephone (850) 245-4683 Fax

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day of

n

2013, to Shelly Arnold, 1034

County Rd., Graceville, FL 32440, and to 352 Sloan Road,

Graceville, FL 32440.

Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTYOF LEON:

BEFORE ME, the undersigned authority, personally appeared SCOTT FLOWERS who was sworn and states as follows: 1)

My name is Scott Flowers.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Senior Management Analyst II (SMAll) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As SMAll of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond: The Time Tracking System is a -computer program which records and tracks DOH's costs

regarding the investigation and prosecution of cases against Florida health care licensees. 5)

Asof today, DOH's total costs for investigating

and prosecuting DOH case number(s) 201 2-1 7218 (Department of Health v. SHELLY LEE ARNOLD) are ONE THOUSAND THIRTY-SEVEN DOLLARS AND

THIRTY-FIVE CENTS ($1,037.35). 6) The costs for DOH dase number(s) 2012-1 7218 (Department of Health v. SHELLY LEE ARNOLD) are summarized in Exhibit 1 (Cost

Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case number(s) 201217218 (Department of Health v. SHELLY LEE ARNOLD) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

keep track of their time in six-minute increments (e.g., investigators

EXHIBIT I

of 2 -

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and Florida expenses are charged against a state health care Board Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time: The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) ,

9) Scott Flowers, first being duly sworn, states that he has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correctto the best of her knowledge and belief. FURTHER AFFIANT SAYETH NOT.

Affiant State of Florida County of Leon

t 2013,

day of Sworn to and subscribed before me this me. known to by S tt Flowers, who is personally

-p

Notary Signature

—

t.fr

W

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

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PuSc- BMS S

CoSSSIOII

.

-

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,

Page

Complaint Cost Summary Complaint Number: 201217218 Subject's Name:

*****

SHELLY LEE Cost to Date *****

Hours

Complaint: investigation: Legal: Compliance:

J

Total:

[

Costs 528L51j

0.00

f

13.2011

to Date:

Prior Amount: Total Costs to Date:

OTIMETRAK/CSDETL.ASP

1

Si ,037.351 so.ool

1

of

1

oF

16/20 13

10

3.50

Sub Total

0.40 0.40 0.40 0.30 0.20 0.20 0.30 0.50 0.30 0.10

Florida Department of Health

HLL96B HLL96B HLL96B HLL96B HLL96B HLL96B HLL96B HLL96B

LL9613

HLL96B

4.40

Sub Total

$63.98 $63.98 $63.98

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

SERVICES UNIT

1.40

2.90 0.10

8139 8139

B139

jINVESTIGATIVE SERVICES UNIT

1.00

0.30

10

0.50 0.50 0.20 0.90

HAl 10 HAl 10

0

1-IAI to

FIAt 10

$54.90 $54.90 $54.90 $54.90 $54.90 $54.90 $54.90

Staff Rate

ICONSUMER SERVICES UNIT

lIO l

Staff Code Activity Hours

Report Date

MQA

Medical QuoIUy Assu,onc-e

Division

$42.54 $42.54 $42.54 $31.91 $21.27 $21.27 $31.91 $53.18 $31.91 SI 0.64

$281.51

$185.54 $6.40 $89.57

$192.15

$27.45 $27.45 $10.98 $49.41 $5.49 $16.47 $54.90

Cost

Activity Description

PREPAREORREVISECLOSINGORDER

REvIEwCLOSING0aDER PRESENTATION OF CASES

31

32 63

6 60 25 64

MISCELLANEOUS SUPPLEMENTAL INVESTIGATION MISCELLANEOUS REVIEW CASE FiLE

INITIALREVIEWANDANALYSISOFCOMPLAINT

INT

.

.

Page

I

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.

SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE SUPPLEMENTAL INVESTIGATION REPORT PREPARATION

INITIAL REVIEW AND ANALYSIS OF COMPLAINT CSU INVESTIGATIVE WORK CSU INVESTIGATIVE WORK CSU INVESTIGATIVE WORK REVIEW CASE FILE REVIEW CASE FILE CSU INVESTIGATIVE WORK

201217218

60

78 78

76

6

100

78 144 144 144 25 25 144

.

- FOR INTERNAL USE ONLY --

02/20/2013 02/21/2013 02/21/2013 03/21/2013 03/21/2013 03/26/2013 03/26/2013 03/26/2013 04/02/2013 05/20/2013

06/27/2013 06/28/20 13 06/28/20 13

11/21/2012 12/06/20 12 01/14/2013 02/12/2013 03/08/2013 03/11/2013 03/12/2013

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFJDENTIAL***

5.30

HLL96B

I-ILL96B .EILL96B

Sub Total

Florida Department of Health

Total Cost

ULL96B

0.20

0.10 0.20 0.40 0.30

ILL96B

0.20

HLL96B I{LL96B

-80

Stall Code Activity Hours

Report Date 09/16/2013

M

__________

$106.35 $106.35 $106.35

$106.35

$106.35

$106.35 $106.35

Staff Rate

$1,037.35

$563.69

$21.27 $10.64 $21.27 $42.54 $31.9!

$85.08 $21.27

Cost

35

Activity Deseriptiou

TELEPHONE CALLS MISCELLANEOUS

EWCASEFILE

Page 2

itemizedcost

IVECOMPLAINT

201217218

MISCELLANEOUS MISCELLANEOUS MISCELLANEOUS

- FOR INTERNAL USE ONLY -

60

25

07/23/2013 07/23/2013

60

60

60

28

07/23/2013

05/20/2013 05/21/2013 05/23/2013 06/03/2013

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

CONFIDENTIAL ***

of2

Total Expenses

SubTotal

Expense Date

09/16/2013

Florida Department of Health

Staff Code

Report Date:

M

Quality Assurance

Amount

Expense

0 NF

ID EN TI AL

***

Expense Code Description

Complaint

- FOR INTERNAL USE ONLY -

Expense Code

C

Time Tracking System Itemized Expense by Complaint

***

.

itemizedexpense

.

Pagel of

1

Rick Scott

Mission:

.

.

.

.

.

Governor

To protect, promote & Improve the health

John H.Annstrong; MD, PACS

. . .

efforth

state oounty &

State Surgeon General & Secretary

lilestsMelntheNabon

.

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health-A12 (JS)

FROM:

Board of Nursing, South Probable Cause.Panel

SUBJECT:

Arnold, .Shelly Lee, L.P.N,

Case No: 2012-172.18

.

DATE OF PROBABLE CAUSE MEETING:

DATE: 5-20-13

This matter was brought before a Probable Cause Panel composed of:

.

Barbara Kemp andMa,y K. Habgocd

On the date set forth above. The. panel, having received the investigativo report and supplemental materials, having carefully reviowed said documentation and the recommendation of the agencyfdepartrnent, and having had

the opportunity to inquire of counsel, finds that: x

Probable báuse exists herein that the Subject violated the following statuteslrules: 464.O18(1)(b), PS (2012) .

.

The panel suggests imposing the following penalty: VI, Costs

cause does not exist and the case should be closed with thefiowing closure code: Ueu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the following: ..

.

OFN

BOAR

Florida Dopartmnnt of Hoalth Office of the General Prosecution unit 4052 SaId Cypress Way, Bin C-65 . Tallahassee, FL 32399-1701 Express mall address: 2585 Mesthanls Row- Suite 105

PHONE: 850/245-4444

•

FAX 850/245-4583

.

SING

,

PANEL

lldasHealth.com TWIT1'ER:HeaIthyFLA

FACEBOOI(FWepanntofflealth VOUTUSE. fldoh

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

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Mission. Ta protect, promote & improve the health

Rick Scott Governor

nunu

John H. Armstrong, MD, FACS

HEAITFI Vision: To

be the Healthiest

State Surgeon General & Secretary

Staten the

NOTICE OF HEARING

November 8, 2013 Case#: 201218899 To:

THERESA DAIS 9126 WANDFLOWER DRIVE INDIANAPOLIS, IN 46231-4290, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201218899

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

.

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C.02 • Tallahassee, FL 32399-3252 PHONE: 850/ 245.4125 • FAX 850/ 245.4172

TWITTEftHeaIthyFLA FACEBOOK:FLDepartrnentofHealth YOUTUBE: fldoh

:

Rick Scott Governor

To protect promote & improve the health of all people in Florida through integrated

John H. Armstrong, MD, FACS

state aDunty&Ixmrnunhtyefforts.

State Surgeon General & Secretary

H EALTH Vision: To

be the

Healthiest State

in the Nation

MEMORANDUM FROM:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Kristal Beharry, Assistant General Counsel

RE:

Determination of Waiver

SUBJECT:

DOH v. Theresa Dais, L.P.N. DOH Case Number 2012-18899

DATE:

October 14, 2013

TO:

s

0

3

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Subject: Theresa Dais, L.P.N. Address of 9126 Wandflower Drive Record: Indianapolis, IN 46231-4290 Enforcement Address: 9126 Wandflower Drive Indianapolis, IN 4623 1-4290

Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s):

5152789

Prior Discipline: Probable Cause Panel:

4050, 07/02/2012, DOH-12-1291-FOI February 21, 2013 Kemp & Habgood

Subject's Attorney:

Pro Se

Complainant/Address:

Theresa Dais 9126 Wandflower Drive Indianapolis, IN 46231-4290

Fiorida Department of Health of the Generai Counsei • Prosewffon Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 8501245-4444-FAX 8501245-4683

Rank:

PN

97055

3/22/2002 None No

None

Section 464.018(1)(d)3, F.S. (2012)

lth.com TWITTER:HealthyFLA FACEBOOK:FLDepartnenton-leaith YOUTkJEE: fidoh

______________________________________________________I

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, CASE NO. 2012-18899

v. THERESA DAIS, LIP.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

An Administrative Complaint was filed against

Respondent on

February 25, 2013. A copy of said Administrative Complaint is attached hereto as Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were sent to Respondent via certified US mail on:

February 28, 2013 (7196 9008 9111 8826 2510). Service on Respondent via

certified mail was not successful. envelope is attached as 3.

A copy of the certified mail receipt and

Exhibit S.

Thereafter, Petitioner requested personal service on Respondent, which

was unsuccessful on April 25, 2013. The affidavit of personal service is attached as Petitioner's Exhibit C.

4.

Thereafter, Petitioner requested that the Indianapolis Recorder

Newspaper publish a Legal Notice of Action beginning on July 5, 2013 and appearing consecutively on July 12, 19, and 26, 2013. Petitioner received proof

of publication on August 9, 2013, which is attached as Petitioner's Exhibit 5.

Rule

D.

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 6.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 7.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits 8.

E

&

F.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 9.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter a Final Order imposing whatever discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FAcS State Surgeon General and Secretary of Health

Kristal Beharry

9

Assistant General Counsel Fla. Bar No.

0078070

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that foregqipg

has

been

true and correct copy of the above and provided by U.S. mail this day of 2013, to: Theresa Dais, 9126 Wandflower Drive, a

Indianapolis, Indiana 46231.

Kristal Beharry Assistant General Counsel

OF FLORIDA DEPARmIEIrr OF HEALTIl STATE

SEALTh,

t v.

CASE NO. 2012-18899

LP.N.

THERESA DAIS,

RESPONDENT.

/ ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through

its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Theresa Dais, L.P.N., and In support

thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

,

456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed practical nurse (L.P.N.) within the state of Florida, having been issued license number PN

flIBif

3.

Respondent's address

of

record is 9126 Wandflower Drive,

Indianapolis, Indiana 42631-4290. 4.

On or about December

of the crime Fraud, Other,

a

5.

Respondent was found guilty

first-degree misdemeanor in violation of

Section 817.034, Rorida Statutes Pinellas County, Florida in Case

.2012, in the

/county

Court in and for

mber

Section 464.018(1)(d)3, Florida Statutes (2012), provides that

being found guilty, regardless of adjudication, of

a

violation of Chapter

817, relating to fraudulent practices, constitutes grounds for discipline. 6.

On or about December 7, 2012, Respondent was found guilty

of the crime Fraud, Other,

a

violation of Chapter 817, Florida Statutes,

in

case number 7.

Based

the

on

foregoing,

Respondent

violated

ion

464.018(1)(d)3, Florida Statutes (2012), by being found guilty, regardless of adjudication, of

a

violation of Chapter 817, relating to fraudulent

practices. WHEREFORE, the Petitioner respectfully requests that the Board of Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of Depaitnent of Health v. Theresa Dais, Case Number 2012-18699

LPN 2

practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, corrective act!on, refurd of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

D

I

day of

•

JOHN H. ARMSTRONG, MD, FACS State Surgeon General and

Secretary of Health

1

FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK Angel Sanders DATE FEB 2 5 ZU13

PCP: PCP

Members:

it General Counsel

DOH Prosecution Services

.

Department of Health v. Theresa Dais, Case Number 2012-18899

Unit

4052 Bald Cypress Way, Bin C-65 Florida 32399-3265 Florida Bar Number 0084752 (850) 245 - 4661 Telephone (850) 245 - 4683 Facsimfle

12W

,

NOTICE OF RIGHTS Respondent has the right to request a hearing to be in accordance with Section 120.569 and 120.37, Florida Statutes, to be representhd by counsel or other qualified representative, to present evidence and to call and witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a heating is requested.

NOflCE REGARDING ASSESSMENT OF COSTS Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section .072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of disciplinary matter, which may include a attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Heafth V. Thei-esa Dais, Case Number 2012-18899

4

Rick Scott

Mission:

Governor

To protect promote & improve the health of all people in Flodda through integrated state, & communky efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

AEAE±H Vision: To be the Healthiest State

in the Nation

AFFIDAVIT OF SERVICE OR DILIGENT SEARCH

1añda Departmen ©t Health Petitioner

Case No. 2012-18899

vs

Theresa Dais. L.P.N. Respondent COMES NOW, the aifrant, Aaron M. Rader, who first being duly sworn, deposes and states: 1) Affiant is a licensed Indiana Private Investigator (#Pl21 200004) and owner of Indiana Legal Support Services.

//25//3_,

Affiant made a diligent effort to locate Respondent, to serve Order compelling examination(s); Subpoena(s); — Administrative CoMplaint and related papers; to cease and desist; ESO/ERO and related papers. order; 2) That on

3) Check applicable answer below:

made personal service on Respondent, or on some person at Respondent's usual over the age of 15 residing there, on (date) was unable to make service after searching for Respondent at: (a) all Respondent shown in the DOH investigation of the case; (b) all official addresses for Respondtat shown in her Indiana professional licensing records on the computer terminal or Board office; (c) Local company for the last area Respondent was known to frequent; (d) Indiana Bureau of Motor database searching Indianapolis. Drivers Li ses; and, .

Affiant State of County of

I

M&vttVt

Before

CJA&II

appeared whose identity is known to me by (type of identification) and who, acknowledges that his/her signature

app ars above. Sworn to or affirmed by Affiant before me this

tL

Notary Public -State of

Type or Print NaMe

Florida Department of Health Office of the General Counsel' Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 • Tallahassee, FL 32399-1701 Express mail address: 2555 Merchants Row — Sufte 105 PHONE: 8501245-4444 'FAX 550/245-4683

751tt1

20il

day of

My Commission Expires CELESTE MUSGRAVE Hendñcks County My Commission Expires December 9 2015

www.florldasHealtfl.com TWIUER:HealthyFLA FACEBOOKFLDeparthientoff-lealth YGUTUBE: fldoh

, SUM MON S

•

PROOF OF PUBLICATION

JJOTJCEOFACflON

ING-

for

+'.

The Indianapolis Recorder Newspaper Indiana's Greatest Weekly 2901 N Tacoma Ave Indianapolis, IN 46218

1NG+OF; Th ER ESA

IS

LkP. N

1

9126 WANDFLOWER

IVE

H

INDIANAPOUS INDIANA 46231-4290

Office (317) 924-5 143

RECEIVED.LEGAL 13P.IIG—g

PM

1:

52

Fax (317)921-6653

CASE NO.

12-18899 LICENCE NO.: PN

State of Indiana, Marion County, ss:

5152789 The Department of Health has filed an Administrative Complaint against you, a copy of which may be

obtained

I

A notary public in the state of Indiana who being duly sworn upon her oath, says (s) he is a clerk for The

by contacting! Tnjitt,- Asttant

Jdhn General. Counsel, Prosecution. Service Unit 4052 rssway ,

Indianapolis Recorder, a weekly newspaper of general circulation, printed and published in the English language in the city of Indianapolis, in the county of Marion, that the notice of which the attached is a true copy, was duly published in said paper for 4_times successively, the dates of publication being as follows:

+.

(850) if no

contact has been made by you concerning above by August 22,

Administrative

Complaint,

will be presented at an .

ensuing meeting

of the

07/05/13, 07/12/13,and 07/19/13 and 07/26/13

with (be *mericars with Disabilities Act persd'ni needing special .

.

£5

proceeding should contact, the •tindividuai. or agency .sendirg this notice. seven

not

later

than 0) days ;prior to the :at. the address given on the

RIBED AND SWORN to before me, this 29 day of July I

i

-

Notary Public

notice. 'TeieØhone: (850) -800-95.5-

.245-4444, '8771

,20— 13 —

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:-tiDD)

9554770 IV), Reiay.Service.

Florida .

.

.

..

amission Expires February 21, 2021 I .7

To the Marion County Clerk:

INVOICE# 133472

Please tax the costs as shown below on the court dockets:

Probate Court, Docket # Superior Court # 2012-18899 Circuit Court, Docket#

Published

07/05/13. 07/12/13. 07/19/13 and 07/26/13

Legal Advertising cost $

Description

128.00

THERESA DAIS. LPN

Minion: To

of

I

,

Rick Scott

promote & hnprove the health people in through Thlegmted rounty & commuraty

John H. Aniisfreog,

FAGS

State Suigeon Geneml & Seaelary

I,

William SDooner

hereby certify in my official capacity as

custodian for the Board of Nursing's ticensure files that the Board of Nursing as of 10/11/2013 . has no evidence of an Election of Rights form or other responsive pleading requesting

a

hearing prior to any agency action regarding CASE

NAME: Theresa Dais, LIPUN... CASE NUMBER 2012-18899 which would affect the Subject's substa ntial interests or rights

Custodi of Records Florida Board of Nursing Before me, personally appeared

William Soooner

identity is known to me Dersonallv

whose

(type of identification) and who, under,

oath, acknowledges that his/her signature appears above. day of

Sworn to and subscribed this 11

October

,

2013.

Notary Public

1

El.EMtAPLASlcEfl -

aPlRaFebruarya

Florida Department of the Geneml Counsel

.f Health •

Proseajlion Seivices Unit

Bald Cypress Way, Bin C-65

2017

EXHIBIT

Wa FiortdasHnlth.conI mWFER:HeatthyFLA FACEBOOlCFLDaoarUnentoMealth

Minion:

I

To protect pioniote & improve the health of all people in Florida through integrated slate, & efforts.

Rick Scott

I

Governor

John H. Armstrong, MD, FACS

,

State Surgeon General & Seottary

Vision: lobe the Health lesi State in the Nation

hereby

Deputy Clerk for the Department Clerk's Office, in my official capacity as custodian for the Department Clerk's records, that the

Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case Name; Theresa Dais, L.P.N., Case No: which would affect the Respondent's substantial interests or rights.

Before me, personally appeared

\

dtu

Custodian of Record Department Clerk's Office

Sttrider5

whose identity is known to me by

personally known (type of identification) and who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this

JU day of

2013.

My Commission Expires:

Fiends Department of Heaith Office of the General Counsei . Prosecuton Unil 4052 Bald Cypress Way. Bin C-65 'Tallahassee, FL 32399-1701 Express neil address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 FAX 850)2454683

Bff

www .Florid asHoe Ith .com

thyFt.A YOUTIJBE: fldoh

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $485.34 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $485.34 as supported by competent, substantial evidence. This assessment of costs is in addition to any other discipline

imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $485.34.

3

DATED this

day of

.

2013.

Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Kristal Beharry Assistant General Counsel Fla. Bar No.

0078070

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-1111 Facsimile: (850) 245-4683 Email: [email protected]

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

.

Motion to Assess Costs has been furnished via U.S. mail to Theresa Dais, L.P.N., at 9126 Wandflower Drive, Indianapolis, Indiana 46231, on this

1

dayof f)Wf0J7eV

Kristal Beharry

Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows: 1) My

name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System

computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. is

a

5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 2-1 8899 (Department of Health v. THERESA

DAIS, L.P.N.) are SIX HUNDRED FORTY-FOUR DOLLARS AND EIGHTY-SEVEN CENTS ($644.87). 6) The costs for DOH case numbers 2012-1 8899 (Department of Health

THERESA DAIS, L.P.N.) are summarized in Exhibit Summary Report), which is attached to this document.

v.

1

(Cost

7) The itemized costs and expenses for DOH case numbers 2012-18899 (Department of Health v. THERESA DAIS, L.P.N.) are detailed in

Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the

following method: DOH employees who work on cases daily are to

I

of 2

keep track of their time in -minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, lorida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the

foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of his knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon

Sworn to and subscribed before me this______ day of by Walters, who is personally known to me.

Notary Signature

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

2013,

Page

1

of

I

Complaint Cost Summary Complaint Number: 201218899 Subject's Name:

DAIS. THERESA Cost to Date *****

nours Complaint:

[ [

Legal:

'Compliance: ISub Total: Expenses to Date: Prior Amount: Total Costs to Date:

'

1 1 6.25

P [

Costs

81

1

S269.75j

$1.61

l1

5441.87

13.00 j

I

j

L

http://mqaapps.doh.state.fl.us/IRMOOTIMETRAKJCSDETL.ASP

10/11/2013

of

10/11/2013

Staff Rate

2.20

Sob Total

1.50

Sub Total

Florida Department of

lth

0.40 0.70 0.40

HLL86A -ILL86A

2.50

2.50

OA

$54.90 $54.90 $54.90

$32.13

$106.35 $106.35 $106.35

$63.98

SERVICES UNIT

1.00

10

Sub Total

149

FIN VESTIGATIVE

HAL IS

15

ICONSUMER SERVICES UNIT

1.00

0.05

Sub Total

lS

0.05

1C27

ICOMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date

Medical Quality

$159.53

25 28 25

4

76

77

78

137

Activity Code Activity Description

-

PREPAREORREVISEADMINISTRATIVECOMPLAINT REVIEW CASE FILE

REVIEW CASE ILE

ROUTINE INVESTIGATIVE WORK

INITIALREVIEWANDANALYSISOFCOMPLATh4T PREPARATION OF DESK INVESTIGATION SYNOPSIS REPORT PREPARATION

IORITYDOWNGRADES/UPcJRADES

-- FOR INTERNAL USE ONLY

08/06/20 13

$42.54

$74.45

01/14/2013 01/15/2013

12/27/2012

12/27/2012 01/04/20 13 01/07/2013

01/14/2013

Activity Date

$42.54

$159.95

$159.95

$120.78

$10.98 $54.90 $54.90

Sl.61

$1.61

Cost

Complaint 201218899

Time Tracking System Itemized Cost by Complaint

IAL*** I

EXHIBIT

Page

I

I

I

I

of2

13

Florida Department of Health

Staff Code Activity Hours

oate

fs./i

Medical Quality Asscrance

Staff Rate Cost

—

Activity Code

FOR INTERNAL USE ONLY

Activity Date

Complaint 201218899

Activity Description

Time Tracking System Itemized Cost by Complaint

*** CONFIDENTIAL ***

itemizedcost

Page2of2

1

r

Expense

$203.00 $203.00

Total Expenses

$128.00 $65.00 $10.00

Amount

SubTotal

07/05/2013 03/26/20 13 04/15/2013

Florida Department of Health

FILL86A

HLL86A HLL86A

SERVICES UNIT

Expense Date

10/11/2013

ION

Staff Code

ReportDate:

Medical Quality Aswrance

LEGAL & OFFICIAL ADVERTISEMENTS PAYMENT FOR INFORMATION AND EVIDENCE PAYMENT FOR INFORMATION AND EVIDENCE

Expense Code Description

Complaint 201218899

- FOR INTERNAL USE ONLY --

497000 497000

133100

Expense Code

ONE IDE N TI AL

Time Tracking System Itemized Expense by Complaint

C

lofI

iteniizedexpense

Page

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be the Healthiest State

in

the Nation

(W Pi4OSABLE CAUSE PANEL TO:

Department of Health

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Theresa Dais, L.P.N.

DATE OF PROBABLE CAUSE MEETING:

CASE NO.: 2012-18899 DATE: February 22, 2013

This matter was brought before a Probable Cause Panel composed of:

Barbara Kemp and Mary K. Habgood

On the date set forth above.

The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that:

xx

Probable cause exists herein that the Subject violated the following statutes/rules:

Section 464.018(1 )(d)3, FS 2012) The panel suggests imposing the following penalty: Costs and V6B cause does not exist and the case should be closed with the flowing closure code: lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the following:

BOARD OF IJRSING

Florida Department of Health Office of the General Counsel• ProsecuUon Services Unit 4052 Bald Cypress Way, Bin 0.65 Tallahassee, FL 32399-1701 PHONE: FAX 850/245.4663

(J

V

lth.com

leaith TWITTER:HealthyFLA

YOUTUBE: fidoh

_________________________________________/

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

v

CASE

0

2012-18899

THERESA DAIS,•LP.N. RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Theresa Dais, L.P.N., and in support

thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutth; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

times

all

Respondent was

a

material

to

this

Administrative

Complaint,

licensed practical nurse (L.RN.) within the state of

Florida, having been issued license number PN 5152789.

3.

Respondent's address of redord is 9126 Wandflower Drive,

Indianapolis, Indiana 42631-4290. 4.

On or about December 7, 2012, Respondent was found guilty

of the crime Fraud, Other, a first-degree misdemeanor in violation of Section 817.034, Florida Statutes in the Circuit/County Court in and for Pinellas COunty, Florida in Case Number 522012MM027783XXXXNO-L. 5.

Section 464.018(1)(d)3, Florida Statutes (2012), provides that

being found guilty, regardless of adjudication, of a violation of Chapter

817, relating to fraudulent practices, constitutes grounds fOr discipline. 6.

On or about December 7, 2012, Respondent was found guilty

of the crime Fraud, Other,

a

violation of Chapter 817; Florida Statutes, in

case number 5220 12M MO27783XXXXNO-L. 7.

Based

the

on

foregoing,

Respondent

violated

Section

464.018(1)(d)3, Florida Statutes (2012), by being found guilty, regardless

of adjudication,. of

a

violation of Chapter 817, relating to fraudulent

practices. WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the. following: penalties:

permanent revocation or suspension of Respondent's license, restriction of

Depaitment of Health v. Theresa Dais, Case Number 2012-18899

LPN

2

practice, imposition of an administrative fine, issuance -of

a

reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

day of JOHN H.

1

2011 MD, FACS

State Surgeon General and Secretary of Health

John J. Truitt Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0084752 (850) 245 - 4640 Telephone (850) 245 - 4683 Facsimile

PCP: PCP Members:

Departhient of Health v. Theresa Dais, LPN Case Number 2012-18899

3

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

0

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Theresa Dais, LPN Case Number 2012-18899

4

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FLORIDA DEPARTMENT

INVESTIGATIVE REPORT Office:

CONSUMER SERVICES

Date of Complaint: January 3,2013

Subject:

Source:

THERESA DAIS, LPN

THERESA

LPN 9126 Wandflower Drive

9126 Wandfiower Drive Indianapolis, IN 46231-4290

Indianapolis, IN 46231-4290 (317) 313-3399

(317)313-3399 Prefix: LPN 1702

License #: 5152789

9

Case Number: 2012-18899

Profession: Licensed Practical Nurse

Period of Investigation: 01/07/13-01/07/13

:

Board:

Report Date: January 7, 2013

Nursing Type of Report: FINAL

Alleged Violation: Being convicted or found guilty of... 464.018(1)(o), F.S: Violating any provision ofthis chapter or chapter 456... , 456..072(l)(dd), FS: Violating any provision of this chapter, the applicable practice..., 456.074(1)(a)F.S.: The department shall issue an emergency order suspending the license of any person licensed under chapter 458, chapter 459,... This investigation is predicated on the receipt of a complaint from DAIS self-reporting that she was arrested and in Pinellas County Jail when her Continuing Education Credits were due. Documents from Pinellas County Clerk of Court show that the DAIS entered a plea of nob contendere to the offense of Fraud/Other (s. 817.034, FS) on 12/07/12 (Ex. #1).

DAIS was notified of this complaint by certified mail letter dated 01/07/13, sent to DAiS' address of record (Ex. #1). DOE! computer information was obtained 01/07/13. It reflects DAIS is duly licensed to practice nursing in the State Florida and that her license is in an Obligations/Active status.

No patient(s) were identified, thus patient notification was not required.

.

DAIS does not appear to be represented by counsel as of the date of this report. DAIS has not responded to this investigator, in writing, as of the date of this

Related Case: None

Investigator/Date:

Antoinette Carter(HAI15) 01/07/13 Investigative Specialist II

Approved By/Date:

Shane Walters

OMC Manager

JAN

07

2013

'

Distribution: Legal/Consumer Services Unit

Pagel

ci,.—

c'

of

:

0011 INVESTIGATIVE REPORT

I.

CASE NUMBER LPN 2012-18899 TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

I.

TABLE OF CONTENTS

Ill.

INVESTIGATIVE DETATLS Summary of Records

2

3

Interview/Statement of DAIS (Source) Interview/Statement of DAIS (Subject) IV.

3

3

EXHIBITS 1)

2)

Case Summary, complaint and certified documents from Pinellas County Clerk of Court DAIS Notification Letter

4-21

22-23

Page 2

11011 INVESTIGATIVE

REPORT

CASE NUMBER LPN 2012-18899

INVESTIGATWE DETAILS SUMMARY OF RECORDS Exhibit #1 is a Case Summary, complaint and documents from the Pinellas County Clerk of Courts. Documents from Pinellas County Clerk of Court show that the DAIS entered a plea of contendere to the offense of Fraud/Other (s. 817.034, FS) on 12/07/12 (Ex. #1).

b

INTERVIEW/STATEMENT OF THERESA DAIS, LPN - Source Address of Record:

9126 Wandflower Drive Indianapolis, IN 4623 1-4290

(317)313-3399 No additional information was received from the Source.

INTERVIEW/STATEMENT OF TI{ERESA DAIS. LPN- — Subject Address of Record:

9126 Wandflower Drive Indianapolis, IN 46231-4290 (317) 313-3399

DAIS has not responded to this investigator, in writing, as of the date

of this report.

**Investigaton Note: Subject Notification was mailed to DAIS on 01/07/13. If a response is received it will be forwarded to Legal. It also appears that the Subject failed to update her change of address with the Florida Board of Nursing. **

Page 3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

11

cJQ

.0

C

i C

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEPJ.]1—I Vision: To be the

Healthiest State

in the

Nathn

NOTICE OF HEARING

November 8, 2013 Case#: 201214881 To:

CARLA MOORE LECOMPTE 26 EAST GREEN STREET EASTHAMPTON, MA 01027, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201214881

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but aftendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin 0-02 • Tallahassee, FL 32399-3252 PHONE: 8501 245-4125 • FAX 850/245-4172

www.FiorldasHeaitb.gov TWITTER:l-lealthyFLA

oepartnientofi-lealth VOUTUBE: fldoh

i HEALTH

Mission: To protect, promote & irnprove the health of all people in Florida through integrated state, county & community efforts.

Rick Scott Governor

John H. Armstrong, MD, FACS Surgeon General

Visionrn To

be the

Healthiest State

in

&

Secretary

the Nation

MEMORANDUM TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM:

Ana M. Gargollo-McDohald, Assistant General Counsel

RE:

Determination of Waiver

SUBJEa:

DOH v. Carla Moore Lecompte, A.R.N.P. DOH Case Number:

DATE:

2012-14881

20, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following

information is provided in this regard;

Subject:

Carla Moore Lecompte, A.R.N.P.

Subject's Address of

26 East Green Street

Record:

Easthampton, Massachusetts 01027

Enforcement Address:

26 East Green Street

Easthampton, Massachusetts 01027

Subject's License No:

9269520

Licensure File No:

356894

Initial Licensure Date:

10/15/ 2007

Board Certification:

No

Required to Appear:

No

Current IPN/PRN Contract:

No

Allegation(s):

Subject violated the following statutes/rules: 464.018(1)(b), F. 5. (2011)

Florida Department of Health Office of the General CounselS Proseaition Services Unit 4052 Bald Cypress Way, Bin C85 'Tallahassee, FL 32399-1701 Express rnait address: 2585 Merchants Row - Suite 105 PHONE: 850)245.4444 'FAX 850(245.4883

Rank:

A.R.N.P.

.com lealth TWIUER:HealthyFLA

VOUTUSE: fldoh

Prior Discipline:

4010, 04/20/2010, OOH-10-0957-S

Probable Cause Panel:

June 28, 2013 Home & Newman

Subjects Attorney:

Pro Se

Complainant/Address:

Department Of Health/Board Of Nursing

AGMfbhh

Florida Department of Health Office of the General Counsel • Prosecution SeMces Unit 4052 Bald Cypress Way. Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row - Suite 105 PHONE: 850/245-4444 • FAX 850/245-4683

.com

TWITTER:HealthyFLA FACEBOOK:FLOeparfrnento*lealth YOUTUBE: fldoh

.

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, v.

CASE NO.

2012-14881

CARLA MOORE LECOMPTE, A.R.N.P.,

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of Order in the above-styled cause on

determined and noticed by the Board.

a

a Final

date and time that has been As grounds therefore Petitioner

states: 1.

An Administrative Complaint was filed against Respondent on

July. 1, 2013. A copy

Petitioner's Exhibit A.

of said Administrative Complaint is attached hereto as .

4

2.

Copies of the Administrative Complaint, Explanation of Rights

form, and Election of Rights form were successfully served on Respondent via certified US mail on: July 9, 2013, article number 7196-9008-9111-93265841. A copy of the certified mail receipt is attached as Petitioner's Exhibit B. 3.

Rule 28-106.111(2), Florida Administrative Code,

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the.decision. 4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a• written request for a hearing within 21 days waives the right to request ahëaring on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the

required twenty-one (21) day period of time. Copies of affidavits supporting

the same are attached hereto as Petitioner's Exhibits 6.

C

&

D.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact

tobe

the Board 7

Respondent has been advised by way of this Motion, that

a

cdpy

of the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find that Respondent has waived the right to dispute any materials facts

captained within the Administrative Complaint and enter a Final Order imposing whatever discipline upon Respondent's license that the Board deems appropriate.

Respectfully submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

LLO-MCDONALD

I

Assistant General Counsel Fla. Bar No.

0085907

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that has

been

provided

a

true and correct copy of the above and by

U.S.

2013, to:

A.R.N.P..,

at 26

mail

of

this

CARLA MOORE LECOMPTE,

EAST GREEN STREET, EAST HAMPTON, MA 01027.

CDONALD Assistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH

•

•

DEPARTMENT OF HEALTH,

•

PETITIONER,

.

CASE NO. 2012-14881

CARLA MOORE LECOMPTE, A.R.N..P.,

RESPONDENt

/

ADMINISTRATIVE COMPLAffir COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Carla Moore LecompiB, A.R.N.P., and in support 1.

thereof alleges:

Petitioner is the state

charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was an advanced registered nurse. practitioner (A.R.rtp.) within

the state of Florida, having been issued License number RN 9269520,

1T

3.

Respondent's address

of record

is 26 East Green Street,

Easthampton, Massachusetts 01027. 4.

On or about September 6, 2011, Respondent surrendered her

Registered Nurse License and Nurse Practitioner Authorization

for an indefinite period, upon executing

a

"Consent Agreement for Surrender

Followed by Probation" with the Massachusetts Board of Registration in Nursing. 5.

licensing

The Massachuset Board of Registration in Nursing

authority for registered

nurses

in

is

the

the Commonwealth of

Massachusetts. 6.

Section 464.018(ij(b), Florida Statutes (2011), provides that

having a license to practice nursing revoked, suspended, or other-wise acted against, including the denial of licensure, by the licensing authority of

another state, territory or country constitutes grounds for disciplinary action. 7.

As set forth above, Respondent had a license to practice

nursing revoked, suspended, or otherwise acted against when Respondent

surrendered

her

Practitioner Authorization DeparUflent of Health v. Cada Moore Case Number 2012-14981

Registered upon

executing

Nurse a

License

and

Nurse

"Consent Agreement for

ARNP

2

Surrender

Followed

Probation" with the

Massachusetts

Board

of

Registration in Nursing. 8.

Based upon the foregoing, Respondent has violated Section

464.O18(1)(b), Florida Statues (2011), by having a• license to practice nursing revoked, suspended, or otherwise acted against, including the

denial of licensure, by the licensing authority of another state, territory or

country which constitutes grounds for disciplinary action.

Department of Health v. Carla Moore Lecompte, ARNP Case

Number 2012-14881

3

WHEREFORE, the• Petitioner respectfully requests that the Board of Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refynd of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

of John l-i.Arrnstro , MD, FACS State Surgeon General and Secretary

Ana M. Gargollo-McDoMld Assistant General Counsel Florida Bar Number: 0085907 DON Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Telephone: (850) 245 - 4444 Ext. 8133 Facsimile: (850) 245 - 4683 -

FILED

DEPARTMENT OF HEALTH DEPUTY CLERK

CLERK ikngeCSantlers DATE JUL 012013

of Health

-

-

/AGP& PCP

mbers:

ment

of v. Carla Moore Lecompte, ARNP Case Number 2312-148S1

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine withesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE

G

ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board costs related to the investigation and prosecution shall of a disciplinaryrnauer, which may inclUde attorney hours and costs, on the Respondent in addition to any other discipline imposed. assess

Departnent of Health v. Carla Moore Lecompte, ARNP Case Number 2012-14881

5

900&

3.2b

Carla Mo

Lecompte RN

13ip

AGM/bhh Sent SENDER: REFERENCE:

Receipt for Certified Mar

o

No Do N

\\t\

7196 9008 9111 9326 5841 3. Service Type

CERTIFIED

TM

4. Restricted Delivery? (Extra Fee) 1. Article Addressed to:

I

%Sl -ACM I

iampwn. MA

PS Form 3811, January 2005

0 027

—

Pk

Rick Scott

Mission:

Governor

To proted, promote & improve the health of people In Floñda through integrated

state,

John H. Armstrong, MD,

efforts.

&

State Surgeon General & Seaetary

HEALTH Vision:

,. for

the

.

Joe Baker, Board

To be the Healthiest State in the Nation

hereby certify in my official capacity as custodian

of Nursing's

912312013

has

licensure

files

that the

Board

of

Nursing

as

of

no evidence of an Election of Rights form or other

responsive pleading requesting a. hearing prior to any agency action regarding CARLA

MOORE

2012-14881. which would affect the Subject's

LECOMPTEI

substantial interests or rights.

Florida Board of Nursing

Before me, personally appeared is

known to me

Joe Baker.

Jr.

whose identity

jtype.. of identification) and who, under, oath,

acknowledges that his/her signature appears above. Sworn to and subscribed this 23

day of

Seotember

2013.

Notary Public VAN ESSA RLSCH Conim1SsiOn # EF 218427 Exp4res July 22, 2016

nda Dope flment of Health Office of the General Counsel •

Services Unft

,com TWJUER:HealthyFLA

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Flodda through integrated state, county & community efforts.

John

H EALTH Vision: To

H Annstrong, MD, State Surgeon General &

FACS

be the Healthiest Stale in the Nation

,

AFFIDAVIT

aerk for the Department Clerk's Office,

hereby ce?(ify in my official capacity as custodian for the Department Clerk's records, that

the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding

CARLA

MOORE

LECOMPTE

R.N.,:

Respondent's substantial interests or rights.

20

which

would

C\

affect

the

iD of Record

CijstcSdiên

Department Clerk's Office

whose identity

Before me, personally is known

to me by Dersoriallv known (type of identification) and who, under

oath, acknowledges that his/her signature appears

of

Sworn to and subscribed before me 2013.

Notary Public

S

My Commission Expires:

LAWANDA M SE

MY (407)

IS# ls

EXPIRES May 09.201

www.FlorldasHealth.com

Florida D.partnlont of Health

TWITTER:HealthyFLA FACEBOOK:FLOeparDiientofhealth VOuTUBE: fldoh

Office of the General Counsel • Proseculion Services UnIt Tallahassee, FL 32399-1701 4052 Bald Cypress Way, Bin PHONE: 850/245-4444 ext. 8109 • FAX 850/245-4683

__b____._

I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE

V.

CARLA MOORE LECOMPTE, A.R.N.P.,

Respondent.

NO: 2012-14881

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, by and through undersigned counsel, and moves the Board of Nursing for the entry of

a

Final Order

assessing costs against the Respondent-for the investigation end prosecution

of this case in accordance with Section 456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing will

take up for consideration the above-styled disciplinary action and will enter Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

a

2001, pursuant to this section or discipline impQsed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

.

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $266.85, based on the following itemized

statement of costs:

***** Hours

Complaint: Investigation: Legal:

Cost to Date

1 11

[

]

Compliance:

1 0.00

***** Costs $100.45 $116.99 0.00

f

Sub Total: lExpenses to Date:

Prior Amount: ITotal Costs to Date:

[

.

1

$266.85

1 $0.00 $0.00

2

Therefore, the Petitioner seeks

an

assessment of costs against the

Respondent in the amount of $149.86 as evidenced in the attached affidavit.

(Exhibit A). 4.

Should the Respondent file written objections to the assessment

of costs, within ten (10) days of the date of this motion, specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine

the amount of costs to be assessed based upon its consideration of the

affidavit attached as Exhibit A and any timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and assess

cOsts in

the amount of $149.86 as supported by competent, substantial This

costs is in -addition to any other discipline

imposed by the Board and is in accordance with Section 456.072(4), Florida

Statutes.

WAEREFORE, the bepartment of Health requests that the Board Of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $149.86.

3

DATED this

day of

2013

Respectfully submitted, John H. Armstrong, MD, FACS 'eon General a

Ith

ANA vi. GARGOLLOAMCDONALD Assistant General Counsel Florida Bar No.: 0085907 DOH Prosecution Services UnJt. 4052 Bald Cypress.Way, Bin C-65 Tallahassee, FL 32399-3265 Telephone (850) 245-4444 Facsimile (850) 245-4683 Email: ana_gargollo-mcdonald©doh.state.fl.us

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the foregoing

Motion to Assess Cost has been furnished via U.S. mail to: CARLA MOORE

LECOMPTE, A.R.N.P., of 26 EAST MA

01027, on, this

STREETEAST HAMPTON,

of

ANA M. GAROOLLO-

2013.

DONALD

Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared ELISA M. FLOYD who as follows: 1) My

name is Elisa M. Floyd.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records.at the Florida Department of Health (DOH).

3)

am a Regulatory Program Administrator (RPA) for the Consumer Services and Compliance Managemeat Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As a RPA of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 2-14881 (Department of Health v. CARLA

MOORE LECOMPTE, A.R.N.P.,) are THREE HUNDRED FIFTY-ONE DOLLARS AND NINETY-FOUR CENTS ($351.94). 6) The costs for DOH case numbers 201 2-14881 (Department of Health v, 1

CARLA MOORE LECOMPTE, A.R.FQP.,) are summarized in Exhibit (Cost Summary Report), which is attached to this document.

7) The itemized costs and expenses for DOH case numbers 2012-14881 (Department of Health v. CARLA MOORE LECOMPTE,.A.R.N.P.,) are

detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

EXHIBIT I

of 2

8) The itemized costs as reflected in Exhibit 2 are determined by the

following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case, If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report)

9) Elisa M. Floyd, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of her knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Elisa M.

State of Florida County of Leon Sworn to and subscribed before me by Elisa M. Floyd, who is personally known to me.

,

2013,

,5 A tt TOWAMDAB.BURNEU j

'tic. r.ckr, Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

Expires September 25,2016

Page

1

of

1

Complaint Cost Summary Complaint Number: 201214881 Subject's Name:

LECOMPTE, CARLA MOCRE

*****

Cost to Date

Hours

Complaint: Investigation: Legal:

f

1 11 1

t

0.001 I

I

Huh Total:

4.60!

I

to

I

Costs

l1

S1.00.45J

$49.41

.081

I

i

EXHIBIT

13

1.90

0.20 0.10 0.50

0.40 0.40 0.20

10 $106.35 $106.35 $106.35 $106.35 $106.35

$106.35 $106.35

SERVICES UNIT

2.70

0.60 0.30 0.90

0.60 0.30

Florida Department of Health

Total Cost

Sub Total

O6A O6A

IO6A IO6A IO6A

ILLIO6A

O6A

ION

Sub Total

F1A62

UA62 UA62 UA62 HA62

$57.62 $54.90 $54.90 $54.90 $54.90

Staff Rate

ICONSUMER SERVICES UNIT

Staff Code Activity Hours

Report Date 09/23/20

MQA

Division or Medical QuoIUy Assurance

$34.57 $16.47 $32:94 $16.47 $49.41

$351.94

$202.08

$10.64 $42.54 $42.54 $21.27 $21.27 $10.64 $53.18

$149.86

-

Cost

REVIEWCASEFILE REVIEW MEMORANDUM

IEWCASEFILE

POST PROBABLE CAUSE PROCESSING

MEETINGS WITH DEPARTMENT STAFF

•

.

PREPAREORREVISEADMINISTRATIVECOMPLAINT

MISCELLANEOUS

REVIEW CASE FILE INITIAL REVIEW AND ANALYSIS OF COMPLAINT REVIEW CASE FILE REPORT PREPARATION

IEWANDANALYSISOFCOMPLAINT

Activity Description

25 27

••

201214881

74

60 28 90 25

76

25

78

25

78

- FOR INTERNAL USE ONLY --

05/15/2013 05/15/2013 07/03/2013 09/18/2013 09/19/2013 09/19/2013 09/19/2013

10/10/2012 01/15/2013 02/05/20 13 03/04/2013 04/09/20 13

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by

***CONFJDENTIAL***

itemizedcost

.

Page

1

of

I

j

-al

-

Total Expenses

SubTotal

Expense Date

09/23/20 13

Florida Department of Health

StaffCode

Report Date:

Divhlon ol Quolity Assurance

-

Expense Amount

EN TI AL ***

ExpenseCodefleseription

Complaint

- FOR JNTERNAL USE ONLY -

Expense Code

N F ID

Time Tracking System Itemized Expense by Complaint

CO

1

of

I

itemizedexpense

Page

l, RIcic

M!islofl

ida

Toprotect,.promote & improve the health Fiodda throvghlhdegrated. of all slate oounty.&

Cott

Governor

John H.Arm.tSfl9, State Surgeon

HEALTH VisIon: To be thei4ialthlestState in the Naflon

FACS

& Secretary

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS

AM

TO:

Department of Health

FROM:

Board:of Nursing, Central Probable Cause Panel

SUBJECT:

:CARLA:MOÔRE

DATE OF PROBABLE CAUSE MEETING:

CASE NO.: 2012-14881

JUNE 28,2013

This matter was.broughtbeforea Probable Cause Panel composed ot

CLAYDELL HORNE and JODY NEWMAN•

on

thedate setforth above. The:panel, having received the investigative report and supplemental

materials, having carefully reviewed said documentation and the recommendation agencyldepartment, and.having hadtheopportunity to inquireof counsel, findsthat:

of the

Probable cause existsherein that:the Subject violated the follOwing statutes/rules:

x

FS 2011

•

The panel suggests Imposln.g:the.fOliowing penalty: & probationto run concurrentW/Massathusetts Costs, -

•_Probable cause does not exist and the• case shoul&be closed with. the foflbwing closure

code: lieu of afinding of probable cause, the abovenamedlicensee shall be issued guidance to address the conduct inquestlon:

a

letter of

The panel has requested supplemental oradditlonal Information on the following:

Other________________________

Florida Department of Health Office of the General Counsel' Prosecution &eMces Unit Bin C-65 • Tallahassee, FL 32399-1701 4052 Bald Cypress Expressmailaddress: 2565 Me(ChafllSROW—SUlte 105 PHONE: 8501245-4444 • FAX 8501245-4683

lealth

www.FlorldnHealth.com

leaithyffLA YOUTUBE:fldob

,

_______________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

v.

CASE

0

2012-14881

CARLA MOORE LECOMPTE, A.R.N.P.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Carla Moore Lecompte, AIR.N.P., and in support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative Complaint,

Respondent was an advanced registered nurse practitioner (A.R.N.P.) within

the state of Florida, having been issued license number RN 9269520.

Respondent's address of record

3.

is

26 East Green

Street,

Easthampton, Massachusetts 01027.

On or about September 6, 2011, Respondent surrendered her

4.

Massachusetts Registered Nurse License and Nurse Practitioner Authorflzaflon for an indefinite period, upon executing

a

"Consent Agreement for Surrender

Followed by Probation" with the Massachusetts Board of Registration in

Nursing.

The Massachusetts Board of Registration in Nursing is the

5.

licensing

authority for registered

nurses

in

the

Commonwealth

of

Massachusetts.

Section 464.018(1)(b), Florida Statutes (2011), provides that

6.

having

a

license to practice nursing revoked, suspended, or otherwise

acted against, including the denial of licensure, by the licensing authority of

another state, territory or country constitutes grounds for disciplinary action. 7.

As set

forth above, Respondent had

a

license to practice

nursing revoked, suspended, or otherwise acted against when Respondent

surrendered

her Massachusetts

Practitioner Authorization

upon

Department of Health v. Carla Moore Lecompte, ARNP Case Number 2012-14881

Nurse

Registered

executing

a

License

and

Nurse

"Consent Agreement for 2

Surrender

Followed

by

Probation" with the

Massachusetts

Board

of

Registration in Nursing.

.

Based upon the foregoing, Respondent has violated Section

018(1)(b),

Honda Statues (2011), by having a license to practice

nursing revoked, suspended, or otherwise acted against, including the

0

denial of licensure, by the licensing authority of another state, territory or

country which const!tutes grounds for disciplinary

Department of Health v. Carla Moore Lecompte, ARNP Case Number 2012-14881

3

WHEREFORE, the Petitioner respectfully requests that the Board of Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board

deems appropriate. day of

SIGN ED this

20_.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

l

Ana M. Gargollo-McDonald Assistant General Counsel Florida Bar Number: 0085907 Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Telephone: (850) 245 - 4444 Ext. 8133. Facsimile: (850) 245 - 4683

/AGM PCP: PCP Members:

Department of Health v. Carla Moore Lecompte, ARNP Case Number 2012-14881

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shah assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Carla Moore Lecompte, ARNP Case Number 2012-14881

5

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

h I HEALTH

7

INVESTIGATIVE REPORT Office:

Date of Complaint:

CONSUMER SERVICES

Case Number: RN 2012-14881

2/4/13

Subject:

Source:

CARLA LECOMPTE, RN

DOH/BOARD CF NURSING

26 East Green St. Easthampton, MA 01027 Prefix:

License #:

Profession:

:

Board:

9269520

Report Date:

Registered Nurse

Nursing

4/9/13

1701

Period of Investigation:

Type of Report:

2/6/13 — 4/9/13

FINAL

Alleged Violation: 456.072(1)(t)(x)(dd), 464.018(1)(b)(c) F.S.: Having a license revoked, suspended, or otherwise acted against including the denial of licensure, by the licensing authority of another state; violate statute/rule/conviction/failing to report

This investigation is predicated on a complaint and the receipt of a copy of a Consent Agreement for Surrender Followed by Probation that went into effect of 9/6/11. This was a result of LECOMPTE engaging in a patter of unreliable and unsafe practice in removing, handling, administering and documenting of medication on or about 7/24/11 while working at Farren Care Center, Turner Falls, MA. (Ex. #1, UCF and attachments).

.

LECOMPTE was notified of this complaint by letter dated 2/6/13. A certified letter was mailed on 3/5/13 and received at LECOMPTE'S address of record on 3/12/13(Exhibit #2).

A check of DOH computer licensure records dated 4/9/13 revealed LECOMPTE'S licensure status is currently Obligations/Active. No patient(s) was/were identified thus patient notification was not required.

LECOMPTE does not appear to be represented by council. Investigator BATES has not received a response from Related Case:

None

Investigator/Date:

Approved By/Date

Diane Bates (HA62) 4/9/13 Government Analyst

Shane Walters OMC Manager

I

Distribution:

Pagel

APR

09

2013

Prosecution Services/Consumer Services Unit

I

—

,

:

DOH INVESTIGATIVE REPORT

I.

. III.

CASE NUMBER RN 201 2-1 4881

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

1

TABLE OF CONTENTS

2

INVESTIGATIVE DETAILS Summary of Records

3

Statement of MASSACHUSETTS BON(Source) Statement of LECOMPTE(Subject)

IV.

3 3

EXHIBITS 1)

UCF with attachments

4-27

2)

Copy of notification Letter

28-3 1

Page

2

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

It

p

C

a

C

C-

C

0- C

4

Rick Scott

Mission:

Governor

To protect, promote & improve the health of at people in Fioñda through integrated

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H E4d.TI—I Vision: To

be the Heaithtest State in the Nauon

NOTICE OF HEARING

November 8, 2013 Case#: 201301808 To:

TAMMIE D CLAYTON 1112 VIKING DRIVE PORT ORANGE, FL 32129, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201301808

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850)412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Fiorids D.partment of Hosith DMsion of Medicai Quality Assurance • Board of Nursing 4052 Bald Cypress Way. Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 85012454125 • FAX 850/ 2454172

www.FioridasHoslth.gov TWIUEA:HealthyFLA

oepartmentof Health

YOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Flonda through integrated state, county & community efforts.

John

HEALTH Vision: To be

H Armstrong, MD, FAGS State Surgeon General & Secretary

the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 2013-01808 To:

TAMMIE 0 CLAYTON 5633 NEWMAN DRIVE PORT ORANGE, FL 32129, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-01808

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place," If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE: 8501 245-4125W FAX 850/ 245-4172

www.FlorldasHealth.gov TWITTER:HealthyFLA FACEBOOK:FLDeparlmentofHealth YOIJTUBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health in through üilegrated of at

ida

John H. Armstrong,

HEALTH Vision: To be the Healthiest State in

D, FACS

Stale Surgeon General & Secretary the Nathn

NOTICE OF HEARING

November 8, 2013 Case #201301808 To:

BONNIE J. QUATROCCI 113 RAIN LILY CIRCLE DAYTONA BEACH, FL 32117

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30AM

Type:

Determination of Waiver

Re:

TAMMIE D CLAYTON/201301808

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954—427-7700

This notice is to inform you, as an involved party or complainant, that the above listed case is scheduled to go before the Board of Nursing. While you are not required to attend, the meeting is open to the public. There is no action needed on your part at this time.

After the conclusion of the meeting, the Board file will file a final order stating the facts of the case and the Board's decision. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. This information will also be available on the Department of Health's website at: www.flhealthsource.com. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at MQA_Nursing©doh.state.fl.us.

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin 0-02 • Tallahassee, FL 32399-3252 PHONE: 850/ 245.4125 • FAX 850/ 245-4172

wwwFlorldasNurslng.gov TWITTER:l-leaithyFLA

FAcEaoox:rLoeparmientofHeaith VOUTUBE: ltdoh

Rick Scott

Mission:

Govemor

To protect, promote & improve the healTh of all people in Florida Through integrated state, county & community efforts.

John H. Armstrong, MD, FACS $

State Surgeon General & Secretary

Vision: To

be the

Healthiest State

in The

Nation

MEMORANDUM TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM:

Michael Lawrence, Jr., Assistant General Counsel

RE:

Determination of Waiver

SUBJECT:

DOH v. Tammie D Clayton, L.P.N.

.

.

DOH Case Number 2013-01808

DATE:•

Seotember 4. 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Tammie D Clayton Subject: 1112 Viking Drive Subject's Address of Port Orange, FL 32129 Record:

Enforcement Address:

Subject's Additional Address:

Subject's License No: Licensure File No: Initial Licensure Date; Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s): Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

Fiorida Department of Health Office of The GeneralCounsel- Prosecution Services Unit 4052 Bald Cypresä Way, Bin 0-65 Tallahassee, FL 32399-1 701 Express mail address: 2565 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX 850/245-4683

1112 Viking Drive Port Orange, FL 32129 5633 Newman Drive Port Orange, FL 32129 Rank: PN 1134341 50752

10/13/1993 No No No

464.018(1)(i), FS (2012) 2: 464.018(1)(h), FS (2012) 1:

None May 31, 2013; Home & Bryant Pro Se

Bonnie J. Quatrocci 113 Rain Lily Circle Daytona Beach, FL 32117

ldasHealth.com ITTER:HealthyFLA FAC EBOOK:FLDepartmentof Health

YOUTUBE: fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, CASE NO. 2013-01808

v.

TAMMIED. CLAYTON, LP.N., Respondent.

•

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of

a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

4, 2013.

A copy of said Administrative Complaint is attached

Petitioner's Exhibit A. 2.

.

An Administrative Complaint was filed against Respondent on June

as

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on

July 13, 2013 (7196 9008 9111 9326 7111). A copy of the certified

mail receipt is attached as Petitioner's Exhibit B.

3. Thereafter, Petitioner requested personal service on Respondent, which

was completed on August 12, 2013. The affidavit of personal service is attached as Petitioner's Exhibit C.

4.

Rule 28-106.111(2),

Florida Administrative

Code,

provides in

pertinent part that: persons seeking a hearing, on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 5.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters.

•

•6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

.

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits D and '7.

Based

E.

the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the SQard.

8.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations, as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find

that

Respondent has waived the right to dispute any materials facts contained within a..

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS Secretary of Health

Mic:

'Assistant General Fla. Bar 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 x8199 Facsimile: (850) 245-4683 Email: [email protected]. us

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of thq above and foregoipg has been provided by U.S. mail this day of 2013, to Tammie Clayton at 1112 Viking Drive, Port cirange, FL 32129, and to 5633 POrt Orange, FL 32129.

JQJ

Mi&ael

4

G.

Assistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, v.

CASE NO.

-01808

TAMMIE D. CLAYTON, L.PSNI,

RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Tammie D. Clayton, L.P.N., and in

support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed practical nurse (LP.N.) within the state of Florida, having been issued license number PN 1134341.

T

Respondent's address of record is 1112 Viking Drive, Port

3.

Orange, Florida 32129. 4.

At

Respondent

all

times

material

to this

Administrative

Complaint,

at The Terrace at Daytona Beach (The

was employed

Terrace), located in Daytona Beach, Florida. 5.

When a patient at The Terrace is prescribed a controlled

substance in tablet form, the pharmacy delivers the medication housed in

blister-pack along with

a

a

Controlled Drug Record (CDR) specific for that

prescription. The CDR is labeled with the patient's name, the medication, the quantity dehvered by the pharmacy, and the physician's order. •

blister-pack is also labeled with the same information.

The

The blister-packs

are secured in a locked medication cart and the CDRs are kept near the

medication cart. 6.

A blister-pack is

a

card that holds tablets in individual plastic

blisters or bubbles. The back side of each bubble is lined with foil or other

material through whichthe 7.

Each time

a

be removed

for administration.

nurse at The Terrace removed a controlled

substance from a patient's blister-pack

in.

order to administer the drug to

the patient, the nurse was required to document that on the CDR specific Department of Health v. Case Number 2013-01608

U.

aayton, L.P.N.

for that prescription. The nurse documented the date, the time, and the quantity of tablets remaining in that patient's blister-pack. In this manner, the nurses kept

a

running total of all controlled substances present in the

medication cart at all times.

In order to: accurately record patient care, hurses at The

8.

-required

to dotument each 'niedication administered to

patient in the patient's medical record.

The Terrace had two places to

document medication, the Medication Administration Record (MAR), where the nurse would initial that

a

medication was given, and the Nurse's

Medication Notes where more details were documented.

For medications

given to patients as needed for pain, the nurses would document the date,

time, the type of pain, and the patient's response to the medication on the Nurse's Medication Notes. 9.

Respondent typically worked the night shift at The Terrace from

about 11:00 p.m. until about 7:00 a.m. 10.

R.H. was a

At all limes material to this Administrative Complaint, Patient patient at The Terrace.

Department or I-feaIth V. Tamrnie Case Number 2013-01808

D.

Clayton, LP,N.

3

11.

At all times material to this Administrative Complaint, Patient

R.H. had a physician's order

for one Vicodln tablet every four (4) hours

as

needed for pain. 12.

Vicodiri. is the brand name for hydrocodone/APAP, which

contains hydrocodone and acetaminophen, or Tylenol, and is prescribed to Section

Statutes,

in the dosages found in hydrocodone/APAP, is a Schedule

III

controlled

substance that has a potential for abuse less than the substances in Schedules I and

II

and has a currently accepted medical use in treatment

in the United States. Abuse

of the substance may lead to moderate or low

physical dependence or high psychological dependence. 13.

From on or about December 11, 2012, to on or about January

10, 2013, Respondent removed thirty-seven (37) Vicodin

5/500 table$

from Patient R.H.'s blister-pack, ostensibly to treat Patient R.H. for pain. During that time, Respondent was the only nurse who removed Vicodin

from R.ft's blister-pack. 14.

During the period of on or about December 11, 2012, to on or

about January 10, 2013, Respondent removed one or more of the following

Department of Nealth v. Tammie Case Number

-01808

D.

aayton, L.P.N.

4

medications from the medication cart, ostensibly for Patient R.H., on one or mare of the foflowing occasions: Medication removed from Cart

Date removed

Time removed

Initials on MAR

Nurse's Med Notes

One hydrococione/APAP 5/500

1/1/13

12 am

No

None

1/1/13

6 am

Yes

6

1/2/13

11:45 pm

None

None

1/3/13

5:45 am

Yes

6 am

tablet (Vicodin) One Vicodin 5/500 tablet

am for back pa'n

One Vicodin 5/500 tablet

One Vicodin 5/500 tablet

for back

pain One Vicodin 5/500 tablet

.

1/4/13

12am

No

1/4/13

6 am

No

1/5/13

11:45 pm

No

None

1/6/13

6 am

Yes

6 am

One Vicodin 5/500 tablet .

None None .

One Vicodin 5/500 tablet

One Vicodin 5/500 tablet •

pain One Vicodin 5/500 tablet

.

1/7/13

12 am

Yes

None

5:30 am

No

None

12am

Yes

None

6 am

No

None

1/9/13

12:30 am

No

None

1/9/13

6 am

Yes

None

1/10/13

12 am

No

None

1/10/13

6 am

Yes

None

One Vicodin 5/500 tablet One Vicodin 5/500 tablet •

OneVicodin 5/500 tablet One Vicodin 5(500 tablet

3 1/8/13

One Vicodiri 5/500 tablet One VicodTh 5/500 tablet One Vicodin 5/500 tablet

Department of Health v, Tammie 0. Oayton, L.P.N, Case Number

for back

Respondent did not document that all the Vicodin tablets were

15.

administered to Patient R.H. and did not consistently document Patient R.H.'s symptoms of pain, or Patient RJ-L's response to the pain medication on the Nurse's Medication Notes.

At all times material to this Administrative Complaint, Patient

16.

1W. was a patient at The Terrace.

At all times material to this Administrative Complaint, Patient

17.

1W. had

-

physician's order for one hydrocodone/APAP tablet every six (6)

a

hours as needed for pain.

From on or about December 16, 2012, to on or about January

18. 10,

2013,

Respondent

removed

approximately

thirty-four

(34)

hydrocodone/APAP tablets from Patient .1W.'s blister-pack, ostensibly to

treat Patient J.W. for pain.

During that time, Respondent was the only

nurse who removed hydrocodone/APAP tablets for Patient 1W. 19.

During the period of on or about December 16, 2012, to on or

about January 10, 2013, Respondent removed one or more of the following medications from the medication cart, ostensibly for Patient J.W., on one

or more of the following occasions:

Deparmient of Health v. Tammle 0, Dayton, L.P.N, Case Number 201301S08

6

Medication removed from Time removed

Initials

Nurse's Med

on MAR

Notes

Illegible

11:45 pm

Date removed

One hydrocodone/APAP 7.5/325

tablet

-

Date removed

!

•

unknown One hydrocodone/APAP 7.5/325

Illegible

tablet

5 am

.

Date

removed illegibleunknown

-

One hydrocodone/APAP 7.5/325

12/16/12

tablet

5:45 am

5:45 am leg

Yes

pain One hydrocodone/APAP 7.5/325

5:15am

12/17/12

tablet

5:15 am leg

Yes

pain

.

One hydrocodone/APAP 7.5/325

12/18/12

6 am

Yes

6 am leg pain

12/19/12

11:30 pm

No

None

12/20/12

12 am

Yes

None

12/21/12

6 am

Illegible

Illegible

tablet One hydrocodone/APAP 7.5/325

tablet One hydrocodone/APAP 7.5/325

tablet One hydrocodohe/APAP 7.5/325

tablet

Illegible date, 12/2? 6 am

One hydrocodone/APAP 7.5/325

tablet

Date removed

None

Ible-

unknown

.

.

One hydrocodone/APAP 7.5/325

tablet

12/23/12

Illegible

Yes •

12 AM BIE (bilateral lower

One hydrocodone/APAP 7.5/325

tablet

12/23/12

6:30 am

No

None

12/24/12

11;45 pm

No

None

12/25/12

6:15 am

No

None

12/27/12

12 am

Yes

12 am BLE

One hydrocodone/APAP 7.5/325

tablet One hydrocodone/APAP 7.5/325

tablet One hydrocodone/APAP 7.5/325

tablet

Deparftnent of Health v. Tammie 0. Clayton, LP.N. Case Number 2013•01808

7

pain

]

One hydrocodone/APAP 7.5/325

tablet

12/27/12

6 am

Yes

6

12/29/12 unclear

12 am

Yes

None

12/29/12

6 am

No

None

12/29/12

Unclear am, pm

No

None

am BLE pain

One hydrocodone/APAP 7.5/325 •

tablet One hydrócodone/APAP 7.5/325

tablet One hydrocodone/APAP 7.5/325

tablet

S

?

One hydrocodone/APAP 7.5/325

tablet

12/30/12

6 am

No

None

12/31/12

12 am

Date cut

None

One hydrocodone/APAP 7.5/325

tablet

off MAR One hydrocodone/APAP 7.5/325

tablet (Lortab)

1/1/13

Illegible but appears to be 12

.

Yes

None

am

One hydrocodane/APAP 7.5/325

tablet

No.

1/1/13

6 am

1/3/12

12am

Yes on ½

Lortab 12 am for leg pain

1/3/13

6 am

Yes

6

1/4/13

12am

No

None

None

One hydrocodone/APAP 7.5/325

tablet One hydrocodone/APAP 7.5/325

tablet

for leg

am paIn

One hydrocodone/APAP 7.5/325

tablet One hydrocodone/APAP 7.5/325

tablet

No

1/4/13

.

6 am

None

One hydrocodone/APAP 7.5/325

tablet

1/6/13

12 am

Yes

None

1/6/13

6 am

No

6 am

One hydrocodone/APAP 7.5/325

tablet

for leg

pain One hydrocodone/APAP 7.5/325

tablet

1/7/13

12 am

Yes

12 am

for leg

pain One hydrocodone/APAP 7.5/325

tablet

6 am

Yes

am for leg pain 6

Department of Healthy, Tammle 0. Claytan, L.P.N. Case Number 2013-01808

•

g

One hydrocodone/APAP 7.5/325

tablet

Illegible

Illegible

Yes for

8

12 am for leg pain

Illegible

Illegible

No for 1/8

6

1/9/13

12 am

Yes

One hydrocodone/APAP 7.5/325

tablet

am for leg pain

One hydrocodone/APAP 7.5/325

tablet

12 ani

for leg

pain One hydrbcodone/APAP 7.5/325

1/9/13

tablet

6 am

No

6 am

for leg

pain One hydrocodone/APAP 7.5/325

tablet

.

1/10/13

12 am

Yes

None

1/10/13

6 am

No

6

One hydrocodone/APAP 7.5/325

tablet

20.

am for leg pain

Respondent did not document that all the hydrocodone/APAP

tablets were administered to Patient LW. and did not consistently

document Patient

/s

symptoms of pain, or Patient J.W.'s response to

the pain medication on the Nurse's Medication Notes COUNT ONE 21.

Petitioner

realleges and

incorporates paragraphs one (1)

through twenty (20) as if fully set forth herein. 22. Section 464.0 18(1)(i),

engaging or attempting to engage

Florida Statutes (2012), provides that in

the possession, sale, or distribution of

controlled substances as set forth in Chapter 893, for any other than

Department of Health v. Case Number 2013-01808

D.

Clayton, L.P.N.

9

legitimate purposes authorized• by this part, constitutes grounds for discipline. 23.

As set forth above, Respondent engaged in the possession, sale,

or distribution of controlled substances for other than legitimate purposes by diverting hydrocodone,

a

controlled substance as set forth in Chapter

893, from patients at The. Terrace during the period from ôñ or

about January 10, 2013. 24.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(i), Florida Statutes (2012), by engaging or attempting to engage in the possession, sale, or distribution of controlled substances as

set forth in Chapter 893, ?or any cther than legitimate purposes authorized by this part.

COUNT TWO 25. Petitioner realleges and incorporates paragraphs one (1) through

twenty (20) as if fully set forth herein. 26.

Sectbn 464.o18(lXh), Honda Statutes

that...

unprofessional conduct as defined by board rule constitutes grounds for

disciplinary action.

Department of Health V. Tammie 0. Cayton, L.P.N. Case Number 2013-01808

to

27.

Rule

64B9-&OOS(1),

Florida

Administrative Code,

defines

unprofessional conduct to include inaccurate recording. 28.

As set forth above, Respondent engaged in unprofessional

conduct by failing to properly document the administration and/or waste of one or more medications during the period of on or about December 11,

through on oriboutJanuaryiO, 2013. 29.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(h), Florida Statutes (2012), by engaging in unprofessional conduct as defined by Rule 64B9-8.005(1), Florida Administrative Code, to include inaccurate recording.

Department of Health v. Tarnmie 0. Clayton, L.P,N. Case Number 2013-01808

IT

WHEREFORE, the Petitioner respectfully

requests that the

Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of

or collected, remedial education and/or any other reliefthat the Board deems appropriate.

SIGNED

this

day of

Twig

, 2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Mic ael

FILED DEPARTMENT OF HEALTH

CLERK .kngq(Sqix(4rs JUN

1U13

Lawrence, J Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 lahassee, Florida 32399-3265 Florida Bar Number 0011265 (850) 245 4640 Telephone (850) 245 - 4683 Facsimile

/DO PCP: PCP Members:

.

' May 31, 2013 Home & Bryant

Department or Health v. Tarnn,ie 0. Clayton, L.P.N. Case Number 2013-01805

12

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accoidance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecutlén of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any otherdiscipline imposed.

alth

v. lammie 0. Clayton, LP.N. Number 2013-0t608

Department or Case

-

13

9111

7196

I

TO: I

Tammy D Clayton, LPN

1808

Pk Sent 7/10/2013 ML-ab/Stip

Tammy D Clayton 5633 Newman Drive. Port Orange, FL 32129

SERVICE

-

-

-

Return Receipt Fee Restricted Deliver Total Postage & Fees

user Receipt for

POSTMARK OR DATE

Certified Mallu No Insuranee

lage

NOtUI.torlnt.matbflS

d

2. Article Number

I

7111

71% 9006 3. Service Type

CERTIFiED MAILTM

4. Restricted Delivery? (Extra Fee)

Addressed to:

1.

fl

i

i.ammy Drive 5633 32129 FL Orange, Port Case No 2013-01808 ML Stip

c

Form

Domestic Return Receipt

EXHIBIT

Mission: To protect, promote

improve thehealth through integrated state, county & community efforts.

ol all Ople

&

in Florida

John H. Armstrong, MD, FACS

HEALTH

State Surgeon General & Secretary

Vision: To be the Healthiest State in the

Nabon

AFFIDAVIT OF SERVICE OR DILIGENT SEARCH•

.

FLORIDA DEPARTMENt OF HEALTH Petitioner

vs TAMMIE D. CLAYTON, Respondent

Case No. PN 2013-01808

COMES NOW, the afflant, who first being duly sworn, deposes and states: 1) Affiant is an Investigator/Inspector employed by the DEPARTMENT OF HEALTH, State of Florida. 2) That on 8/1 2/1 3, Affiant made a diligent effort to locate Respondent, to serve related papers; — Order compelling examination(s); Subpoena(s); and desist; ESO/ERO and related papers.

.

X Administrative Complaint and

order;

to cease

3) Check applicable answer below: X

Affiant made personal service on Katherine Van Horn, (Tamie Clayton's daughter), at 5633 Newman Drive

Port Orange,

Fl

,

on

was unable to make service after searching for Respondent at: (a) all addresses for Respondent shown in the DOH investigation of the case; (b) all official addresses for Respondent shown in his licensing records on the computer terminal or Board office; (c) Local telephone company forthe last area Respondent was known to frequent; (d) Division of Drivers

(electric, cable,. etd.); any others:

Aft iant State Of Florida County Of Duval

Before me, personally appeared Todd

McCormick whose identity is known to me by personal knowledge identification) and who, acknowledges that his/her signature appears above, P.

(type of.

I

Sworn Not

r

affi

ed

Affiant before me this

hc-State

/'.c-c. Type or Print Name Florida Department of Health Division of Medical Quality Assurance' Investigative Services Unit 1912 Hamilton Street. Unit 104' Jacksonville, FL 32210 PHONE: 904-381-6022 • FAX: 904-381-6050

INV FORM 321

of August 2013.

commission # EE 027906 Expires November 1,2014

My Commission

.com FACE 30

EXHIBIT

C—

a

Mission: To protect, proniole &.irnprove the health of all people in Florida through Integrated state.

—

efforts,

&

Rick Scott Governor

"r

John H. Annstron9, MD, FACS State Surgeon General & Secratary

HEALTh

Vision: To be the Healthiest Slalom

.

Affidavit of Non-Receipt

hereby certify in my official capacity as

Robert Johnson

I,

the Nation

custodian for the Board of Nursing's licensure files, that the Board, as of 9/4/2013

has no

evidence Of an.E:lecti.on, of Rights form or othei

responsive pleading requesting a hearing prior to any agency action regarding Tammi

Clayton,

'N;

rights.

which would affect the Subject's substantial interests or

Custodian of/ecords Florida Board of Nursing

Before me, personally appeared

whose

Robert Johnson

identity is known to me personally and who, under, oath,, acknowledges that his/her

signature appears above, Sworn to and subscribed before me this SeDtember

,

4

day of

2013.

it EE 218427 2016. bmraita

Notary Public Signature My commission expires: Florida Department of'Hsaith Offi

of the General Counsel

•

Services Unit

www•Flo

ft

/

Minion:

/

Rick Scott Governor

& improve the health

To protect of all people

in

state, county

&

Florida through Integrated community effort.

John H. Annshong, MD, FACS

,

Slate Surgeon General & Secretary

HEALTH

Vision: To be the

Healthiest State

rn

the Nafon

AFFIDAVIT •

Deputy Clerk for the Department

Clerk's

Office, hereby certi& in my official capacity as custodian for the Department Clerk's

records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action

regarding Tammie D. Clayton. LPN; substantial interests or rights.

which would affect the Respondent's

Custodi Department Clerk's Office

Before me, personally appeared

whose identity is

'

known to me personalLy and who, under oath, acknowledges that his/her signature

appears above.

Sworn to and subscribed before me this

day of___________________ .2013.

Public My Commission Expires:

Florida Department of Health Office of the General Counsel • Services Unft 4052 Bald Cypress Way! Bin C-65 • Tallahassee, EL 32399-1701 PHONE: 850/245.4444 'FAX 850/245-4683

Noisy Polio .

v Come.

i.

of Nova, 2010

# U 044542

EXHIBIT

E

STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2013-01808

v.

TAMMIE D. CLAYTON, L.P.N., Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW the

Department of Health, by and through

undersigned counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take-tip for consideration the above-style& disciplinary

action and will enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and. prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney .and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

.

The investigation

3.

prosecution of this case has

and

resulted in costs in the total amount of $7,023.48, based on the

following itemized statement of costs: cost to Date Hours

Investigation: Legal:

Sub Total:

0.00

88.50 [

$7,004.86

Expenses to Date:

...

.

$0.00

$18 62

Prior Amount:

$0.00

to Date:

1

1

1 1

Costs

.

.

$7,023.48

]

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $3,418.13 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessmentof costs,withiaten (10)

the

this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner,

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

costs in the amount of $3,418.13 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes. WHEREFORE, the Department of Health requests• that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $3,418.13.

3

,2013.

' •

•

•

Assistant General Couns DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0011265 (850) 245-4444 x8199 Telephone (850) 245-4683 Fax I

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that foregoing Motion to Assess

of

a

true and correct copy of the

has been provided by U.S. Mail this ,

2013, to Tammie Clayton, and to 5633 Newman

1112 Viking Drive, Port Orange, FL 32129

Drive, Port Orange, FL 32129.

Lawrence, Assistant General Counsel Mich el

.

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows: 1) My

2)

name is Shane Walters,

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at I

the Florida Department of Health (DOH). 3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties includereviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs

regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today; DOH's total costs for investigating and prosecuting DOH case number(s) 2013-01808 (Department of Health v. TAMMIE 0.

CLAYTON) are SEVEN THOUSAND TWENTY-THREE DOLLARS AND FORTY-EIGHT CENTS ($7,023.48). 6) The costs for DOH case number(s) 201 3-01 808 (Department of Health v. TAMMIE D. CLAYTON) are summarized in Exhibit 1 (Cost

Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case number(s) 201301808 (Department of Health v. TAMMIE D. CLAYTON) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

EXHIBIT I

of 2

and lawyers). A designSted DOH employee in the Consumer Services Unit, Legal Department, •and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of her knowledge and belief. FURTHER AFFIANT SAYETH NOt.

Shane Walters, Affiant State of Florida County of Leon

5

Sworn to and subscribed before me this day of by Shane Walters, ally known to me.

N ota

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

Page

1

of

Complaint Cost Summary Complaint Number: 201301808

Subject's Name:

CLAYTOft TAMMIE I) ] .

Complaint: investigation: Legal:

J

]

***** Cost

to Date

Hours

1

)

I

Isub Total: Expenses to Date: Prior Amount: Total Costs to Date:

88.50

I

1

1

Costs

$3,344.61.

1

$0.00' $7,023.48

EXHIBIT

OOTTMETRAK!CSDETL.ASp

9/5/2013

1

Division ol

Medical Quolify Msurance

MOA Report Date 09/05/20 13

Staff Code Activity Hours

1.00

1.00

$54.90

Staff Rate

ICONSUMER SERVICES UNIT

S

Sub Total

1.50

$6198

I1NVESTIGATIVE SERVICES UNIT

1.80

0.50 0.50 2.00

J193 J193

J193

J193

1193 3193 3193

1.00

0.50 6.50 2.00 4.00

1188

Jt93 3187

JI93 JI87 J193

193 J193

1.00

0.50 0.50 0.30 7.20 2.00 0.80 0.50

193 193

3193

JI93

3193 3193

1.00 1.00

2.00 2.00 0.50 2.00

193 JI93

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

193

Florida Department of Health

Cost

$54.90 $54.90

$95.97 $31.99 $31.99 $127.96 $115.16 $31.99 $415.87 $127.96 $255.92 $63.98 $127.96 $127.96 $31.99 $127.96 $63.98 $63.98 $31.99 $31.99 $19.19 $460.66 $127.96 $51.18 $31.99 $63.98

Activity Date

01/28/2013

01/29/2013 01/30/2013 01/30/2013 01/31/2013 01/31/2013 01/31/2013 02/01/2013 02/04/2013 02/04/20 13 02/05/20 13 02/18/2013 02/19/2013 02/19/2013 02/25/2013 02/26/20 13 03/05/2013 03/06/2013 03/11/2013 03/12/2013 03/13/20 13 03/14/2013 03/15/2013 04/02/2013 04/I 1/2013

***CONF!DENTIAL***

Complaint 201301808

ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORTPREPARATION ROUTINEINVESTIGATIVE WORK REPORTPREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION ROUTINE INVESTIGATIVE WORK SUPPLEMENTAL INVESTIGATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTALINVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION

Page

itemizedcost

T

INITIAL REVIEW AND ANALYSIS OF COMPLAINT

Activity Description

Time Tracking System Itemized Cost by Complaint

Activity Code

78

4 4 76 4 76 4 4 4

6

76 76 4 6

76 6 6 6 6

6 6 6 6 6 6

-- FOR INTERNAL USE ONLY --

1

of 4

I

I

Division op MedLcoi Quolity Assurance

MQA Report Date 09/05/2013

Staff Code Activity Hours

1.00

1.70 1.00 0.50

1193 1193 1193

1.70

0.40 0.20 2.60

0.90 0.10 0.10 2.00 2.00 0.30 0.20 2.50 0.50 1.80 1.60

3.40 0.20

Staff Rate $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

SERVICES UNIT

47.70

0.50 0.40 0.10 0.70 0.20

1193

J193

11 191 191 Sub Total

ION HLOIN

HL0IN FILOIN

OIN FILOIN

HLOIN

IN IN IN IN FILO IN

OIN HLOIN ULOIN HLOIN 1-ILOIN

1.00

3.60

HLOIN

IN IN

Florida Department of Health

Cost $108.77 $63.98 $31.99 $63.98 $31.99 $25.59 $6.40

$4479 $12.80

$3,051.85

$42.54 $21.27 $276.51 $180.80 $95.72 $10.64 $10.64 $212.70 $212.70 $31.91 $21.27 $265.88 $53.18 $191.43 $170.16 $361.59 $21.27 $106.35 $382.86

81

81

81 81

25

81

103

103

26

115

25

103

115 25 25 25 25 115 103

4

76

CON FIDE NT! AL

Complaint 201301808

i

CONTACT WITFI INVESTIGATORS REVIEW CASE FILE REVIEW CASE FILE REVIEW CASE FILE REVIEWCASE FILE CONTACT WITHINVESTIGATORS REVIEW SUPPLEMENTAL REPORT REVIEWSUPPLEMENTALREPORT REVIEW CASE FILE CONTACT INVESTIGATORS PREPARE OR REVISE MEMORANDUM REVIEWSUPPLEMENTAL EPORT REVIEWSUPPLEMENTALREPORT ESO/ERO REVIEW CASE FILE ESO/ERO ESO/ERO ESO/ERO ESO/ERO

.

.

.

.

Page 2 of4

temizedeost

SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK

Activity DescriptiOn

Time Tracking System Itemized Cost by Complaint

100 4

6 6

6

6 6

Activity Date Activity Code 04/18/2013 04/19/2013 05/16/2013 05/20/2013 08/12/2013!

08/12/2013 08/12/2013 08/13/2013 08/13/2013

01/31/2013 02/12/2013

02/26/2013 02/28/2013 02/28/2013 03/06/2011 03/21/2013 04/01/2013 04/01/2013 04/02/2013 04/02/2013 04/08/2013 04/30/2013 04/30/2013 05/01/2013 05/01/2013 05/02/2013 05/02/2013 05/02/2013

- FOR INTERNAL USE ONLY -

M Report Date 09/05/20 13

1.30

0.70 0.50 1.50

2.00 1.50

0.10

Staff Rate $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

:35

$106.35 $106.35

$106.35

$106.35 $106.35

0.20 0.10 0.10 0.30 0.10 0.20

.

Staff Code Activity Hours HLOLN

IN HLLIO5A

O5A O5A O5A O5A HLL38B O5A -ILL38B HLL38B HLL38B 0.20

SB ILL38B 33.90

J185

185 185 1.00 1.00

0.50

0.40 2.00 0.50

$49.62 $49.62 $49.62 $49.62 $49.62 $49.62 $49.62

Sub Total

185

JL85

1185

0.50 5.90

.1185

Sub Total

Total Cost

Florida Department of Health

Cost

Activity Date

.

$138.26 574.45 $53.18 $159.53 $212.70 $159.53 $10.64 $21.27 $10.64 $10.64 $31.91

01/29/2013 01/30/2013 01/30/2013 02/19/2013 05/16/2013 05/16/2013 05/17/2013

05/03/2013 05/10/2013 05/17/2013 05/17/2013 05/20/2013 05/21/2013 05/21/2013 06/04/2013 06/04/2013 06/12/2013 07/09/2013 07/19/2013 08/07/2013 08/20/2013

$10.64 $21.27 $21.27

53,605.35

$19.85 $99.24 $24.81 $24.81

$49.62 $49.62 $24.81 $292.76

$7,004.86

Complaint

ESO/ERO ESO/ERO

201301808

Activity Description

Time Tracking System Itemized Cost by Complaint

Activity Code 81 81

REVIEW CASE FILE PREPAREORREVISEADMINISTRATIVECOMPLAINT

29

CONTACT WITHEXPERTS

INISTRATIVECOMPLAINT

PREPARE OR REVISE ADMINISTRATIVE COMPLAINT

114

PREPARE OR REV1SE ADMINISTRATIVE COMPLAINT

25 28 28

18

28 79

.

.

Page 3

.

temizedcost

of 4

WORK ROUTINE INVESTIGATIVE WORK SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE

INVESTIGATIVE

ROUTINE INVESTIGATIVE WORK UL-TRAVEL TIME

COPYING FILES STIPULATION REVIEW CASE FILE REVIEW CASE FILE REVIEW CASE FILE REVIEW CASE FILE 25 25 25 25

4 4

9058 4

100 100 100

- FOR INTERNAL USE ONLY -

__________ MedicuituoRtyAssuronce

M Report Date 09/05/2013

Staff Code Activity Hours I

Florida Department of Health

Staff Rate Cost

Activity Date

C

ON F IDE N TI AL

Complaint 201301808

Activity Description

Time Tracking System Itemized Cost by Complaint

Activity Code

- FOR INTERNAL USE ONLY --

Page 4 of 4

itemizedcost

of

Medtcol Quolily Assurance

Expense Date

09/05/20 13

MOA. Report Date:

Staff Code

Expense Amount

SubTotal $18.62

$18.62

$18.62

Total Expenses

05/28/2013

JPROSECUTION SERVICES UNIT

O5A .

Florida Department of Health

Expense Code

133100

***CONFIDENTIAL*** Time Tracking System Itemized Expense by Complaint Complaint 201301808

Expense Code Description •

LEGAL&OFFICJAL ADVERTISEMENTS .

- FOR INTERNAL USE ONLY --

.

Page

1

I

of I

itemizedexpense

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

STATE OF

iDA

DEPARTMENT OF HEALTH INVESTIGATIVE REPORT Date of Case: 01/28/2013 Source:

Office: Jacksdnvifle Subject: TAMIE CLAYTON LPN 1112 Viking Drive Port Orange FL 32129

Case Number: PN 2013-01808

I

BONNIE QUATROCCI The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114 (386) 255-6571

"

Profession: Licensed Board: Nursing Report Date: License # 1134341. Prefix: PM Practical Nurse 02/19/20 13 of Repárt: through 02/19/2013 Type Supplemental-i Investigation: 02/05/2013 Period of Alleged Violation: PS 456.072 (1) The following acts shall constitute grounds ..." (dd) Violating any provision of this chapter (j) Engaging 464.018..." (1) The following acts constitute grounds..." (i) Engaging or attempting to engage in the possession or attempting to engage in the possession.." o) Violating any provision of this chapter or .

Synopsis: This investigation is predicated upon receipt of additional information received subsequent to submission of the final report on 02/05/2013, to the Prosecution Services Unit. The information includes a response from IPN, and a video tape from The Terrace of Daytona Beach.

On 02)05/20 13, a response from 1PM was received via fax. It stated that there is no record of CLAYTON participating in IPN,

(S-i). On 02/14/2013. a video contained on a CD was received from BONNIE QUATROCCI RN, of The Terrace of Daytona Beach, via Federal Express delivery. The video is comprised of viewing times of 3 patient's rooms that coincide with CLAYTON'S shift at the Terrace of Daytona Beach. This is important because according to QUATROCCI. CLAYTON is not seen entering the rooms of these patiçnts, despite claiming to have administered pain medication to these patients during the time periods represented. The video covers the 11pm to 7am shift beginning on 01/03/2013 and ending on 01/04/2013. The outside of 2 separate patient's room can be viewed on this video. These patients are RH and JW. A separate video for 01/09/2013. beginning at 1 1pm and endingat Sam on 01/10/2013, shows the outside of AP'S room is also contained on this CD. QUATROCCI has explained that she personally reviewed these videos in their entirety, (S-2). The Confidential Index of Names is Exhibit 5-3). *

EXHIBITS CONTAXN INFORMATION WHICH IDENTIFIES PATIENT(S) PURSUAflT TO SECTION 456.057(10) (a), FLORIDA STATU'TES.

BY NPINE AND ARE

SEALED

Exhibits

(S-i) IPN response pg.2-3 5-2) Video Tape surveillance pg.4-5 * (5-3) Confidential Irdex of Names pg.5

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Related Case: None

Investigator/Date:

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Phonc: 386-255-6571

Fax: 386-254-1949

Date: 2/10/13

To: Paul Kloko 1912 flamilton St. Unit 104

Jacksonville, FL 32210

From: Bonnie Quatrocci, RN-BC, LHCRM Re: Disk Requested

Enclosed is the disk as requested regarding Tammie Van Horn Clayton. There is a player saved on the disk. As per our discussion, the dates included areJan 11-7a and Jan 9 lip through Jan 10 through 8 am.. Please call me if you have any questions.

Bonnie Quatrocci, RN-BC, LHCRM Director of Nursing

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COMPLAINT NUMBER: PN 2013-01808

CONFIDENTIAL INDEX TO NAMES INITIALS

JW

JAMES WHITE PATIENT/RESIDENT The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114 (386)255-6571

RITA HALL PATIENT/RESIDENT The Terrace of Daytona Beach

RH

AP

NAMES

I

ANDERSON PATE PATIENT/RESIDENT The Terrac e of Daytona Beaôh

EXHIBIT

3AGE

5

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county.&communityefforls.

John

H.

Armstrong,

State Surgeon General & Secretary

Vision: To be the

Healthiest State in the

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO: Department of Health FROM: Board of Nursing, Special Probable Cause Panel

suaJEa: Tammie D. Clayton,

L.P.N. CASE NO.: 013-01808

DATE OF PROBABLE CAUSE MEETING: May 31, 2013

This matter was brought before

a

Probable Cause Panel composed of:

Claydell Home, RN & aody Newman Bryant, EdD,

EcIS

A-10(DO)

The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that: Probable cause exists herein that the Subject violated the following statutes/rules:

Count

I:

Count I:

Section 464.018(1)(i), Florida Statutes (2012) Section 464.018(1)(h), Florida Statute (2012), as define.d by Rule 6489-8.005(1), Florida Administrative Code

The panel suggests imposing the following penalty: VS

_Probable

cause does not exist and the case should be closed with the following closure code:

3n lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question: The panel has requested supplemental or additional information on the following:

Other

( PRaABLE c4QsE PANEL 6$ NURSING

Florida Department of Health Office of the General Counsel • Prosecution Services Unit Tallahassee, FL 32399-1701 4052 Bald Cypress Way, Bin Express nail address: 2585 Merchants Raw — Suite 105 FAX 8501245-4683 PHONE: 850(245-4444 ext.

leafth

www.FioridasHealth.com TWITTER:HeaUhyFLA YOUTUBE: fldoh

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a -I

STATE OF FLORIDA

DEPARTMENT OF HEALTH INVESTIGATIVE REPORT

Date of Case: 01/28/2013 Case Number: PN 2013-01808 Source: BONNIE J. QIJATROCCI The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114 (386) 255-6571 Prefix: PN License # 1134341 Profession: Licensed Board: Nursing Report Date: Practical Nurse 02/05/2013 Period of Investigation: 01/28/2013 through 02/05/2013 Type of Report: FINAL Alleged Violation: FS 456.072 (1) The following acts shall constitute grounth (dd) Violating any provision of this chapter 464.018.." (1) The following acts constitute grounds (i) Engaging or attempting to engage in the possession (o) Violating any provision of this chapter U) Engaging or attempting to engage in the possession or chapter

Office: Jacksonville Subject: TAMIE CLAYTON LPN 1112 Viking Drive Port Orange FL 32129

.

Synopsis: This investigation is predicated upon receipt of a complaint submitted by BONNIE J QUATROCCI RN, in regard to TAMIE D CLAYTON LPN, alleging that while employed by The Terrace of Daytona Beach, and between the dates of 12/2012 and 01/2013, CLAYTON was signing out pain medication for patients, but not actually administering them. CLAYTON is believed to have been diverting these narcotics for unknown reasons. (Exhibit 1).

CLAYTON was notified of the investigation by letter dated 01/29/2013, and was provided with a Department of Health's Case Summary, (Exhibit 2).

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A check of DOH computer records revealed CLAYTON first received her license on 10/13/2013, an&-her license is

currently listed as Clear, Active As there is no patient identified in this complaint, notification is not required.

CLAYTON is not known to be represented by an attorney. On 01/30/2013, a notification letter and attachments were hand delivered by Investigator BILL DOZOIS. The letter was given to a person identifying themselves as the sister of TAMIE CLAYTON. She assured DOZOIS that she would give the letter to TAMIE CLAYTON. The service of this letter occurred at CLAYTON'S listed address of 11.12 Viking Drive, Port Orange Fl 32129. To date, no response has been received. Any information and/or interviews conducted subsequent to the completion of this final report will be forwarded in the form of a supplemental report.

Related Case: None

Investigator/Date

Approved By/DateS

Paul D. Kloko Investigative Spec

Wendy Investigator Supervisor

Distribution: HQ/ISU INV Form 300 7/02

V

gatlve Services

FEB06 OOHJMQA HO

1

DOH INVESTIGATIVE REPORT

CASE NUMBER: PN 2013-01808

INVESTIGATIVE DETAILS Summary of Exhibits Exhibit#

Summary and attachments. The attachments include a HealthCare Practitioner Report and a Case Summary. There were no other supporting documents provided. 1

is a Case

Exhibit #3 was received via fax from BONNIE QUATROCCI RN, and Director of Nursing, of The Terrace of Daytona Beach. The items obtained include a laboratory drug test on CLAYTON which was negative. A record of pharmacy orders made for various patients by CLAYTON, records of medication administration records and copies of patient prescriptions. Of note, these records seem to show a pattern of a reduction in administration of pain medications to all patients, immediately after CLAYTON'S suspension on 01/10/2013. The exhibit also contains statements from. CLAYTON denying any knowledge of missing medications or false recording of medication disbursement to patients. A statement by AMANDA LPN is included. It details a discussion with. patient JW an 82 year old male patient, on 12/30/2013. In it, JW denies receiving any recent pain medication. CHRISTIE was unavailable for interview, but JW was interviewed and his statements are contained in the interview portion of this report. He denies taking pain medication on a regular basis. A statement by JEANA CLARK LPN is also included. In this statement, CLARK describes an incident with Clayton on 12/29/2012, when CLAYTON allegedly had an incorrect narcotic count. Other statements are included by different employees in this exhibit. Those statements are also contained and expanded on in the interviews of these employees. These interviews are located in the later portion of this report.

iSTIE

INVESTIGATOR'S

:

According to QUATROCCI, CLAYTON is also known as TAMIE CLAYTON VANHORN, or TAMIE VANHORN. When reviewing medical records, it appears CLAYTON has signed all documents using the last name of VANHORN.

Exhibit #5

request sent on 02/01/2013, to the Intervention Nurses Program (IPN). The request is to determine if there is any involvement on the part of CLAYTON with this program. To date, no response has been received. Any information and/or interviews conducted subsequent to the completion of this final report will be forwarded in the form of a supplemental report. is a fax

Exhibit# 6 is a second request for IPN records faxed on 02/05/2013. Any information and/or interviews conducted subsequent to the completion of this final report will be forwarded in the form of a supplemental report.

INTERVIEW OF BONNIE J OUATROCCI RN Director of Nursing The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114

(386) INV Form 300

/02

Page 3

DOH INVESTIGATIVE REPORT

CASE NUMBER: PN 2013-01808

INTERVIEW OF SARMA BLAIR CNA The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114 (386) 255-6571

F

BLAIR was interviewed on 02/01/2013, at her place of employment. She .. • • •

.• •

•

• •

• • •

• • • • • • • • • • • • • • •

INV,

BLAIR works the 11am to.7prn shift, She is assigned predominantly to the 400 floor On occasion she would work with CLAYTON who was assigned the 400, 500 and 600 H floors. . CLAYTON would begin her rounds by taking all the pills out in advance, rather than at each room individually. BLAIR explained that CLAYTON often opened the medications on her cart at a location between the 400 and 500 floors that could not be detected by the security camera. The 400 floor had a large number of patients who suffered from memory problems such as dementia, There were also patients who could not verbalize wellbeeause of medical issues. PB is an elderly female patient who suffers from memory issues and various physical problems. Although she has difficulty remembering long term, she often knows when she needs pain medication, and if she received it th.at evening. On. one occasion during 01/2013, she began screamin.g for her pain pill.. PB walked down the hail and confronted CLAYTON. CLAYTON told her she had given PB her pill. PB insisted on her pill. CLAYTON was observed by BLAIR pulling a pill from her pocket and giving it to PB. BLAIR was unable to identify what type of pill it actually was. Many times CLAYTON would not make her rounds at all. BLAIR stated that this angered her, because she feared CLAYTON was not only denying patient's pain medications, but all of their medications. On many occasions CLAYTON could be found in the bathroom. She also would go to her truck in the parking lot about 530am every morning. On or about the middle of 01/2013, CLAYTON was observed by BLAIR as possibly impaired. The staff was looking for her because she was missing. CLAYTON was located in her truck. She was sweating and holding her head with her hands. She also appeared to be unsteady on her feet.

Form 300

/02

Page 5

DOH INVESTIGATIVE REPORT

• • •

CASE NUMBER: PN 201 3-01808

CLAYTON stated she was ill. The weather outside was cool and inside the temperature inside the building was also very cool. BLAIR had nothing further to add at this time.

INTERVIEW OF MARIE GABRIELLE BICHIMEAU LPN The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114 (3 86) .255-6571 BICI-HMEAU was interviewed on.02/01/2013, ather place of employment. She essentially • • • • •

• • •

• •

• • •

On 12/12/2012, she was beginning her 7am to 3pm shift. CLAYTON was ending her shifi. CLAYTON had only been working at this location a few months. BICHIMEAU also rotated shifts and floor locations. She described her position as a floater. This makes her sensitive to making certain her pill counts match up, because she works with manynurses she does not know well. BICHIMEAU wanted to reconcile her med cart with CLAYTON. BICHTMEAU had the paper records of JW, a patient CLAYTON had treated during the 11pm to 7am shift. CLAYTON had the actual card which contained unopened pain pills secured in a bubble pack. BICHIMEAU thought it was strange that CLAYTON would not confirm the count until BICHIMEAU told her what her paper record was showing for pills left. At the end of BICHIMEAU'S shift, she noticed that the count was off. 2 pain pills were missing. BICHIMEAU had nothing further to add at this time.

INTERVIEW OF BONNIE LEWIS LPN The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 321 14 (386) 255-6571 LEWIS was interviewed on 02/01/2013, at her place of employment She essentially stated: • •

LEWIS has been employed as an LPN atThe Terrace of Daytona Beach for 6 years. All of the patients are elderly and have a number of health issues she is familiar with.

INV Form 300 7102

Page 6

DOH INVESTIGATIVE REPORT

• • •

• •

• •

• • • • •

• •

• •

CASE NUMBER: PN 2013-01808

She began noticing inconsistencies in the administration of painmedication to some of these patients when being treated by CLAYTON. OL is a patient who has scheduled Lorazapam three times daily. On 12/30/2012, she noted that two extra Lorazapam had been apparently used by CLAYTON for GL. Although possible GL may have needed them, this was inconsistent with her past record of treatment. OL was of a mental state of mind, that it was impossible for LEWIS to inquire with her about this issue. LEWIS questioned CLAYTON about the inconsistency. LEWIS explained that pill numbers 25 and 26 were unaccounted for in the bubble pack. CLAYTON stated she only signed out numbers 27,28and 29. She stated that she simplyforgot numberw25-and26 before administering them, and that the correct pill number for the next administration was 24. This incident aroused LEWIS'S suspicion. She then checked. other records. RH is an elderly female patient that takes Hydrocodone on an as needed basis. LEWIS noted that CLAYTON was the only nurse consistently providing her pain medications according to the records. In addition to the record inconsistencies, LEWIS recalled an incident in the early part of 01/2013, when AP, a wheelchair bound elderly male patient suffering from advanced prostate cancer, complained he needed his pain medication. Records show CLAYTON had already provided it to him. LEWIS also expressed concerns of some possible impairment or physical health issues while CLAYTON was atwork. She explained that CLAYTON was always extremely hot and sweaty no matter what the temperature inside or out. LEWIS had no additional information to add at this time.

ly

INTERVIEW OF KENYA WILLIAMS LPN The Terrace of Daytona Beach 1704 Huntington Village Circle Daytona Beach FL 32114 (386) 255-6571 WILLIAMS • • • • •

interviewed on 02/01/2013, at her place of employment. She essentially stated:

On 01/03/2013, WILLIAMS received a request from AP for pain medication. It was 8:45am. WILLIAMS told AP that the records showed that he had received, his medication at 630am, and about 4 hours previous to that. CLAYTON was the nurse of record who dispersed the pain medication to AP. AP insisted no one had been in his room to give him medication during this time.

INV Form 300 7/02

Page 7

:

DOH INVESTIGATIVE REPORT

•

CASE NUMBER: PN 201 3-01 808

WILLIAMS had no additional information to add at this time.

INVESTIGATOR'S

.

On 02/01/2013, an attempt to interview AP was made. It was unsuccessful based upon problems

with AP'S memory.

INTERVIEW OF JW

•

.

JW, an 82 year old male patient, was interviewed on. 02/01/2013, at The Terrace of Daytona Beach. He essentially stated:

•

• • • • •

He The.Terracè. Beach.hecause he is confined to.ihe...use.of.a.............. walker or wheel chair. He has no difficulties with his memory. He takes pain medication very infrequently. When he does, it is for either pains in his back, or toe. He denied ever needing medication twice daily, and if he does need medication, it is no more than one pill that day. He explained that one pill will usually stop the pain. 1W had no additional information to add at this time. -

INTERVIEW OF MEt MH is an 80 year old female patient, who was interviewed on 02/01/2013, at The Terrace of Daytona Beach. She essentially stated:

• • • • • • •

She is a resident of The Terrace of Daytona Beach because she is confined to a wheel chair. MI-I has occasionally pain in her leg. This requires her to request pain medication. She explained that there are no other times she requests pain medication. She explained that she asks for the medication only when needed, and only occasionally. She stated that she never uses medication for pain on a daily basis. MH had no additional information to add at this time.

:

INVESTIGATOR'S On 01/30/2013, a notification letter and attachments were hand delivered by Investigator Bill DOZOIS. The letter was given to a person themselves as the sister of TAMIE CLAYTON. She assured DOZOIS that she would give the letter to TAMIE CLAYTON. The service of this letter occurred at CLAYTON'S listed address of 1112' Viking Drive, Port Orange Fl 32129. To date, no response has been received. Any information and/or interviews conducted subsequent to the completion of this final report will be forwarded in the form of a supplemental report. The confidential Index of Names is Exhibit #6 INV Form 300

7/02

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Page 8

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

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Rick Scott

Mission:

Governor

To protect, promote & improve the health

cflpeoinFbridatuglfintegrated

John H. Armstrong, MD, FACS State Surgeon General & Secretary

H EA&TLFI Vision: To be The

Heaithiest State in the Nathn

NOTICE OF HEARING November 8, 2013 Case#: 201307511 To:

LISA LEIGH MUNOZ 4702 NW 80TH ROAD GAINESVILLE, FL 32653, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201307511

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850)412-2205. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under

'Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health DMsion of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C.02 • Tallahassee, FL 32399-3252 PHONE: 85012454125 • FAX 850/2454172

www.FiorldasHealth.gov TWI1TER:HealthyFLA FAcEB00K:FLDepartrnentofHealm YOUTL.JBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Annatrong, MD, FACS

.

Surgeon General & Secretary u

Vision:

To be the Healthiest State in the Naflon

MEMORANDUM TO: FROM: RE: SUBJECT:

DATE:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Renee Harkins, Assistant General Counsel

Determination of Waiver DOH v. Lisa Leigh Munoz, R.N. DOH Case Number 2013-07511

October 3, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for

final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of

Lisa Leigh Munoz, R.N. 4702 NW 80th Road

Record:

Gainesville, FL 32653 4702 NW 80th Road Gainesville, FL 32653

Enforcement Address: Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s):

9340085

Prior Discipline: Probable Cause Panel:

None

Rank:

RN

435444

4/2/2012 None No

None

Section 464.018(1)0), F.S. (2012)

July 30, 2013 Home & Newman

Subject's Attorney:

Pro Se

Complainant/Address:

Intervention Project for Nurses Attention: Casey Linn, BA, CMHP Post Office Box 49130 Jacksonville Beach, FL 32240

Fiorlda Department of Kea!th Office of the General Counsel- Prosecution Services Unit 4052 Bald Cypress Way. Bin C-65 Tallahassee, FL 32399-1701 Express rnaii address: 2585 Merdiants Row— Suite 105 PHONE: 8501245-4444 FAX 8501245-4683

lealth

www.FlorldasHeaith.com TWrrrERHealth FLA

1

YOUTUBE fkloh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTh,

Petitioner, V.

CASE NO.

2013-075 11

LISA LEIGH MUNOZ, R.N.,

Respondent.

I MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

August

An Administrative Complaint was filed against Respondent on 1, 2013.

A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on: August 15, 2013 (7196 9008 9111 8821 9581). A

copy of the

certified mail receipt is attached as Petitioner's Exhibit B. 3.

Rule

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 4

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits 6.

C

& D.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

9.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing a prima fade case regarding the violations as set corth

s

WHEREFORE, Petitioner respectfully requests

n

the

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter a Final Order imposing whatever discipline upon

license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

ReneeHar ins Assistant General Counsel Fla. Bar No.

089054

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of the above and has been provided by U.S. mail this day of 2013, to: Usa L. 4702 NW Road, Gainesville, FL 32653.

)

Re eeHárttins Assistant General Counsel

th

STATE OF FLORIDA DEPARTMENT OF HEALTH OF

PETITIONER, CASE NO.

2013-07511

LISA LEIGH MtJNOZ,.R.N.. RESPONDENT.

I ADMINISTRATIVE COMPLAINT Petitioner, Department of Health (Department), by and through its undersigned counsel, flies this Administrative Complaint before the Board

of Nursing against Respondent, Lisa Leigh Munoz, and in support thereof alleges: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

ive .

456, Florida Statutes; and Chapter 464, Florida Statutes (2012). 2.

•At

all

Respondent was

times a

materiaJ

to

this

Registered Nurse within the

been issued license number RN 9340085.

Complaint,

of Florida, having.

Respondent's address of record

3.

is

4702

NW

th

Road,

Gainesville, Florida 32653.

on or about March 27, 2013, Respondent contacted the

4.

Intervention Project for Nurses ("IPN"). IPN is the impaired practitioner program for the Board of

5.

Nursing,

pursuant to Section

.076,

Florida Statutes (2012).

JPN

monitors the evaluation, care and treatment of impaired nurses.

IPN

oversees random drug screens and provides far. the exchange of information between treatment providers, evaluators and the Department for the protection of the public. 6.

On

evaluation by 7.

or about April 5, 2013, Respondent submitted to an

Dr. S.T., an

IPN-approved evaluator.

Respondent provided

a

urine sample for.drug screening.

The

sample was positive for aiprazoram, Tramadol, ethyl glucuronide and ethyr

sulfate. Respondent refused to allow additional testing of her blood or hair. 8.

anxiety.

Alprazolam is a benzodiazepine and

According to

alprazolam is

a

Section

893.03(4),

is,

'prescribed to treat

FlOrida

Statutes

Schedule IV controlled substance that has

a

low potential

for abuse relative to the substances in Schedule TIfand has Department of Health v. Case No. 2013-07511

a

Leigh Munoz, RN.

(2012),

a

currently 2

accepted medical use in treatment in the United States.

le

Abuse of

aiprazolam may lead to limited physical or psychological dependence

relative to the substances in 9.

III.

Tramadol, commonly known by the, brand name Ultram, is an

oploid class medication prescribed to treat pain.

drug, but not

a

Tramadol is

a

legend

controlled substance. Tramadol, like all opiold class drugs,

can affect mental alertness, is subject to abuse andcan be habit forming. 10.

Ethyl glucuronide and ethyl sulfate are metabolites of alcohol.

Abuse of alcohol interferes with the brain's communication pathways, can

change mood and behavior, and can disrupt the ability to think clearly and move with coordination. 11.

Dr.

S.T diagnosed Respondent with acute intoxication and at

risk of relapse, along with anxiety disorder, not otherwise specified. Dr. 5.1.

opined that Respondent is not safe to practice nursing., 12.

Dr. 5.1.

recommended that Respondent 'enter, into

evaluation for further assessment

of substance

possible addiction to opiates and sedatives.

a

4-to-7 day

abuse disorder due to

Dr. S.T. also

recommended

that Respondent seek further psychiatric evaluation of her anxiety disorder and headache history. Oepartnient or Health v. Lisa Leigh Munci, Case No. 2013-07511

13.

An

IPN

case

recommendations.

manager informS

Respondent refused to follow

of

Dr.

S.T.'s

through with the

recommendations and requested that IPN close her file. 14.

On or about May 7, 2013, IPN closed RespOndent's file.

15.

Section 464.018(1)(j), Florida Statutes (2012), allows the Board

of Nursing to impose discipline, including suspension, against a licensee for being unable to practice nursing with reasonable skill by reason of illness or use of alcohol, drugs,

other type of material or as 16.

a

safety to patients or chemicals or any

result of any mental or physical condition.

Respondent violated Section

Florida

(2012), by being unable to practice nursing with reasOnable skill and safety to patients due to her use of alcohol, other controllechsubstances or legend

drugs, and an anxiety disorder. 17.

Based

on

the

foregoing,

Responderjt

464.018(1)(j), Florida Statutes (2012), by being

violated

Section

to practice nursing

with reasonable skill and safety to patients by reasqn of illness or use of alcohol, drugs, narcotics or chemicals or any othertype of material or as

a

result of any mental or physical condition.

ment201.3-075U of Health Case No.

v. Lisa Leigh Munoz

RN.

4

WHEREFORE, the Petitioner respectfully requethts that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of

placement of the Respondent on probation,

ve

a

reprimand,

action, refund of

fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNEDthjs

dayof John H. Armstrong, MD, State Surgeon Generat. Secretary of Health

FACS

Renee C. Harkins Assistant General Counsel Fla. BarNo, 089054 FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK DATE

O

12013

PCP: PCP Members:

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL Telephone: (850) 245-4444 ext 8228 Facsimile: (850)245-4652 Email: Renee [email protected] us

55

July 30, 2313 Claydell Home and Jody Newman

Department of Health v. Lisa Leigh Mono; RN. Case No. 2013-07511

5

NOTICE OF RIGHTS Respondent has the right to request a hearing to be cnnrjucted hi. with Sectior Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine withesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this mailer. Pursuant to

Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution disciplinary matter, which may include attorney hours and of a costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Lisa Leigh Munoz, R.N. Case No. 2013-07511

6

7196 9008 9111 862? 956? TO:Ljsa L. Munoz, RN 4702 NW 80th Road Gainesvflle, Florida 32653 AC

BNlunoz 2013-07511

SENDER: REFERENCE:

PS Form 3800, January 2005

RETURN

.

Fee

Return Receipt Fee

I

Deuvery

Total Postage & Fees

POSTMARK OR DATE

Receipt for

8/12/13

Certified MaiI'

d

No Insurance Coverage Pwvlded lnternctonal Do Not Use

r

—

-

Article Number

_

I

A

Print Clearly)

I

F

7196 9008 9111 8827 9587

?

3. Service Type 4. Restricted 1.

CERTIFIED MAILTM

(&tra Foe)

Article Addressed to:

...

Lisa L. Munoz, RN 4702 NW 80th Road Gainesvi!ie, Florida 32653

0-

01 PS Form 3811, January 2005

—1

C

I.

Rick Scott

a on

To protect piormte & improve the health

Rorida through hthgrated

of all people

stS

Join.

effort

&

14.

Annsbung,

MD, FACS

Surgeon General & Seaetary

Vision: To be

the Healthiest Stats in the Nation

William Snooner

1,

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure files that the Board of Nursing as of

10/2/2013

,

has no evidence of an Election of Rights form or other

responsive pleading requesting a hearing prior to any agency action regarding CASE

NAME: Lisa Leigh Munoz.

CASE NUMBER

2013-07511 which would

affect the Subject's substantial interests or ri hts.

Custodian of Records Florida Board of Nursing

Before me, personally appeared known to me

William SDooner

oersonallv

S

whose identity is

•(type of identification) and who, under,

oath, acknowledges that his/her signature appears above. Sworn to and subscribed this

2

day of

October

2013.

Notarj Public

ELERffipLASKErr

T4

V COkA11SSION

EE 852527

EXPIRES: February 5. 2017

BSedTtn.i HolayPticUrthfiudtTh

ida Department of Health

Office or the GeneS Counsel • 4052 Bald Cypress Way, Bin C-65

Services Unit FL 32399-1701

.com lea!th

IrTER:FtealthyftA

Mission To protect promote & niprove the health of at people in Flortda through integrated effoits. state, ccunCf &

hn H. Annsbong,

-

To be

FACS

sbseswgeonGenernl&seaethry

HEALTH

I

Vision:

,

Governor

tie Healthiest State

in the Nation

AFFIDAVIT

i,

.

Deputy Clerk for the Department

Clerk's Office, hereby certify in my official capacity as custodian for the

Department Clerk's records, that the Department Clerk's Office has not

.

received an Election of Rights form or other responsive pleading, which

requests a hearing prior to any Department action regarding USA LEIGH

MUNOZ, R.N.; Case Number 2013-07511, which would affect the

n

Respondent's substantial interests or rights.

of Record

Department Clerk's Office

STATE OF FLORIDA COUNTY OF LeCfl

Before me, personally appeared is rDersonallv known to me or

whose identity

of

me by

identification) and who, under oath, acknowledges that his/her signature appears above. Sworn

to

and

subscribed

before

me

2013.

ass My Commission Expires:

•

vOmS4gS

&

this

day

of

/

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner, v.

)

CASE NO.

LISA LEIGH MUNOZ, R.N,

Respondent.

2013-07511

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW the

Department of

Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of

a

Final Order assessing costs against the Respondent for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to. salaries and benefits of personnel, costs related to the time snent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

.

.

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $1,534.99, based on the following itemized

statement of costs:

***** Cost to Date Hours F

*****

Costs

1

Compliance:

0.95

1

Sub Total: Expenses to Date:

20.35

$1,534.99

Complaint:

1.00

]

Investigation: Legal:

12.00 6.40] F

Prior Amount: Total Costs to Date:

I

$0.00

$1,534.99

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $854.33 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

in the

amount of $854.33 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $854.33.

3

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared AMIE H. RICE who was sworn and states as follows: 1) My

2)

3)

name is Arnie H. Rice.

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH). I

am the Investigation Manager for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 I

I

Tallahassee, Florida 32399-3275. 4) As Investigation Manager of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases

against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH

case number(s) 2013-07511 (Department of Health v LISA LEIGH MUNOZ, R.N.) are ONE THOUSAND FIVE HUNDRED THIRTYFOUR DOLLARS AND NINETY NINE CENTS ($1,534.99).

for DOH case 2013-07511 (Department of Health v. LISA LEIGH MUNOZ, R.N..) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document.

6) The costs

7) The itemized costs and expenses for DOH case numbers 2012-1 6914 (Department of Health v. LISA LEIGH MUNOZ, R.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

I

of2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Forida 3oard Board of 3oard of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9)

FU

Amie H. Rice, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

HER AFFIANT SAYETH NOT.

Arnie H. Rice, Affiant

State of Florida County of Leon Sworn to and subscribed before me this______ day by Amie H. Rice, who is personally known to me.

,

:S

TOWANDA B. BURNEff Commission # EE 838342 Expires September25, 2016 OOS4

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of 2

2013,

m It

550485.7019

_________________

rage

i

ui

Complaint Cost Summary Complaint Number: 201307511 Subject's Name:

MUNOZ. LISA LEIGH

*****

Cost to Date *****

Hours

'Complaint: jinvestigation:

[

Legid: ICornpliancc: ]

Sub Total: Expenses to i)ate: Prior Amount: Total Costs to Date:

r

1.00

1 1

1

Costs $54.90 $767.76 5680.66

! $31.67

so.ooj

.ooI

1

.11 EXHIBIT

http //mqaapps doh state fi us/IRMO0TIMETRAKICSDETL ASP

9/24/2013

ol

Staff Rate

0.95

Sub Total

1.00

Sub Total

$54.90

$33.33 $33.33 $33.33

1.00

12.00

of Health

Florida

0.50 0.50 0.50 0.50 0.50 0.50

1.00

2.00

1.00

0.50 2.50 0.90 0.10

Sub Total

6127 6127 6127

127

6127 6127 6127 6127 6127 6127 6127 6127 6127

127 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

ESTIGATIVE SERVICES UNIT

1.00

IO7

ICONSUMER SERVICES UNIT

0.50 0.40

HC27 HCI3 HCI3

0.05

ICOMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date 09/24/2013

Medical Quolily Msurance

$767.76

$63.98 $31.99 $159.95 $57.58 $6.40 $63.98 $127.96 $63.98 $31.99 $31.99 $31.99 $31.99 $31.99 $31.99

$54.90

$54.90

—

FOR

06/03/20 13 06/03/2013 06/04/2013 06/05/2013 06/06/20 13 07/17/2013 07/17/2013 07/18/2013 07/18/2013 07/19/2013 07/19/2013

13

05/20/2013 05/20/2013 58 4 4 4 4 4 76 76 58 4 58 6 100 76

78

07/25/2013

$13.33

05/20/2013

123

07/25/2013

531.67

125 35

120I3

201307511

Activity Description

Page I

of 2

I

I

I

-

EXHIBIT

WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION REPORT PREPARATION TRAVELTIME ROUTINE INVESTIGATIVE WORK TRAVELTIME SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTiCE TO CEASE REPORTPREPARATION

IGATIVE

TRAVEL TIME

INITIALREVIEWANDANALYSISOFCOMPLAINT

TELEPHONE CALLS AUDIT FILE

ICENSESTATUSCHANGE

USE ONLY

Activity Code

$L67

Activity Date

$16.67

Cost

Complaint

Time Tracking System Itemized Cost by Complaint

x * C 0 N F ID E N T IA L

ol

Florida Department of Health

Total Cost

6.40

0.60

1.50

0.50

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35

HLLIOOB ULLIOOB ULLIOOB

$106.35

1.50

0.70 0.40

1.20

Sub Total

Staff Rate

SERVICES UNIT

ILLIOOB

OR

IOOB

J

ION

Staff Code Activity Hours

Report Date 09/24/2013

J'V%

Medical Ouclily Asstrance

$1,534.99

$680.66

$63.81

$42.54 $127.62 $53.18 $159.53

$74.45

$159.53

Cost

28 89 89

201307511

Activity Description

INT —

PROBABLECAUSEPREPARATION PROBABLECAUSEPREPARATION CONTACT WITH WITNESSES

ESO/ERO

ESO/ERO ESO/ERO

- FOR INTERNAL USE ONLY

113

81

07/05/2013 07/29/2013 07/30/2013 07/30/2013

81

81

Activity Code

07/02/2013

06/27/2013 07/01/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

*** CON F IDE N TI AL

itemizedcost

Page 2 of 2

I

Aniount

Date

Total Expenses

SubTotal

Expense

Expense

09/24/20 13

Florida Department of Health

Staff Code

Report Date:

Medical Quality ttsstronce

Expense Code Description

- EOR INTERNAL USE ONLY -

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

***CONFIDENTJAL***

1

oft

itemizedexpense

Page

Waiting on a Signed PCP Memo

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

DOH INVESTIGATIVE REP

,i(T

NUMBER 201 3-07511

TABLE OF CONTENTS

I.

II. III.

:

INVESTIGATIVE REPORT COVER

1

TABLE OF CONTENTS

2-3

INVESTIGATIVE DETAILS Case Summary

4

Summary of Exhibits / Records / Documents

4

Interviews!

Julie Samples (witness)

5.

Lisa Leigh Munoz (subject)

6-7

Investigator Notes

7

IV. EXHIBITS

*

1.

Case Summary and attachments

*

2

Copy of Notification letter, dated 05/20/2013

*

3 Status 30 letter, dated 05/28/2013

*

4 IPN program status request letter dated, 05/29/2013

44-45

*

5 IPN program status response received 05/29/2013

46-47

*

6 Written response form MUNOZ, dated 05/24/2013

48-51

*

7 Authorization for Release of Patient Information completed by MUNOZ

*

8. Urine Drug Screen results

8-41

42 43

for MUNOZ from IMT. Verified date, 02/19/2013

Page 2

52

53-54

DOH INVESTIGATIVE REPCJtI.T

CASe NUMBER: 2013-07511

*

9. Documents concerning Dr Scott

*

10. Email transmission dated, 03/14/2013 from Bambi BAILEY to SAMPLES

*

EXHIBITS CONTAIN INFORMATION WHICH IDENTIFIES PATIENT(S) BY NAME AND ARE SEALED PURSUANT TO SECTION 4.56.057(10)(a), FLORIDA STATUTES

TEITELBAUM provided by MUNOZ

55-81

82-83

** THESE RECORDS ARE SEALED PURSUANT TO SECTION 456.057(10)(a), FLORIDA STATUTES AND COPIES OF SAME ARE NOT MAINTAINED IN THE ALACHUA

INVESTIGATIVE OFFICE THIS EXHIBIT CONTAINS CONFIDENTIAL RECORDS CONCERNING REPORTS OF ABUSE, NEGLECT OR EXPLOITATION OF THE VULNERABLE ADULT, INCLUDING REPORTS MADE TO THE CENTRAL ABUSE HOTLINE, AND IS SEALED PURSUANT TO SECTION 41 5.107(1), FLORIDA STATUTES

Page 3

DOH INVESTIGATiVE REPÜRT

:

CAbE NUMBER: 2013-07511

INVESTIGATIVE DETAIL SU1VWATW

th

On 11/08/2012 The Florida Department of Consumer Services Unit received a letter and memorandum submitted by the INTERVENTION PROJECT FOR NURSES (IPN) regarding MUNOZ. It was reported that MUNOZ's file had been closed effective 05/07/2013 due to her request. According to IPN, MUNOZ refused in-patient evaluation and a second opinion evaluation. MUNOZ had been reported by her employer for falling asleep on the job and a number of irregularities with her

medication administration, impairment and diversion. SUMMARY OF EXHIBITS I RECORDS I DOCUMENTS Exhibit #1 is the Case Summary and attachments received by the Florida Department of Health Consumer Services Unit on 05/20/2013.

Exhibit #2 is the notification letter dated 05/20/2013. Investigator KNEZEVICH hand delivered this letter to MUNOZs home on 05/20/2013. Exhibit #3 is a Status 30 letter sent to IPN on 05/28/2013. Exhibit #4 is a program status request letter sent to IPN on 05129/2013. Exhibit #5 is the IPN program response received on 05/29/2013. Exhibit #6 is a written response dated, 05/24/2013 submitted by MUNOZ. Exhibit #7 is an Authorization for Release of Patient Information provided by MUNOZ on 05/29/2013.

Exhibit #8 is a Urine Drug Screen showing negative results provided by North Florida Regional Healthcare (from IMT). This drug screen was dated, 02/07/2013 and verified on 02/19/2013. This documents was provided to Investigator KNEZEVICH on 06/04/2013. Exhibit #9 is various documents concerning Dr Scott TEITELBAUM provided by MUNOZ on 05/29/2013.

's

Exhibit #10 is an email correspondence from Bambi BAILEY to SAMPLES dated, 03/14/2013 documenting involvement in the discharge process of MUNOZ.

Page 4

DOH INVESTIGATIVE REPIJRT

STATEMENT/INTERVIEW OF LISA LEIGH MUNOZI RN RN 9340085

th

)

NUMBER: 2013-07511

4702 NW Road Gainesville, FL 32653 (C) 352-262-4657

or

MUNOZ's provided a written statement dated, 05/24/2013 (Exhibit #6). MUNOZ was also interviewed by KNEZEVICI-I at the Alachua ISU office on 05/29/2013. In her statement and during the interview, MUNOZ denied any allegation of substance abuse or impairment. MUNOZ stated she feels she was singled out and targeted by the hospital administrative staff after voiced concerns about increasingly burgeoning problems in the unit she was assigned, MUNOZ stated she had received excellent marks on her evaluation one month prior to this incident taking place. After voicing the concerns, MUNJOZ was approached by the interim unit manager, Beth RICHMAN who disciplined MUNOZ for her scanning percentages being too low. MUNOZ attributed this to faulty equipment, which she had advised her supervisors about previously. MUNOZ advised she was given a urine drug screen following this, which was negative. MUNOZ stated she was advised the process of evaluating the urine drug screen would take three days. It wasn't until approximately thirty days later that MUNOZ received the negative results. MUNOZ advised on her last night at North Florida Regional Healthcare, she had contacted the dayshift charge nurse and attempted to call in sick. MUNOZ was told she could not do so, because she had no personal leave time due to using it all during her recent 30 day hiatus. MUNOZ stated she came into work that night despite being ill, taking medication and being under a doctor's care. MUNOZ stated after her shift she was contacted by hospital administrative personnel, her person and belongings searched and ordered to take another urine drug screen. MUNOZ was also questioned about her scanning procedures, which she said were at 96 %. MUNOZ said the medication her supervisors claimed were missing were not found on her person or in the urine drug screen. MUNOZ stated the urine drug screen was again negative for any type of substance other than those she has a valid prescription for.

MUNOZ was then referred to IPN and went for an evaluation with Dr Scott TEITELBAUM at the University of Florida, Florida Recovery Center. MUNOZ advised she went for the initial evaluation and again provided a urine drug screen which was negative for any of the substance tested for other than those for which she has a legitimate prescription. MUNOZ stated TEITELBAUM later requested a second drug screen, this time wanting a sample of her hair and blood. MUNOZ stated she refused this test due to the cost involved and the fact she had already spent over five hundred dollars on a drug screen that was negative. TEITELBAUM recommended a 4 to 7 day in- house treatment evaluation, which MUNOZ advised she did not agree was necessary. On 06/06/2013, MUNOZ was asked to about the email provided to SAMPLES from BAILEY dated, 03/14/2013. MUNOZ advised on the date in question, all of her belongings had been taken prior to Page 6

DOM INVESTIGATIVE

cAbth NUMBER: 2013-07511

being asked to submit to the urine drug screen. MUNOZ stated she was asked to read the Informed Consent form without her glasses, causing her to have to squint and look through one eye. MUNOZ also stated she did act disheveled and "like hell" because she had worked all night and was ill.

INVESTIGATOR NOTES MUNOZ also conducted her own research into Dr TEITELBAUM. MUNOZ provided several internet survey results and rating results casting a negative light on TEITLEBAUM. MUNOZ also stated TEITELBAUM suffered from drug and alcohol addiction for dose to 15 years and had his license to practice medicine in the State of Connecticut revoked in 1997. MUNOZ questioned TEITELBAUM's ability to evaluate any practitioner or person for addiction when he himself has suffered from substance abuse issues during his lifetime. Copies of these search results and the Connecticut Medical Examination Board Memorandum of Decision is included as Exhibit #9. is unknown if the email from BAILEY to SAMPLES was included in the documentation filed when MUNOZ was terminated from her employment. It

IPN program status request form is Exhibit #4. IPN program status response is Exhibit #5.

Page 7

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

a

p

H—H

'S

I C

0 n a 0 0

C

0

0

7

Mission: ofaPpeoinFioddatghthtegrated

Fluri HAITFI Vision: To be the

,

Rick Scott

To protect, promote & improve the health

John H. Armstrong,

Governor

FACt

State Surgeon General & Secretary

Heaithlest State in the Nation

NOTICE OF HEARING November 8, 2013 Case#: 201307814 To:

STEPHANIE THERESA RUTHERFORD 1336 CEYLON DR GULF BREEZE, FL 32563, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201307814

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441 954—427-7700

.

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of H.aith DMsion of Medical Quality Assurance • Board of Nursing 4052 Batd Cypress Way, Bin 0-02 • Tallahassee, FL 32399-3252 PHONE: 850/ 245-4125 • FAX 850/ 245-4172

www.FiorldasHealth.gov ITTER:HeafthyFLA FACEBOOK:FLDeparurentolHeatth YOUTUBE: fldoh

_____________

Rick Scoff

Mission:

Governor

To protect, promote & improve the health through integrated of all people in state, county & community efforts.

ida

John H. Armstrong, MD, FACS State Surgeon General & Seottary

H EALTH Vision: To be the Healthiest State

in

the Nathn

MEMORANDUM TO: FROM: RE: SUBJECT:

DATE:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Renee Narkins, Assistant General Counsel

taut

Determination of Waiver DON v. Stephanie Theresa Rutherford, R.N. DON Case Number 2013-07814

October 4, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of Record:

Enforcement Address:

Stephanie Theresa Rutherford, R.N. 1336 Ceylon Drive Gulf Breeze, FL 32563 1336 Ceylon Drive Gulf Breeze, FL 32563

Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s):

9239337

Prior Discipline: Probable Cause Panel:

None

Subject's Attorney:

Pro Se

Complainant/Address:

Intervention Project for Nurses Post Office Box 49130 Jacksonville Beach, FL 32240

Florida Department of Health Office of the General Counsel • Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1 701

Express mail address: 2585 Merthants Row— Suite 105 PHONE: • FAX 8501245.4683

.4444

Rank:

RN

332044

11/29/2005 None No

None

Count 1: Section 464.018(1)0), F.S. (2012) Count 2: Section 456.072(1)(hh), F.S. (2012)

July 30, 2013 Home & Newman

lealth

www.FlorldasHealth.com TWIUER:HealthyFLA VOUTUBE: Odoh

STATE OF FLORIDA

BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, CASE NO.

v.

2013-07814

STEPHANIE THERESA RUTHERFORD, R.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on

a

date and time that has been determined

and noticed by the Board. As grounds therefore Petitioner states: 1.

An Administrative Complaint was filed against Respondent on

August 1, 2013. A copy of said Administrative Complaint is attached hereto as Petitioner's Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on:

August 21, 2013 (7196 9008 9111 8827 9570). A copy of the

certified mail receipt is attached as Petitioner's Exhibit B. 3.

Rule

28-106.111(2), Florida Administrative Code,

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the dedsion. 4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C & D. 6.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

7.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

ReneeHar

s Assistant General Counsel Fla. Bar No. 089054 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 I

Telephone: (850) 245-4640 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of the above and day of mail this tjas been provided by U.S. 2013, to: Stephanie 1. Rutheitrd, i336 Drive, Gulf Breeze, FL 32563. /7 1

s Assistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH. I

01

PETITION ER, CASE NO.

2013-07814

STEPHANIE THERESA RUTHERFORD, RN. RESPONDENT.

I ADMINISTRATIVE COMPLAINT Petitioqer, Department of Health

by and through its

undersigned counsel, files this Administrative Complaint before the Board of Nursing against Respondent, Stephanie Theresa Rutherford, and in support thereof afleges:

Petitioner is the state agency charged with regulating the practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 1.

456, Florida Statutes; and Chapter 464, Florida Statutes (2012). 2.

At

all

times

material

to

this Administrative

thmplaint,

Respondent was a Registered Nurse within the state of Florida, having been issued license number RN 9239337.

3.

Respondent's address of record is 1336 Ceylon Drive, Gulf

Breeze, Florida 32563. 4.

On or about November

ii,

Intervention Project for Nurses C'IPN").

2013 Respbrident contacted the IPN is the impaired practitioner

program for the Board of Nursing, pursuant to Section 456.076, Florida Statutes (2012). IPN monitors the evaluation, care and treatment of impaired nurses. IPN oversees random drug screens and provides for the exchange of information between treatment providers, evaluators and the Department for the protection of the public. 5.

In December 2012, Respondent

substance abuse/mental health 6.

a

two year dual

agreement with IPN.

On or about March 15, 2013 and AprU

., 2013, Respondent.

underwent urine toxicology screenings, which returhedipositive for alcohol. 7.

Based

upon

Respondent's

relapse,. IPN

mandated

Respondent refrain from the practice of nursing and, submit to

a

that

second

evaluation to determine whether Respondent was safe to practice nursing. 8.

On or about April 24, 2013, Dr.

Respondent

pursuant to the requirements of her IPN contract..

p.r.

3.!. diagnosed

Respondent with anxiety disorder, not otherwise. specified, and alcohol Department of Health v. Stephanie Theresa Case No.

20L307814

PJ4.

..

2

abuse.

Dr. 3.1.

:.,.Yt-.

determined that Respondent was not safe to practice

nursing. 9.

On or about April 26, 2013, an IPN case manager contacted

Respondent to inform her of the requirement that the submit for

a

drug

screening of her blood on April 29, 2013. 10.

Respondent did not submit for a drug screening as directed.

Respondent requested on or about April 29, 2013, that her IPN monitoring

contract be terminated due to her inability to 11.

contract.

participate in IPN.

Respondent did not rescind her request to €erminate her

1PM

Therefore, IPN closed Respondent's qle on or about May 14,

2013.

COUNTI 12.

Section 464.018(1)0), Florida Statutes (2012), subjects

registered nurse to discipline for

b]eing

unable

a

nursing with

skill and safety to patients by reason drugs, narcotics or chemicals or any other type of material or as

of alcohol, a

result of

any mental or physical condition." 13.

Respondent violated Section 464.018(1)U), Florida Statutes

(2012), by being unable to practice nursing with reasonable skill and safety Depaitnent or Health v. Stephanie Theresa Rutherford, R.N. Case No.

3

to patients due to her use of alcohol and benzodiäzepines, and/or

as a

result of her mental or physical condition. 14.

Based

the

on

foregoing,

Respondent

violated

Section

464.018(1)(fl, Florida Statutes (2012), by being unable to practice nursing with reasonable skill and safety to patients by reasdn of illness or use of alcohol, drugs, narcotics or chemicals or any other

of material or

as a

result of any mental or physical condition.

COUNT 15.

II

Section 456.072(1)(hh), Florida Statutes (2312), provides that

being terminated from

a

treatment program for impaired practitioners,

which is overseen by an

practitioner consultant as described

in

Section 456.076, Florida Statutes (2012), for faiftwè to comply without

good cause, with the terms of the monitoring

treatment contract

entered into by the licensee, or for not successfully completing any drug

treatment

or

alcohol

treatment

program,

constitutes

-

grounds

for

disciplinary action. 16.

Respondent violated Section 456.072(1)(hh), Florida

(2012), by being terminated from IPN due to the Respondent failing to comply with the terms of her IPN monitoring Department or Heafti, v. Stephanie Theresa Rutherford, RN. No. 2013•a7814

Case

17.

Based

on

the

foregoing,

Respondent

violated

Section

456.072(1)(hh), Florida Statutes (2012), by being terminated from a treatment program for impaired Practitioners, which is overseen by an impaired practitioner consultant as described in Section 456.076, Florida

Statutes (2012), for failure to comply without good cause, with the terms of the monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug treatment or alcohol treatment program. WHEREFORE, the Pefitioner respectfully requests that the Board of

Nursing enter an order imposing one or more

of;tIiefollowing penalties:

permanent revocation or suspension of

restriction of

practice, imposition of an administrative fine, issuance of

placement of the Respondent on probation,

a

reprimand,

action, refund of

fees billed or collected, remedial education and/or anyother relief that the Board deems appropriate.

(Signatures appear on the following

Deparfrnent of Healthy. Stephanie Theresa Rutherford, RN.

Case No. 2013-OThM

5

•

SIGNED

this 31

_ ,

day of

K.

.

rmstrong,

State Surgeon

2013.

FACS

General

Secretary of Health

4

FILED DEPARTMENT OF HEALTH CLERK AngilSanters DATE AUG 0 12013

PCP: PCP Members:

Re ee C. HarkMs Assistant General Counsel Fla. Bar No. 089054 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin C-65

Tallahassee FL 32399-3265 Telephone: (850) 245-4444 ext 8228 Facsimile: (850) 245-4662 Email: [email protected]

July 30, 2013 Claydell Home and Jody Newman.

Department of Health v. Stephanie Theresa Rutherford, Case P4o. 2013-07814

•

6

NOTICE OFRIGHTS

the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by Counsel or other qualified representhtjve, to present evidence and to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinaiy matter, which may on the Respondent in addition include attorney hours and costs, to any other discipline imposed.

Department of Health v, Stephanie Theresa Rutherford, R.N. Case No. 2013-07514 7

___________________ ________________________

719k

9111 M.#? 95?!!

TO:Stephaflje 1. Rutherford,

RN

1336 Ceylon Dr. Gulf Breeze, Florida 32563 AC

Rutherford 2013-07814 SENDER: REFERENCE:

PS Form SeDO. January 2005

Postage

RETURN RECEIPT SERVICE

certified Fee Return Receipt Fee

•

Restricted. Delivery

Total Postage & Fees

•

POSTMARK OR DATE

Receipt for Certified Mair

8/12/13

No Insurance Coverage Provided Do Not U.. be International Meg

. 2. ArtIcle Number A. Received by (Hease Print Clearly)

lilt I

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Dale of Delivery

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7196 9008 9111 8827 9570

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delivery address YES, enter delivery

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CERTIPIED MAILIM

4.

Restiicted Delivery?

1.

Article Addressed to:

(aim

Fee)

lives

_s 20 13-07814 Harkins

Stephanie T. Rutherford, RN 1336 Ceylop Dr. Gulf Breeze, Florida 32563

C'

F

PS Form 3811, January 2005

Domestic Return Receipt

EXHIBIT

Mission: To pmlect, proinc4e My

&

&

Rick

improve the heat,

flflltf

aS

John Ii. *nnstyop,g, MD Sate Surgeon General &

I,

William Sooorier

t FACS

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure files that the Board of Nursing as of 10/4/2013 has no evidence of an Election of Rights form or other responsive pleading requesting a hearing prior to any agency action regarding CASE

NAME: Stephanie

Theresa Rutherford, RN,,

CASE NUMBER: 2013-

07814 which would affect the Subject's substantial interests or rights. odian of Records Florida Board of Nursing C

Before me, personally appeared

known to me

William

pooner

whose identity

is

(type of identification) and who, under, oath,

acknowledges that his/her signature appears above. Sworn to and subscribed this_j.. day of

October

,

2013.

Notary Public

%s -

WlTh&tiIS$JQN$EE852527 BWIRES:Febnmiys 2017

Florida D.psrtinsnt of Haalth Offs of the General

Pmseajbon Unit 4052 Bald Cypress Way, Sin C-OS - Tallahassee, FL 32399-1701

www.FloddasHSalth.ccfli

•

I

lWtTTERhlealthyftA FACEBOOKfWeparhrentefi4aaith

Rick Scott

Mission: To protect. proimte

&

Governor

.

improve the health

Jobs H. *nnstmng,

D, FACt

HEALTH Vision: Tote the HealtSst State in the Nelion

AFFIDAVIT

9)rikCs

I,

,

Deputy Clerk for the Department

Clerk's Office, hereby certify in my official capacity as custodian for the

Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which

requests a hearing prior to any Department action regarding STEPHANIE

THERESA RUTHERFORD, RN.; Case Number 2013-07814, which would affect the Respondent's substantial interests or rights.

of Record

Custodi

Department Clerk's Office STATE OF FLORIDA COUNTY OF

Leon

Before me, personally appeared is nersonally known

whose identity

-

to me or known to me by

of

identification) and who, under oath, acknowledges that his/her signature appears above. subscilbed

before

me

this

day

of

l My Commission Expires:

Nay

.

ISa of 14.

0

Eqfls 11ev 0. Coimsus, aft 044542

My Corns.

_____________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO.

v.

2013-07814

STEPHANIE THERESA RUTHERFORD, R.N.,

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW the

Department

of Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of Final Order assessing costs against the Respondent

a

for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

wilt take up for consideration the above-styled disciptinary action and will

enter

a Final

2.

Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to. salaries and benefits of personnel. costs related to the time spent by the attorney and other personnel working on the case. and any other expenses incurred by the department for the case. The board. or the department when there is no board. shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

.

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $2,474.01, based on the following itemized

statement of costs: *****CosttoDate***** (

Complaint: [ Investigation: Legal:

i

[

Compliance: Sub Total: Expenses to Date: Prior Amount:

Total Costs to Date:

Hours

1 1

Costs

I

$38.43

1 0.051

]

1

I

1.671

$2,474.011

30.051

00 . [

,',

$0.00

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $1,070.15 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $1,070.15 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline

imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter

a

Final Order assessing costs against the Respondent in the

amount of $1,070.15.

3

of

DATED this

0

,

2013.

Respectful!y Suhm!tted,

John

Armstrong, MD, FACS State Surgeon ?eneral and Secretary of Health H.

HaridiSs Assistant General Counsel Fla. Bar No.

089054

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: Renee. [email protected]

CERTIFICATE OF SERVICE I HEREBY CERTIFY

that

a

true and correct copy of the foregoing

Motion to Assess Costs has been furnished via U.S. mail to Stephanie

Theresa Rutherford, R.N., at 1336 Ceylon Drive, Gulf Breeze, FL 32563, on

this

day of

Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared AMIE H. RICE who was sworn and states as follows: 1) My

2)

name is Arnie H. Rice.

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at I

the Florida Department of Health (DOH). 3)

1

am the Investigation Manager for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As Investigation Manager of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases

against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-07814 (Department of Health v Stephanie

Theresa Rutherford, R.N.) are TWO THOUSAND FOUR HUNDRED SEVENTY- FOUR DOLLARS AND ONE CENT ($2,474.01). 6) The

costs for DOH case 2013-07814(Department of Health v. Stephanie Theresa Rutherford, R.N.) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document.

7) The itemized costs and expenses for DOH case numbers 2013-07814 (Department of Health v. Stephanie Theresa Rutherford, RN.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

I

12

,

and A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of F!or!da Board of 9oard of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Amie H. Rice, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of her knowledge and belief. FUR

R

AFFIANT SAYETH NOT.

State of Florida County of Leon

Sworn to and subscribed before me by Amie H. Rice, who is personally known to me.

T

U'

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

of

,

2013,

Page

1

of

1

Complaint Cost Summary Complaint Number: 201307814 Subject's •N

am e:

RUTHERFORD, STEPHANIE THERESA Cost to Date *****

[

Hours

Complaint:

0.701

jinvestigation: Legal:

16.101

I

13.20

Compliance:

[

L

Sub Total: Expenses to Date: Prior Amount: Total Costs to Date:

Costs

0.05

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http://mqaapps.doh.state.fI.us/IRMOOTIMETRAJ(JCSDETL.ASP

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9/24/2013

Stall Rate

0.05

Sub Total

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Sub Total

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0.70 0.80 0.50 0.40 0.30 0.30 0.40 0.30 0.30 0.40 0.30 0.70

1.10 1.00

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Florida Department of Health

8135

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8135

135 135

8135 8135

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8135

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IJNVESTIGATIVE SERVICES UNIT

0.70

HA52

ICONSUMER SERVICES UNIT

0.05

HC27

ICOMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date 09/24/2013

MQA

Medical Quality Assurance

Division ol

$12.80 $38.39 $44.79 $70.38 $63.98 $44.79 $51.18 $31.99 $25.59 $19.19 $19.19 $25.59 $19.19 $19.19 $25.59 $19.19 $44.79

$38.43

$38.43

$1.67

$1.67

Cost

76 4 76 4 4 76 4 76 4

4

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Activity Code

201307814

Activity Description

1

of3

1

I

f

Page

ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE REPORT PREPARATION ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINEINVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK

INITIAL REVIEW AND ANALYSIS OF COMPLAINT

LICENSE STATUS CHANGE

- FOR INTERNAL USE ONLY -

05/28/20 13 05/28/2013 05/29/2013 05/29/2013 05/29/2013 05/30/2013 05/30/2013 05/31/2013 05/31/2013 06/03/20 13 06/04/2013 06/04/2013 06/05/2013 06/05/2013 06/07/2013

/2112013

05/20/2013

05/17/20 13

07/11/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

IDENTJAL***

I

Of

0.40 0.30

1.00

0.90

135 135

B135

8135

Florida Department of Health

Total Cost

13.20

0.40

I-ILLIOOB

Sub Total

1.50

0.20 0.80 2.70 2.30 2.30 0.40 0.90 0.90 0.30 0.50

HLLIOOB

HLLIOOB

OB 00 OB OB OOB

IOOB

HLL83B HLLIOOB

OOB $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

IPROSECUTION SERVICES UNIT

52,474.01

$1,403.86

$53.18 $159.53 $42.54

$31.91

$21.27 $85.08 $287.15 $244.61 $244.61 $42.54 $95.72 $95.72

51,030.05

$63.98 $63.98 $63.98 $63.98 $63.98

16.10

$63.98 $25.59 $19.19 $63.98 $57.58

$63.98

1.10 1.00

Sub Total

$70.38

$63.98

0.80

$51.18 $51.18

Cost

8135 8135 8135 8135

$6198

Staff Rate

-80

Staff Code Activity Hours

Report Date 09/24/2013

tsv&

Medical Quality Asrnrance

4

28 89 89 89 25

81

89

81 81

81

81

25

I

201307814

Activity Description

Page 2

of 3

-

PROBABLECAUSEPREPARATION REVIEW CASE FILE

PROBABLE CAUSE PREPARATION PROBABLECAUSEPREPARATION

iteniizedcost

PREPAREORREVISEADMINISTRATIVECOMPLAINT

REVIEW CASE FILE ESO/ERO ESO/ERO ESO/ERO ESO/ERO PROBABLE CAUSE PREPARATION ESO/ERO

.

.

I

ROUTINE INVESTIGATIVE WORK REPORTPREPARATION IEINVESTIGATIVE WORK REPORTPREPARATION REPORTPREPARATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE REPORT PREPARATION

-- EOR INTERNAL USE ONLY

05/22/2013 06/25/2013 06/25/2013 06/28/2013 06/28/2013 07/01/2013 07/02/2013 07/05/2013 07/15/2013 07/29/2013 07/30/2013 09/13/2013

76 76 6 100 76

06/11/2013

06/11/2013 06/12/2013 07/12/2013 07/12/2013 07/12/2013

4 76

Activity Code

06/10/2013 06/10/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

WWCONFIDENTIAL***

Florida Department of Health

Staff Code Activity Hours

Report Date 09/24/2013

1

Medical Quality Assurance

l ll Rate

Cost

Activity Code

Complaint

- FOR INTERNAL USE ONLY -

Activity Date

CONFIDENTIAL 201307814

Activity Description

Time Tracking System Itemized Cost by Complaint

***

itemizedcost

Page 3

of 3

Total Expenses

SubTotal

Expense Date

09/24/20 13

Florida Department of Health

StaffCode

Report Date:

N4

Medical Qualily Ass,nance

Expense Amount

ExpenseCodeftescription

- FOR INTERNAL USE ONLY -

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

*** CON F ID EN TI AL

1

of

1

temizedexpense

-

Page

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Waiting on a Signed PCP Memo

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

STATE OF FLORIDA

DEPARTMENTOF HEALTH INVESTIGATIVE REPORT Office: Area Subject:

Pensacola

Date of Case: 5/15/13 Case Number: RN 2013-07814 Source: STEPHANIE THERESA RUTHERFORD, RN INTERVENTION PROJECT FOR NURSES (IPN) 1336 Ceylon Dr. Post Office Box 49130 Gulf Breeze, FL 32563 Jacksonville Beach, FL 32240 I,

(850) 384-4447

(904) 270-1620

License #: Profession: Prefix: Board: Report Date: 9239337 REGISTERED NURSE RN NURSING 6/12/13 Period of Investigation: 5/20/13-6/12/13 Type of Report: FINAL Alleged Violation: FS 456.072(1)(z) Being unable to practice with reasonable skill and safety ... (aa) Testing positive for any drug ... (dd) Violating any provision of this chapter (hh) Being terminated from a treatment program for impaired practitioners FS 456.074(3) The department may issue an emergency order suspending or restricting the license of any health care practitioner as defined in s. 456.001 (4) who tests positive for any drug ... FS 464.018(1)(h) Unprofessional conduct ... U) Being unable to practice nursing with reasonable skill and safety ... (I) Knowingly violating any provision of this part ... (o) Violating provision of this chapter ... FAC 64B9-8.005(12) Testing positive for any drugs Synopsis: This investigation is predicated upon receipt of a complaint (Case Summary and Attachments) EXHIBIT submitted by IPN in regard to RUTHERFORD reporting that file has been closed effective 5/14/13 due to noncompliance with monitoring. On .11/2/12, RUTHERFORD was reported to IPN by her employer, Gulf Breeze Hospital (GBH), due to impairment on the job and a screen for Xanax. On 13/1 2, RUTHERFORD was evaluated and assigned diagnoses of AXISJ - anxiety

)

's

disorder, NOS; sedative related disorder, NOS. RUTHERFORD completed the recommended program. RUTHERFORD engaged in a two year dual substance/mental health Monitoring was cleared to resume clinical nursing. On 3/12/13 and 4/15/13, the toxicology screens RUTHERFORD returned positive for EtG/EtS (alcohol). She was refrained from RUTHERFORD engaged in the required IPN evaluation on 4/24/1 3, resulting in A)(lS - alcohol out dependency; anxiety disorder, NOS. On 4/29/1 3, RUTHERFORD failed to provide the test. On 4/30/131 RUTHERFORD requested her Monitoring Agreement be terminated. I

RUTHERFORD was notified of the investigation by letter dated 5/20/13 EXHIBIT copy of the Case Summary and originating documents from Exhibit 1.

)

ajjse, wle

and was provided a

A check of DOH computer licensure records revealed RUTHERFORD is-currently licensed as a REGISTERED NURSE. RUTHERFORD did not provide a resume.

There was no patient involved in this case; therefore, notification was not required.

RUTHERFORD is not known to be represented by an attorney in this matter. On 5/21/13, Investigator LANIER interviewed RUTHERFORD by telephone. RUTHERFORD stated she was noncompliant with IPN because she did not have any more money to participate. RUTHERFORD stated she was not thinking and took a Xanax that belonged to her fiancé, too soon to her work time and fell asleep at work. Related Case: None Investigator/Date: Approved By/Date:

1 -

Ben Lanier, Bl-35, Investigator Distribution: HQIISU

Cathy Main, Investigator

C,

)f

1

MQA

O

DOH INVESTIGATIVE REPORt

CASE NUMBER: RN 201 3-07814

TABLE OF CONTENTS I.

INVESTIGATIVE REPORT COVER

1

II. TABLE OF CONTENTS

2

III. INVESTIGATIVE DETAILS

Summary of Exhibits/Records/Documents

3-5

Interview of ANITA ALVES, Case Manager (Source) Interview of JULIA KLIMETZ, RN, Director of Nursing (DON) (Witness) Interview of PATSY MYERS, RN, CNO (Witness) Interview of REBECCA BURTON, RN, Staff Nurse (Witness) Interview of KAREN TILTON, RN, Supervisor (Witness) Interview/Statement of STEPHANIE THERESA RUTHERFORD, RN (Subject) IV. EXHIBITS * 1.

*

Case Summary & Attachments

6 6

6-7

5

9-126

2. Copy of Notification Letter dated 5/20/13 with 3.

5

5-6

losures

127-131

Subpoena Duces Tecum A-0080931 directed to ROSEMARY STONER, Human Resources Director, GBH, for a copy of employment documentation on

RUTHERFORD *

4. Copy of employment documentation on

132-135

RUTHERFORD from GBH

EXHIBITS CONTAIN INFORMATION WHICH IDENTIFIES PATIENT(S) BY NAME AND ARE SEALED PURSUANT TO FLORIDA STATUTES.

NV FORM

300 7/02

136-241

iON

456.057(10) (a),

Page 2

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 2013-07814

INVESTIGATIVE DETAILS SUMMARY OF EXHIBITSIRECORDS/DOCUMENTS

I is information forwarded by the Consumer Services Unit (CSU) with the complaint. This information consists of a Case Summary, complaint form by IPN, and a copy of RUTHERFORD's IPN file. EXHIBIT 3 is a copy of Subpoena Duces Tecum A-0080931 (and supporting affidavit) directed to ROSEMARY STONER, Human Resources Director, GBH, for a copy of employment documentation on RUTHERFORD, with a Certification of Completeness of Records Form. EXHIBIT 4 is a copy of employment documentation on RUTHERFORD delivered on 6/7/13 by TERESA KIRKLAND to the Pensacola ISU office, with a completed Certification of Completeness of Records form. The employment documentation includes the following: • Notice of Disciplinary Action Employee Personnel Record signed and dated 11/5/12 by RUTHERFORD. RUTHERFORD's employment was terminated effective 10/26/12 for violating the drug free policy by using medication prescribed to her fiancé (p. 143). RUTHERFORD was referred to IPN. The additional comments noted RUTHERFORD climbed in bed with a patient and then said she was kidding. • Chain of custody noting a specimen was taken from RUTHERFORD on 10/26/12 which screened positive, noting "took fiance's Xanax for sleep." (p. 144) • Notice of Disciplinary Action Employee Personnel Record signed and dated 10/26/12 noting RUTHERFORD's employment was suspended on 10/26/13 pending the results of the reasonable cause drug screen. • Statement signed and dated 10/26/12 by DEBRA HAUPT, RN (RN 9162697), noting that RUTHERFORD was standing at the Accudose sign-in computer swaying (p. 146). When HAUPT approached her, RUTHERFORD said, "I can't do this." RUTHERFORD was pushing keys over and over and her eyes were drooped, almost closed: HAUPT told her to swipe her badge and she said she "just couldn't." RUTHERFORD continued to try to login unsuccessfully. She became upset and said, "Why can't do this?" At this 0infRUTHERFORD's eyes were closed and she swayed. HAUPT asked her if she was lright and RUTHERFORD said she was just a little tired. HAUPT looked up and saw RUTHERFORD's head bowed, eyes closed, and she was very still. At this point, HAUPT suspected impairment and went to KAREN TILTON, RN (RN 9250662), to voice her strong concern for RUTHERFORD's ability to continue. • Statement signed and dated 10/26/12 by REBECCA BURTON, RN (RN 9314147), noting on 10/25/12 she saw RUTHERFORD enter a patient's room (p. 147). RUTHERFORD stumbling around in the room and fell into the patient's bed after telling the patient that she had been sick before entering the room. RUTHERFORD told the patient she was kidding and just fooling around. • Statement signed and dated 10/26/12 by DORIS THOMPSON, RN (RN 722512), noting that on 10/25/12 she had walked up to the nurse's station and found a mess on the floor in front of a sink with foot prints beside the Diebold (p. 148). There was a red substance, either blood or Robitussin, spread thinly on the floor. THOMPSON asked about it and RUTHERFORD jumped out of her seat saying, "Oh, that's my blood. I've been draining a cyst occasionally for about six months." RUTHERFORD continued, saying, "It's a bad night, trying to get use to my new glasses. ""I'm 45 years old and wearing glasses." i've thrown-up. "Just an awful night." THOMPSON was amazed at the fact that RUTHERFORD bled on the floor and did not seem to know it. RUTHERFORD cleaned most of it up I

LNV FORM 300 7/02

Paae 3

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 2013-07814

and THOMPSON asked her where she was bleeding from. RUTHERFORD showed her the inside of her left wrist where there was a large puncture area about over her radial artery. THOMPSON told her she needed to clean it up and apply a band-aid. RUTHERFORD said, "I'm a nurse," and indicated that THOMPSON should proceed with her own business. THOMPSON told her that her left hand was swollen and noticed that the back of her hands were wrinkled as if they were dehydrated. RUTHERFORD stepped close to THOMPSON, in her personal space, and said "At least found have this rare disease." RUTHERFORD tried to pronounce some word and then said, "I found it when had my eyes checked." RUTHERFORD's face had some wrinkles, she appeared ill, and her color was off. THOMPSON usually thought of RUTHERFORD as perky. Later THOMPSON returned to 2 East and RUTHERFORD was attempting to log in on the Diebold. THOMPSON noticed a long list of characters on the user name line. RUTHERFORD had made several attempts and exclaimed a lot about not achieving her goal. THOMPSON asked if she could get the med for her and she said yes and returned to her seat. RUTHERFORD was slightly dry heaving on the way to her seat, and reached for a towel at her station to vomit or "spit-up" in. THOMPSON asked her what med she needed and at first RUTHERFORD said she did not remember and then said a pain med or "whatever 23 gets and probably his 10 o'clock." RUTHERFORD put her head in her hands and did not move. THOMPSON waited a couple minutes, but there was still no response. THOMPSON said, "Maybe you can get someone else to help you." THOMPSON then called her supervisor. Statement signed and dated 10/26/12 by TILTON noting that on 10/25/12 RUTHERFORD came to work very energetic and excited about her new eye glasses (pp. 151-162). Later in the night, HAUPT asked TILTON to observe RUTHERFORD. HAUPT told her that RUTHERFORD was falling asleep/zoning off. TILTON went to talk with RUTHERFORD, but she was in a patient's room. Because of the severe mood swing and because TILTON was familiar with her personally, as a friend, TILTON decided RUTHERFORD should not be working and she felt strongly that she should be given a drug screen. TILTON called her supervisor who advised TILTON not to perform a drug screen because humanresources would need to be involved. TILTON was advised to send RUTHERFORD home; however, TILTONI did not want RUTHERFORD driving. TILTON stated she knew RUTHERFORD's significant other was an alcoholic and would not be able to pick her up. TILTON stated she felt that if she confronted RUTHERFORD that RUTHERFORD would feel that she was being accused of something and that she would go home and kill herself. TILTON received a call from THOMPSON with concerns about RUTHERFORD and TILTON told her that she was on her way to send RUTHERFORD home. Within seconds TILTON was at the nurse's station and RUTHERFORD was at the desk, fairly motionless with her head down. RUTHERFORD stated she was sick and did not know what was wrong but she blamed her new glasses and threw them down. RUTHERFORD looked tired, worn out, her eyes were droopy, and her hands were shaking/trembling. RUTHERFORD had trouble finishing a thought, a sentence, and she was zoning out. TILTON called her husband who agreed to give RUTHERFORD a ride home. TILTON approached RUTHERFORD and told her that she would need to go home because she was sick. RUTHERFORD was worried about losing her job for missing too much work. TILTON tried to quickly gather her things together. When TILTON briefly wSlked away and came back, she did not see RUTHERFORD but was told that she was in a patient's room. TILTON went to the patient's room and saw RUTHERFORD at the sink (presumably) washing her hands, but she had a syringe with her with a needle on it. RUTHERFORD then went over to the patient's PCA, and the machine was off. A glass syringe was on the floor and the plunger component was disassembled. RUTHERFORD turned the PCA on because she repeated the settings were wrong. RUTHERFORD stated several times out loud, "this isn't right." She then used the syringe and inserted the needle into the Dilaudid and said, "I'm trying to get the air out of the I

I

I

•

02

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CASE NUMBER: RN 2013-07814

line." TILTON did not understand what she was doing. RUTHERFORD's hands were shaking terribly and she was sticking a long needle into a email area and TILTON could not figure out why. RUTHERFORD stated again that she was trying to get the air out of the line and asked TILTON, "Haven't you ever done this?" TILTON asked RUTHERFORD to leave the room and said she would take care of it. RUTHERFORD put the syringe in the PCA, shut the door, and locked it, but the machine beeped. RUTHERFORD slumped down and said out loud, "Oh KAREN, I'm so f---ed up." TILTON escorted RUTHERFORD to her husband's car who took her home. TILTON then went to address a patient's concerns regarding RUTHERFORD. The patient told TILTON that RUTHERFORD was drunk and that she did not know they had nurses like that. The patient also said RUTHERFORD told her that she was not feeling well and then said, "I'm so tired, think I'll just jump in bed with you." The patient said RUTHERFORD got in bed with her. Per KLIMETZ, TILTON checked the MedSelect to see what medications were dispensed by RUTHERFORD. RUTHERFORD had only dispensed Crestor for one patient. One patient had the PCA and both were complaining they had asked for medications but were still waiting to get them. TILTON noted that RUTHERFORD did say she was going to give some pain medications to someone, but she could not remember who.

INTERVIEW OF ANITA ALVES, CASE Employment: IPN Post Office Box 49130 Jacksonville Beach, FL 32240 (904) 270-1620

I

On 5/29/13, Investigator LANIER attempted to telephone ALVES; however, she was not available and a voicemail message was left requesting a return call. On the same date, ALVES returned the call and stated she had not had any contact or updates since she closed RUTHERFORD's file.

INTERVIEW OF JULIA KLIMETZ, RN, DON (RN Employment: GBH 1110 Gulf Breeze Parkway Gulf Breeze, FL 32561 (850) 934-2000 (w) (850) 450-8630 (c)

On 5/21/13, investigator LANIER attempted to telephone KLIMETZ; however, she was not available and a voicemail message was left requesting a return call. On 5/28/13, Investigator LANIER received a voicemail message from KLIMETZ requesting a return call. On 5/28/13, Investigator LANIER interviewed KLIMETZ by telephone. KLIMETZ stated she sent RUTHERFORD for a drug screen because she was caught falling asleep at work. KLIMETZ stated RUTHERFORD feel asleep at the nurse's station and crawled into bed with a patient. KLIMETZ stated RUTHERFORD did not fall asleep in the patient's bed, but RUTHERFORD told the patient she looked comfortable and that she was going to crawl in bed with her for a nap. KLIMETZ stated RUTHERFORD crawled into the bed, but she did not stay there. KLIMET2 stated that after RUTHERFORD screened positive for the Xanax, she could not produce a prescription for it. KLIMETZ stated RUTHERFORD never offered an excuse as to where she got it. KLIMETZ stated this incident was the only time RUTHERFORD was suspected of being at work impaired. KLIMETZ stated she did not suspect diversion and there were no patient complaints regarding

INVFORM

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:: :

CASE NUMBER: RN 2013-07814

RUTHERFORD's behavior or missing medications. KLIMETZ stated there was an issue regarding a PCA pump but it was addressed at the time. KLIMETZ stated that there was air stuck in the pump and RUTHERFORD tried to get the air out with a syringe, but she was stopped. KLIMETZ stated RUTHERFORD was educated on a better way to get the air out of the pump. KLIMETZ stated RUTHERFORD had worked for them for the past eight years and she was an excellent nurse. stated she knew RUTHERFORD was going through some personal issues because RUTHERFORD's best friend was murdered by a city councilman in Orange

IZ

County.

INTERVIEW OF PATSY MYERS, RN, CNO RN Employment: GBH 1110 Gulf Breeze Parkway Gulf Breeze, FL 32561 (850) 934-2000

On 5/30/13, Investigator LANIER attempted to telephone MYERS; however, she was not available and a message was left with her assistant, "DANIELLE," requesting a return call. On the same date, MYERS returned the. call. MYERS stated she was not really involved in the situation and advised that Investigator LANIER speak with KLIMETZ.

INTERVIEW OF REBECCA BURTON, RN (RN Employment: GBH 1110 Gulf Breeze Parkway Gulf Breeze, FL 32561 (850) 934-2000

On 6/10/13, Investigator LANIER interviewed BURTON by telephone. BURTON informed the statement she provided GBH was true and accurate. BURTON stated she had never seen RUTHERFORD come to work impaired before, but she was obviously impaired on that day. BURTON stated she was not sure what RUTHERFORD was impaired with but she was swaying around a patient's room when she saw her. BURTON stated that RUTHERFORD fell into bed with a patient and then said she was fooling around and got out of the patient's bed.

iEW

OF KAREN TILTON, RN, SUPERVISOR (RN 9250662) Employment: GBH 1110 Gulf Breeze Parkway Gulf Breeze, FL 32561 (850) 934-2000

On 6/10/1 3, Investigator LANIER attempted to telephone TILTON at work; however, staff informed that she was not currently working and they would not say when she was working next. On the date, Investigator LANIER called TILTON at home; however, she was not available and a message was left requesting a return call. On 6/11/13, Investigator LANIER attempted to telephone TILTON at work; however, staff informed she was not working, but the house supervisor stated he would text TILTON with a message to call Investigator LANIER.

me

INV FORM 300 7/02

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On the same date, TILTON returned the call and informed the statement she provided GBH was still accurate. TILTON stated she was asked to put her observations in writing, but that she did not think anyone else would see it. TILTON stated RUTHERFORD was not feeling well that night and she was impaired on Xanax. TILTON felt RUTHERFORD took a Xanax too close to her work time. TILTON stated she had no suspicion of diversion by RUTHERFORD on that night or any other night. TILION stated RUTHERFORD was an excellent nurse and she had never seen her in that condition before. TILTON stated RUTHERFORD was referred to IPN. TILTON stated she thought IPN needed an overhaul because it was very unaffordable.

INVESTIGATOR'S NOTE: On 6/10/13, Investigator LAMER attempted to telephone THOMPSON at work; however, staff informed she was not working. On the same date, Investigator LANIER performed a reverse address search which provided the number (850) 453-4918, but the line was disconnected. On 6/11/13, Investigator LANIER performed an Accurint search which provided the telephone numbers (850) 623-0384 and (850) 455-2902; however, both numbers were disconnected. On 6/11/13, Investigator LANIER attempted to telephone THOMPSON at work; however, she was not available and a message was left requesting a return call. If an interview is obtained with THOMPSON a supplemental report will be forwarded.

:

INVESTIGATOR'S NOTE: On 6/10/13, Investigator LANIER searched COMPAS for HAUPT's telephone number, but there was none. On the same date, Investigator LANIER performed a reverse address search which provided the number (850) 969-1408, but the line was disconnected. On 1/1 3, Investigator LANIER attempted to telephone HAUPT at work; however, she was not available and a message was left requesting a retum call. If an interview i obtained with HAUPT a supplemental report will be forwarded.

1

INTERViEW/STATEMENT OF STEPHANIE THERESA RUTHERFORD, Address of Record: 1336 Ceylon Dr. Gulf Breeze, FL 32563 (850) 384-4447 Employment: Unemployed

.

On 5121/13, Investigator LANIER interviewed RUTHERFORD by telephone. Investigator LANIER informed RUTHERFORD of the allegations and that a letter was sent to her regarding the incident EXHIBIT RUTHERFORD stated she was noncompliant with IPN because she did not have any more money to participate. RUTHERFORD stated she was not thinking and took a Xanax too soon to her workiime and fell asleep at work. RUTHERFORD stated working the night shift also contributed to her sleepiness. RUTHERFORD stated she did not see any patients before she was sent home. RUTHERFORD stated she did not divert the Xanax or any medications. The Xanax was given to her by her fiancé. RUTHERFORD stated she was not taking any medications currently. RUTHERFORD stated she screened positive for alcohol while participating with IPN. RUTHERFORD stated alcohol has never been an issue so she was not sure why she had to abstain from drinking. RUTHERFORD stated she jumped through all of IPN's hoops until she ran out of money. RUTHERFORD stated she did not want to lose her license, but she thought IPN was a scam, Investigator LAMER asked RUTHERFORD to call when she received the notification letter.

INVFORM 300 7/02

Paqe

7

DOH INVESTIGATIVE REPORT

CASE NUMBER: RN 2013-07814

On 5/28/1 3, Investigator LANIER received a voicemail message from RUTHERFORD stating she had received the notification letter EXHIBIT and she had several questions. On the same date, Investigator LANIER returned the call; however, she was not available and a voicemail message was left requesting a return call. On the same date, RUTHERFORD returned the call. RUTHERFORD stated she had questions about the ISU process and Investigator LANIER explained the basic process to her. RUTHERFORD stated all she knew was that she could not afford IPN anymore. RUTHERFORD stated she was currently applying for jobs, but that she had no interviews scheduled.

)

INVFORM 300 7/02

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8

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

No iDccument. ëceived For •

•S

canning/Imaging Image API,

0

,n

Mission: To protect, promote & improve the health of &I in Florida integrated

ick Scott -

John H. Annstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be the

Healthiest State

in the Nation

NOTICE OF HEARING November 8,2013 Case#: 201301256 To:

ALBERTA PERRY 2244 WILTON PARK DRIVE WILTON MANORS, FL 33305, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201301256

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Fiorlda Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 8501245—4125 • FAX 850/245-4172

www.FiorldasH.aith.gov TWi1TER:HeahtiyFLA FAcEBO0K:FLDepartmentoHealth YOLJTUBE: fldoh

Rick Scott

Mission:

l

To protect, promote & improve the health of at in through hilegrated

Governor

John H. Armstrong, MD, FACS

I

State Surgeon General & Secretary

HEALTH Vision: To be

the Healthiest State in the Nation

NOTICE OF HEARING November 8, 2013 Case#: 2013-01256 To:

ALBERTA PERRY 3206 MAHOGANY DRIVE BOYTON BEACH, FL 33436, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-01256

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under

"Place" If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health

-

Division of Medical Quality Assurance' Board of Nursing 4052 Bald Cypress Way, Bin C-02 'Tallahassee, FL 32399-3252 PRONE: FAX 850/245-4172

www.FlorldasHeaith.gov TWITTER:HeallbyFLA FACEBOOK:FLDepartmentolHealth YOUTUBE: fldoh

HEALTH

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Fiodda through integrated state, county & community efforts.

John H. Armstrong, MD, FACS Surgeon General & Secretary

Vision: To be the Healthiest State

in the Nation

MEMORANDUM TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM:

Lauren Leikam, Assistant General Counsel

RE:

Determination of Waiver

SUBJECT:

DOH v. Albert A. Perry, L.P.N. DOH Case Number: 2013-01256

DATE:

V

October 22, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for

final agency action for the December 5, 2013 meeting of the board. The following

information

is

provided in this regard.

Subject:

Albert A. Perry, L.P.N.

Subject's Address of

3206 Mahogany Drive

Record:

Boynton Beach, FL 33436

Enforcement Address:

2244 Wilton Park Drive

Wilton Manors, FL 33305

Subject's License No:

5182381

Licensure File No:

130449

Initial Licensure Date:

5/16/2008

Board Certification:

No

Required to Appear:

No

Current IPN/PRN Contract:

No

Allegation(s):

Violated Section 456.072(1)(q),

Prior Discipline:

None

Florida Department of Health Office of the General Counsel • Proseajflon Services Unit 4052 Bald Cypress Way! Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merthants Row - Suite 105 PHONE: 8501245-4444 • FftX 85012454683

Rank: L.P.N.

F. S.

(2011-2012)

ldasHeaith.com 11TER:HealthyFLA FACE BOO K: FLOepa rUnentofi-lea Ith VOUTUBE: fldoh

Probable Cause Panel:

May31, 2013 Home & Newman

Subject's Attorney:

Pro Se

Complainant/Address:

Department Of Health/Compliance Management Team

LAL/bhh

Florida Department of Health Office of the General Counsel • Prosecufton Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row - Suite 105 PHONE: 850)2454444• FAX 850/245-4683

www.FloridasHealtltcom TWITTER:l-lealthyFLA FACEEOOK:FLoepartmentofl-lealth YOUTUBE: fldch

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, v.

CASE NO.

2013-01256

ALBERT A. PERRY, L.P.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of

Order in the above-styled cause on

a

a Final

date and time that has been determined

and noticed by the Board. As grounds therefore Petitioner states: 1.

An Administrative Complaint was filed against Respondent on June 3,

2013. A copy of said Administrative Complaint is attached hereto as Petitioner's

Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on: September 5, 2013, article

number 7196-9008-9111-9325-8102 and

on June 21, 2013, article number 7196-9008-9111-8826-9168. A copy of the

certified mail receipt is attached as Petitioner's Exhibit 3.

Rule

28-106.111(2),

Florida

B.

Administrative

Code,

provides

in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. •

4.

.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits C & D. 6.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 7.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case wilt be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint.

WHEREFORE, Petitioner respectfully requests that the Board find that Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final

Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State S rgeon General and Secretary of Health

LAUREN A. LEIKAM Assistant General Counsel Fla. Bar No.

0887700

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

fore oing

has

been

provided

a

true and correct copy of the above and by

U.S.

mail

this

2013, to: ALBERT A. PERRY, L.P.N.,

day

of

at 2244

WILTON PARK DRIVE, WILTON MANORS, FLORIDA 33305, and at

3206 MAHOGANY DRIVE, BOYNTO

FLORIDA 33436.

LAUREN A. LEIKAM Assistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

v.

CASE NO.

2013-01256

ALBERT A. PERRY, LP.N. RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Albert A. Perry, LIP.N. and in support

thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes;. Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

a

licensed practical nurse (L.P.N.) within the state of Florida, having been issued license number

PN

5182381.

Respondent's address of record is 2244 Wilton Park Drive,

3.

Wilton Manors, Florida 33305. On or about

4.

Il

6, 2012, the Florida Board

of Nursing issued

a

Final Order in case number 2012-01284

The Final Order required Respondent to pay a fine in the

5.

amount of $250.00, and costs in the amount of $122.00 with thirty (30) days from the date of entry of the Final Order

Respondent failed to pay the fine in the amount of $250.00,

6.

and costs in the amount of $122.00 with thirty (30) days from the date of

entry of the Final Order 7.

The Final Order required Respondent to complete and submit

six (6) hours of General continuing education credits, and two (2) hours of

credits for Prevention of Medical Errors by August 1, 2012. 8.

Respondent failed to complete and submit six (6) hours of

General continuing education credits, and two (2) hours of credits for

Prevention of Medical Errors by August 1, 2012. 9.

Section 456.072(1)(q), Florida Statutes (2011-2012), provides

that violating

Department of Health Case No.: 201301256

a

lawful order of the department or the board, or failing to

v. ftJbM A, Petty, L.P.N.

2

comply with a lawfully issued subpoena of the department constitutes

grounds for discipline. 10.

As set forth above, Respondent violated a lawful order of the

department or the board in one or more of the following ways: a.

By failing to pay the administrative fine in

the amount of

$250.00, and costs in the amount of $122.00 with thirty

(30) days from the date of entry of the Final Order and; b.

By failing to complete and submit six (6) hours

of General

continuing education credits, and two (2) hours of credits

for Prevention of Medical Errors by August 11.

Based

on

the

foregoing,

Respondent

456.072(1)(q), Florida Statutes (2011-2012), by violating

1, 2012.

violated a

Section

lawful order of

the department or board, or failing to comply with a lawfully issued subpoena of the department.

Department of Health v. .4ibert A. Petty, LD.N. Case No: 2013-01256

3

WHEREFORE, the Petitioner respectfully

Nursing enter an order imposing one or more

requests that the

Board of

of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

.

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Lauren A. Leikam Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0088700 (850) 245 - 4444 Telephone (850) 245 - 4683 Facsimile

HEALTH

DEP ARTMENTOF DEPUTY CLERK

CLERK DATE

"

ML PCP Members

Department of Health v. .AJbert Case No.:

201301256

.

Perry, LP.N.

4

NOTICE OF RIGHTS

Respondent

right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. has the

NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, whith may include attorney hours and costs, on the Respondent in addition toany other discipline imposed.

,:

Department of Health v. Albert A. Petty, LP.N. Case

2013-01256

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Heller-Hutchison, Blondell From:

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Subject: U.S. Postal Service Track & Confirm email Restoration -71969008911188269168 This isa post-only message. Please donot respond. blondell heller-hutchison has requested that you receive this restoration information for Track & Confirm as listed below.

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Delivered Available for Pickup Arrival at Unit Processed through USPS Sort Facility Undeliverable as Addressed Depart USPS Sort Facility Processed through USPS Sort Facility Depart USPS Sort Facility Processed through USPS Sort Facility

TALLAHASSEE FL 32399 TALLAHASSEE FL 32399 TALLAHASSEE FL 32301 TALLAHASSEE FL 32301 FORT LAUDERDALE FL 33305 OPA LOCKA FL 33054 OPA LOCKA FL 33054 TALLAHASSEE FL 32301 TALLAHASSEE FL 32301

June June June June June June June

21, 2013 10:36 am 20, 2013 9:42 am 20, 2013 4:49 am 19, 2013 10:25 pm 13, 2013 5:00 pm 13, 2013 12, 2013 9:01

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Rick Scott

Minion:

Governor

To protect, prnmote & improve the health of all people in Florida throu9h integrated state, county & community efforts.

John H. Armstrong, MD, FACS

HEALTH Vision: To be the Healthiest State In the

Naffon

AFFIDAVIT I,

,

State Surgeon General & Seaetary

I

Deputy Clerk for the Department Clerk's Office,

hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding CASE NAME: ALBERT A. PERRY. LP.N.. CASE NUMBER: which would

affect the Respondent's substantial interests or rights.

Custodian f Record Department Clerk's Office Before me, personally appeared

1

R(1(Tk!'S

me by øersonally known (type of

whose identity is known to

and who, under oath, acknowledges that

his/her signature appears above. Sworn to and subscribed before me this 2.2 day of

11

,

Notary

201.

AMY L. CARRA WAY Commission # DO 941628 Expires Januaay 17,2014 Tuy F½,

My Commission Expires:

,

Florida Department of Health Office of the General Counsel • 4052 Bald Cypress Way, Bin C-65

Services Unit

•

FL 32399-1701

PHONE: 850/245-4444 ext 8109 • FAX 850/245-4683

lb

.com weajth

EXHIBIT

TWITTER :HeaithyFLA

I

VOUTUBE: fboh

/

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO.:

v. ALBERT A. PERRY, L.P.N.,

Respondent.

2013-01256

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, by and through undersigned counsel, and moves the Board of Nursing for the entry of a Final Order assessing costs against the Respondent for the investigation and prosecution

of this case

in accordance

with Section 456.072(4), Florida Statutes. As

grounds therefore, the Petitioner states. the following: 1.

At its next regularly scheduled meeting, the Board of Nursing will

take up for consideration the above-styled disciplinary action and will enter Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

a

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case. and any other expenses incurred by the deøartment for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

.

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $376.05, based on the following itemized

statement of costs:

***** Hours

Complaint: Investigation:

j

Legal:

Cost to Date *****

1 1 1

Costs

0.00

Sub Total: lExpenses to Date: prior Amount:

Total Costs to Date:

]

_________________________ [

1 1

l1l j1 $32.94]

I

]

I

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $120.78 as evidenced in the attached affidavit.

(Exhibit A). 4.

Should the Respondent file written objections to the assessment

of costs, within ten (10) days of the date of this motion, specifying the grounds for the objections and the specific elements of the costs to which

the objections are made, the Petitioner requests that the Board determine

the amount of costs to be assessed based upon its consideration of the

affidavit attached as Exhibit A and any timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $120.78 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida

Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $120.78.

3

day of

DATED this

2013.

Respectfully submitted, John H. Armstrong, MD, FACS Stat Surgeon General and Secretary of Health

LAUREN A. LEIKAM Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar No.: 0887700 Telephone: (850) 245-4444 Facsimile: (850) 245-4683. Email: [email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

a

true and correct copy of the foregoing

Motion to Assess Cost has been furnished via U.S. mail to: ALBERT A.

PERRY, L.P.N.,

of 2244 WILTON PARK DRIVE,WILTON MANORS,

FLORIDA 33305, and 3206 MAHOGANY DRIVE, BOYNTON BEACH, FLORIDA 33436, on,

day of

2013.

UREN A. LEIKAM Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows: 1) My

name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs

regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-01256 (Department of Health v. ALBERT A.

PERRY) are THREE HUNDRED SEVENTY-SIX DOLLARS AND FIVE CENTS ($376.05). 6) The costs for DOH case number(s) 2013-01256 (Department of Health v. ALBERT A. PERRY) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case number(s) 201301256 (Department of Health v. ALBERT A. PERRY) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the

T

following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

Iof2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine: Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report)

Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

9) Shane

FURTHER AFFIANT SAYETH NOT.

Share Walters, Affiant State of Florida County of Leon

Sworn to and subscribed before me this_____ day of by Shane Walters, who is personally known to me.

2013,

ItOWERS

Notary Signature

I

p I

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of 2

_

Page

1

of I

Complaint Co st Summary Complaint Number: 291301256

Subject's Name:

PERRY. ALBERT A

***** ] ]

complaint: investigation:

Total: Expenses to Date: Prior Amount: Total Costs to Date:

Esub

Hours 0.601

1.60

Legal:

Compliance:

Cost to Date *****

2.40

F

0.00

4.60

Costs $32.94

1

1 $0.00j

.05I

EXHIBIT

http://mqaapps.doh.state.fl.us/IRMOOTIMETRAKJCSDETL.Asp

10/22/2013

2.40

Sub Total

Florida Department of Health

0.30 0.10

10

HLL97A HLL97A HLL97A

ILL97A

HLL97A

ILL97A

HLL97A HLL97A

ILL97A

$106.35 $106.35 $106.35

106.35

$255.27

$10.64

$31.91

$21.27 $31.91 $53.18 $21.27 $21.27 $42.54 $10.64 $10.64

0.20 0.30 0.50 0.20 0.20 0.40 0.10

FILL97A

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35

$120.78

$32.94 $21.96 $21.96 $43.92

2.20

0.60 0.40 0.40 0.80

Cost

Sub Total

O2

102 IO2 IO2 $54.90 $54.90 $54.90 $54.90

Staff Rate

ICONSUMERSILRVICES UNIT

Staff Code Activity Hours

Report Date

Medical Quality Assurance

Division ol

25 25 28 28 25 36 37 25 36 27

4 76

4

78

Activity Code

Activity Description

INITIALREVIEWANDANALYSISOFCOMPLAINT

201301256

REVIEW MEMORANDUM

REVIEWCASEFILE PREPARATIONORREVISIONOFLETTER

REVIEW LETTER

PREPARATIONORREVISIONOFLETTER

REVIEW CASE FILE

PREPAREORREVISEADMIN1STRATIVECOMPLAINT

IVECOMPLAINT

REVIEW CASE FILE REVIEW CASE FILE

iGATIVE

ROUTINE INVESTiGATIVE WORK ROUTINE WORK REPORT PREPARATION

- FOR INTERNAL USE ONLY -

04/15/2013 04/16/2013 04/16/2013 04/22/2013 06/10/2013 06/10/2013 07/23/2013 07/23/2013 07/30/2013 09/16/2013

01/17/2013 02/19/2013 03/13/2013 04/04/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

IAL***

itemizedcost

Page

I

of2

I

Florida Department of Health

Staff Code Activity Hours

Report Date 10/22/2013

M

OMsion of Quality Assurance

Staff Rate Cost

Activity Code

Complaint

--FOR INTERNAL USE ONLY--

Activity Date

D E NT IAL 201301256

Activity Description

Time Tracking System Itemized Cost by Complaint

CO NF

S

iternizedcost

Page 2 of 2

Total Expenses

SubTotal

Expense Date

10/22/2013

Flodda Department of Health

StafiCode

Report Date:

Medical Quolity Assurance

Dlvhion

Expense

Amount

***

Expense Code Description

Complaint

- FOR INTERNAL USE ONLY -

Expense Code

CON F ID EN TI AL

Time Tracking System Itemized Expense by Complaint

***

1

of!

itemizedexpense

Page

Rick Scott

Mission:

Governor

To protect, promote & Improve the health

John H. Annstrong, MD, FACS

of all people In Fiotida through Integrated & community efforts. state

State Surgeon General & Secretary

HEALTH Vision: To be the Heaithleit State In the Nation

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health —A2-LL

FROM:

Board of Nursing, Central Probable Cause Panel

SUBJECT:

ALBERTA. PERRY, L.P.N.

DATE OF PROBABLE CAUSE MEETING:

CASE NO.: 2013-01256 MAY 31, 2013

This matter was brought before a Probable Cause Panel composed of:

CLAYDELL HORNE and JODY NEWMAN on the date set forth above. The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that:

/

Probable cause exists herein that the Subject violated the following statutes/rules:

,072(1)(q) FS 2011-2012

The panel suggests Imposing the following penalty: Costs, V5F cause does not exist and the case should be closed with the following closure code: lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the following:

PAN EL

OF

Fioulds

D.psrtin.nt of Hsslth

Office of the General Counsel Prosecution Services Unit 4052 Bald Cypress Way, Bin (>85 • Tallahassee, FL 32399-1701 address: 2585 Merthants Row — Suite 105 Express PHONE: 850/245-4444 - FAX 850/245-4683

SING

www.FiorldasH snith coin TWFrrER:HeaithyFl.A FACEBOOK:FweparfrnentoiHeaith YOUTUBE: fldoh

lE

Scott i

G

v

rnor

To protect, promote & improve the health

FIÔtIdä

John H. Annstronv, MD, FAGS

HEALTH State

in The Netior

MEMORANDUM. OF PROBAELE CAUSE PANEL FINDINGS TO:

Department of Health —A2-LL

FROM:

Board of Nursing, Central Probable Cause Panel

SUBJECT:

ALBERTA. PERRY, L.P.N.

DATE OF PROBABLE CAUSE MEETING:

CASE NO.: MAY 31, 2013

This matter was brought before a Probable Cause Panel composed of:

CLAYDELL HORNEand JQDY NEWMAN the investigative report and supplemental and the recommendation of the documentation reviewed soid materials having carefully counsel, finds that: inquire of to opportunity the having had and agency/department on the date set forth above,

the panel, having received

Probable cause exists herein that the Subject violated the following statutes/rules: 456.072(1)(q) FS 20t1 -201.2

The panel sUggests imposIng the following penalty: Costs, V5E cause does not exist and the case should be closed with the following closure codeS

lieu of a finding of probable cause, the above named licensee shall be issued guidance to address the conduct in question:

a

letter of

The panel has requested supplemental or additional information on the following:

Florida :o.paithtont of H.i$th Unit OfOté.of the GerteralCoun$ei ' Prosecution Way, Ski 0-65' Taishassee. FL 32399.1701 4052Baid 105 address: 2585 Merchants Row— PHONE: 85012454444' FAX 850?245-4683

Ite

ldnHositb.cOm

ITTER:HeaithyFLA

F ACE 800K:F LO a

Ith

YOUTIJBE: fldoh

_________________________________________/

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE

0

2013-01256

ALBERT A. PERRY, L.IP.N. RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Albert A. Perry, L.P.N. and in support

thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was a

licensed practical nurse (L.RN.) within the state of Florida, having been issued license number PN 5182381.

3.

Respondent's address of record is 2244 Wilton Park Drive,

•

Wilton Manors, Florida 33305. 4.

On or about

lorida Board of Nursing

issued a

case number 2012-01284.

Order 5.

6, 2012, the

The Final Order required Respondent to pay a fine in the

amount of $250.00, and costs in the amount of $122.00 with thirty (36) days from the date of entry of the Final Order. 6.

Respondent failed to pay the fine in the amount of $250.00,

and costs in the amount of $122.00 with thirty (30) days from the date of

entry of the Final Order. 7.

The Final Order required Respondent to complete and submit

six (6) hours of General continuing education credits, and two (2) hours of

credits for Prevention of Medical Errors by August 1, 2012. 8.

Respondent failed to complete and submit six (6) hours of

General continuing education credits, and two (2) hours of credits for

Prevention of Medical Errors by August 1, 2012. 9.

Section 456.Q72(1)(q), Florida Statutes (2011-2012), provides

that violating

a

lawful order of the department or the board, or failing to

Department of Health v. Albert A. Perry, L.P.N. Case No.: 2013-01256

2

comply with -th

a

lawfully issued subpoena of the department constitutes

,

grounds for discipline. 10.

As set forth

above, Respondent violated

a

lawful order of the

department or the board in one or more of the a.

By failing to pay the administrative fine in the amount

of

$250.00, and costs in the amount of $122.00 with thirty

(30) days from the date of entry of the Final Order and; b.

By failing to complete and submit six (6) hours

of General

continuing education credits, and two (2) hours of credits

for Prevention of Medical Errors by August 11.

Based

on

the

foregoing,

Respondent

456.072(1)(q), Florida Statutes (2011-2012), by violating

1, 2012.

violated a

Section

lawful order of

the department or board, or failing to comply with a lawfully issued subpoena of the department.

Department of Health v. Aibert A. Perry, L.P.N. Case No.: 2013-01256

3

______

WHEREFORE, the Petitioner respectfully requests •

that the Board of

•I

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's Ucense, restriction of

of

practice,

administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriates

SIGNED

this

day of

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Lauren A. Leikam Assistant General Counsel DOH Prosecutipn Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0088700 (850) 245 - 4444 Telephone (859) 245 - 4683 Facsimile

/LAL PCP: PCP Members Department of Health v. Albert A. Perry, L.P.N. Case No.: 2013-01256

4

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

F

HEALTh Office: CONSUMER SERViCES

Date of Complaint January 16,2013

Subject:

ALBERTA. PERRY, LPN

REPORT

ce'

Case Number

-01256

Department of Health/Compliance Management Team

2244 Wilton Park Drive Wilton Manors, FL 33305

.

(954)446-5169 Prefix: LPN

License #: 5182381

Profession: Lic. Practical Nurse

Period of Investigation: January 23, 2013 through April 4, 2013

Board: Nursing

Report Date: April 4,2013

Type of Report FINAL

Alleged Violation: 55. 456.035, 464.018(1)(o), F.S. and Rule 64B9-5.002(1) F.A.C., Violate Statute/Rule, Continuing Education violation, Failed to update address with the Board of Nursing. SynoDsis: This investigation is predicated by the Florida Department of Health/CMT (Ex. #1), that PERRY failed to comply with Citation No. 2012-01284, filed on 4/6/12, by failing to submit certification for 2 hours prevention of medical errors and 6 hours of General Continuing education credits by 8/1/12. Subject also failed to pay fine and costs in the amount of $372.00 by 5/6/12 with an extension till 9/6/12 and a second extension till 11/6/12. Subject has also failed to update his address with the Board of Nursing.

PERRY was therefore notified of this complaint by letters dated 1/23/13, via regular mail (Ex. #2), to the address on file with the Board including a copy of the Case Summary; on 2/20/13, via Certified Mail to the address on file with the Board and returned marked 'unable to Forward"; on 3/15/13 a search in Accurjntdetem,ined two new addresses. On 3/15/13, via certified mail the notification packet was mailed to the first address found in Accurint and returned marked "Unable to Forward"; and to the second address and was returned marked "Unable to Forward". DOR computer information obtained on 4/4/13 reflects PERRY's license to practice as a Licensed Practical Nurse in the State of Flojida is Clear/Active. No patient was identified, thus patient notification was not required.

PERRY is not known to be represented at this time, No response has been received by PERRY. Any response received will be forwarded for review.

Related Case: none

Approved By/DateS

Distribution: PSU/CSU

DOH

.

CASE NtjiwBER 2013-01256

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER

II.

INVESTIGATIVE DETAILS Summary of Records

Statement of ALBERTA PERRY, LPN Subject

IV.

I

3 3

EXHIBITS

1)

Uniform Complaint Form and attachments

4-13

2)

Copy of Notification Letter wI attachments

14-58

DOH INVESTIGATIVE REPORT

CASE NUMBER 2013-01256

INVESTIGATIVE DETAILS SUMMARY OF RECORDS Exhibit #1 includes a complaint initiated by the Florida Department of Health/CMT (Ex #1), that PERRY failed to comply with Citation No. 2012-01284, filed on 4/6/12, by failing to submit certification for 2 hours prevention of medical errors and 6 hours of General Continuing education credits by 8/1/12. Subject also failed to pay fine and costs in the amount of $372.00 by 5/6/12 with an extension till 9/6/12 and a second exten&on till 11/6/12. Subject has also failed to update his address with the Board of Nursing.

Exhibit #2 includes the notification packages that were mailed to PERRY on 1/23/13. via regular mail (Ex. #2), to the address on file with the Board including a copy of the Case Summary; on 2/20/13, via Certified Mail to the address on file with the Board and returned marked "Unable to Forward"; on 3/15/13 a search in Accurint determined two new addresses. On 3/15/13, via certified mail the notification packet was mailed to the first address found in Accurint and returned marked "Unable to Forward"; and to the second address and was returned marked "Unable to Forward".

RESPONSE FROM ALBERT A. PERRY. LPN. SUBJECT 2244 Wilton Park Drive Wilton Manors, FL 33305 (954) 4464169

No response has been received by PERRY. Any response received will be forwarded for review.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

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NOTICE OF HEARING

November 8, 2013 Case#: 2013-02193 To:

BIANCA LOUISE TALARICO 5181 CEDAR LAKE ROAD, APT 1121 BOYTON BEACH, FL 33437, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-02193

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individuafly by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Health Division of Medical Quality Board of Nursing 4052 Bald Cypress Way, Bin C.02 Tallahassee, FL 32399-3252 PHONE: 8501 245-4125 'FAX 850/ 245-4172

www.FloridasHealth.gov TWITTEftHeaIthyFLA

BOOK:FLOepartmentofHealth YOUTUBE: fldoh

Rick Scott

Mission:

Governor

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To protect, promote & improve the health

of all people In Flonda through integrated state, county & community efforts.

John

Healthiest State

Armstrong, MD, FACS

State Surgeon General & Secretary

HEALTH Vision: To be the

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in

the

NOTICE OF HEARING

November 8, 2013 Case#: 2013-02193 To:

BIANCA LOUISE TALARICO 5200 WOODLAND LAKES ROAD LAKE WORTH, FL 33418, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-02193

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please

contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality of Nursing 4052 Bald Cypress Way! Bin 0-02 'Tallahassee, FL 32399-3252 PHONE: 850/ 245.4172

www.FlorldasHeaith.gov ITTER:HealthyFLA FACEBOOK:FLDepartmentotHealth YOUTuBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated

John

ALtH

state, county & community efforts.

Vision:

H

Armstrong, MD, FACS

State Surgeon General

&

Secretary

To be the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 2013-02193 To:

BIANCA LOUISE TALARICO 210 OCEAN BREEZE LAKE WORTH, FL 33460, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-02193

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (550) 245-4125 or via email at If you have any

Florida Department of Health DMsion of Medical Quality Assurance • Board of Nursing 4052 BakI cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 8501245.4125 • FAX 850/245.4172

wwwSioridasHeaithgov TWITTER:HealthyFLA FAOEBOOK:FLOepartiientoftlealth VOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of at

horiua

John H. Armstrong, MD, FACS State Surgeon General & Secretary

EIEAJ.1}I

p

Vision: To

be the

Heaithlesl State

in

the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201302193 To:

BIANCA LOUISE TALARICO 1280 RANCHETTE ROAD WEST PALM BEACH, FL 33415, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201302193

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C.02'Tallahassee, FL 32399-3252 PHONE: 8501245-4125 • FAX 8501245-4172

lth

www.FlorldasHealth.gov

TWflTER:HeaIthyFLA VOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Flonda through integrated state, county & community efforts.

John

HEALTH Vision:

H Annstrong, MO, FACS Stale Surgeon General & Secretary

To be the Healthiest State in the Nabon

NOTICE OF HEARING

November 8, 2013 Case #201302193 To:

WELLINGTON REGIONAL MEDICAL CENTER 10101 FOREST HILL BOULEVARD ATTN: MARY JO CARACCIOLO, HR DIRECTOR WELLINGTON, FL 33414

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING:

—

Date:

Thursday, December

Time:

8:30AM

Type:

Determination ot'Waiver

Re:

BIANCA LOUISE TALARICO/201302193

Place:

5,

letree by Hilton 100 Fairway Drive Deerfleld Beach, FL 33441

954-427-7700

This notice is to inform you, as an involved party or complainant, that the above listed case is scheduled to go before the Board of Nursing. While you are not required to attend, the meeting is open to the public. There is no action needed on your part at this time.

After the conclusion of the meeting, the Board file will file a final order stating the facts of the case and the Board's decision. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. This information will also be available on the Department of Health's website at: www.flhealthsource.com. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at MQA_Nursing©doh.state.fI.us.

Florida Department of Health Division of Medical Quality Assurance' Board of Nursing 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3252 PHONE: 850/ 245-4125 • FAX 850/ 245-4172

www.Floridastlursdng.gov TWflTER:HealthyFLA FACEBOOK:FLDepartmenlofl-lealth YOUTUBE: fldoh

HEALTH

Rick Scott

Mission:

Governor

To protect, prornote & improve the health of all people in Florida through integrated state, & efforts.

John H. Armstrong, MD, FACS Surgeon General & Secretary

Vision: To be the Healthiest State in

the Nadon

MEMORANDUM TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM:

Lauren Leikam, Assistant General Counsel

RE:

Determination of Waiver

suB3Ea:

DOE-I

v. Bianca Louise Talarico, R.N.

DOH Case Number: 2013-02193

DATE:

October 15, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for

final agency action for the December 5, 2013 meeting of the board. The following

information is provided in this regard.

Subject:

Bianca Louise Talarico, R.N.

Subject's Address of

1280 Ranchette Road

Record:

West Palm Beach, Florida 33415

Enforcement Address:

210 Ocean Breeze Lake Worth, Florida 33460

Additional Addresses:

5200 Woodland Lakes Road Lake Worth, Florida 33418

5181 Cedar Lake Road, Apt#1121

Boynton Beach, Florida 33437 Florida Department of Health Office of the General Counsel• Proseaition SeMces Unit 4052 Bald Cypress Way! Bin C65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row - Suite 105 PHONE: 850/245-4444 • FAX 850/245-4683

www.FloridasHealth.com TWIflER:HealthyFLA FACEBOOKFLDeparthientofl-lealth YOUTUBE: fldoh

Subject's License No:

9328344

Licensure File No:

431317

Initial Licensure Date:

7/22/2011

Board Certification:

No

Required to Appear:

No

Current IPN/PRN Contract:

No

Allegation(s):

Violated Section 464.018(1)Q),

Prior Discipline:

None

Probable Cause Panel:

May 31, 2013

Rank: R.N.

F. S.

(2012)

Home & Newman

Subject's Attorney:

Pro Se

Complainant/Address:

Wellington Regional Medical Center 10101 Forest Hill Boulevard

Attn: Mary Jo Caracciolo, HR Director Wellington, FL 33414 LAL/bhh

Florida Department of Health Office of the General Counsel • Prosecuuon Services Jnft 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row - Suite 105 PHONE: FAX 850/245-4683

1ealth

www.FlortdasHealth.com TWI1TER:HeatthyFLA YOUTUSE: fldoh

IDA

STATE OF BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, v.

CASE NO.

2013-02193

BIANCA LOUISE TALARICO, R.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on

a

date and time that has been determined

and noticed by the Board. As grounds therefore Petitioner states: 1.

2013. A copy of said Administrative Complaint is attached hereto as

Exhibit A. 2.

s

An Administrative Complaint was filed against Respondent on June 3,

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified

US mail on:

September 4, 2013, article number 7196-9008-9111-9325-9963. A

copy of the certified mail receipt is attached as Petitioner's Exhibit B. 2(a). Copies of the Administrative Complaint, Explanation of Rights form, and Election of Rights form were sent to Respondent via certified US mail on: June 11, 2013, article number 7196-9008-9111-8826-7614, June 21, 2013, article

number 7196-9008-9111-8826-7621.

Service on Respondent via certified mail

was not successful. A copy of the certified mail receipt and envelope is attached as Petitioner's Exhibit B. 3.

Rule

28-106.111(2),

Florida

Administrative

Code,

provides

in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits C & D.

6..

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 7.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth

in

the Complaint.

WHEREFORE, Petitioner respectfully requests that the Board find that Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter a Final Order imposing whatever discipline upon Respondent's license that the Board deems appropriate.

Respectfully submitted,

John H. Armstrong, MD, FACS State urgeon General and Secretary of Health

LAUREN A. LEIKAM Assistant General Counsel Fla. Bar No.

0887700

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-1111 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that has

been

provided

a

true and correct copy of the above and by

U.S.

mail

this

of

2013, to: BIANCA LOUISE TALARICO, R.N.,

of 1280 RANCH ETIE ROAD, WEST PALM BEACH, FLORIDA 33415, 210 OCEAN BREEZ, LAKE WORTH, FLORIDA

33460, 5200 WOODLAND

LAKES ROAD, PALM BEACH GARDENS, FLORIDA

CEDAR LAKE ROAD, APT.

33418 and 5181

#1121, BOYNTON BEACH, FLORIDA 33437.

LAUREN A. LEIKAM Assistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, V.

CASE NO.

2013-02193

BIANCA LOUISE TALARICO, R.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Bianca Louise Talarico, R.N. and in

support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

a

registered nurse (R.N.) within the state of Florida, having been issued license number RN 9328344.

3.

Respondent's address of record is 1280 Ranchette Road, West

Palm Beach, Florida 33415. 4.

At all times material to this Order, Respondent was employed

by Wellington Regional Medical Center (WRMC) located in Wellington, Florida. 5.

On or about January 12, 2013, Respondent reported to the

emergency department of WRMC for her assigned nursing shift. 6.

On or about January 12, 2013,

two staff members advised

WRMC administrators that Respondent took excessive breaks during her

shift, seemed "hyper," and was "unable to stay focused on tasks." 7.

One staff member indicated he had observed a "trend of

patients not having pain relief after being given strong doses of narcotic medication, particularly Dilaudid," by Respondent. At least one patient who had

been

reportedly

administered

multiple

doses

of narcotic pain

medications by Respondent did not show any signs of pain relief until he was admitted to WRMC and administered the same narcotic medication by

another staff member.

Depanntentofl-Ieajth v. BiancaLouiseTajarigo RN. CsseNo.: 2013.02193

2

,

Dilaudid

is

the

brand

name

for

hydromorphorie

and

is

prescribed to treat pain. According to Section 893.03(2), Florida Statutes

(2012), hydromorphoneis a Schedule II controlled substance that has high potential for abuse and has

a

a

currently accepted but severely

restricted medical use in treatment in the United States. Abuse of

hydromorphone may lead to severe psychological or physical dependence. 9.

Additional staff members stated that Respondent repeatedly

offered to help other nurses administer narcotic pain

medication to patients who were not assigned to her. 10.

Due to the staff members' allegations, WRMC administrators

also observed Respondent's behavior. The administrators observed that

Respondent's pupils were "pinpoint" and her skin was flushed. Thereafter,

the administrators asked Respondent to submit to a reasonable suspicion urine drug screen. 11.

Respondent told WRMC administrators she would hot submit to

the urine drug screen because she would test positive for marijuana. Marijuana is also known ascannabis.

12.

893.03(1), Florida Statutes (2012), cannabis is DcparunentofHcaltl, 2013-02L93

v.

Bianca Louise Talarico, RN.

a

According to

ion

Schedule I controlled 3

substance that has a high potential for abuse and has no currently accepted medical use in treatment in Florida. 13.

WRMC administrators reviewed WRMC's substance abuse policy

with Respondent and advised her that treatment would be an option if her urine drug screen was positive. Respondent again refused to submit to the urine drug screen and surrendered her employee identification badge. 14.

On or about March 7, 2013, the Department issued an Order

compelling Respondent to submit to an evaluation to determine her ability to safely engage in the practice of nursing. 15.

On or about April 11,

2013, Respondent submitted to an

evaluation conducted by Dr. D.B., a specialist in the field of addiction medicine. 16.

As part of the evaluation, Respondent was required to submit

to a urine and hair drug screen. Respondent's hair sample was determined

to be positive for marijuana. 17.

On or about May 6, 2013, the Department received Dr. D.B.'s

evaluation. Dr. D.B. diagnosed Respondent with cannabis abuse. Dr. D.B. opined that Respondent is unable to practice nursing with reasonable skill

c}-{catth 2013.02193 Case

No1

Hianca Louise Tajarico RN. 4

and safety unless she enters an intensive outpatient treatment program,

remains abstinent from the use of marijuana, and is monitored by the

Intervention Project for Nurses (1PM). 18.

IPN. is the impaired practitioner program for the Board of

Nursing pursuant to Section 456.076, Florida Statutes (2012). IPN is an

independent program that monitors the evaluation, care, and treatment of impaired nurses. IPN oversees random drug screens and provides for the exchange of information between treatment providers, evaluators, and the

Department for the protection of the public. 19.

As

of May 15, 2013, Respondent has not contacted IPN, or

complied with Dr. D.B.'s recommendations. 20.

Section 464.018(1)Q), Florida Statutes (2012),

subjects

a

licensee to discipline, including suspension, for being unable to practice

nursing with reasonable skill and safety to patients by reason of illness or use

of alcohol, drugs, narcotics, or chemicals or any other type of material

or as a result of any mental or physician condition. 21.

As set forth above, a specialist in addiction medicine recently

evaluated Respondent and opined that she

is

unable to practice nursing

with reasonable skill and safety; unless she enters an outpatient diemical Department of Healthy. Bianca l.ouise Talarico, RN,

2013.02193

dependency treatment program and is monitored by IPN. Subject is not

currently engaged in

a

chemical dependency treatment program and is not

being monitored by IPN. 22.

Based

on

the

foregoing,

Respondent

violated•

Section

464.018(1)0), Florida Statutes (2012), by being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as

a

result of any mental or physician condition.

i 193

Department Case No.:

Health v. Bianca Louise

RN.

6

WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

3/5tday of

2013.

John H. Armstrong, FACS State Surgeon General and Secretary of Health

DEPARTMENT OF HEALTH DEPUTY CLERK CLERK Jur%O 3 2013 DATE

Lauren A. Leikam Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Rorida Bar Number 0088700 (850) 245 - 4444 Telephone (850) 245 - 4683 Facsimile

PCPMernbers:

193

Dwasuncnt of Health v. Bimlcft Louise Case

larico.

RN.

7

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Depamnent of Health v. Bianca Louise Talarico, RN. Case No.: 201302!93

8

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11 Location

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Tuesday, October 15, 2013 10:10AM

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Subject: U.S. Postal Service Track & Confirm email Restoration -719690089111.88267621 This is a post-only message. Please do not respond. blondell heller-hutchison has requested that you receive this restoration information for Track & Confirm as listed below. Current Track & Confirm e-mail information provided by the U.S. Postal Service.

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Label Number: 71969008911188267621

Service Type: Certified Shipment Activity Delivered Available for Pickup

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USPS has not verified the validity of any email addresses submitted via its online Track & Confirm tool. For more information, or if you have additional questions on Track & Confirm services and features, please visit the Frequently Asked Questions (FAQs) section of our Track & Confirm tool at

http://www.usps.comfshipping/trackandconfirmfaqs.htm.

10/15/2013

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7196 9008 9111 8826 7621 TO:

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secution Services Unit 2 Bald Cypress Way, Bin #C65 32399-3265

Ill

71% 900& 9131 8&26 7621

2

11

,

m

t I

'C

w

02

Rick Scott

Minion:

Governor

To protect promote & improve the heaTh ot all people In Florida through integrated efforts. nunty &

John N. Annetrong, MD, FACS

HEALTH

,

Surgeon

&

Swetary

Vision: To be the Healthiest State In the Nation

I, for

the

Sherri Sutton-Johnson Board

of Nursing's

hereby certify in my offidal capacity as custodian

.

licensure

/2013

files

that the

Board

of

Nursing

as

of

has no evidence of an Election of Rights form or

other responsive pleading requesting

hearing prior to any agency action regarding

a

BIANCA LOUISE TALARICO, R.N..: CASE NUMBER: the Subject's substantial interests or rights.

whIch would affect

Custodian of Records Florida Board of Nursing

Before me, personally appeared

identity is known to me

Sherri Sutton-Johnson

.

whose

(type of identification) and who, under,

oersonallv

oath, acknowledges that his/her signature appears above. Sworn to and subscribed this 15

day of

October

,

2013.

Notary

Z?

Florida

D.partn.nt of H.aith

EXPIAES:FSuwys.2017

Bonds lptu

fly Put Utjder*ts

EXHIBIT

I

.FiouldasHnlth.com

Mission: To protect, promote & improve the health of a(l people in Florida through slate, county & community efforts,

,

,,

Rick Scott Governor

John H. Annstrong, MD, FACS

HEALTH Vision:

Stale

To be the Healthiest Stale in the Nation

AFFIDAVIT

General &

Clerk for the Department Clerk's Office,

hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights farm or other responsive pleading, which requests a hearing prior to any Department action regarding

BIANCA

ISE TALARICO.

R.N.,: CASE NUMBER:

affect the Respondent's substantial interests or ri hts.

which would

Custodi of Department Clerk's Office Before me, personally appeared

2.

Sby"\

i

is known to me by øersonally known

whose identity

(type of identification) and who, under oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

li5tf'àay of

2013.

\-o bcr 1

My Commission Expires:

Ncisy 1'

REP4ADA

cciuy

m.

Nov 9. FE

Florid. D.p.rtm.nt of Health of the General Counsel • Prosecution Services Unit 4052 8&d Cypress Way. Bin C-65 . Tallahassee, FL 32399-1701 P1-lONE: 850/245.4444 ext. 8109 • FAX 850/245-4683

$4454f

.com

TWITTER :HealthyFLA FACE BOO K : FLDeparrjnen tofi4ealtjr YOLJTUBE: tldcli

Rick Scott

Mission:

Govemor

To protect promote & improve O)e health of all people in Florida through integrated state, & cemmunity efforth.

John H. Armstrong, MD, FACS State Surgeon General & Seaetary

Vision; To

be the Healthiest State in the Nation

May 21, 2013,

Bianca Louise Talarico, R.N. 5200 Woodland Lakes Road Palm Beach Gardens, FL 33418

Case Name: Case Number

Re:

DOH v. Bianca Louise Talarico, R.N.

2013-02193

Dear Ms. Talarico,

Pursuant to our conversation today, you indicated you wish to voluntarily relinquish your license in the state of Florida. Enclosed you should find a Voluntary Relinquishment Form. In order to relinquish your license, you will need to execute the form in the presence of a notary and return it to my office at the address listed or via fax at 850-245-4683, at your earliest convenience. Once receive your executed Voluntary Relinquishment Form will place your case on the next Board of Nursing agenda as a relinquishment.

topractice nursing

I

I

Likewise, although have added your new address to my file, please be sure to officially update your address so you can receive further correspondence from the Board of Nursing. If you have any questions, please contact me at 850-245-4444, extension (8150). I

Lauren A. Leikam Assistant General Counsel

LALJBH

Enclosures: Voluntary Relinquishment

Florida Department of Health Office of the General Counsel' Prosecution Services Unft 4052 Bald Cypress Way, Bin C-ES' Tallahassee, FL 32399-1701 PHONE: 850/2454444 FAX 8501245-466X

www.FlorjdasHealth.com TWI1TER:HealthyFLA YOUTIJBE: fidoh

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH, Petitioner, DOH Case No. 2013-02193

v.

BIANCA LOUISE TALARICO, R,N, Respondent.

VOLUNTARY RELINQUTSHMENT OF LICENSE Respondent Bianca Lousie Talarico, license No. 9328344, hereby voluntarily relinquishes Respondent's license to practice nursing in the State of Florida and states as f&lows: 1.

Respondent's purpose in executing this Voluntary Relinquishment is to

avoid further administrative action with respect to this cause. Respondent

understands that acceptance by the Board of nursing (hereinafter the Board) of this Voluntary Relinquishment shall be construed as disciplinary action against

Respondent's license pursuant to Section 456.072(1)(f), Florida Statutes. As with any disciplinary action, this relinquishment will be reported to the National

Practitioner's Data Bank as disciplinary action. Licensing authorities in other states may impose discipline in their jurisdiction based on discipline taken in

Florida.

2.

Respondent

agrees

to

voluntarily

cease

practicing

nursing

immediately upon executing this Voluntary Relinquishment. Respondent further agrees to refrain from the practice of nursing until such time as this Voluntary

Relinquishment is presented to the Board and the Board issues a written final order in this matter. 3.

In order to expedite consideration and resolution

of this action by the

Board in a public meeting, Respondent, being fully advised of the consequences

of so doing, hereby waives the statutory privilege of confidentiality of Section 456.073(10), Florida Statutes, and waives a determination of probable cause, by the Probable Cause Panel, or the Department when appropriate, pursuant to

Section 456.073(4), Florida Statutes, regarding the complaint, the investigative

report of the Department of Health, and all other information obtained pursuant to the Department's investigation in the above-styled action. By signing this

waiver, Respondent understands that the record and complaint become public

record and remain public record arid that information is immediately accessible to the public. Section 456.073(10) Florida Statutes. 4.

Upon the Board's acceptance of this Voluntary Relinquishment,

Respondent agrees to waive all rights to seek judicial review of, or to otherwise challenge or contest the validity of, this Voluntary Relinquishment and of the

Final Order of the Board incorporating this Voluntary Relinquishment.

5.

Petitioner and Respondent

hereby agree that upon the Board's

acceptance of this Voluntary Relinquishment, each party shall bear its own attorney's fees and costs related to the prosecution or defense of this matter. 6.

Respondent authorizes the Board to review and examine all

investigative file materials concerning Respondent in connection with the

Board's consideration of this Voluntary Relinquishment. Respondent agrees that consideration of this Voluntary Relinquishment and other related materials by the Board shall not prejudice or preclude the Board, or any

of its members,

from frirther participation, consideration, or resolution of these proceedings if the terms of this Voluntary Relinquishment are not accepted by the Board.

DATED this

,201.

day of

Bianca Louise Talarico, R.N. STATE OF FLORIDA COUNTY OF: Before me, personally appeared whose identity is known to me by (type of identification) and who, under oath, acknowledges that his signature appears above. Sworn to and subscribed before me this day of

201.

NOTARY PUBLIC. My Commission Expires:

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner, v.

)

CASE NO.:

BIANCA LOUISE TALARICO, R.N.,

Respondent.

2013-02193

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, by and through undersigned

counsel, and moves the Board of Nursing for the entry of a Final Order assessing costs against the Respondent for the investigation and prosecution

of this case

in accordance

with Section 456.072(4), Florida Statutes. As

grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing will

take up for consideration the above-styled disciplinary action and will enter Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

a

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or tha department when there is not board, shalt assess costs related to the investigation and prosecution of the case. Such costs related to the investiciation and prosecution include, but are not limited to. salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other penses inc urr by the department for the case. The board, or the department when there is no board, shall de termine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections .

.

S

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $2,775.21, based on the following itemized

statement of costs:

***** Cost to Date ***** Hours F

Complaint:

Investigation: Legal:

1

Costs 1.00

$17.53]

13.90]

$889311 $1,116.79]

10.50

Compliance:

8.34 [

Sub Total:

r

dnses to Date: Prior Amount: I

[

52,031.97 $743.24]

$0.00 $2,775.21]

F

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $1,658.42 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the assessment

of costs, within ten (10) days of the date of this motion, specifying the grounds for the objections and the specific elements of the costs to which

the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its consideration of the

affidavit attached as Exhibit A and any timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $1,658.42 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida

Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $1,658.42.

3

of

DATED this

2013.

Respectfully submitted,

Armstrong, MD, FACS State Surgeon General d Secretary of Health

John,1-1.

LAUREN A. LEIKAM Assistant General Counsel Florida Bar No.: 0887700 DOH Prosecution Services Unit .4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Telephone (850) 245-4444 Facsimile (850) 245-4683 Email:

[email protected]

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of the foregoing

Motion to Assess Cost has been furnished via U.S. mail to: BIANCA

LOUISE TALARICO, R.N., of 1280 RANCHt BEACH,

FLORIDA 33415,

210 OCEAN

iE

ROAD, WEST PALM

BREEZ,

LAKE WORTH,

FLORIDA 33460, 5200 WOODLAND LAKES ROAD, PALM BEACH GARDENS, FLORIDA 33418 and 5181 CEDAR LAKE ROAD, APT.

#1121

BOYNTON

BEACHJ

FLQRIDA

33437,

day of

on,

this

2013.

LAUREN A. LEIKAM Assistant General Counsel 4

AFFIDAVIT OF FEES AND COSTS EXPENDED

STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

I

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at

the Florida Department of Health (DOH). 3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, I

respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-02193 (Department of Health v. BIANCA

LOUISE TALARICO, R.N.) are TWO THOUSAND SEVEN HUNDERD SEVENTY-FIVE DOLLARS AND TWENTY-ONE CENTS ($2,775.21). 6) The costs for DOH case numbers 2013-02193 (Department of Health v. BIANCA LOUISE TALARICO, R.N.) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case numbers 2013-02193 (Department of Health v. BIANCA LOUISE TALARICO, R.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

I

of2

determined by the on cases daily are to following method: DOH employees who work keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report)

8) The itemized costs as reflected in Exhibit 2 are

9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of his knowledge and belief. FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon day of Sworn to and subscribed before me this known to me. personally who is by Shane Walters,

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of 2

2013,

Page

1

of

Complaint Cost Summary Complaint Num her: 201302193 Subject's Name:

l

TALARICO, BIANCA LOUISE I

I

Investigation:

Compliance:

l11

I

17.53j

1

$1,116.79

25.65

$2,031.97

S8.34j

********** ISub Total: Expenses to I)ate:

Prior Amount: Total Costs to Date:

[

[

S743.24

I

I

I

$2,775.21

—

http://mqaapps.doh.state.fl.us/IRMOOTIMETRAK/CSDETL.ASP

EXHIBIT

Divisionol Medical Quolily Assurance

Ivt Report Date 10/16/2013

Staff Code Activity Hours

UC08 0.25

0.20 0.05

13 Sub Total

-IAI66 1.00

1.00

$17.53

$33.33 $33.33

Staff Rate

ICONSUMER SERVICES UNIT

Sub Total

0.80 0.90 0.80 1.10

0.60 0.20 0.50 0.40 1.30

0.50 0.40 0.40 1.80

0.90 2.20 0.50 th40

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

$63.98

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

INVESTIGATIVE SERVICES UNIT WilOl

lOl hO! hO!

WIlOl

lOl

lO!

101

IlOl

l llI l Florida Department of Health

Cost

$6.67 $1.67 58.34

$17.53 $17.53

$51.18 $57.58 $51.18 $70.38 $38.39 $12.80 $31.99 $25.59 $83.17 $31.99 $25.59 $25.59 $115.16 $57.58 $140.76 $31.99 $25.59

*** C

ON F IDE NT I AL

Complaint 201302193

***

Activity Description

Time Tracking System Itemized Cost by Complaint

Activity Code

AUDIT FILE UPDATING COMPLIANCE RECORDS

Activity Date

129

123

05/16/2013 05/16/2013

INITIAL REVIEW AND ANALYSIS OF COMPLAINT

4

78

(01/2013

76 76 4 4

6 6 6 6

100

100 6 6

I

I

If

Page! of3

itomizedcost

ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE REPORTPREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATiON SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION

1/3 1/2013

02/04/2013 02/04/2013

100

02/05/2013 02/06/2013 02/07/2013

4 76

4

(05/2013

02/I 1/2013 02/11/2013 02/19/2013 02/27/20 13 03/20/2013 03/21/2013 05/17/2013 05/20/2013 05/20/2013 05/28/20 13

- FOR INTERNAL USE ONLY -

13

Medical Quolity Assurance

I\4 Report Date

0.20

Staff Code Activity Hours

ho!

Staff Rate $63.98

$106.35

13.90

0.30

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

$10635 $10635

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

106.35

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35

0.60 0.10 0.10 0.10 0.20 0.30 0.10 0.50 0.10 0.20 0.10 0.30 0.30 0.10

10

1.50

0.30 0.20 0.30 1.90 0.20 0.10 0.20 0.90 0.40 0.30

Sub Total

ULOIN HLOIN ULL97A HLL97A ULL97A HLL97A HLL97A HLL97A HLL97A -ILL97A HLL97A I-ILL97A

ILL97A

8

HLL97A ULL97A HLL97A I-ILL97A -1LL97A HLL97A HLL97A HLL97A FILL97A

ILL97B HLL97A HLL97A HLL97A

Florida Department of Health

C

0 N F ID EN TI AL

Cost

05/30/2013

Activity Date 6

Activity Code

Complaint 201302193

***

PROOFING AND SIGNING LETTERS REVIEW LETTER TELEPHONE CALLS

MEETINGS WITH DEPARTMENT STAFF PREPARATION OR REVISION OF LETTER REVIEWLETTER

ISTRATIVECOMPLAINT

REVIEW MEMORANDUM ESO/ERO MEETiNGS WITH DEPARTMENT STAFF TELEPHONECALLS REVIEW MEMORANDUM CONFERENCES WITH LAWYERS ESO/ERO TELEPHONE CALLS

/ERO

REVIEW CASE FILE

ITNESSREPORT

REVIEW CASE FILE TELEPHONE CALLS REVIEW CASE FILE PREPARATION OF OR REVISION OF A PLEADING REVIEW CASE FILE TELEPHONE CALLS REVIEW SUPPLEMENTAL REPORT PREPARATION OF OR REVISION OFA PLEADING

SUPPLEMENTAL INVESTIGATION

INT

Activity Description

Time Tracking System Itemized Cost by Complaint

$12.80

78

$889.31

02/05/2013 35

25

]

35

37

35 28 74 36 37 88

81

74 35 27 70

27

!

102

40

103

25 40 25 35

25

$31.91

02/18/2013 02/27/2013

02/27/2013 02/28/2013 02/28/2013 03/01/2013 03/01/2013 03/05/2013 05/08/2013 05/08/2013 05/08/2013 05/09/2013 05/13/2013 05/14/2013 05/14/2013 05/15/2013 05/15/2013 05/15/2013 05/20/2013 05/20/2013 05/20/2013 05/20/20 13 06/05/2013 06/10/2013 06/25/2013 06/25/2013

$31.91

$21.27 $31.91 $202.07 $21.27 $10.64 $21.27 $95.72 $42.54 $31.91 $159.53 $10.64 $63.81 $10.64 $10.64 $10.64 $21.27 $31.91 $10.64 $53.18 $10.64 $21.27 $10.64 $31.91

$31.91 $10.64

- FOR INTERNAL USE ONLY -

.

Page2of3

iLemizedcost

I

.

Medical Quality Assurance

___________ Report Date 10/16/2013

HLL97A HLL97A ULL97A HLL97A 10.50

0.20 0.10 0.30 0.10

Staff Code Activity flours

Sub Total

Total Cost

Florida Department of Health

Staff Rate $106.35 $L06.35 $ L06.35 $106.35

***CONFTDENTIAL

Activity Date

Activity Code

Complaint 201302193

REVIEW SUPPLEMENTAL REPORT REVIEW MEMORANDUM PREPARATION OR REVISION OF LETTER REVIEW LETTER

Activity Description

Time Tracking System Iteñiized Cost by Complaint

Cost 103

37

36

27

$21.27 $L0.64

07/15/2013 07/23/2013 08/28/20 13 09/10/2013

$31.91

$10.64

$1,116.79

$2,031.97

- FOR INTERNAL USE ONLY

Page

itenhizedcost

3

of 3

13

Expense Date

10/16/20

Medtcal Quoiiiy Assurance

tvt Report Date:

Staff Code

HLL97A HLL97A

05/07/20 13 06/11/2013

IPROSECUTION SERVICES UNIT

l

Total Expenses

Florida Department of Health

Expense

Amount

$725.00 $18.24

$743.24 $743.24

Expense Code

131747 133100

*** C ON F IDE N TI AL ***

Time Tracking System Itemized Expense by Complaint Complaint 201302193

Expense Code Description

PHYSICIAN SERVICES (OPS) LEGAL & OFFICIAL ADVERTISEMENTS

- FOR INTERNAL USE ONLY --

Page

1

of I

I

itemizedexpense

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Rick Scott

Mission:

Govemor

To protect promote & improve the health of all people in Flodda through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: lobe the Healthiest State

In the Nalion

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO: Department of Health FROM: Board of Nursing, Special Probable Cause Panel

SuB)Ecr: Bianca Louise Talarico, R.N.

CASE NO.: 2013-02193

DATE OF PROBABLE CAUSE MEETING: May 31, 2013 This matter was brought before

a

Probable Cause Panel composed of:

Claydell home, RN & Jody Newman Bryant, EdD, EdS

)

The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that: XX

Probable cause exists herein that the Subject violated the following statutes/rules:

Section 464.O18(1)(j}, Florida Statutes (2012 The panel suggests imposing the following penalty: Costs & VGA

_Probable cause

does not exist and the case should be closed with the following closure code:

_In lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the following:

Other________________________________

Florida Department of Health Office of the General Counsel ProseaiUon Services Unit 4052 Bald Cypress Way, Bin C-85 Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 ext. 8103• FAX 850/2454683

www.FiorldasHealth.com I1TER:HealthyFLA

BE:

FACEBOOK:FLOeparthientoHealth fldoh

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

STATE OF FLORIDA

DEPARTMENT OF HEALTH INVESTIGATIVE REPORT Office:

West Palm Beach

Date of Case:

1/31/13

j

Case Number

2013-02193

Subject:

Source:

BIANCA LOUISE TALARICO, RN 1280 Ranchette Rd West Palm Beach FL 33415 C: 617-851-6185 * new address

WELLINGTON REGIONAL MEDICAL CENTER 10101 Forest Hill Blvd Wellington FL 33414 (561) 798-8604 Att: MARY JO CARACCIOLO

Prefix:

License #:

Profession:

Board:

Report Date:

RN

9328344

Registered Nurse

Nursing

2/12/13

13

Period of Investigation:

Type of Report:

FINAL

Alleged Violation(s): F.S.464.018 (1)(h)(i)j)(n)(o): Unprofessional conduct; failing to meet minimal standards of acceptable and prevailing nursing practice, and violating any provision of this chapter or chapter 456. Synopsis: This investigation is predicated upon receipt of a complaint (EX 1) submitted by MARY JO CARACCIOLO, Human Resource Director at WELLINGTON REGIONAL MEDICAL CENTER (WRMC) alleging that TALARICO, an Emergency Room nurse at WRMC in Wellington,•FL on 1/12/13 was suspected of allegedly diverting narcotics ordered for patientsthat were reporting no physical symptoms of relief of pain. Nursing supervisors noted TALARICO's unusual behavior, including frequent breaks outside the building and TALARICO's personal request to an ER physician for a prescription for doxycycline. Supervisors on duty confronted TALARICO and during the conversation the Supervisors noted TALARICO's eyes were pinpoint, her skin was flush and she was wearing a long sleeve shirt with a wet wrist area. The hospital's substance abuse policy was reviewed with TALARICO at which time she was asked to submit to a drug screen; allegedly TALARICO refused indicating she would test positive for marijuana; TALARICO was immediately suspended and terminated from WRMC on 1/1 4/1 3.

TALARICO was notified of the investigation by phone on 2/1/13 and by certified letter dated 2/1)13 (EXk) and was provided with a copy of the case summary. A check of the Department computer records revealed TALARICO is a Registered Nurse. Patient(s) have not been identified, thus patient notifications have not yet been issued.

TALARICO is not known to be currently represented by an attorney in this DOH matter. In a phone interview on 2/1/13 with DOH investigator MANNING, TALARICO denied the allegations of diversion and impairment and also declined to report to IPN. TALARICO admitted she declined to submit to a drug screen while at work at WRMC on 1/12/1 3; TALARICO admitted to smoking marijuana three days prior to the allegations reported by WRMC on 1/12/13. *new address: 5181 Cedar Lake Rd, Apt #1121; Boynton Beach, FL 33437. Related Case(s):

N/A

Investigator/Date:

JACKIE MANNING Distribution:

Approved BylDate:

lnvestigator4

CHRISTOPHER FERGUSON,

I

HO/ISU .L.LJ

i

I 21113

DOHIMQA Taflahassee HO

:

DOH INVESTIGATIVE REPORT

CASE NUMBER: 2013 -02193

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER

1

TABLE OF CONTENTS

2

II. INVESTIGATIVE DETAILS

3

I.

II.

Summary of Exhibits/Records/Documents

3

MARY JO CARACCIOLO (Source) BIANCA LOUISE TALARICO, RN (Subject)

3-4 5-6

IV. EXHIBITS 1.

Case Summary, complaint letter

7-9

2. Copy of Subject Notification dated 2/1/13, certified mail receipt

10-11

3. Copy of Source Notification dated 2/11/13

12

4. DOH communication to IPN dated 2/4/13 & 2/11/13

13-14

*

5. Subpoenaed records from Wellington Regional Medical Center

15-37

*

6. Confidential Index to Patient's name

38

EXHIBITS CONTAIN INFORMATION WHICH IDENTIFIES PATIENT(S) BY NAME AND ARE SEALED PURSUANT TO SECTION 456.057(1O)(a), FLORIDA STATUTES

Page

2

DOH INVESTIGATIVE REPORT

CASE NUMBER: 2013 -02193

INVESTIGATIVE DETAILS SUMMARY OF EXHIBITS/RECORDS/DOCUMENTS

Exhibit I includes the case summary and correspondence submitted by MARY JO CARACCIOLO, HR Director at WELLINGTON REGIONAL MEDICAL CENTER (WRMC) dated 1/22113 in which she report TALARICO to the Board of Nursing of a suspected violation of diversion and impairment on 1/12/13.

Exhibit 2 is the subject notification mailed to TALARICO's new address on 2/1/13 and certified mail receipt with TALARICO's signature dated 2/8/13.

a

retumed

Exhibit 4 is

a faxed request for IPN status issued from DOH to IPN on 2/4/13 & 2/11/13. receipt of a response, a supplemental report will be forwarded to PSU.

Exhibit 5

is a copy of DOH Subpoena Duces Tecum A 0074918 served via fax to CARACCIOLO at on 2/5/13. Requested items include a copy of WRMC's investigative file pertaining to the

WRMC allegations of diversion and impairment against TALARICO, witness statements provided by Nursing Supervisor LISA KRAMER, RN; WILLIAM AGOCS, PA and Nursing Supervisor TINA BULLOCK, RN all three witnesses gave written statements pertaining to their observations and interaction with TALARICO on 1/12/13 documenting what appeared to be TALARICO's diversion of Dilaudid 1mg and Morphine 5mg prescribed for patient WAL; allegedly WAL reported no pain relief once the medications were administered; statements document independent accounts of TALARICO's alleged impairment on 1/12/13 and subsequent substance abuse counseling on the job; TALARICO refused to submit to a drug screen because she would test positive for marijuana; BULLOCK was concerned that TALARICO should take a taxi home; TALARICO was suspended and later terminated the following week.

:)

Also submitted are pyxis activity and diversion reports for TALARICO on 1112/13 including patient identification and a standard deviation report; also included is an all station report for TALARICO for 1/12/13-1/14/13. Included is WRMC's Substance Abuse policy.

INTERVIEWS &

Investigators note: upon receipt of the records and statements (EX

5) subpoenaed from WRMC on 2/11/1 3, a patient (WAL) was identified. A request for the patient's contact information was made via phone to CARACCIOLO on 2/11/1 3. Upon receipt of the information, patient notification will be mailed.

INTERVIEW OF MARY JO CARACCIOLOI WELLINGTON REGIONAL MEDICAL CENTER 10101 Forest Hill Blvd Wellington, FL 33414 (561) 798-8604

On 2/5/13, and on subsequent dates, DOH investigator MANNING interviewed CARACCIOLO via phone; CARACCIOLO reported the incident (EX 1) on 1/22/13 to the Board of Nursing; and submitted subpoenaed documents (EX 5); she essentially stated:

Page

3

DOH INVESTIGATIVE REPORT

CASE NUMBER: 2013 -02193

•

She is the Human Resource Director at WELLINGTON REGIONAL MEDICAL CENTER (WRMC).

•

She submitted a complaint to the Board of Nursing (EX 1) regarding the allegation BIANCA LOUISE TALARICO, RN possibly diverted narcotics from ER patients at the hospital on 1/1

1

3.

•

She never heard of TALARICO prior to the events of 1/1 2/1 3.

•

TALARICO had been hired on 10/8/12 and had just started working in the ER.

•

There were allegations (EX 5) presented by the nursing supervisors and co-workers that TALARICO demonstrated unusual behaviors on 1/12/13 and was noted as taking frequent breaks while at work and leaving the building frequently to go to her car.

•

The nursing supervisors learned that earlier that day TALARICO reportedly approached an ER physician and requested a prescription for doxycycline. The request was denied by the physician since he felt the prescription could easily be changed to roxycodone.

•

An ER physician (later identified as BLAKE KENDALL, DO) and his PA (WILLIAM AGOCS, PA) reported TALARICO'S patients appeared to be receiving frequent strong doses of narcotics, specifically dilaudid, without reported physical symptoms of relief. CARACCIOLO knows that one patient (later identified as WAL) was admitted and once admitted the patient reported pain relief

•

To her knowledge, there were no prior suspicions of diversion prior to the events of

•

The nursing supervisors confronted TALARICO to discuss the hospital's controlled substance policy (EX 5) & procedures. The staff observed TALARICO's inability to focus on tasks. TALARICO's face was flushed, her eyes were pinpoint and was acting very unusual.

•

TALARICO was asked to submit to a drug screen, which she declined. She indicated she would test positive for marijuana and refused to consent. TALARICO was sent home.

•

CARACCIOLO spoke with TALARICO on 1/14/13 and advised her that her employment at WRMC was terminated due to her refusal to submit to a drug screen, she told TALARICO of the IPN program and that she would be reported to DOH, as required.

•

CARACCIOLO indicated there were statements taken on 1/1 2/1 3, however she would submit whatever documentation (EX 5) was available upon receiving a subpoena.

1 1 3.

STATEMENT OF BIANCA LOUISE TALARICO, RN

)

Page

4

DOH INVESTIGATIVE REPORT

CASE NUMBER: 2013 -02193

** New address 5181 Cedar Lake Rd

#1121 Boynton Beach, Fl 33437 C: (617) 851-6185 On 2/1/13, DOH investigator MANNING interviewed TALARICO via phone; She indicated she would not submit a written response; she essentially stated:

•

She is a licensed Registered Nurse in Florida (RN 9328344).

•

She has five years of nursing experience.

•

Prior to moving to Florida, she was a Registered Nurse in California.

•

She worked as an ER nurse at Wellington Regional Medical Center for about 105 days. She had "just finished her 90 day stint with a preceptor."

•

She does not know what the allegations against her were. She was terminated because she declined to submit to a drug screen; she had smoked "pot" three days prior to the incident at Wellington.

•

She does not know the date she was suspended.

•

She does not know who the patients were on the day in question. She "thinks" this complaint might be related to a male patient she had that needed a CT scan at about 8am (it may have been on 1/12/1 3, she is not sure). He was in room 13. That is all she knows

•

She was working with a Physician's Assistant named BILL * who was working alone. She was given pain medications to give to this patient, which she did. She believes it might have been Dilaudid 1mg. The "patient's appendix was about to bust" and she was told to medicate him again. She got morphine 2mg and medicated him. He was reporting no relief from any of the medications.

*

Investigator's note: later identified as WILLIAM AGOCS, PA, assistant to BLAKE KENDALL,

DO.

•

She was genuinely concerned that the patient did not receive enough medication, especially "since there is a stigma about Dilaudid."

•

When asked, she did not know if anyone witnessed her administering Dilaudid or morphine to the patient.

•

About eight hours later that day, she was called to speak with supervisors; she thinks PALTRICK** was present.

Investigator's note: later identified as PATRICK KELLY, RN, Nursing Supervisor.

Page

5

DOH INVESTIGATIVE REPORT

CASE NUMBER: 2013 -02193

•

She was asked to submit to a drug test, she said "no" because she would test positive for "pot."

•

The supervisor spoke to her about IPN; she was not told to report to IPN, they just told her about IPN.

•

She denied any substance abuse, she denied taking narcotics. She denied drinking alcohol.

•

She denied removing narcotics from WRMC for personal use. She denied diverting pain medication intended for patients.

•

She is working at

a

home health agency.

Investigator's note per a simple internet search, it appears she is employed at Maxim Health Care Services. A CONFIDENTIAL INDEX TO PATIENT'S NAME IS EX

6

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

No Document ëceivcd For •

Scanning/Imaging Image API,

4

Rick Scott

Mission:

Governor

To protect, promote & improve the health

of a!l people in Flonda through integrated

state, county & community efforts.

AEA Vision:

John

I

To be the Healthiest State

H

Armstrong, MD, FACS

State Surgeon General & Secretary

in

the Nation

NOTICE OF HEARING November 8, 2013 Case#: 2012-1 3990 To:

JEFFREY ALAN KEYT 135 ADAMS COURT NORTHWEST PORT CHARLOTTE, FL 33952, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/2012-1 3990

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 'Tallahassee, FL 32399-3252 PHONE: 8501 2454125 • FAX 85012454172

www.FloridasHealth.gov TWITTER:HeaIthyFLA

oepartmentoWlealth

YOUTLJBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health

of all people in Flonda through integrated

John

state, count3' & community efforts.

HEALTH Vision: To be the

Healthiest State

H Armstrong, MD, FACS State Surgeon General & Secretary

in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 2012-13990 To:

JEFFREY ALAN KEYT 301 CAPRI ISLES COURT PUNTA GORDA, FL 33950, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

/2012-1 3990

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441

-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance' Board of Nursing 4052 Bald Cypress Way, Bin 0-02 Tallahassee, FL 32399-3252 PHONE: 850! 245-4125' FAX 850/ 245-4172

lth

www.FicridasHealth.gov

TWITTER:HealthyFLA

VOUTUBE: fldoh

Rick Scott

Mission To protect, promote & improve the health of all people in Florida through integrated efforts state county &

John H. Armstrong, MD, FACS

AITI1

I

Vision: To be

State Surgeon General & Secretary

the Healthiest State in the Nation

NOTICE OF HEARING

.

November 2013 Case#: 201213990 To:

JEFFREY ALAN KEYT PMB 2694093 DIAMOND RUBY STE. CHRISTIANSTED, VI 00820, FL

7

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201213990

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

.

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board.

Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 85012454125• FAX 850/245-4172

-lealth

www.FloridasHnlth.gov

TWIUER:HealtiyFLA YOIJTLJBE:fldoh

HEALTh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

John H. Armstrong, MD, FACS Surgeon General & Secretary

Vision: To be the

Healthiest State

in the Naflon

MEMORANDUM

., E*ecutive Director,

Florida Board of Nursing

TO:

Joe Baker,

FROM:

Lauren Leikam, Assistant General Counsel

RE:

Determination of Waiver

SUBJECT

DOH v. Jeffrey Alan Keyt, R.N. DOH Case Number: 2012-13990

September 23, 2013

DATE:

.

Enclosed you will find materials in the above-referenced case to be placed on the agenda

final agency action for the December 5, 2013

information

is

provided in this regard.

for.

of the board. The following

Subject:

Jeffrey Alan Keyt, R.N.

Subject's Address of

PMB 269

Record:

4093 Diamond Ruby Ste. 7

Christiansted, VI 00820

Enforcement Address:

PMB 269

4093 Diamond Ruby Ste.

7

Christiansted, VI 00820

Additional Address:

301 Capri Isles Court

Punta Gorda, Florida 33950 135 Adams Court North West

Port Charlotte, Florida 33952

Subject's License No:

9166688

Licensure File No:

252156

Florida Department of Health Services Unit Office of the General Counsel • 4052 Bald Cypress Way, Bin 0-65 • Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants RowS Suite 105 PHONE: 8501245-4444 • FAX 850/245-4683

Rank: R.N.

lealth

www.FlorldasHealth.com TWITTER:HealthyFLA VOUTUBE: fldoh

Initial Licensure Date:

4/4/2000

Board Certification:

No

Required to Appear:

No

Current IPN/PRN Contract:

No

Violated Sectiori456.072(1)(q),

Prior Discipline:

4050, 05/05/2009,

Probable Cause Panel:

February 28, 2013

F. S.

(2010)

Home & Connors

Subject's Attorney:

Pro Sc

Complainant/Address:

Department Of Health/Compliance Management Unit

LAL/bhh

Florida Department of Health Services Unit Office of the General Counsel • 4052 Bald Cypress Way! Bin 0-65. Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row - Suite 105 PHONE: 8501245-4444 • FAX 850/245-4683

www.FloridasHoalth.com TWIrrER:HealthyFLA

$OOKFLOeparfrnentofl-lealth VOUTUBE: fldoh

IDA

STATE OF BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, CASE NO

v.

2012-13990

3EFFREY ALAN KEYT, R.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER; the Florida Department

Health, by and through the

undersigned counsel, hereby moQès the Board of Nursing for entry of a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As groUnds therefore Petitioner states: 1.

1,

2013.

An Administrative Complaint was filed against Respondent on March A copy

of said Administrative Complaint

is

attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were sent to Respondent via certified US mail on:

March 5, 2013, article number7l96-9008-9111-5773-0422, March 5, 2013

articlénUftiber 71.96-9008-9111-5773-0330, April 8, 2013, article number 71969008-9111-8826-3494.

Service on Respondent via certified mail was not.

successful. A copy of the certified mail receipt and envelope is attached as

Petitioner's Exhibit B. 3.

Thereafter, Petitioner requested personal- service on Respondent,

which was unsuccessful on June 4, 2013.

attached as Petitioner's Exhibit -

4.

The affidavit of personal service is

C.

Thereafter, Petitioner requested that the -Sarasota Herald-Tribune

publish a Legal Notice of Action beginning on July -26, 2013 and appearing

consecutively on August 2, 9, and 16, 2013. -

Petitioner received proof of

publication on August 22, 201-3, which is attached as Petitioner's Exhibit D.

Thereafter, Petitioner requested that the Virgin Island of the United States Judical District of St. Thomas publish a Legal Notice of Action beginning on July -.

29, 2013 and appearing consecutively on August 5, 12, and 19, 2013. Petitioner

received proof of publication on September 17, 2013, which is attached as

Petitioner's Exhibit 5.

Rule

ft 28-106.111(2), Florida Administrative Code, provides in

pertinent part that:

-

'

—

persons seeking a hearing on .an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 6.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. Respondent has not filed an Election of Rights form, or any other responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits 8.

E

&

F.

Based upon the foregoing, Respondent has waived the right to

dispute any materials fads contained within the Administrative ComplEint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 9.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint.

WHEREFORE, Petitioner respectfully requests that the Board find that Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final

Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

LAUREN A. LEIKAM Assistant General Counsel Fla. Bar No.

0887700

Florida Department of Health Office. of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850)245-4683 Email:

us

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY

foregoing

has

been

that

provided

a

true and correct copy of the above and by. U.S.

mail

this

2013, to: JEFFREY ALAN

2694093 DIAMOND

day

KEfl, RN., at

of

PMB

RUBY STE. 7, CHRISTIANSTED, VI 00820, 135

ADAMS COURT NORTH WEST, PORT CHARLOTTE, FLORIDA 33852 AND 301 CAPRI ISLES COURT, PUNTA GORDA, FLORIDA 33950.

LAUREN A. LEIKAM Assistant General Counsel

•

DEPARTMENT

STATE OF FLORIDA DEPARTMENT OF HEALTH

.

HEALTH,

.

PETITIONER,

•

v.

CASE NO.

.

JEFFREY ALAN KEYT, R.N.,

2012-13990

:.

RESPONDENT.

.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Jeffrey Alan Keyt, R.N., and in

support thereof alleges:

Petitioner

1.

is

the state department charged with regulating the

practice of nursing pursuant to Section .20.43, Florida Statutes; Chapter 456, Florida Statutes; andChapter 464, Florida Statutes. 2.

•

At

aD

material to this Complaint, Respondent was

a

registered nurse (R.N.), within the state of Florida, having been issued license number RN 9166688.

EXHIBIT

LA

3.

Respondent's address of record• is PMB 269 4093 Diamond

Ruby Suite 7, Christiaristed, Virgin Islands 00820. 4.

An alternate address for Respondent may be 154 Adams Court

North West, Port Charlotte, 5.

lbrida 33952.

On or about May 5, 2009, the Florida Board of Nursing filed

a

Final Order in case numbS 2008-13802. 6.

The Final Order required Respondent to pay an administrative

fine in the amount of $250.00, and costs in the amount of $1,228.14,

within two (2) years from the date of entry of the Anal Order. Respondent failed to pay the administrative fine in the amount

7.

of $250.00, and costs in the amount of $1,228.14 within two (2) years from the date of the Final Order in case number 20Ô8-13802. 8.

Section 456.072(1)(q), Florida Statutes (2010), provides that

violating a lawful order of the

with

a

or the board, or failing to comply

lawfully issued subpoena of the department constitutes grounds for

disciplihe. 9.

As set forth above, Respondent violated a lawful order of the

department or board when he failed to pay an administrative fine of

Departhient of Health v. Jeffrey Alan Keyt, RN., Case No.: 2012-13990

$250.00, and costs in the amount of $1,228.14 within two (2) years from

the date of the Final Order in case number 2008-13802. 10.

As

such,

Respondent has violated

Section

456.072(1)(q),

Florida Statutes (2010), by violating a lawful order of the department or

the board, or failing to comply with department.

.

Deparfrnent or Health v. Jeffrey Alan Keyt,R.N., 2012-139g0

3

a

lawfully issued subpoena of the

WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems

/

/

SIGNED this

,

John

ft

20

Armstrong, MD, FACS State Surgeon General and Secretary of Health

FILED•• DWARTMEpçr OF HEALTH

CLEdt

.Leikam & Assistant General Counsel DON Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee; Florida 32399-3265 Florida Bar Number 0088700 (850) 245 - 4640 Telephone (850) 245 - 4683 Facsimile

/LAL PCP: PCP Members: Department of Health v. Jeffrey Alan Keyt, RN., Case No.: 2012-13990

/ 4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. •

NOTICE REGARDING ASSESSMENT OF COSTS

•

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board Shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department cf Heafth Case No.: 2012-13990

v. Jeffrey Alan Keyt,

RN.,

7196 9008 9111 6826 3494 TO:

Stip Pack

llLeikam

Date Mailed 4/8/2013 2012-13990

—

SENDER:

REFERENCE:

PS Form 3800 Janus

—

2005

REtURN

Postage

RECEIPT SERVICE

Certified Fee

—

-

Return Receipt Fee Restricted Delivery

—

Total Postage & Fees

POSTMARK OR DATE

USPS"

Rec&pt for Certified Mair No Insurance COVOT*90 Do Net Use for Intematloflel M&

-

2. Article Number

-

IS

-

SECTION ON DELIVERY

A. ReceIved by (Theses Print Clearly)

I

CERTIFIED

,

Ill

C Agent C Addressee

X 0. is delivery address different from Item It YES, enter delivery address below:

Service Type

Date or Daivery

C. Signature

11

7196 9006 9111 6826 3494 3.

B.

TM

4. Restricted Delivery? (Extra Fee)

]Yes

1?

lfl

Yes No

Reference Information

Kcfl, R.N. 301 Capri Isles Court Punta Gorda, Florida 33950 Stip Pack/2012-13990 Blondell/Leikam PS Form 3811, January 2005

Domestic Return Receipt

a

EXHIBIT

7196 9008 911]. 5773 0330 TO:

Stip Pack * *

Date Mailed 3/5/2013 2012-13990

o

SENDER: CD

REFERENCE:

3800 RETURN

Return Receipt Fee

fl

Deliver

•

I

Total

US Postal Servicee

POSTMARK OR DATE

Receipt for• I

Certified Mair No Insurance Coverage Provided Do Not Use for Internationar Mail

2.

IS

Article Number A.

I

11111

I

Received by (Please Print

SECTION ON DELIVERY

Clseiy)

8. Date 0! DelIvery

c. Signature

71.96 9006 9111 5773 0330

DAgent

x 0.

0

EAddressae delivery address different from ten, 1? II YES, enter delivery address below: Is

LI Yes

CERTIFIED MAILYM

3.

Service Type

4,

Restricted Delivery? (Extra Fee)

1.

Article Addressed to:

flYes

Reference Information

Jeffrey Keyt, RN. 135 Adams Court North West Port Charlotte, Florida 33852

Stip Pack/2012-i3990

dllfLeikam PS Form 3811, January 2005

Domestic Return Receipt

EXHIBIT

IJ

:

rosecution Services Unit 052 Bald Cypress Way, Bin #C65 Florida 32399-3265

NUMBER

I

II!

5773 719L 9t10& 9111

NO

!NSUppjc,

Jeffrey Keyt, RN 135 Adams Court North West Port Charlotte, Florida 33852

ZIPCCiOL

7196

9111

0422

TO:

j

* *

Stip Pack

BlondeiLteikam Date Mailed 315/2013

t t

SENDER: REFERENCE:

3800 Janus

RETURN

2005

Postage

RECEIFr

Certified Fee

SERVICE

Return Receipt Fee

Er

Restricted Del Total Postage & Fees

US Postal Servicea

POSTMARK OR DATE

e 5 Receipt for

Certified I

No

Coverage Provided Do Not Use for Internadons Mail

2. ArtIcle Number

COMPLETE1HIS SECTION

1

A,

Received by (Please Print Clearly)

C.

Signatire

IM

7196 9008 9111 5773 0422

X D.

•

Is If

U.

3. Service Type

CERTIFIED MAILTM

)

4. Restricted Delivery? (Extra Fee)

W

65

William Hiers 829 Whippoorwill Terrace West Palm Beach, FL 33411

w

Case No 2013-04348 Slip Pk - ML

PS Form 3811, January 2005

Domestic Return Receipt

-

EXHIBIT

Rick Scott

Mission:

Govethor

To protect p Sate a improve the health of all people through integrated state, counly&eonwnunftyefforts.

i ida

John H. Annotrong,

FACS

State Surgeon Geneial & Secrataty

HEALTh Vision: To be The Healthiest State in the

Affidavit of Non-Receipt

I,

hereby certify in my official capacity as custodian

Joe Baker. Jr.

for the Board of Nursing's licensure files that the Board, as of

,

/2013

has no evidence of an Election of Rights form or other responsive pleading requesting a

hearing prior to any agency action regarding William Robert

R.N.; 2013-04348,

interests or rights.

Florida Board of Nursing

Before me, personally appeared

whose identity is

Joe Baker. Jr.

known to me personally and who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

Sentember

.,

23

day of

201.3.

V Nbtary Public Signature

Rn Ia

VANESSA RI$CH

Commissjon#EE 215427 Expires July22, 2016

b*o

My commission expires:

ssItaaIth.com

Florida Department of Health of the General Coursel • Prasecuthn

Unit

EXHIBIT

I

Rick Scott

Mission: To protect, promote & Improve the health

John H. Armstrong, MD, FACS

,

State Surgeon General

HEALTH ViSion: To

be the

Healthiest State

&

Secretary

in the Nation

AFFIDAVIT

Deputy Clerk for the Department

,

Ckrk's

Office, hereby certify in my official capacity as custodian for the Department Clerk's

records, that the Department Clerk's Office has not received an Election of Rights form

or other responsive pleading, which requestsa heating prior to any i-epartment action regarding William Robert

hers,

R.N.:

Respondent's substantial interests or rights.

which would affect the

of Record Department Clerk's Office Custodi

Before me, personally appeared

,

I

known to me personally and who, under oath, acknowledges

whose identity is

his/her signature

appears above.

Sworn to and subscribed before me this

of

,

2013.

Notary Public My Commission Expires:

?

ANGELA BARTON

tThi

ii

FloSs Notaty Public. Slut My Comm. Wires Coainfluloii 0 FF41115

paSThlMvpS

Florida Department of Health Office of the General counsel • Prosecution services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 PHONE: 850/2454444' FAX 850/245-4683

FACEBOO

EXHIBIT

STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2013-04348

v.

WILLIAM ROBERT HIERS, R.N., Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW the Department of Health,

by and through

undersigned counsel, and moves the Board of Nursing for the entry

of

a

Final Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At

•its

next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter 2.

a

Final Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution Include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

3.

.

The investigation

and

prosecution• of this case has.

resulted in costs in the total amount of $2,251.20, based on the

following itemized statement of costs: I

***** Cost to

1

Hours

Complaint: Investigation:

I

Legal:

11

.

Compliance: ISub Total:

30.15

Expenses to Date:

Prior Amount:

Total Costs to Date:

1

l

1

Date Costs

-

$43.92! .

$1,516.32! $595.60! $1.61

$2,157.45 $93.75

.

.

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $1,655.60 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections tO the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and. the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $1,655.60 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes. WHEREFORE, the Department of Health

requests that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $1,655.60.

3

-.

DATED this

of

I i

2013.

e G. LKwrence,

Assistant General CouAsel Prosecution Services Unit 4052 Bald Cypress Way, Bin CL6S Tallahassee, FL 32399-3265 Florida Bar # 0011265 (850) 245-4444 x8199 Telephone (850) 245-4683 Fax

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day of

2013, to William Hiers, 829

Whipporwill Terrace, West Palm Beach,

Mich e G. L wr nceflr. Assistant General Corinsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED •

•

STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared AMIE H. RICE who was sworn and states as follows: 1)

My name is Arnie H. Rice.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Investigation Manager for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

1

I

I

4) As Investigation Manager of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's. costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-04348 (Department of Health v WILLIAM

ROBERT HIERS) are TWO THOUSAND TWO HUNDRED SEVENTYTWO DOLLARS AND FORTY-SEVEN CENTS ($2,272.47).

6) The costs for DOH case number(s) 2013-04348 (Department of Health v WILLIAM ROBERT HIERS) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case number(s) 201304348 (Department of Health v WILLIAM ROBERT HIERS) are

detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

keep track of their time in six-minute increments (e.g., investigators

EXHIBIT

lof2

i 4

1

.

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and ineach areaoffice, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) H

9) Arnie H. Rice, first being duly sworn, states that she has read the

foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

I

YETH NOT

FU

(

H. Rice, Affiant

State of Florida County of Leon. Sworn to and subscribed before me this______ day by Amie H. Rice, who is personally known to rne.

,

2013,

TOWANDA B. BURNErr commission # EE 838342 Expires September 25,2016

&ncjed flvu

Name of Notary Printed Stamp Commissioned Name of Notary Public:

2

of 2

Ir,yfai, nifirce

rage

i

or i

Complaint Cost Summary Complaint Number: 201304348 Subject's Name:

I-TIERS. WILLIAM ROBERT

***** Cost to Date J

0.80

Investigation: Legal: Compliance:

(

o.osll [

-

Sub Total: Expenses to Date:

Amount: Total Costs to Date:

1

23.70

1

1

Costs

Hours

.871 $l.61j

**********!l

.35

1

$2,178.72

_____________

.ooI

]

I

http://mqaapps.dob.state.fl.us/IRMOOTIMETRAK/CSDETL.ASP

9/24/2013

\

Staff Rate

0.05

Sub Total

0.80 2.10 0.70 0.30 0.50 0.20 0.90 0.40

1.40

2.60 0.30 0.20 0.30 0.10 0.20 0.10 0.50

Florida Department of Health

W189

189

W189 W189 W189

WI89

W189

WI89

189

W189

189 189

WI89

W189 W189 W189 W189

$54.90 $54.90

$32.13

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

SERVICES UNIT

0.80

Sub Total

IVE

0.70 0.10

HA73 HA52

CONSUMER SERVICES UNIT

0.05

1C27

IANCE MANAGEMENT UNIT

Staff Code Activity ilours

Report Date 09/24/20 13

tVlc

Medical Quality Assurance

Division ol

$51.18

$134.36 $44.79 $19.19 $31.99 $12.80 $57.58 $25.59

.

$89.57

$31.99

$166.35 $19.19 $12.80 $19.19 $6.40 $12.80 $6.40

$43.92

$38.43 $5.49

51.61

$1,61

Cost

4 76 4

4

4 4 4 100 4 76 4 76 4

4

4 4 76

78 35

137

Activity Code

201304348

.

Activity Description

Page

1

of 3

I

I

I

ROUTINE INVESTIGATIVE WQRK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE W9RK SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE EXHIBIT

INITIAL REVIEW AND ANALYSIS OF COMPLAINT TELEPHONE CALLS

.

PRIORITY DOWNGRADES/UPGRADES

-- FOR INTERNAL USE ONLY --

03/14/2013 03/14/2013 03/14/2013 03/18/2013 03/19/2013 03/19/2013 03/19/20 13 03/19/2013 03/19/2013 03/19/2013 03/20/2013 03/20/2013 03/21/2013 03/21/2013 03/21/2013 03/22/2013 03/22/20 13

03/13/2013 03/15/2013

04/25/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

_______________

—

23.70

Sub Total

$63.98 $63.98 $63.98 $63.98

$63.98

$63.98

$63.98

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

$63.98

Staff Rate

0.80 0.40 0.60 0.10

Florida Department of Health

SA

HLOIN HLO1N HLL1O5A $63.81

$10.64

$106.35

$106.35

$85.08

$42.54

$106.35

.

$1,516.32

$25.59 $31.99 $19.19 $25.59 $51.18 $140.76 $12:80 $19.19 $25.59 $19.19 $12.80 $19.19 $12.80 $44.79 $25.59 $38.39 $19.19 $38.39 $25.59 $12.80 $19.19 $12.80 $70.38 $51.18

Cost

$106.35

IPROSECUTION SERVICES UNIT

0.80

WI89

0.30 0.20 0.30 0.20 0.70 0.40 0.60 0.30 0.60 0.40 0.20 0.30 0.20

0.40

IQ

.

0.50 0.30 0.40 0.80 2.20 0.20 0.30

0.40

W189

189

WI89

189

W189 W189 W189 W189

189 189 189

WI89

189 189

WI89

189 189 189

W189

189 189 189

S9

Staff Code Activity Hours

Report Date 09/24/20 13

M

28 74

26

25

76

6

6

Activity Description

REVIEW CASE FILE PREPARE OR REVISE MEMORANDUM PREPARE OR REVISE ADMINISTRATIVE COMPLAINT MEETINGS WITEI DEPARTMENT STAFF

iON

201304348

Page 2 of 3

itemizedcost

I

ROUTINEINVESTIGATIVE WORK SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK REPORT PREPARATION SUPPLEMENTAL INVESTIGATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SERVICE OF ADMINISTRATIVE COMPLAINTS, SUBPOENAS, NOTICE TO CEASE SUPPLEMENTAL INVESTIGATION REPORT PREPARATION REPORT PREPARATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION SUPPLEMENTAL INVESTIGATION REPORT PREPARATION

- FOR INTERNAL USE ONLY --

04/25/2013

04/24/20 13 04/25/20 13

04/24/2013

76

05/06/2013 05/14/2013 05/16/2013 05/28/2013 05/28/2013 6

76

6

6 76 6 100

6

76

6

76

6

76

6

76

4

76

4

100

4

Activity Code

05/03/2013

03/25/2013 03/26/2013 03/27/2013 03/27/2013 03/28/2013 03/28/2013 04/01/2013 04/01/2013 04/02/2013 04/02/2013 04/04/20 13 04/04/2013 04/10/2013 04/26/20 13 04/26/20 13 05/02/2013 05/02/2013 05/03/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFJDENTIAL***

$93.75 $93.75

Total Expenses

$63.50 $30.25

Expense Amount

SubTotal

05/28/20 13 05/28/20 13

SERVICES UNIT

Florida Department of Health

189 189

Staff Code

Expense Date

09/24/20 13

IVE

Report Date:

M

Quohly Assurance

__________

-- FOR

ON F ID EN TI AL

.

PAYMENT FOR INFQRMATION AND EVIDENCE PAYMENT FOR INFORMATION AND EVIDENCE

Expense Code Description

Complatnt 201304348

INTERNAL USE ONLY--

497000 497000

Expense Code

C

Time Tracking System Itemized Expense by Complaint H

***

I

oft

itemIzedexpense

:

E

.

aa

Mission: To protect, promote & improve the health of all people in Flortda through integrated slate, county & community efforts.

Rick Scott• Governor

John H. Armstrong, MD, FACS

HEALTH

State Surgeon General & Secretary

Vision: To be the Healthiest State in the

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health- A-03 (ML)

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Fliers, William Robert, R.N.

CASE NO: 201 3-04348

DATE: 8-16-13

DATE OF PROBABLE CAUSE

This matter was brought before a Probable Cause Panel composed of:

Linda Horton and Mary K. Habgood

On the date set forth above. The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that: x

Probable cause exists herein that the Subject violated the following statutes/rules: (464.018(1)(i), F.S. (2012) The panel suggests imposing the following penalty: Costs, V6B Probable cause does not exist and the case should be closed with the flowing closure code: lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

-

The panel has requested supplemental or additional information on the following: Other

Florida Department of Health Office of the General Counsel • Prosecution Services unft 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245.4444 • FAX 850/245.4683

lealth TWITTER:HealthyFLA

YOuTuBE: fldoh

_________________________________________I

9

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

CASE

WILLIAM ROBERT HIERS, R.N.,' RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, William Robert Hiers, R.N., and in

support thereof alleges: 1.

Petitioner

is

the state depai-tment charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9303380.

3.

Respondent's address of record is 829 Whippoorwill Terrace,

.

West Palm Beach, Florida 33411. 4.

At

all

times

material

to

Complaint,

this

Respondent was employed by Defray Medical Center (DMC), which is located in 5.

lray Beach,

From on or about July 1, 2012 to on or about February 7, 2013,

Respondent diverted Dilaudid from DMC. 6.

On or about February 7, 2013, Respondent admitted to his

supervisor that he had been diverting Dilaudid from DMC. 7.

Dilaudid

is

the brand

name for

a

hydromorphone and is prescribed to treat pain. Florida Statutes, hydromorphone is

substance that has

a

a

drug

that contains

According to Section Schedule

II controlled

high potential for abuse and has a currently accepted

but severely restricted medical use in treatment in the United States, and abuse of hydromorphone may lead to severe psychological or physical

dependence. 8.

Section 464.018(1)(i), Florida Statutes (2012), provides that

engaging or attempting to engage in the possession, sale, distribution of

Department of Health v. William Robert Hiers, RN. Case Number 2013-04348

2

.

controlled substances as set forth in Chapter 893, for any other than legitimate purposes constitutes grounds for disciplinary 9.

Respondent

engaged

or

attempted

to

engage

in

the

possession, sale, or distribution of Dilaudid without a legitimate purpose for possessing Dilaudid. 101

Based

018(1)(i),

on

the

foregoing,

Respondent

violated

Section

Florida Statutes (2012), by engaging or attempting to

engage in the possession of controlled substances as set forth in Chapter 893, for any other than legitimate purposes.

Department of Health v. William Robert Hiers, RN. Case Number 2013-04348

3

WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administratiye fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

day. of John H. Armstrong, MD, FACS State Surgeon General and Health

Secretary of

Michael C. Lawrence, Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0011265 (850) 245 -4444 Telephone (850) 245 - 4683 Facsimile

PCP: PCP Members: Department of Health v. William Robert Hiers, RN. Case Number 2013-04348

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted bt accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by couns& or other representative, to present evidence and argument, to call and

0

cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is ASSESSMENT

COSTh

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shah assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. William Robert Hiers, Case Number 2013-04348

,

5

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

No I..ocument.. ëcei*d For 'S canning/Imaging

Image API,

t

4

Rick Scott

Minion:

ernor

1

To protect, promote & improve the heaith

John H. Armstrong, MD, FACS

HEA]11

I

State Surgeon General & Secretary

To be the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201307335 To:

MEGAN THOMPSON MULLINS 1500 NE 127TH STREETAPT 108 NORTH MIAMI, FL 33161, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1702/201307335

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal Iicensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but aftendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board

of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health DMsion of Medical Quality Assurance • Board cd Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 3239g-3252 PHONE: 850/ 245-4125 • FAX 8501245-4172

www.FlorldasHealth.gov I1TER:HealtiyFLA VOUTUBE: fldoh

Mission:

-

To prätect, prarnate & improve the heafth

at all people in Florida through integrated state, county & cornrnunity efforts. I

Vision: To

l

Rick Scott

.

be the

Healthiest State

Governor

John

H

Armstrong, MD, FACS

State Surgeon General & Secretary

in

the Nation

MEMORANDUM TO: FROM:

RE: SuBJECr:

.

Joe Baker, Jr., Executive Director, Florida Board of Nursing Michael Lawrence, Jr., Assistant General Counsel

Determination of Waiver DOH v. Megan Thompson Mullins, L.P.N.

2013-07335 20. 2013

DOH Case Number

DATE:

ptember

Enclosed you will find materials in the above-referenced case to be placed on the agenda for flnal agency action for the December 5, 2013 meeting of the board. The fOllowing information is provided in this regard. Megan Thompson Mullins Subject: 1500 NE 127th Street, Apt 108 Subject's Address of North Miami, FL 33161 Record: 1500 NE 127th Street, Apt 108 Enforcement Address: North Miami, FL 33161 Rank: PN 5207036 Subject's License No: " 139919 Licensure File No:

Initial Licensure Date:

10/9/2012

Board Certification: Required to Appear: Current IPN/PRN Contract:

No

Allegation(s):

Ct 1: 456.072(1)(hh), FS (2012) Ct 2: 456.072(1)(q), FS (2012)

Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

None

No No

August 16, 2013; Habgood & Horton Pro Se

Department Of Health/Board Of Nursing

Florida Department of Health

www.FloridasHealth.com

.

Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express rnail address: 2585 Merchants Row — Suite 105 FAX 850/245-4683 PHONE: Office of the General Counsel

•

.

TWI1TER:HealthyFLA FACEBOOK:FLDepartrnentafflealth VOUTUBE: fldoh

3.

Rule

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. •

4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters.

•

•

5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C and D. 6.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 7.

Respondent has been advised by way of this Motion, that a copy of.

the investigative file in this case will be furnished to the Board, establishing

a

prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Order imposing whatever

Final

discipline upon Respondents license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Su geon G neral and Secretary of Health

Assistant General Couns Fla. BarNo. 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin .#C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 x8199 Facsimile: (850) 245-4683 Email: [email protected] I

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of the above and has been provided by U.S. mail this day of

to Megan Mullins,15 North Miami, FL 33161.

Assistant General Counsel

NE 127 St,

#108,

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE NO.

v.

2013-07335

MEGAN THOMPSON MULLINS, L.P.N.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Megan Thompson Mulliris, L.P.N.,

and in support thereof alleges: 1.

Petitioner

is

the state agency charged with regulating the

practice of nursing pursuant to Section 20!43, Florida Statutes; Chapter 456, Florida Statutes, and Chapter 464, Florida Statutes .2.

At

times

all

Respondent was

a

material

to

this

Administrative

Complaint,

licensed practical nurse (L.P.N.) within the state of

Florida, having been issued license number

PN

5207036.

•

3.

Respondent's address of record is 1500 Northeast

th

Street,

Apartment 109, North Miami, Florida 33161. 4.

On or about February 4, 2010, Respondent went before the

Board of Nursing for licensure by endorserrient as 5.

a

practical nurse.

On or about February 26, 2010, the Board

of Nursing filed

a

Notice of Intent to Approve with Conditibns, which would issue Respondent an L.P.N. license after Respondent underwent an evaluation coordinated by

the Intervention Project for Nurses (IPN), arid complied with any and all terms and conditions imposed by IPN as 6.

a

result of the evaluation..

IRN is the impaired nurses program

designated pursuant to Section

for the Board of Nursing,

Florida StatutS.

IPN

is a

program that monitors the evaluation, care, and treatment of impaired nurses.

IPN also provides for the exchange

of information between

treatment providers and the Department for the, protection of the public. 7.

Respondent did not contact IPN.

8.

On or about April 7, 2011, Respondent went before the Board

of Nursing for licensure by endorsement

Department of Health v. Megan Thompson Mullins, L.P.N, Case Number 201.3-07335

as a

practical nurse.

2

9.

On or about April 28, 2011, the Board of Nursing filed an

Amended Notice of Intent to Approve with Conditions, which issued Respondent her L.P.N. license. 10.

The Amended Notice of Intent to Approve with Conditions

required Respondent to undergo an evaluation coordinatS IPN. 11.

IPN is

the impaired nurss program for the Board of

designated pursuant. to Section

.076,

Florida Statutes.

1

IPN

is

a

program that monitors the evaluation, care, and treatment of impaired nurses.

IPN also provides for the exchange of information between

treatment providers and the Department for the protection of the public. 12.

The Amended Notice of Intent to Approve with Conditions

required that if Respondent was in need of monitoring or treatment, she comply wfth all conditions of the IPN Advocacy Contract or she would be in violation of the Board Order. 13.

Respondent was evaluated by an IPN approved evaluator.

14.

The evaluator recommended that Respondent be monitored by

15.

On or. about March 9, 2012,

IPN. Respondent entered into an

Advocacy Contract with IPN.

of Health v. Megan Thompson Mulling, L,P.N Case Number 20L3-07335

3

16.

the

Advocacy Contract had a projected active monitOring

period from on or about March 5, 2012, through on

•or

about March 5,

2017. 17.

On or about May 7, 2013, Respondent was terminated from IPN

due to noncompliance with the terms of Respondent's Advocacy Contract. 18.

Respondent failed to comply with alt conditions of the IPN

Advocacy Contract as required by the Notice of Intent to Approve with

Conditions. COUNT ONE 19.

Petitioner realleges and

incorporates

paragraphs one

(1)

through eighteen (18), as if fully set forth herein. 20.

Section 456.072(1)(hh), Florida Statutes (2012), provides that

being terminated from

a

treatment program for impaired practitioners,

which is overseen by an impaired practitioner consultant as described in Section 456.076, Florida Statutes, for failure to comply without good cause,

with the terms of the monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug treatment or alcohol

treatment program, constitutes grounds for disciplinary action.

Department of Hee(th v. Megan Thompson Muthns, L.P.N, Case Number 2013-07335

•

vr

.

.'

21.

.

—r

•

.

..

..

.

Respondent is licensed pursuant to

Statutes, and is

a

.

.

.

Chapter 464,

.

Florida

health care practitioner as defined in Section 456.001(4),

Florida Statutes (2012). 22.

As set forth above, on or about May 7, 2013, Respondent was

terminated from IPN due to noncompliance with the terms of Respondent's Advocacy Contract. 23.

Based

the. foregoing,

on

Respondent

violated

Section

456.072(i)(hh), Florida Statutes (2D12), by being terminSted from treatment programS for impaired practitioners, which .

is

a

overseen by an

impaired practitioner consultant as described in Section 456.076, Florida

Statutes, for failure to comply without good cause, with the terms of the

monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug treatment or alcohol treatment program.

COUNT TWO 24.

Petitioner realleges and

incorporates

paragraphs one (1)

through eighteen (18), as If fully set forth herein. 25.

Section

,072(1)(q),

Florida Statutes (2012), provides that

violating a lawful order of the department or the

Department of Health v. Megan Thompson Mullins, LP.N Case Number 2013-07335

or failing to comply

5

•

—

with

a

lawfully issued subpoena of the department, constitutes grounds for

disciplinary action. 26.

Respondent is flcensed

Statutes, and is

a

pursuant to Chapter 464, Florida

health care practitioner as defined in Section 456.00 1(4),

Florida Statutes (2012):

H

Respondent violated

a

lawfulbrder of the Board of Nursing by

failing to comply with all conditions of the IPN Advocacy Contract as required by the Notice of Intent to Approve with Conditions filed by the Board of Nursing on or about February 26, 2010, and the Amended Notice

of Intent to Approve with Conditions filed by the Board of Nursing on or about March 9, 2012. •

28.

Based

(1)(q),

on

the

foregoing,

Respondent

Statutes (2012), by violating

a

department or the board, or failing to comply with

violated

Section

lawful order of the a

lawfully issued

subpoena of the department.

v, Megan Thcrnpson Mullins, L.P.N. Department af Case Number 201307335

6

______

WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of

a

reprimand,

placement of the Respondent on probation, corrective action, refund of

fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

201j±.

day of John H. Armstrong, Mb,

FACS

State Surgeon General and Secretary of Health

VMICHAEt dJ Assistant General Couul'sel Fla. Bar No. 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 FILED

DEPARTMENI OF HEALTH

DEPUTY CLERK CLERK ..2.in9 DATE

Tallahassee, FL 32399-3265 Telephone: (850) 245-4444, extension 8199 Facsimile: (850) 245-4683

@dohstate.fl.us

/MGL PCP: PCP Menibers:

August 16, 2013 Habgood & Horton

Department of Heaith v. Megan 2013-07335

Case

Mutlins, L.P,N

7

NOTICE OF RIGHTS

Respondent has the right to request a hearing to. be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is.requested. .

NOTICE REGARDING ASSESSMENT OF•COSTS

.

Respondent is placed on notice that Petitioner has incurred costs related, to the investigation and prosecution of this

Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department or hea(th v, Megan Thompson Muffins, L.PJI. Case Number

-07335

a

7196 913fl8 9111 9325 8973 TO:

Megan T Mullins, LPN

13-07335 ML-ab/Stip Pk Sent 8/22/20 13

Megan Mullins 1500 NE 127 St. #108 North Miami, FL 33161

SERVICE

Return Receipt Fee Restricted Delivery

tJsps.

POSTMARK OR DATE

Receipt for Certified Mair

d

No Insurance Coverage Provid.d Do Not U.. tot In1.rnatiooal

2. ArtIcle Number

1111

?196 9008 j

3.

Service Typo

I Ill

9325

CERTIFIED MAILTM

4.Restrlcted DeiWery? (E%ta Fee) 1.

Article Addressed to:

,

Megan Mullins 1500 NE 127 St. #108 North Miami, FL 33161 Case No 2013-07335 Stip Pk - ML

PS Form 3811, January 2005

—

a,

Domestic Return Receipt

at

r-o

,

-)

EXHIBIT

Rick Scott

Mission:

Governor

To protect promote & improve the health of all people in Florida through integrated state, county & efforts.

Rcinaa

John H. Armstrong, MD, FACS State Surgeon General & S&etery

HEALTh Vision: To be the Healthiest State in

the Nation

Affidavit of Non-Receipt

I'

,

William SDooner

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure files that the Board, as of 9/20/2013

,

has

no evidence of an Election of Rights form or other

responsive pleading requesting a hearing prior to any agency action regarding Megan

Thompson Muffins, LPN; interests or Tights.

which would affect the Subject's substantial

Custodian. of ReSt$iCds Florida Board of NUrsing

Before me, personally appeared

William Snooner

whose identity is

known to me personally and who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

.

20

day of.

September .2013.

A

IQNIEE8S2S27 EXPIRES:.FebIuaJy5, 2017

My commission expires: Florida Dspartnisnt of Health of the General

Prosecution Services

.rn

EXHIBIT

C

Rick Scott

Minion; To protect, promote & improve the health of all people in Florida through integrated state, county & community efforla.

Governor

John H. Armstrong, MD, FACS

,,

State Surgeon General & Secetary

H EALTH

Vision; To

be the

Healthiest State in

The

Nabn

AFFIDAVIT ,

Deputy Clerk for the Department

Clerk's

certi& in my official capacity as custodian for the Department Clerk's

Office,

records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action

regarding

gan

Thompson

which would affect the

Respondent's substantial interests or rights.

Custodian of Record Department Clerk's Office

Before me, personally appeared

5

I

,

whose identity is

known to me personally and who, under oath, acknowledges that his/her signature

appears above.

Sworn to and subscribed before me

Notary Public

thisZdayof aNu

y

My Commission Expires:

Florida Department of Health of the General Counsel • Prosecution SeMces Unit 4052 Bald Cypress Way, Bin C-65 • Tallahassee. FL 32399-I 701 PHONE: 850/245-4444 FAX 850/245.4663

?

otvyPst . $I*e ii RedO mm. talc.. St• —

www.FiorldasH.aith.com

STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2013-07335

v. MEGAN THOMPSON MULLINS, L.P.N.,

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WiTH SECTION COMES

NOW the Department of Health, by and through

undersigned• counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: •

1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter 2.

a Final

Order therein.

•

Section 456.072(4), Florida Statutes, states as follows:•

In addition to any other discipline imposed through final order, or citatioh, entered on or after July 1, 2001; pursuant to this section or

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investiaation and orosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other oersonnel working on the case, and any other expenses incurred by or the department for the case. The the department when there is no board, shall determine the amount of costs to be assessed after its consideration of affidavit of itemized costs and any written objections

3.

.

.

The investigation

_

and

prosecution of this case

has

resulted in costs in the total amount of $367.77, based an the

following itemized statement of costs:

Complaint:

*****

[

Hours I

[

Cost_to_Date

1 .801

Legal:

2.10]

1

J

Costs

I

Investigation:

*****

]

0.05 Total:

4.75

.

$0.00

I

Costs to IDate:

] $1.67

'Expenses to Date:

Prior Amount:

1 1 $43.92f

I

.

$0.00

1

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $144.41 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that.the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $144.41 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and

is in accordance

with

Section 456.072(4), Florida Statutes. WHEREFORE, the Department of Health

requests that the

Board of Nursing enter a Final Order assessing costs against the -

Respondent in the amount of $144.41.

3

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows: 1) My

name is Shane Walters.

2) F'am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of HeaLth (DOH). 3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs

regarding the investigation and prosecution of cases against Florida health care licensees.

today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-07335 (Department of Health v. MEGAN THOMPSON MULLINS) are THREE HUNDRED EIGHTY-NINE DOLLARS AND FOUR CENTS ($389.04).

5) As of

6) The costs for DOI-I case number(s) 201 3-07335 (Department of Health v. MEGAN THOMPSON MULLINS) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document.

costs and expenses for DOH case number(s) 201307335 (Department of Health v. MEGAN THOMPSON MULLINS) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

7) The itemized

8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

keep track of their time in six-minute increments (e.g., investigators

EXHIBIT of 2

and lawyers). A designatectDOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), ahd/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon

-

Sworn to and subscribed before me this_____ day of by Shane Walters, who is personally known to me.

Signature La •

Name of Notary Printed Stamp CommissionedName of Notary Public:

i

Si&25, 2016

BOOded

fliij Trw Far kniws,to

2of2

2013,

rage

i

oi

i

Complaint Cost Summary Complaint Number: 201307335 Subject's Name: N4ULI.JNS. MEGAN HOMPSON

*****

Cost to Date

Flours

Complaint:

l:

Compliance:

1

{

[

0.80

S43.92j

2.30

$244.63

0.05

51671

.95

j

Expenses to Date:

nor A mount: Costs to l)atc:

1.80

Costs $98.82

*******&,**

Total: P

*****

.

I

ICSDETL.ASP

I

EXHIBIT.

ol

Staff Rate

0.05

Sub Total

0.30 0.80

2.60

Sub Total

$54.90 $54.90 $54.90 $54.90

$33.33

$106.35 $106.35

$106.35

0.10'

,20

2.30

Sub Total

0.10

0.40

Florida Department of Health

Total Cost

$106.35

$106.35 $106.35

0.50

$389.04

$244.63

$21.27

$42.54 $10.64 $10.64

$42.54 $53.18 $10.64

$106.35

0.10

$53.18

$106.35

$142.74

$38.43 $43.92 $16.47 $43.92

$1.67

$1.67

Cost

0.50 0.40

HLL38B HLL38B HLL38B HLL38B HLL38B HLL38B HLL3SB HLL38B

ECUTION SERVICES UNIT

0.80

0.70

HA73 I-IA73 FIA73 HA73

CONSUM ER SERVICES UNIT

0.05

HC27

COMPLIANCE MANAGEMENT UNIT

Staff Code Activity Hours

Report Date 09/26/2013

MQA

Medical Quolily Assurance

25

25

25

79

68

28

28

25

76

144

144

78

141

:

201307335

.

Page

1

of2

I

I

I

EXHIBIT

I

REVIEW CASE FILE PREPARE OR REVISEADMLNISTRATIVECOMPLAINT PREPARE OR REVISE ADMINISTRATIVE COMPLAINT SIGNING CLOSING ORDERS, ADMINISTRATIVE COMPLAINTS AND REASONAB STIPULATION REVIEW CASE FILE REVIEW CASE FILE REVIEW CASE FILE

REPORT PREPARATiON

CSU INVESTIGATIVE WORK

CSU INVESTJGATIVE WORK

Activity Description

OFCOMPLAINT

DATA CLEAN UP

--FOR INTERNAL USE ONLY--

09/04/2013 09/20/2013

07/01/2013 07/03/2013 08/16/2013 08/21/2013 08/27/2013

07/01/2013

05/30/2013 06/21/2013

05/08/2013 05/14/2013

05/31/2013

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFIDENTIAL***

.

-

—

\

Florida Department of Health

Staff Code Activity Hours

Report Date 09/26/2013

M

Staff Rate Cost

ID EN TI AL

Activity Code

ONLY--

Comptaint

-- FOR INTERNAL USE

Activity Date

F

201307335

Activity Description

Time Tracking System Itemized Cost by Complaint

*** CON

itemizedcost

Page 2

12

Total Expenses

SubTotal

florida Department of Health

Staff Code

Expense Date

Report Date: 09/26/2013

MQA

ci Medicol Quolily Assctonce

Expense

Amount

.

-.

-

.

.

Expense Code Description

--FOR INTERNAL USE ONLY--

.

.

Expense Code-

Complaint

Time Tracking System Itemized Expense by Complaint

.

I

of

itemizedexpense

Page

STATE OF FLORIDA BOARD OF NURSING

IN RE THE APPLICATION FOR LICENSURE OF

DATE

APR

i

2011

MEGAN THOMPSON MULLINS

AMENDED NOTICE OF INTENT TO APPROVE WITH CONDITIONS MEGAN THOMPSON MULLINS applied for licensure by endorsement as a

practical nurse. The application came before the Board of Nursing at a duly-noticed

public meeting on February 4, 2010, in Tallahassee, Florida. The Board has determined that the applicant has been diagnosed with a condition that may impair her

ability to practice nursing with reasonable skill and safety. Based on the foregoing, the Board imposed the following conditions on the

approval of her application: The license of MEGAN THOMPSON MUWNS will not be issued until the

applicant undergoes an evaluation coordinated by the Intervention Project for Nurses (IPN), and complies with any-and all terms and conditions imposed by IPN as a result of said evaluation. It is the duty of the licensee to contact the IPNat P.O. Box 49130,

Jacksonville Beach, Florida 32240-9130, (904) 270-1620 within 30 days. If the licensee is not in need of monitoring or treatment and the IPN is not suitable, no further action

will be required. The licensee shall comply with all conditions of the IPN Advocacy

Contract or she will be in violétion of the Board Order. The application again came before the Board at a duly-noticed public meeting on

April 7, 2011. As that date, the applicant had not contacted the IPN. The Notice of I

Intent to Approve with conditions is amended to provide that if the applicant does not

undçrgo an evaluation within 30 days of the date this Notice is filed, the application will

bedenied. day of•

DONE AND ORDERED

2011.

BOARD OF NURSING

-

Joe B Exed iv Director for Jessie RN, PhD,

-

hn,

air

NOTICE OF HEARING RIGHTS You may seek review of this Order, pursuant to Sections 120.569 and 120.57,

Florida Statutes, by filing a petition with the Executive Director of the Board, 4052 Bald

Cypress Way, Bin C02, Tallahassee, Florida 32399-3252, within 21 days of receipt of this Order. If you dispute any material fact upon which the Board's decision is based, you may request a hearing before an administrative law judge pursuant to Section

120.57(1), Florida Statutes; your petition must contain the information required by Rule 28-106.201, Florida Administrative Code, Including a statement of the material facts

which are in dispute.

If you do not dispute any material fact, you may request a

hearing before the Board pursuant to Section 120.57(2), Florida Statutes; your peiftion must include the information required by Rule 28-106.301, Florida Administrative Code.

Pursuant to Section 120.573, Florida Statutes, you are hereby notified that mediation pursuant to that section is not available.

2

CERTIFICATE OF SERVICE I

HEREBY CERTIFY that a true and correct copy of the foregoing has been

furnished by certified mail, seturn receipt requested, to MEGAN THOMPSON MULLINS, 1457 Sunset Road, West Palm Beach FL 33406, and MEGAN THOMPSON MULLINS,

Street #37; North Miami FL 33161 and Jean D'Aprix, P.O. Box 491301 Jacksonville Beach, Florida 32249, and by interoffice mail to TerriSue Aldridge-Russell, Board of Nursing, 4052 Bald Cypress Way, Bin C02, Tallahassee, Florida 32399-3252 and Lee Ann Gustafson, Senior Assistant Attorney General, Department of Legal

Affairs,

1

The Capitol, Tallahassee FL 32399-1 050

2011.

MullinsMeganPN.rtf

7010

702? 6262

7010 1060

7027 6279

L

L1

3

of

STATE OF FLORIDA BOARD OF NURSING

iN RE THE APPLICATION

•'LERK:

re

FOR

ICENSURE OF: MEGAN THOMPSON MULLINS

NOTICE OF INTENT TO APPROVE WITH CONDITIONS MEGAN THOMPSON MULLINS has applied for licensure by endorsement as a

practical nurse. The application came before the Board of Nursing at a duly-noticed public meeting on February 4, 2010, in Tallahassee,'.Florida. Upon review of the application file the Board has determined that the applicant has been diagnosed with a condition that may impair her ability to practice nursing with

reasonable skill and safety. Based on the foregoing, the Board may refuse to certify an applicant for licensure, or restrict the practice of the licensee, or impose conditions, pursuant to

Sections 464.018(2) and 456.072(2), Florida Statutes.

-

It is therefore ORDERED that the application for certification to be licensed of

MEGAN THOMPSON MULLINS is hereby APPROVED subject to the following

conditions: The license of MEGAN THOMPSON MULLINS will not be issued until the

applicant undergoes an evaluation coordinated by the Intervention Project for Nurses (1PM),

and complies with any and all terms and conditions imposed by 1PM as

a result

said evaluation, It is the duty of the licensee to contact the IPN at P.O. Bok 491 30,

1

of

-

-.-..

..

-

-

-

-

Jacksonville Beach, Florida 32240-9130, (904) 270-1620 within 30 days. If the licensee is not in need of monitoring or treatment and the IPN is not suitable; no

further action

will be required. The licensee shall comply with all conditions of the IPN Advocacy

Contract or she will be in violation of the Board Order. DONE AND ORDERED this

day

of___________ BOARD

0.

IURSING

Rick Garcia, MS, RN, CCM Executive Director for Jessie Cohn, RN, PhD, Chair

NOTICE OF HEARING RIGHTS

You may seek review of thisOrder, pursuant to Sections 120.569 and 120.57,

Florida Statutes, by filing

a

petition with the Executive Director of the Board, 4052 Bald

's

Cypress Way, Bin C02, Tallahassee, Florida 32399-3252, within 21 days of receipt of

this Order. If you dispute any material tact upon which the

decision is based,

you-may request a hearing before an administrative law judge pursuant to Section 120.57(1), Florida Statutes;-yóur petition must contain the information required by Rule

28-106.201, Florida Administrative Code, including a statement

of the material facts

which are in dispute. If you do not dispute any material fact, you may request a hearing before the Board pursuant to Section 120.57(2), Florida Statutes; your petition

must include the information required by Rule 28-106.301, Florida Administrative Code.

2

1

Pursuant to Section 120.573, Florida Statutes, you are hereby notified that mediation pursuant to that section is not available.

CERTIFICATE OF SERVICE

HEREBY CERTIFY that a true and correct copy of the foregoing has been

I

furnished by certified mail, return receipt requested, to MEGAN THOMPSON MULLINS, 1457 Sunset Road, West Palm Beach FL 33406 and Jean D'Aprix, P.O. Box 49130,

Jacksonville Beach, Florida 32249, and by interoffice mail to TerriSue Aldridge-Russell,

I

Board of Nursing, 4052 Bald Cypress Way, Bin C02, Tallahassee, Florida 32399-3252

and Lee Ann Güstafson, Senior Assistant Attorney General, Department of Legal

Affairs,

The Capitol, Tallahassee FL 32399-1050 thiscQiO.day

Poslal Service

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rl r ru

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C

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1 rn

CERTIFIED

RECEIPT

AqeflCY Clerk

Mail Only: No lr,s,,rrnice Cover:eqc Providndl

OFFICIAL_USI —

calfied

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Rick Scott Mission:

Governor

Tdprotect promote&irnprove the

health

of all people in Florida through integrated eff art state, county &

John

HEALTH Vision:

H.; Armstrong, MD, FACS State Surgeon General & Secretary

To be the Healthiest State in the Naflon

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health- A-04 (ML)

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Mulling, Megan Thompson, LP.N.

CASE NO: 2013-07335

DATE: 8-16-2013

DATE OF PROBABLE CAUSE MEETING:

This matter was brought before a Probable Cause Panel composed of:

Linda Horton and Mary K. Habgood

1

having received the investigative report and supplemental materials, On the date set forth above. The and the recommendation of the agency/department, and having had documentation having carefully reviewed said that: finds counsel, of to inquire the opportunity x

Probable cause exists herein that the Subject violated the following 456.072(1)(hh), F.S. (2012), Count 2 456.072(1)(q), F.S. (2012)

statutes/rules:

(Count I

The panel suggests imposing the following penalty: Costs, V6A

cause does not exist and the case should be closed with the flowing closure code: lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to

address the conduct in question: The panel has requested supplemental or additional information on the following: Other

•

P .

Florida Department of Health SeMces unit Office of the General counsel4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX850/245-4683

.FlorldasHealth.com TWI1TER:HeaIthyFLA FACEBOOK:FLDepartmentofl-lealth YOUTUBE: fidoh

,

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

CASL

0

MEGAN THOMPSON MULLINS, LP.N.,

RESPONDENt ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Megan Thompson Mullins, L.P.N.,

and in support thereof alleges: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed practical nurse (L.RN.) within the state of Florida, having been issued license number PN 5207036.

3.

Respondent's address of record is 1500 Northeast

th

Street,

Apartment 109, North Miami, Florida 33161. 4.

On or about February 4, 2010, Respondent went before the

Board of Nursing for

5.

by endorsement as a practical nurse.

On or about February 26, 2010, the Board of Nursing filed a

Notice of Intent to Approve with Conditions, which

an

L.P.NO aicense

ld

issue Respondent

after Respondent underwent an evaluation coordhiated by

the Intervention Project for Nurses (IPN), and complied with any and terms and conditions imposed by IPN as 6.

a

ll

result of the evaluation..

IPN is the impaired nurses program for the Board of Nursing,

designated pursuant to Section 456.076, Florida Statutes.

IPN is a

program that monitors the evaluation, care, and treatment of impaired nurses.

IPN also provides for the exchange of information between

treatment providers and the Department for the protection of the public. 7.

Respondent did not contact IPN.

8.

On or about April 7, 2011, Respondent went before the Board

of Nursing for licensure by endorsement as

Department of Health v. Megan Thompson Mullins, I..P.N. Case Number 2013-07335

a

practical nurse.

2

9.

On or about

l

28, 2011, the Board of Nursing flied an

Amended Notice of Intent to Approve with Conditions, which issued Respondent her L.P.NP license. 10.

,

The Amended Notte of Intent to Approve with Conditions

required Respondent to undergo an eva'uation coordinated IPN. 11.

IPN is the impaired nurses program for the Board of Nursirtg,

designated pursuant to Section 456.076, Florida

IPN is a

program that monitors the evaluation, care, and treatment of impaired nurses.

IPN also provides for the exchange

of information between

treatment providers and the Department for the protection of the public. 12.

The Amended Notice of Intent to Approve with Conditions

required that if Respondent was in need of monitoring or treatment, she

will comply with all conditions of the IPN Advocacy Contract or she would be in violation of the Board Order. 13.

Respondent was evaluated by an IPN approved evaluator.

14.

The evaluator recommended that Respondent be monitored by

15.

On or about March 9, 2012, Respondent entered into an

IPN.

Advocacy Contract with IPN.

Department of Health v. Megan Thompson Mullins, L.P.N. Case Number 2013-07335

3

16.

The Advocacy Contract had a projected active monitoring

period from on or about March 5, 2012, through on or about March 5, 2017. 17.

On or about May

7,

2013, Respondent was

from IPN

due to noncompliance with the terms of Respondent's Advocacy Contract.

0 18.

Respondent faUed to comp'y with

condiflons of the IPN

Advocacy Contract as required by the NoUce of Intent to Approve

19.

COUNT ONE Petitioner

realleges and

incorporates

paragraphs one

(1)

through eighteen (18), as if fully set forth herein. 20.

Section 456.072(1)(hh), Florida Statutes (2012), provides that

being terminated from a treatment program for impaired practitioners,

which is overseen by an impaired practitioner consultant as described in Section 456.076, Florida Statutes, for failure to comply without good cause,

with the terms of the monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug treatment or alcohol

treatment program, constitutes grounds for disciplinary action.

Department of Health v. Megan Thompson Mullins, L.P,N. Case Number 2013-07335

4

Respondent is

21.

licensed

pursuant to Chapter 464,

Statutes, and is a health care practitioner as defined in Section 456.001(4),

florida Statutes (2012). As set forth above, on or about May 7, 2013, Respondent was

22.

terminated from IPN due to noncompliance with the terms of Respondent's Advocacy Contract. Based

23.

on

the

foregoing,

Section

Respondent

456.072(1)(hh), Florida Statutes (2012), by being terminated from

treatment program for impaired practitioners, which

is

a

overseen by an

impaired practitioner consultant as described in Section 456.076, Florida Statutes, for failure to comply without good cause, with the terms of the

monitoring or treatment contract entered into by the licensee,

or for not

successfully completing any drug treatment or alcohol treatment program.

COUNT TWO Petitioner

24.

realleges and

incorporates

paragraphs one (1)

through eighteen (18), as if fully set forth herein. Section 456.072(1)(q), Florida Statutes (2012), provides that

25.

violating

a

lawful order of the department or the board, or failing to comply

Department of Health v. Megan Thompson Mullins, L.P.N. Case Number 2013-07335

5

with

a

lawfufly issued subpoena of the department, constitutes grounds for

disciplinary action. 26.

Respondent is Ucensed

Statutes, and

is a health care

pursuant to Chapter 464, florfida

practitioner as defined in Section 456.001(4),

Florida Statutes (2012). 27.

Respondent violated a lawful order of the Board of Nursing by

conditions of the IPN Advocacy Contract as

faffing to comply with

required by the Notice of Intent to Approve with Conditions filed by the Board of Nursing on or about February 26, 2010, and the Amended Notice

of Intent to Approve with Conditions filed by the Board of Nursing on or about March 9, 2012. 28.

Based

on

the

foregoing,

Respondent

456.072(1)(q), Florida Statutes (2012), by violating

a

violated

Section

lawful order of the

department or the board, or failing to comply with a lawfully issued subpoena of the department.

Department of Health v. Megan Thompson Mullins, L.RN. Case Number 2013-07335

6

WHEREFORE, the Petitioner respectfully requests that the Board

of

Nursing enter an order imposing one or more of the following penalties:

permanent revocadon or suspensbn of Respondent's practice, imposition of an administrative fine, issuance of

restriction of a

reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or Board

remedial education and/or any other relief that the

deems appropriate. SIGN ED this

day of John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

MICHAEL G. LAWRENCE, JR. Assistant General Counsel Fla. Bar No. 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65

Tallahassee, FL 32399-3265 Telephone: (850) 245-4444, extension 8199 Facsimile: (850) 245-4683 Email: [email protected]

/MGL PCP: PCP

Members:

Department of Health 'e. Megan Thompson Mullins, L.P.N. Case Number 2013-07335

7

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to cafl cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has costs related to the investigation and prosecution of this matter Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Departnient of Health v. Megan Thompson Mullins, LP.N. Case Number 2013-07335

8

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FLORIDA DEPARTMBNI'

INVESTIGATIVE REPORT Office:

Date of Complaint:

Case Number

CONSUMER SERVICES

May 13, 2013

LPN 201 3-07335 Source: DOR BOARD OF MJRSING 4052 Bald Cypress Way Bin C-02 Tallahassee, FL 32399-3252 (850) 245-4133

Subject: It'WLUNS, LPN MEGAN 1500 NE 127th Street, Apt 108 North Miami, FL 33161 (786) 285-8189

: Prefix: LPN

License #

Profession:

5207036

Licensed Practical Nurse

Board: Board of Nursing

Report Date: June 21, 2013

Type of Report: FINAL

Period of Investigation: May 14, through June 21, 2013

456.072(1 )(q)(dd)(hh) 464.018(1 )(l)(o), ES. violating Final Order of the Board; failure to Alleged Violation: monitoring agreement; violating statute/rule with comply This investigation is predicated from a complaint from the Florida Board of Nursing reporting MULLINS'S failed to satisfactorily comply with her Board-Ordered Intervention Project for Nurses (IPN) participation. Complainant states MULLINS was on the April 2011 Board of Nursing Agenda as a PN via Endorsement and referred to IPN as a V6B. MULLINS contacted IPN twice on April 13, 2010 and June 3, 2011 and each time decided not to participate. On January 27, 2012 MULLINS re-contacted IPN and was evaluated on February 14, 2012 and diagnosed with AXIS I: poly substance dependence, in remission; bulimia nervosa, in remission; major depression, recurrent, in full remission. AXIS II: none and AXIS Ill: GERD. No treatment recommendations were made however monitoring was recommended and MULLINS executed an IPN Monitoring Agreement for March 5, 2012 through March 5, 2017. MULLINS has refrained from employment as an LPN since she began IPN monitoring and complainant states the specific event that led to IPN monitoring termination was MULLINS' request to have her IPN file closed due to financial issues. MULLINS did state she has been an active member of PA, has a sponsor and four years sobriety and a deadline was set by IPN for MULLINS to reconsider her decision to terminate IPN monitoring however there has been no further contact with her. (Ex. #1)

MULLINS was notified of this complaint by letter dated May 20, 2013 sent to MULLINS' address of record by INVESTIGATOR WATSON. (Ex. #2) Forwarded with this letter was a copy of the UCF and the initiating documents, (Ex. #1) DOH computer information reflects the status of MULLINS'S license to practice as a Licensed Practical Nurse in the State of Florida is Conditional and Active.

No patient involved in this case, therefore patient notification was not required.

MULLINS is not known to be represented. MULLINS provided a response to date at all attempts of notification. (Ex. #3) Letters of Reference on behalf of MULLINS received May 30, 2013 and June 10, 2013 (Ex. #4) Related Case: None

Approved By/Dates-

Investiciator/Qate:

ShOndra A. Watson, Government Analyst,

I

(HA-73)

Nicole Singleton,

Manager

Distribution: Prosecution Services Unit/Consumer Services Unit —.

m

"7

C)

r-.

1)

:

2)

Copy of Notification letters

3)

Response from MULLINS (Subject)

60-61

4)

Letters of Reference for MULLINS (Subject)

62-65

DOH INVESTIGATIVE REPORT

CASE NUMBER LPN 2013-07335

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE TABLE OF CONTENTS II.

2

INVESTIGATIVE DETAILS

Summary of Records

Statement of MULLIMS (Subject)

I.

i

3

3

EXHIBITS

Uniform Complaint Form and attachments

4-58 59

**These records are sealed pursuant to Section 456.057(lOfla), Florida Statutes and copies of same are not maintained in the Investigative Services office

DOI-I INVESTIGATIVE REPORT

CASE NUMBER LPN 201 3-07335

INVESTIGATIVE DETAILS SUMMARY OF RECORDS Exhibit #1 contains: o o o

A Uniform Complaint Form signed by INVESTIGATOR WATSON on May 14,2013. Copy of memo from the Board of Nursing received May 7, 2013. Copy of IPN Dismissal File Received May 13, 2013.

Exhibit #2 contains:

•

Copy of letter dated May 20, 2013 from INVESTIGATOR WATSON sent to MULLINS' address of record.

Exhibit #3 contains: o

MULLINS response letter received June 10, 2013.

Exhibit #4 contains:

• •

Reference letter from MEYERS dated May 26, 2013. Reference letter from DIAZ dated June 4, 2013.

INTERVIEWS/STATEMENTS

STATEMENT OF MEGAN THOMPSON MULLINS, LPN

—

Subject

Mailing Address on Correspondence: 1500 NE 127th Street, Apt 108 North Miami, FL 33161

MULLINS provided response in letter received June 10, 2013 indicating her IPN suspension came about because she was honest on her application to the Board abut her substance abuse within the past five years of which she attended from 2008 through August 2009. MULLINS states she became clean and sober has remained so through the present day and has a sponsor and also sponsors others herself. MULLINS states she has groups in her home and attends meetings daily and when she left Kentucky she was in good standing and eligible for rehire. MULLINS indicates she has discussed her situation at length with her IPN case manager however was unable to find employment as she was in IPN and hasn't worked in four years and has never worked in Florida. MULLINS states while in IPN she was in compliance and feels like under these circumstances of being unemployed, a suspension of her license seems like a stiff penalty.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

e

Mission: To protect, promote & improve the health

of

in

Flodda through integrated

Vision:

l

Rick Scott Governor

John H. Armstrong, MD, FACS State Surgeon General & Secretary

To be the Healthiest State in the Nation

NOTICE OF HEARING

To:

November 8, 2013 Case#: 2013-05045

LEE ALLEN TREFFEISEN 26 SYDNEY LANE ASHEVILLE, NC 28804, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

-05045

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information.

For questions regarding meeting location directions, contact the hotel at the number listed above under 'Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 'Tallahassee, FL 32399-3252 PHONE: 8501 245-4125 'FAX 850) 245.4172

www.FloridasKeaith.gov TWITTER:HeallhyFLA FACEBOOK:FLDepartmentof Health YCUTUBE: lldoh

Minion To protect, promote & improve the health of at

lTH Vision: To

John H. Armstrong, MD, FACS State Surgeon General & Secretary

be the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201305045 To:

LEE ALLEN TREFFEISEN 301 CRICKLEWOOD SQUAREAPT E ASHEVILLE, NC 28804, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201 305045

Place:

Doubtietree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board.

Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please

contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assuran% • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 85W 245-4125 • FAX 850/ 245-4172

www.FiortdasHealth.gov TWITTEftHeaIthyFL.A FACEBOOK:FLDepaflmentofHealth YOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect promote & improve the health of all people in through integrated state, county & community efforts.

ida

John

H. Annstrong, MD, FACS

HEAlTH Vision: To

State Surgeon General & Secretary

be the Heafthiest State in the Nabon

MEMORANDUM TO: FROM:

Joe Baker, Jr., Executive Director, Florida Boa Lucy Schneider, Assistant General

RE:

Determination of Waiver

SUBJECT:

DOH v. Lee Allen Treffeisen, R.N. DOH Case Number 2013-05045

DATE:

October 18, 2013

f

QS

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of

Lee Allen Treffeisen, R.N. 26 Sydney Lane

Record: Enforcement Address:

Asheville, NC 28806 301 Cricklewood Square, Apt Asheville, NC 28804

Subject's License No: Licensure File No:

9162935

Initial Licensure Date:

11/3/1999

Board Certification: Required to Appear: Current IPN/PRN Contract:

None

Allegation(s):

Section 464.018(1)(b), F.S. (2012)

Prior Discipline: Probable Cause Panel:

None

Rank:

E

RN

240138

No

None

August 16, 2013 Horton & Habgood

Subject's Attorney:

Pro Se

Complainant/Address:

Department of Health! Board of Nursing

Florida Department of Health Office of the General Counsel • ProsecuOon Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express mail address: 2585 Row — Suite 105 PHONE: 8501245-4444 • FAX 850/245-4683

hants

lth.com IeaIthyFLA

FACEBOOK:FLDepartaientofHealth YOUTUBE: fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, v.

CASE NO.

2013-05045

LEE ALLEN TREFFEISEN, R.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

An Administrative Complaint was filed

against Respondent on

August 16, 2013. A copy of said Administrative Complaint is attached hereto as Petitioner's Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on:

August 26, 2013 (7196 9008 9111 9325 9055). A copy of the

certified mail receipt 3.

Rule

is

attached as Petitioner's Exhibit B.

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall. file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits C & D. 8.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

9.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima fade case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final

Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

of Health

Ucy

S

As

ant Ge eral Counsel

F

.

Bar

der N

0815349

epartment of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4640 Facsimile: (850) 245-4683 Ion

Email:

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

a

fo regal

true and correct copy

and

th!s

of

by

to:

Lane,

NC 28806

I

cyS hneider Assist t General

Counsel

/

STATE OF FLORIDA DEPARTMENT OF HEALTH

OF

PETITION ER, CASE NO.: LEE ALLEN TREFFEISEN,

2013-05045

RN.,

RESPONDENT.

ADMINISTRATIVE COMPLAINt Petitioner, the Florida Department of Health, by and through the undersigned counsel, files this Administrative Complaint before the Board

of Nursing against Respondent, Lee Allen Treffeisen, RN., and in support thereof states: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

times

afi

Respondent was

a

material

to

this

Administrative

Complaint,

registered nurse (R.N.) within the state of Florida,

having been issued license number

RN

9162935.

T

Respondent's address of record is 301 Cricklewood Square, Apt.

3. E,

Ashville, North Carolina 28804.

The North Carolina Board

4.

of

Nursing is the licensing authority

for nurses in the State of North Carolina. At

5.

aH

times

material

to this Administrative

Respondent was licensed by the State of North Carolina as

Complaint a

registered

nurse possessing Registered Nurse Certificate #235022. On or about March 18, 2013, the North Carolina Board of

6.

Nursing issued an Order to Invoke Voluntary Surrender Following NonCompliance with Alternative

Program for Chemical Dependency, that

constituted formal disciplinary action against Respondent's North Carolina nursing license. Section 464.018(1)(b), Florida Statutes (p012), provides that

7.

having

a

license to practice nursing revoked, suspended, or otherwise

acted against, including the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action. 8.

As set forth above,

Respondent had

a

license to practice

nursing revoked, suspended, or otherwise acted against, including the Department of Health Case Number

v, Lee Allen

Treffeisen, RN.

2

______

denial of licensure, by the licensing authority of another state, territory, or

country, when on or about March

18,

2013, the North Carolina Board of

Nursing took formal disciplinary action ordering the voluntary surrender of

Respondent's North Carolina nursing license. 9.

Based

on

the

foregoing,

Respondent

464.018(1)(b), Florida Statutes (2012), by having

a

violated

Section

license to practice

nursing revoked, suspended, or otherwise acted against, indluding the

denial of licensure, by the licensing authority of another state, territory, or

country. WHEREFORE,

Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of

a

reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

day of

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health Department of Health v. Lee Allen Treffeisen RN. Case Number 2013-05045

3

Counsel Department of Health DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Fla. Bar No. 0815349 Telephone: (850) 245-4444, ext: 8159 Facsimile: (850) 245-4680

FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK Amy CarraWa'J DATE

r3

/LS PCP: PCP

August 16, 2013 Members: Horton and Habgood

NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has Incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Lee Men Treffeisen, RN Case Number 2013-05045

4

___________

719h 900& 9111 9325 9055

Stip Pack Cassandra/Schneider Date Mailed 8/22/2013

2013-05045 SENDER:

REFERENCE:

Treffeisen, Lee PS Fern, 3800. January 2005 Postage RETURN RECEIPT Certified Fee SERVICE

tee

Return Receipt Fee

.

Icefiet Lane

'

ss06

26

Restricted Delivery Total Postage &

P0 ST Mt

Receipt for Certified Mali'" No Insorance Covwage Proyld.d Do Not Use lot Inhemalional Ma

2. Article Number

1

7196 9005 9111 9325 9055 3. Service Type

CERTIFIED MAILTM

4.

flestricled Delivery? (Extra Fee)

1.

Article Addressed to:

n

Lee Allen Treffeisen 26 Sydney Lane

Asheville, NC 28806

N)

Stip Pack 2013-05045 Cassandra/Schneider PS Form 3811, January 2005

-D

LI] Yes

Domestic Return Receipt

>. -4 -1

r,. S

-

Minion: To pmted promote

&

n

improve the health

cat Governor

H.

FACS

I

Vision: to

William Snooner

I,

be the

,

Healthiest Stala

in Vie Nation

hereby certify in my official capacity as

custodian for the Board of Nursing's licensure files that the Board of Nursing as of

10/4/2013

,

has no evidence of an Election of Rights form or other

responsive pleading requesting

a

hearing prior to any agency action regarding

//j

1

'which

would affect the Subject's substantial interests or rights.

ustodian of Records

y

Florida Board of Nursing

Before me, personally appeared

identity

is

known to me

William Soooner

(type of

whose

identification)

and

who,

under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this

day of

October

,

2013.

Notary Public

KErT EXPIRES: February 5. 2017

4052 Bald

T

lth.com I

F4CEBCfWeoarthwnb*sm

Mission:

Hick Scott

I

Governor

To protect promote & improve the health ci all people in Flodda through integrated state,

efforts.

&

,

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEALTH Vision: To be

czroo

1

,

the Healthiest State in the NaUon

Deputy Clerk for the Department Clerk's Office,

hereby certify in my official capacity as custodian for the Department Clerk's records, that the

,

Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case Name:

Lee Allen Treffeisen.

Case No:

substantial interests or rights.

which would affect the Respondent's

Department Clerk's Office Before me, personally appeared PW1OQJ

whose identity is known to me by

øersonally known (type of identiricatiWn) and who, under oath, acknowledges that his/her

signature appears above. Sworn to and subscribed before me

of

2013.

S

No

Pubt

My Commission Expires;

iFFANY WIGGINS * EEO38086

MY COUMISSION

EXPIRES

24.2016

florida Department of Health Office of the General Counset Prosecuflon Services Unit 4052 Bald Cypress Way, Bin C-65 • Tallahassee. FL 32399-1701 Expresa nail address: 2585 Merchants Row — Suite 105 PHONE: 8501245-4444 • FAX 8501245.4663

.com

TWITFER:HeatthyFLA FACE BOOK: F L D e p a rune VOUTUBE: fldoh

lealth

_/ STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner, v.

)

CASE NO.

LEE ALLEN TREFFEISEN,

RN.,

Respondent.

2013-05045

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW

the

Department

of

Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of Final Order assessing costs against the Respondent

a

for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter

a Final

2.

Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not salaries and benefits of personnel, costs limited related to the time spent by the attorney and other other personnel working on the case. and expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

,

3.

.

y

The investigation and prosecution of this case has resulted in

costs in the total amount of $230.02, based on the following itemized

statement of costs:

***** Cost to Date Hours

Complaint: Investigation: Legal:

1 1 1

Compliance:

0.00

Sub Total: Expenses to Date: Prior Amount:

4.00

f

Total Costs to Date:

*****

Costs

1

1l $17331

$230.02 . [

00

$0.00

$230.02

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $38.56 as evidenced in the attached affidavit.

(Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $38.56 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $38.56.

3

DATED

of

2013.

of Health

Counsel Fla. Bar No.

0815349

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: Lucy.Schneider©flhealth .gov

CERTIFICATE OF SERVICE I HEREBY CERTIFY that

a

true and correct copy of the foregoing

Motion to Assess Costs has been furnished via U.S. mail to Lee Allen

Treffeisen R.N., at 26 Sydney Lane, Asheville, NC 28806, on this day .

eneral Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 3-05045 (Department of Health v. LEE ALLEN

TREFFEISEN, R.N.) are TWO HUNDRED THIRTY DOLLARS AND TWO CENTS ($230.02). 6) The costs for DOH case numbers 201 3-05045(Department of Health v.

LEE ALLEN TREFFEISEN, R.N.) are summarized in Exhibit Summary Report), which is attached to this document.

1

(Cost

7) The itemized costs and expenses for DOH case numbers 2013-05045 (Department of Health v. LEE ALLEN TREFFEISEN, R.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document.

ci

8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

I

of2

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., F!orida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of his knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Shané Walters, Affiant

State of Florida County of Leon Sworn to and subscribed before me this \t.p day of by Shane Walters, who is personally known to me.

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of 2

Lc.(

,

2013,

Page

1

of

1

Corn pkint Cost Summary Complaint Num her:

Subject's Name:

)5045

TREFFE1SE]'4. LEE ALLEN

***&* Cost to Date Hours Costs

int:

I

L lExpenses to Date:

Prior Anount: Total Costs to Date:

5230.02

$0.00 S0.00 S230.02 1

1

,us/IRMOOTIMETRAKICSDETL.ASP

10/16/20 13

10/16/2013

Staff Rate

$106.35

$106.35 $106.35

0.20

0.50

.10

0.70

HLL94B HLL94B

0.10 0.10

1.80

HLL94B HLL94B

Sub Total

Florida Department of Health

Total Cost

10

ILL94B

HLL9413 1-1LL948

$106.35

2.20

$106.35 $106.35 $106.35

$17.53 $17.53

Sub Total

0.20 0.10 0.30

1.00

$17.53 $17.53

0.10

HA!66

166 166 HA 166 166

$17.53 $17.53 $17.53

0.40 0.10

1A166

IAI66

ICONSUMER SERVICES UNIT

Staff Code Activity Hours

Report Date

MQA

Medical Quality Assurance

Division ci

$230.02

$191.46

$74.45 $10.64 $10.64 $10.64

$10.64

$21.27 $53.18

$38.56

$17.53

$1.75 $5.26

$1.75 $1.75 $3.51

$7.0!

Cost

25

37

90 25

90

25 28

76

25

25

25

25

25

78

Activity Code

201305045

Activity Description

REVIEWLETTER REViEW CASE FILE

SSfNG ILE

11

1

I

of2

EXHIBIT

Page

ftemizedcost

INT Nc3 IEWCASEFILE

ION

REVIEWCASEFILE REVIEWCASEFILE REVIEW CASE FILE

REVIEW CASE FILE REVIEW CASE FILE

IEWANDANALYSISOFCOMPLAINT

- FOR INTERNAL USE ONLY -

06/21/2013 06/21/2013 08/20/2013 08/21/2013 09/04/2013 09/11/2013 09/19/2013

03/27/2013 03/27/2013 04/10/2013 06/03/2013 06/04/2013 06/13/2013 06/19/2013

Activity Date

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFIDENTJAL**k

ci

Florida Department of Health

Staff Code Activity Hours

ReportDate 10/16/2013

1\4 ___________

Medical Quality Msuronce

Staff Rate Cost

Activity Code

Complaint

-- FOR INTERNAL USE ONLY

Activity Date

ON F JOE NT! AL ***

201305045

Activity Description

Time Tracking System Itemized Cost by Complaint

C

itemizedcost

Page2of2

Total Expenses

SubTotal

Expense Date

10/16/2013

Florida Department of Health

Stall Code

Report Date:

MQA

Divisional Medical Quality Assejance

Amount

Expense

Expense Code Description

--FOR INTERNAL USE ONLY--

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

itemizedexpense

Rick Scott

Mission:

Governor

To protect, prornote & irnprove the health of all people in Florida through integrated state, & community efforts.

John H. Armstrong, MD, FACS

H EAL.TH Vision: To be

State Surgeon General & Secretary

the Healthiest State in the Nation

CAUSE PANEL FINDINGS TO:

Department of Health- A-02 (LS)

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Treffeisen, Lee Allen, RN.

DATE OF PROBABLE CAUSE MEETING:

CASE NO: 201 3-05045 DATE: 8-16-13

This matter was brought before a Probable Cause Panel composed of:

Linda Horton and Mary K. Habgood

On the date set forth above.

The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that: x

Probable cause exists herein that the Subject violated the following statutesirules: (464.018(1)(b), F.S. (2012) The panel suggests imposing the following penalty: Costs, Suspended until North Carolina License is

Reinstated

Probable cause does not exist and the case should be closed with the flowing closure code: lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the-following: Other

N,

o

l

Florida Department of Health of the General Counsel' Prosecuion Services Unit 4052 Bald Cypress Way, Bin 0-65. Taitahassee, FL 32399-1701 address: 2585 Merchants Row — Suite 105 PHONE: 650/245-4444 FAX 850)245-4683

TNEL

www.FiorldasHealth.com ITTER:NealthyFLA YOUTUBE: fidoh

_________________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE

2013-05045

LEE ALLEN TREFFEISEN, R.N.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT Petitioner, the Florida Department of Health, by and through the undersigned counsel, files this Administrative Complaint before the Board

of Nursing against Respondent, Lee Allen Treffeisen, R.N., and in support thereof states: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

times

all

Respondent was

a

material

to this

Administrative

Complaint,

registered nurse (R.N.) within the state of Florida,

having been issued license number RN 9162935.

Respondent's address of record is 301 Cricklewood Square, Apt.

3. E,

Ashville, North Carolina 28804.

The North Carolina Board of Nursing is the Ucensing authority

4.

for nurses in the State of North At

5.

all

times

lina.

material

to

this

Administrative

Respondent was licensed by the State of North Carolina as

Complaint a

registered

nurse possessing Registered Nurse Certificate #235022. On or about March 18, 2013, the North Carolina Board

6.

of

Nursing issued an Order to Invoke Voluntary Surrender Following Non-

Compliance with Alternative Program for Chemical

Dependency, that

constituted formal disciplinary action against Respondent's North Carolina nursing license. Section 464.018(1)(b), Florida Statutes (2012), provides that

7.

having

a

license to practice nursing revoked, suspended, or otherwise

acted against, including the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action. 8.

As set forth above,

Respondent had a license to practice

nursing revoked, suspended, or otherwise acted against, including the Department of Health v. Lee Allen Treffeisen, RN. Case Number 2013-05045

2

denial of licensure, by the licensing authority of another state, territory, or

country, when on or about March 18, 2013, the North Carolina Board of Nursing took formal disciplinary action ordering the voluntary surrender of

Respondent's North Carolina nursing Hcense. 9.

Based

on

the

foregoing,

Respondent

464.018(1)(b), Florida Statutes (2012), by having

a

violated

Section

license to practice

nursfrig revoked, suspended, or otherwise acted against,

the

denial of licensure, by the licensing authority of another state, territory, or

country. WHEREFORE, Petitioner

respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

day of

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health Department of Health v. Lee Allen Treffeisen, R.N. Case Number 2013-05045

3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Rick Scott

Mission;

Governor

To protect promote & improve the health of all people in Flortda through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

Vision:

To be the Healthiest State in the Naflon

INVESTIGATIVE REPORT Office:

Date of Complaint: March 26, 2013

CONSUMER SERVICES

Case Number:

RN 2013-05045 Source: Department of Health/Board of Nursing

Subject: LEE ALLEN TREFFEISEN 301 Cricklewood Square, Apt. E

.

Asheville, NC 28804 828-484-8112

: Prefix: 1701

License #:

Profession:

9162935

Registered Nurse

Period of Investigation: March 27—June 19, 2013

Board:

Report Date: June 19, 2013

Nursing

Type of Report: FINAL

Alleged Violation: § 456.072(1 )(c)(x)(dd), F.S,, 464.018(1 )(b)(o), F.S., Violate statute-rule; Out of state discipline This investigation is predicated on the receipt of a complaint received on March 26, 2013 informing that TREFFEISEN's North Carolina license had been disciplined. On March 18,2013 the North Carolina Board of Nursing did issue an Order to Invoke Voluntary Surrender due to non-compliance with an alternative program for chemical dependency (AP). TREFFEISEN failed to comply with the AP program on March 18, 2013 when he tested positive on a random drug screen. (EX 1)

TREFFEISEN was notified by letter mailed to his address of record with the Board on March 27, 2013 and by certified letter June 3,2013, Both mailings did include the initiating document, the Order from North Carolina dated March 18, 2013, and the Case Summary. A check of the Florida Department of Health licensure database reveals that TREFFEISEN's Florida license is in delinquent/active status as of April 30, 2013.

Patient notification is not required as there is no patient involvement. TREFFEISEN is not known to be represented by counsel at this time.

TREFFEISEN has not responded to the notification attempts as of June forwarded to the Prosecution Services Unit.

Related Case:

191

2013. If a response

is

received it will be

None

Investigator/Date:

3 Distribution:

Legal/Consumer Services Unit

Page

1

Co

DOH INVESTIGATIVE REPORT

RN 2013-05045

TABLE OF CONTENTS

I.

INVESTIGATIVE REPORT COVER PAGE

1

.

TABLE OF CONTENTS

2

.

INVESTIGATIVE DETAILS Summary of Records / Documents

3

Interviews / Statements

3

Statement of (Source) Statement of (Subject) IV.

3

3

3

EXHIBITS 1)

Complaint Summary and attachments

4-8

2)

Copy of Notification letter

9-11

Page 2

DOH INVESTIGATIVE REPORT

)) RN

INVESTIGATIVE DETAILS

SUMMARY OF RECORDS Exhibit! contains the initiating documents received on March 28, 2013 which consist of a NURSYS Speed Memo and a discipline Report. Also included is the ORDER invoking voluntary surrender from North Carolina dated March 18, 2013 arid the Case Summary. Exhibit 2 includes the attempts to notify TREFFEISEN dated March 27, 2013 sent by regular mail and June 7, 2013 sent certified.

INTERVIEW/STATEMENT OF Florida Department of No further information was obtained from complainant

INTERVIEW/STATEMENT OF LEE ALLEN Address of Record 301 Cricklewood Square Apt E Ashevi!le, NC 28804 828-484-8112

No response has been received from TREFFEISEN as of June 19, 2013

Page

3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

-

-a

p 0

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C

S

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/D

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a

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Annstrong, MD, FACS

HEALTII Vision: To

State Surgeon General & Secretary

be the Healthiest State in the

NOTICE OF HEARING November 8, 2013 Case#: 201302801 To:

JENNIFER MARIE ROMAN AVE. NOEL ESTRADA368 ISABELA, PR 00662, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201302801

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

5,

2013

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under

"Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health

i

OMsion of Medical Quality Assurance • Board Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 • FAX 850/ 245.4172 PHONE:

lealth

www.FlorldasHealth.gov TWI1TER:HealthyFLA

Y0UTuBE: fldoh

Rick Scott

Mission To protect, promote & improve the health of at peop1e in Hodda throu hhitegrated

John H. Armstrong, MD,

HEALTH Vision:

e

State Surgeon General & Secretary

To be the Healthiest State in the Nation

MEMORANDUM FROM:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Lucy Schneider, Assistant General Counsel

TO: RE:

Determination of Waiver

SUBJECT:

DOH v. Jennifer Marie Roman, R.N. DOH Case Number 2013-02801

DATE:

September 6, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Subject: Jennifer Marie Roman, R.N. Subject's Address of 368 Noel Estrada Avenue Record: Isabela, PR 00662

Enforcement Address:

368 Noel Estrada Avenue Isabela, PR 00662

Subject's License No: Licensure File No:

9334167

Initial Licensure Date:

11/23/2011

Board Certification:. Required to Appear: Current IPN/PRN Contract:

None

Allegation(s):

Section 456.072(1)(k), F.S. (2011), by failing to perform a statutory or legal obligation required under Section 464.009(1)(c), F.S. (2011)

RN

427509

No

None

.

Prior Discipline: Probable Cause Panel:

Rank:

None

.

July 18, 2013 Kirkpatrick & Habgood

Subject's Attorney:

Pro Se

Complainant/Address:

Department of Health/Board ofNursing 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399

Fiorida Department of H.aith

.

. .

Office of The General Counsel• Prosecution Services Unit 4052 Cypress Way, Bin C-65 Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 8501245-4444 FAX 850/245-4683

ld

.FioridasHeaith.com TWITTER'H Ith FLA FACEBOOK:FLOepartnientofHealth YOUTUBE' fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENTOF HEALTH,

Petitioner, v.

CASE NO.

.

2013-02801

JENNIFER MARIE ROMAN,. R.N.,

.

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

PETITIONER, the Florida Department of Health, by and through the counsel, hereby moves the Board. of Nursing !or entry, of a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1

18, 2013.

An Administrative Complaint was filed against Respondent oil July

A copy of said Administrative Complaint is attached hèretQ as

Petitioner's Exhibit A.

2.

Copies of the Administrative Complaint, Explahation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on:

August 1, 2013 7196 9008 9111 9325 8126). A copy of the certified

mail receipt is attached as Petitioner's Exhibit B. 3.

Rule

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision.

•

4.

Rule 28.106.111(4), Florida Administrative Code, .provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters.

•

•

5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C & D. 6.

Based upon the foregoing, Respondent has waived the right

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

7.

Respondent has been advised by way of this Motion, that a copy

of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth

in the Complaint.

WHEREFORE, Petitioner. respectfully requests that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Adnilnistrative -complaint and enter a Final -Order imposing whatever discipline upon Respondent's license that the Board deems appropriate.

John State

•

FACS 1

and Secretary of Health

chn&der .A

sistaht

Fla. •

•

eral Counsel

arNo.0815349

Florida Departmentof Health Office Of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 ext. 8159 Facsimile: (850) 245-4683 Email:

©doh.state.fl.us

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of foreqging bas , provided by U.S. mail this 2013, to: Estrada Isabela, PR 00662.

rat Counsel

above and

of Noel

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

v.

CASE NO.

.

2013-02801

JENNIFER MARIE ROMAN, R.N.,

RESPONDENT..

.

1

H

ADMINISTRATIVE COMPLAINT Petitioner, the Florida Department of

by and through the

undersigned counsel, files this Administrative Complaint before the in support

of Nursing against Respondent, Jennifer Marie Roman, R.N., and thereof states: 1.

the

PetitIoner is

practice Of nursing pursuant to Section 20.43/ Florida Statutes; Chapter 456, Florida Statutes; and chapter 464, Florida Statutes. 2, •

A

all.

to

.

complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9334167.

3.

Respondent's address of record is 368 Ave Noel Estrada, #1,

Isabela. Puerto Rico 00662. 4.

1

On or about November 23, 2011, Respondent was granted

licensureby endorsement to practice nursing in the state of Florida. 5.

Section 464.009(1)(c), FIor!da Statutes (2011), requires that

applicants granted

a-

license to practice nursing by endorsement must,

within six (6) months after obtaining their license, complete a laws and rules course approved by the Board. 6.

the

As of February 13, 2013, Respondent failed to

laws and rules course required by Section 464.009(1)(c), Florida Statutes

(2011). 7.

Section 456.072(1)(k), Florida Statutes (2011), provides that

upon failing to perform any statUtory or legal obligation placed

a

licensee

constitutes grounds for disciplinary action. 8.

set forth

legal obligation placed upon a licensee when she

a

statutory or

to complete the

laws and rules course required for licensure by endorsement in Section

464.0O9(1)(c), Florida Statutes (2011).

Department of Health v, Jennifer Marie Roman, RN. Case Number 2013-02801

2

9.

Based

on

the

foregoing,

Respondent

Section

violated

456.072(1)(k), Florida Statutes (2011), by failing to perform

a

statutory Or

Florida Statutes

legal obligation required under Section

(2011). WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one

or more of the following penalties:

permanent revocation or suspension of Respondent's Ucense, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund àf fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

this

of__________________, 2013. John

State S

re

ge

MD, FACS neral and

fHea

H

H

H eider sistant eneral Counsel partrnent of Health Florida Prosecution Services Unit. 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Ha. Bar No. 0815349 Telephone: (850) 245-4444, ext 8159

L

Facsimile: (850)245-4680 Department of Health v. Jennifer Marie Roman, R.N. Case Number 2013-02801

3

•

.

FLED

DEPARTMENT OF HEALTH DEPUTY CLERK. CLERK:

LS/

PCP Members:

21124k NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, qualified Florida Statutes, to be represented by counsel or other, to call arid representative, to present evidence and argument, .

cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if.a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida. Statutes, the Bàard shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed. .

Departnientaf Health

v. Jennifer Marie Roman, Case Number 2013-02801

tN

4

7196 90P& ¶111 9325 8126 TO:

Slip Pack Cassandra/Schneider

Date Mailed 7/30/2013 2013-02801 SENDER: REFERENCE:

Roman, Jennifer PS

Form. 3800, January 2005

RETURN RECEIPT SERVICE

1

Certified Fee Return Receipt Fee

Roman 3ennifer Marie Avenue. 368 Noel Estrada 00662 isabela, PR

Restricted Delivery Total Postage & Fees

USPP

Receipt for Certified MaiI' i

No Insurance Coverage Provided Do Not Use br Internatonat

III

.]s

2. Article Number

I

I

C. Signature

lilt

.

liui

.

E Addressee C Yes

D. Is delivery address dIfferent from tern 1? if YES, enter delivery address below:

No

:3. Service Typo CERTIFIED MAILT

fl

Article Addressed to:

.

Yes

—. Reference Informa*Mi C, •

Jennifer Marie Roman 368 Noel Estrada Avenue Isabela, PR 00662

Cassandra/Schneider Domestic Return Receipt

.

.

r-O

a -,"

Stip Pack 2013-0280 1

PS Form 3811, January 2005

. :

I tIE 9008 9111 9325 8126 .11

Restricted Delivery? (Extra Fee)

re

n

EXHIBIT

Mission: To proted, proniots& improve the health throu9h integrated oF all poopie in state, county &community efforts

. Vision: To be the Healthiest

Governor

hn H. Auinstroflg, MD, FACS State Surgeon General & Secretary

State in the Nalion

hereby certify in my official capacity as

Robert Johnson

I,

Rick Scott

custodian for the Board of Nursing's licerisure files that the Board of Nursing as of 9/4120 13

leading

has no evidence of an Election of Rights form or other

which would

NAME: 3ennifer Marie Roman. CASE NUMBER affect the Subject's substantial intere

r rights..

of Records

Florida Board of Nursing

identity

is

known to me

nersoriallv

under, oath, acknowledges that.

er

Sworn to and subscribed this 4

whose

Robert Johnson

Before me, personally appeared

•(type

of identification) and who,

signature appears above. day of

September

2013.

Notary Public

FJoflda Department at Health Office of the General Counsel • Prvsewlion Services Unit 4052.Bald Cypress Way, Bin C-65 •Tallahassee,

www.FlortdasHoalth.com TWITTER:HealthyFLA FACEBOOK:FLDeoarthientofrlealth

Mission:

Rick Scott

To protect promote & improve the heafth of all people in Florida through integrated state, & efforts.

Governor

John H. Armstrong, MD, FACS

._

HEALTH Vision: To

Stale S&ugeon General & Secretary

be the Healthiest State in the Na€on

AFFIDAVIT

i,

:

Deputy Clerk for the Department Clerk's Office, hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Off)cé has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case

Jennifer Marie Roman. R.N..

Case Np:

Respondent's substantial interests or rights.

which would affect the

Custodian of Record Department Clerk's Office Before me, personally appeared

identity is known to me by

personally known (type of identification) and who, under oath, acknowledges that his/her signature appears above. Sworn to and subscribed before me this

c2cL

0

day of

,

2013.

ic

My Commission Expires:

Notary PIAIIC .

My Comm.

SIS of Rend.

t

Ees Nov fOil

Comaflsjona

LE $44541

Florida Department of Health Office of the General Counsel • Services Unit 4052 Bald Cypress Way, Bin 0-65• Tallahassee, FL 32399.1701 Express mail address: 2585 Merchants Row— Suite 105 PHONE: • FAX 85012454683

-4444

12J

www.Florldasfloafth.com

lhyFLA

SOOK:FLDeparthlentofi-feath YOUTUBE: fldch

STATE OF FLORIDA

DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH, Petitioner,

v.

CASE NO.

2013-02801

JENNIFER MARIE ROMAN, R.N.,

Respondent.

•

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION 456.072(41 COMES

NOW

the

Department of

Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of

a

Final Order assessing costs against the Respondent for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter

a Final

2.

Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of Dersonnel. costs related to the time spent by the attorney and other personnel working an the case, and any other expenses incurred. by the department for the case. The board, or the department when. there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

.

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $365.06, based on the following itemized

statement of costs:

***** Cost

to Date

Hours Complaint: Investigation:

..

.

Compliance:

S255.26j

0.00

I

4.40

.

Expenses to Date:

Prior Amount: Total Costs to Date:

1

$109.80J

.

.

.

Sub Total:

.

Costs

•

0.00

$365.06

.

$0 00

.

.

.

.

.

$0.00

$365.06

2

1

the Petitioner seeks an assessment of costs against the

Respondent in the amount, of $109.80 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $109.80 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed. by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $109.80.

3

DATED this

day of

Respectfully Submitted,

of Health

Lu Sch A sistant F

.

eider

o.

neral Counsel

0815349

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email: Lucy_Schneider©doh.state.fl.us

CERTIFICATE OF SERVICE I HEREBY CERTIFY

that

a •true

and correct copy of the foregoing

Motion to Assess Costs has been fUrnished via U.S. mail to Jennifer Marie Roman, R.N., at

Estrada Avenue, Isabi

00662, on

this

General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED

•

1

STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned personally appeared SHANE WALTERS who was sworn and states as follows:

1) My name is

Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM). for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees.

DOH's total costs for investigating and prosecuting DOH case number(s) 201 3-02801 (Department of Health v. JENNIFER MARIE ROMAN, R.N.) are THREE HUNDRED SIXTY-FIVE DOLLARS AND SIX CENTS ($365.06).

5) As of today,

6) The costs for DOH case numbers 201 3-02801(Department of Healthy. JENNIFER MARIE ROMAN, RN.) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document. 7) The itemized costs and expenses for DOH case numbers 2013-02801

(Department of Health v. JENNIFER MARIE ROMAN, R.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the

following method: DOH employees who work on cases daily are to

EXHIBIT

lof2

I

1L

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses arecharged against a state health care Board (e.g., Florida Board of Dentistry, Florida Bqard.of Osteopathic Medicine), and/or a case If no Board or case can be charged, then the time and expenses are charged as administrative time The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Report). 9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon Sworn to and subscribed before me this_'k day of by Shane Walters, who is ally known to me.

atu re

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of 2

13,

Page

1

of I

Complaint Cost. Summary Complaint Number: 201302801

Subject's Name:

ROMAN, JENNIFER MARIE Cost to Date

.

Hours

[

j

Costs

}

Complaint:• investigation:

$109.80

.

[

.

.

Legal: Compliance:

{

[

2.40

[

¶0.00 5255.26

0.00

.

Sub Total: Expenses to Date: Prior Amount: Total Costs to Date:

0.00

$0.00

t*********

**********

4.40

$365.06 [

[

[

.j [

1

so.ool

so.ool

EXHIBIT

/ http://mqaapps.doh.state.fl.us/IRMOOTIMETRAK/C SDETL.ASP

9/3/2013

10

HAl

2.00

1.30

0.10

0.60 $54.90 $54.90

0.10

0.20 0.10

2.40

ILL94B

ULL94B !-ILL94B

Sub Total

Florida Department of Health

I-ILL94B

ILL94B

0.30 0.40 0.10 0.20 0.20 0.60 0.20

HLL94B HLL94B l-ILL94B FILL94B HLL94B

$106.35 $106.35

$106.35

$106.35 $106.35 $106.35 $106.35 $106.35 $106.35 $106.35

IPROSECUTION SERVICES UNIT

Sub Total

0

-IA!

$54.90

Staff Rate

JCONSUMER SERVICES UNIT

Stall Code Activity Hours

Report Date 09/03/2013

MQA

Division of Medi.col cuauty Assurance

.

•

•

.

$255.26

$21.27 $10.64 $21.27 $10.64

$63 .81

$31.91 $42.54 $10.64 $21.27 $21.27

¶109.80

$32.94 55.49 $71.37

Cost Activity Description

60

90 90

28 89

60

ING

MISCELLANEOUS PREPARE ORREVISE CLOSING ORDER MISCELLANEOUS PREPARE OR REVISE ADMINISTRATIVE COMPLAINT PROBABLE CAUSE PREPARATION POST PROBABLE CAUSE POST PROBABLE CAUSE PROCESSING MISCELLANEOUS

60 31

REVIEWCASEFILE

IINGORDER

CSU INVESTIGATIVE WORK CSU INVESTIGATIVE WORK

INT

201302801

25

!

144

78 144

Activity Code

Complaint

- Fog INTFRNAL USE ONLY -

05/28/2013 05/28/2013 06/04/2013 06/12/2013 06/12/2013 06/12/2013 07/17/2013 07/18/2013 07/30/2013 08/12/2013

05/09/2013

13 02/14/2013

Activity Date

ONF IDE NT JAL

Time Tracking System Itemized Cost by Complaint

C

.

.

.

Page

1

.

of2

I

13

Florida Department of Health

Staff Code Activity Hours

Report Date 09/03/20

—

\4QA

Assurance

Staff Rate Cost

Activity Code

Complaint

- FOR INTERNAL USE ONLY

Activity Date

CONFIDENTIAL *** 201302801

Activity Description

Time Tracking System Itemized Cost by Complaint

***

itemizedcost

Page 2

of 2

13

Total Expenses

SubTotal

Expense Date

09/03/20

Florida Department of Health

Staff Code

Report Date:

MQ.A

Medical Quolily Assurance

Ojyftion or

Amount

Expense

:

I

AL

.

-

.

Expense Code Description

Complaint

-- FOR INTERNAL USE ONLY

Expense Code

ONF

Time Tracking System Itemized Expense by Complaint

C

1

of

ise

Page

I

/ •

•

•

Mission:

l

To protect pmmoté:&:lmprove the health all peopleln FlorIda through Integrated stale unty &ouminunlty.oflorts,

:

Rick Scott Governor

John H. Annstrong,

FACS

Stale Surgeon General & Secretary

Vision: To be the Healthleststate

In the Nafton

MEMORANDUM OF PROBABLE CAUSE PANEL Department of Health- A-09 (LS) FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Roman, Jennifer Marie, R.N.

CASE NO: 2013-02501

DATE: July18, 2013

DATEOF PROBABLE CAUSE

This matter was brought before a Probable Cause Panel composed of:

Lavlgne Kirkpatrick and Mary

it Habg.ood

01, the date set forth above. The panel, having: received the investigative report and supplemental ma...terials, having carefully reviewed, said documentation and the recommendation of the agency/department, and. having had the'opportunlty toinquire ofcounsel, finds that:

x

Probable cause exists herein• that the Subject violated the following statutes/rules: (4.56.072(1)(k), F.S. (2011)

The panel suggests imposing the following penalty: V8 cause does not exist and the case should be closed with the flowing closure code: lieu of a findingof probable cause, the above named licensee shall be issueda letter of guidance to address the conduct In question: The. panel has requested supplemental or additional information on the follcAing:

,

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS

Florida Department of Health Office of the General Counsel • ProseoiOon Services Unit 4052 Bald Cypress Way Bin 0.65 'Tallahassee, FL 32399-1701 Express nail address: 2585 Mervhants Row — Suite 105 PHONE: 8501245.4444 'FAX 850/245.4683

•tNEL

om

TWITTER:HeaIlhyFLA YOUTUBE:ftdoh

_________________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, CASE

0

2013-02801

JENNIFER MARIE ROMAN, RN., RESPONDENT.

ADMINISTRATIVE COMPLAINT Petitioner, the Florida Department of Health, by and through the undersigned counsel, files this Administrative Complaint before the Board

of Nursing against Respondent, Jennifer Marie Roman, R.N., and in support

thereof states: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9334167.

3.

Respondent's address of record is 368 Ave Noel Estrada, #1,

Isabela Puerto Rico 00662. 4.

On or about November 23, 2011, Respondent was granted

licensure by endorsement to practice nursing in the state of Rodda. 5.

Section 464.009(1)(c), Florida Statutes (2011), requires that

applicants granted

a

license to practice nursing by endorsement must,

within six (6) months after obtaining their license, complete

a laws and

rules course approved by the Board. 6.

As of February 13, 2013, Respondent failed to complete the

laws and rules course required by Section 464.009(1)(c), Florida Statutes

(2011). 7.

Section 456.072(1)(k), Florida Statutes (2011), provides that

failing to perform any statutory or legal obligation placed upon

a

licensee

constitutes grounds for disciplinary action. 8.

As set

forth above, Respondent failed to perform

a

statutory or

legal obligation placed upon a licensee when she failed to complete the

laws and rules course required for licensure by endorsement in Section

464.009( 1)(c), Florida Statutes (2011).

Department of Health v. )ennifer Marie Roman, R.N. Case Number 2013-02801

2

9.

Based

on

the

foregoing,

Respondent

violated

Section

456.072(1)(k), Florida Statutes (2011), by failing to perform a statutory or legal obligation required under Section 464.009(1)(c), Florida Statutes

(2011). WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED

day of

this

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Lucy Schneider Assistant General Counsel Florida Department of Health DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Fla. Bar No. 0815349

Telephone: (850) 245-4444, ext: 8159 Facsimile: (850) 245-4680 Department of Health v. Jennifer Marie Roman, R.N. Case Number 2013-02801

3

LS/ PCP: PCP

Members:

NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Jennifer Marie Roman, RN. Case Number 2013-02801

4

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated

John H. Annstrong, MD, FACS

,c

stale, county & communit' efforts.

Stale Surgeon General

Vision: To be the

&

Secretary

Healthiest Stale in the Nail on

STATE OF FLORIDA DEPARTMENT OF HEALTH INVESTIGATIVE REPORT Office: Consumer Services Unit

Date of Case: 02/13/2013

Subject:

JENNIFER MARIE ROMAN, RN Ave. Noel Estrada 368

Isabela, PR 00662

.7035 Prefix: RN

License #: 9334167

Period of Investigation:

Case Number: RN201302801

Source: DEPARTMENT OF HEALTH/BOARD OF NURSING 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399 (850) 245-4125

Profession:

Board: Florida Board of Nursing

Registered Nurse

Report Date: 05/09/13

Type of Report: FINAL

02/14/13-05/09/13

Alleged Violation: SS. 456.072(1)(k)(dd), 464.009(1)(c) and 464.01 8(1 )(o) F.S. Legal obligation, rule/statute, Laws &Rules course, and violate rule/statute.

Synopsis: This investigation is predicated upon receipt of a referral from The Board of Nursing. ROMAN was to complete the Laws and Rules course within 6 months of licensure by endorsement. ROMAN failed to provide proof of completion of the Laws and Rules course as required by Section 464.009(1 )(c). (Exhibit #1)

.

ROMAN was notified of the investigation by letters (Exhibit #2) and was provided a copy of the CASE SUMMARY and originating documents from Exhibit #1 A search of the DOH licensure database reveals ROMAN is licensed as a Registered Nurse. The license is in a Clear Active status. No patient(s) were identified, thus patient notification was not required.

ROMAN is not known to be represented by an ROMAN has not responded to this investigation.

c..i

•-c Ca3

C

r) n,

Related Case(s):

Approved By/Date:

Investi ator/Date:

Angela Potter

I

C)

May 9, 2013

Co

Scott Flowers, Senior Management Analyst

Distribution: Consumer Services UniUProsecution Services Unit.

:

Rick Scott

Mission:

Governor

To protect, promote & improve the health at all people in Florida through integrated

I.

II.

I.

i

!

-

John H. Armstrong, MD, FACS Slate Surgeon General & Secretary

Vision:

To be the Healthiest State

in

the Nation

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER

1

TABLE OF CONTENTS

2

INVESTIGATIVE DETAILS Summary of Exhibits/Records/Documents

3

None

IV. EXHIBITS 1.

Case Summary and Originating Documents

2. Copy of Notification letters

4-5 6-11

Page

2

Rick Scott

Mission:

Governor

To protect promote & improve the health ol all people in Florida through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

Vision:

o

To be the Healthiest State in the Nation

NVESTIGATNE DETAILS

SUMMARY OF EXHIBITS/RECORDS!DOCUMENTS Exhibit #1 is the case summary and originating documents. Exhibit #2 is a copy of subject notification letters.

INVESTIGATOR NOTE: ROMAN was provided an initial notification dated 02/14/13 sent to the address of record Ave. Noel Estrada 368, Isabela, PR 00662. There was no response. A second certified letter dated 03/21/13 was sent to same address and signed for by Moises Salamanca. An Accurint check showed address listed as 368 Ave Noel Estrada #1, lsabela, PR 00662. A final notification letter dated 05/08/13 was sent to the address generated through the Accurint search. Any response will be forwarded to the file. (Exhibit #2)

Page

3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

No Document. ëcei*d For Scanning/Imaging 4

Image API,

Rick Scott

Minion:

Governor

To prolect, promote & improve the health of at people in Fiohda through integrated

nvriA

John H. Armstrong, MD, FACS State Surgeon General & Secretary

HEAL111

p

Vision: To be

the Healthiest State in the Naflon

NOTICE OF HEARING November 8, 2013 Case#: 201308171 To:

KYLE JAMES AHLER KJA 581 RANIER ST. NE

PALM BAY, FL 32907, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201 308171

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Dopartm.nt of Hesith DMsion of Medical Quality Assurance • Board ol Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 85W 2454125 • FAX 850/ 245-4172

www.FiorldasHnith.gov

lofHealth TWITTER:HealthyFL.A VOUTLJBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General

HEALTH Vision: To be

&

Secretary

the Healthiest State in the Nation

NOTICE OF HEARING

November 8, 2013 Case #201308171 To:

CENTRAL FLORIDA REGIONAL HOSPITAL 1401 WEST SEMINOLE BLVD SAN FQRD, FL 32771

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING:

S

5,S

Date:

Thursday, December

Time:

8:30AM

Type:

Determination of Waiver

Re:

KYLE JAMES AHLER KJA/201308171

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

This notice is to inform you, as an involved party or complainant, that the above listed case is scheduled to go before the Board of Nursing. While you are not required to attend, the meeting is open to the public. There is no action needed on your part at this time.

After the conclusion of the meeting, the Board file will file a final order stating the facts of the case and the Board's decision. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. This information will also be available on the Department of Health's website at: www.flhealthsource.com. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at MQA_Nursing©doh.state.fl.us.

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald Cypress Way, Bin 0-02 'Tallahassee, FL 323g9-3252 PHONE: 8501 245-4125 'FAX 850/ 245-4172

www.FlorldasNursinggoy .

TWITFER:HealthyFLA VOUTUBE: fldoh

Rick Scott

Mission:

Govemor

To protect, promote & improve the health of all people in Ftorida through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

Vision: To be the Heaithiest State in

The

Nation

MEMORAND UM

.

TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM: RE: SUBJECT:

Mary Miller, Assistant General Counsel

Determination of Waiver DOH v. Kyle James

.

ler Kja, R.N.

.

DOH Case Number 2013-08171

DATE:

September

2013

Enclosed ydu will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Kyle James Kja Subject: 581 Ranier NE Subject's Address of St. Record: Palm Bay, FL 32907 Enforcement Address: 581 Ranier St. NE Palm Bay, FL 32907 9343360 Rank: RN Subject's License No: 440798 Licensure File No:

ler

Initial Licensure Date:

6/14/2012

Board Certification: Required to Appear:

No

Current IPN/PRN Cofltract: Allegation(s): Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

No

Fiorida Departm.nt of Heaith: Office of the General Counsel . ProsecutiOn Services Unit 4052 Bald Cypress Way, Bin C-OS

Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: FAX 850/245-4683

No

464.018(1)(h),

FS

(2012)

None July 18, 2013; Habgood & Kirkpatrick Pro Se -

-

Central Florida Regional Hospital 1401 West Seminole Blvd Sanford, FL 32771

.sHeaith.com TWITTER:HealthyFLA FACE BOOK F LD e pa rtme n tofrlealth VOUTUBE: fldoh :

STATE OF FLORIDA

BOARD OF NURSING DEPARTMENT OF HEALTH, Petitioner, CASE NO 2013-08171

v.

KYLE JAMES

JA AHLER,

R.N.,

Respondent MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Bpard of Nursing for entry of a Final Order in the above-styled cause on

a

date and time that has been determined

and noticed by the Board. As grounds therefore Petitioner states: 1.

18, 2013.

An Administrative Complaint was filed against Respondent on July A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on

July 31, 2013, (7196 9008 9111 9326 5391). A copy of the certified

mail receipt is attached as Petitioner's Exhibit B.

3.

Rule

28-106.111(2), Florida Administrative Code,

provides

in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. •

4.

Rule 28. 1Q6. 111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

--

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or.•the Board of Nursing! within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C and D. 6.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by

the!

Board. 7.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final

Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State' Surgeon General and Secretary of Health

Mary S.

Assistant General Counsel Fla. Bar No. 0780420 Florida Department of Health Office of the General Counsel 4052.Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 x8104 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the above and foregoing has been provided by U.S. mail this 2013, to Kyle

day of

ler, 581 Ranier Street NE, Palm

Bay, FL 32907.

Mary S. Miller Assistant General Counsel

STATE OF FLORIDA. DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH

PETITIONER, CASE NO. KYLE JAMES

2013-08171

KM AHLER, R.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the •Board

of Nursing against Respondent, Kyle James Kja

ler,

R.N., and in

support thereof alleges:

it

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20:43; Florida Statutss; Chapter 456,

lorida Statutes; 2.

and Chapter 464, Florida Statutes.

At all times material to this Complaint, Respondent was

a

registered nurse (R.N.) in the State of Florida, having been issued license

number RN 9343360.

EXHIBIT

LA

I

Respondent's address of record isSSl Ranier Street, Northeast,

3.

Palm Bay, Florida 32907.

At all times material to this Complaint, Respondent was

4.

employed as a registered nurse by Central Florida Regional

Hospital

(CFRH), in Sanford, Florida. On or about May 9, 2013, Respondent was required to submit

5.

to an employer-ordered drug screen. On

6.

or about May 9, 2013, Respondent provided

a

urine

specimen for use in the drug test. On or about May 15, 2013, the Medical Review Officer for CFRH

7.

that

verified

Respondent's

test

drug

returned

positive

for

cannabinoids/THC. Carinabinoids are related

8.

Tetrahydrocannabinols

(THC)

are

to Tetrahydrocannabinols (THC).

the

psychoactive

marijuana, or cannabis. According to Section

(2012), THC is

a

ingredients

in

Florida Statutes

Schedule I controlled substance that has a high potential

for abuse and has no currently accepted medical use in treatment in Florida.

Its use under medical supervision does not meet accepted safety

standards.

Department of Health v. Kyle Ahier, RN. Case Number: 2013-08171

2

9.

informed

On or about May 15, 2013, CFRH's Medical Review Officer

Respondent

that

his

drug

test

returned

positive

for

cannabinoids/THC. 10.

To date, Respondent has not provided a lawful prescription and

legitimate medical reason for using cannabinoids/THC. 11.

Section 464.018(1)(h), Florida Statutes (2012), subjects

a

licensee to discipline, including suspension, for engaging in unprofessional

conduct, as defined by Rule 64B9-8.005(12), Florida Administrative Code, which defines unprofessional conduct to include testing positive for any

drugs under Chapter 893, Florida Statutes (2012), on any drug screen when the nurse does not have

a

prescription and legitimate medical reason

for using such drug. 12.

On

or about May 9, 2013, Respondent submitted to an

employer-ordered

drug

screen

which

returned

positive

for

cannabinoids/THC, drugs for which he did not have prescriptions and

a

legitimate medical reason for using. 13.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(h), Florida Statutes (2012), unprofessional conduct, as defined by Rule 64B9-8.005(12), Florida Administrative Code, to include testing

Department of Health v. Kyle Ah!er, RN. Case Numben 2013-08171

3

positive for any drugs under Chapter 893, Florida Statutes, on any drug screen when the nurse does not have a prescription and legitimate medical

reason for using such drugs. WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

Department of Health v. Ky'e Abler, R.N. Case Number: 2013-08171

4

SIGNED this

day of

JLLkLfr

,

2013.

John H. Armstrong, MD, FACS Surgeon General and Secretary of Health

S.

•

•

Mary S. MillerO Assistant General Counsel DOH Prosecution Services 4052 Bald Cypress Way, Bin C-&5 Tallahassee, Florida 32399-3265 Florida Bar Number 0780420 Telephone (850) 245 — 4444, ext. 8104 Facsimile (850) 245 — 4683

@doh.state.fl.us

/MSM PCP:

,\tsLz,j

I

Department of Health v. Kyle Case Number: 2013-08171

to13

ler,

RN.

5

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoenaS and subpoena duces tecum issued on his or her behalf if a hearing is requested.

n

NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred of this matter. costS related to the investigation and Pursuant to Section 456.072(4), Florida Statues, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Department of Health v. Kyle Case Number: 2013-08171

,

RN.

6

719L 9008 91].]. 932h 539]. TO:

Kyle James KJA Ahier, R.N. 581 Ranier Street, Northeast Palm Bay, FL 32907 4

SENDER: REFERENCE:

.

RETURN

I

Postage

cerlified

Fee

.

•

Total Postage & Fees

ISPS.

POSTMARK OR DATE

Receipt for Certified Mar

onal

No Insurance Coverage Provided Do No4 Us. for Mail

1

early)

Os

I 7196 9008 9111. 9326 539.1

a.

service Type

CERTIFIED

4.Restrlcted Delivery? (Extra Fee) 1

Article Addressed to:

-

E

Kyle James KJAAELer, R.N. 581 Ranier Northeast Palm Bay, FL 32907 Case No. 2013-08171 Stip Pack, M.Miller,baj

PS Form 3811, January 2005

Domestic Return Receipt

it

f

Rick Scott Governor

lnteW3S To protect, promote & Improve The health

John H. Armstrong, MD, FACS

-

state county & community Stone.

Slate Surgeon General & Seaetaiy

HEALTH Vision: To be The Healihiset State

in lbs Nalion

Affidavit of

I,

Sarah

,

,

hereby certify in my official capacity as custodian

of _2LI1L2fflA___, for the Board of Nursing's licensure files that the Board, as responsive pleading requesting a has no evidence of an Election of Rights form or other

Ahler. R.Na hearing prior to any agency action regarding Kyle James Kia which would affect the Subject's substantial interests or rights. Custodian of Records Florida Board of Nursing Before me, personally appeared

Sarah

,

whose identity is

signature known to me personally and who, under, oath, acknowledges that. his/her appears above. Sworn to and subscribed before me this

cptember

,

ii

day of

2013.

Notary Public Signature

J

My commission expires:

Florida Department of Health Office of TheGencral

Prosecution Servtesunft

I

EXHIBIT

Rick Scott

Minion:

Governor

To protect promote 8 improve the health ol all people in Flodda through integrated state, county & community efforts.

John H. Annetrong, MD, FACS

,

State Sumeon General & Secretary

HEALTH Vision: To be the

Keatthiest State

in

the Naton

AFFIDAVIT i

,

.

Deputy Clerk for the Department

Clerk's

Office, hereby certify in my official capacity as custodian for the Department Clerk's

records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Kyle James Kia

R.N.;

Respondent's substantial interests or rights.

which would affect the

Custodian of Record Department Clerk's Office

Before me, personally appeared

'

,

I

whose identity is

known to me personally and who, under oath, acknowledges that his/her signature appears above.

J

Sworn to and subscribed before me this

My Commission

I

Office of the General Counsel • Prosecuton Services Unft 4052 Bald Cypress Way. Bin C-65 • Tallahassee, FL 32309-1701 PHONE: 850/245-4444• FAX 850/245-4683

of

,

2013.

Pile . Ws ii

My Ciua. Ecims

Florida Dopartm.nt of H•alth

day

$svt fits'

11

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner v.

)

'

CASE NO.

KYLE JAMES KJA AHLER, R.N.,

Respondent.

2O13-08171

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW the

Department of Health, by and through

undersigned counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

7 discipline imposed through final order, qr citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries arid benefits of oersonnel, costs related to the time snent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board. shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

.

The investigation and

3.

prosecution of this case

has

resulted in costs in the total amount of $1,001.47, based on the

following itemized statement of costs:

*****

______________

_____________ fcompiaint:

l:

Investigation:

Cost to Date

***** costs

Hours 0.40]

$21.96]

11.60] 2.20]

Legal;

Expenses to Date:

Prior Amount:

0.10

$3.34

14.30

$1,001.47] 00

$0.00

to

2

Therefore, the Petitioner seeks an assessment ofcosts against the Respondent in the amount of $767.48 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, Within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $767.48 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and

is in accordance

with

Section 456.072(4), Florida Statutes. WHEREFORE, the Department of Health requests that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $767.48.

3

DATED this

tt'day of

2013.

Respectfully submitted,

Mary Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL Florida Bar #0780420 (850) 245-4444 x8104 Telephone (850) 245-4683 Fax

CERTIFICATE.OF SERVICE

I

HEREBY CERTIFY

that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day of

2013, to Kyle

ler,

581

Ranier Street NE,Palm Bay, FL 32907.

Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared SCOTT FLOWERS whp was sworn and states as follows: 1)

My name is Scott Flowers.

2)

am over the age of 18, competent to testify, and make this affidavit records at upon my own personal knowledge and after review the Florida Department of Health (DOH).

3)

I

am the Senior Management Analyst II (SMAll) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

I

4) As SMAll of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System

and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH

case number(s) 2013-08171 (Department of Health v. KYLE AHLER) are ONE THOUSAND ONE DOLLARS AND FORTY-SEVEN CENTS

($1,001.47). 6) The costs for DOH case number(s) 2013-08171 (Department of Health v. KYLE AHLER) are summarized in Exhibit 1 (Cost Summary Report), which is attached to this document.

7) The itemized costs and expenses for DOH case number(s) 201308171 (Department of Health v. KYLE AHLER) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

I

of2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost. Report) 9) Scott Flowers, first being duly sworn, states that he has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the be tipfjier knowledge..and beliefr

FURTHER AFFIANT SAYETH NOT

Affiant State of Florida County of Leon Sworn to and subscribed before me this_____ day of by Scott Flowers, who is personally known to me.

Notary Signafure

LCtWaMrId Efarne of Notary Phnted

Stamp Commissioned Name of Notary Public:

16

LAWMDA HAYES

# EE 838344

Bnnded

Tmy

Fin

2

of 2

2013,

_

Page

lot

1

Complaint Cost Summary Complaint Number: 201308171

Subjeces Name:

AFILER. KYLE JAMES KM ***** Cost to Date ***** [

1 1

Hours

[

Investigatkn:

II

11

Legal:

Compilance:

o..ioM

Costs

1

j

***.*******I Isui Total: I.Expenses to Date:

-

14.3DM

Prior Amount:

,001.471 so.oo{

Costs to Date:

lilBif

OTIMETRAKJCSDETL.ASP

9/11/2013

—

13

Staff Rate

0.10

Snb Total

I

0.40

Sal, Total

$54.90

$33.33 $33.33

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

$63.98

0.30 0.20 0.30 0.30 0.80 0.30 0.20 0.20

0.40

0199

0.40 0.20

Florida Department of Health

0199 0199 0199

0199 0199

0199 0199

(99

0199 0199 0199 0199 0199

$63.98 $63.98 $63.98 $63.98 $63.98

$63.98

0.30

0199

0.30 0.10 0.90

$63.98 $63.98

0.60 0.20

(99

0199

INVESTIGATIVE SERVICES UNIT

0.4O

1A102

ECONSUMER SERVICES UNIT

0.05 0.05

HC27

HC27

jCOMPLIANCE MANAGEMENT UNIT

Staff Code Activity flours

Report Date

f\4

Medical Quality

__________

$12.80 $12.80 $25.59 $19.19 $6.40 $57.58 $25.59 $12.80

$19A9

$38.39 $12.80 $L9.19 $19.19 $12.80 $19.19 $19.19 $51.18

$21.96

$21.96

$3.34

$1.67 $1.67

Cost

CONFIDENTIAL ***

4

4

76

4

76 4

4

4

4

4

4 76 4

4

4

4

4

78

137

137

201308171

Activity Description

VE

iVE

ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATiVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE WORK REPORT PREPARATION ROUTINE INVESTIGATiVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUT1NEINVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE WORK ROUTINE INVESTIGATIVE WORK

IEWANDANALYSISOFCOMPLAINT

PRIORITY DOWNGRADES/UPGRADES PRIORITY DOWNGRADES/UPGRADES

- FOR INTERNAL USE ONLY -

05/22/20 13 05/22/2013 05/23/20 13 05/23/2013 05/23/2013 05/23/2013 05/28/20 13 05/28/2013 05/28/20 13 05/28/2013 05/28/2013 05/28/2013 05/29/2013 05/29/2013 05/29/2013 05/29/2013 06/03/2013

05/21/2013

05/29/2013 06/14/2013

'Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

***

Page I

EXHIBIT

__________

of3

I

I

I

—

\

0.10 0.10 0.60 0.50 0.90

2.20

Sub Total

Florida Department of Health

Total Cost

HLL7OA

1-ILL7OB

-ILL7OA

ILL7OA

$63.98 $63.98

$6198

$63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98 $63.98

Staff Rate

$106.35 $106.35 $106.35 $106.35 $106.35

SERVICES UNIT

11.60

0.10 0.60 0.20 0.30 0.60

1.10 1.10

0.20 o:oo 0.20 0.40 0.20

ULL7OA

ION

Sub Total

0199 0199 0199 0199 0199 0199 0199 0199 0199

199 199

0199

Staff Code Activity Hours

Report Date 09/11/2013

M 4 4 4

76 76

06/03/20 13 06/03/2013 06/03/2013 06/Q3/2013 06/04/2013 06/04/2013 06/04/20 13 06/04/20 13 06/05/2013 06/05/2013

$1,001.47

$233.99

$10.64 $10.64 $63.81 $53.18 $95.72

$742.18

a 15

t-i

a

***

25 25 25 26 28

201308171

Activity Description

PREPARE OR REVISE ADMINISTRATIVE COMPLAINT

PREPAREORREVISEMEMORANDUM

REVIEW CASE FILE

REVIEWCASEFILE

REVIEW CASE FILE

ROUTINE INVEStIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION REPORT PREPARATION ROUTINE INVESTIGATIVE WORK REPORT PREPARATION ROUTINE INVESTIGATIVE WORK ROUTINE INVESTIGATIVE WORK REPORT PREPARATION

Complaint

- FOR INTERNAL USE ONLY -

05/23/2013 06/04/2013 06/11/2013 06/12/2013 06/14/20 13

4 76 4 4 76

4 4

06/03/2013

06/03/2013

$1180

Activity Code

Activity Date

Cost

$38.39 $12.80 $25.59 $12.80 $70.38 $70.38 $6.40 $38.39 $12.80 $19.19 $38.39

a

Time Tracking System Itemized Cost by Complaint

'.511

IAt-i

itemizedcost

Page 2 of3

Assmance

Florida Department of Health

Staff Code Activity Hours

Report Date 09/11/2013

Ivt

Medicql

__________

Staff Rate Cost

Activity Code

- FOR INTERNAL USE ONLY -

Activity Date

Complaint 201308171

Activity Description

Time Tracking System Itemized Cost by Complaint

***CONFIDENTJAL***

iternizedeost

Page

3

of3

Total Expenses

SubTotal

Expense Date

Florida Department of Health

Staff Code

Report Date:

Medical Quolity Assurance

Amount

Expense

Expense Code Description

- FOR INTERNAL USE ONLY -

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

***CONFIDENTIAL

1

itemizedexpense

1

of at

i

Rick Scott

t

Mission promote'&lmprovetheheaith through fritegrated

rvovGmor

John HrAnnitrong, MD, FAGS

HEALTH ViSlon:'To be the Healthiest State

In

the Nation

)

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health-A-12

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

ler, Kyle James KJA, R.N.

DATE OF PROBABLE CAUSE MEETING:

CASE NO: 201 3-08171

DATE: 7-18-2013

This matterwas brought before a Probable Cause Panel composed of:

lgno KIrkpatrick and Mary K. Habgood On the date set forth, above. The panel, having received the investigative report and supplemental materials, 'having carefufly.reviewe'd said documentation and the recommendation of the agency/department, and having had theopportunity to inquire of'counsel, finds that:

x

Probable cause exists herein that the Subject violated the following statutes/rules: (464;018(1)(h), F.S. (2012)

Thepanel suggests imposing the following penalty: V6A, Costs, Administrative Fine $250 cause does not exist and the case should be closed with the flowing' closure code:.

lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct.i'n question:

The panel has requested supplemental or additional information on the'following: Other

Florida Dep.rtmsnt of Itsaith Office of The General counsel • Prosecuflon Services Unit 4052 Bald cypress Way, Bin 0-65 'Tallahassee, FL 32399-4701 Express mail address: 2565 Merchants Row — Suite 105 PHONE: 8501246-4444 'FAX 8501245-4683

www FiorldssH.sI

,

m

TIE R'.HealthyFLA

• ,

epa Y

entoir,ea,u TUBE. fldoh

STATE OF FLORIDA DEPARTMENT OF HEALTh

DEPARTMENT OF

9

PFflTION

9

v.,

CASE NO.

2013-08171

KYLF JAMES KIA AHLER, RESPONDENTU

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board. of Nursing against Respondent, Kyle James Kja

ler,

R.N., and in

support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

a

resistered nurse (R.N.) in the State of Florida, having been issued license

number RN 9343360.

3.

Respondent's address of record 1s581 Ranier Street, Northeast,

Palm Bay, Florida 32907. 4.

At

employed as

a

Respondent was

times material to this

aD

registered nurse by Central

Regional

(CFRH),.in Sanford, Florida. 5.

to an employer-ordered drug 6.

0

On or about May 9, 2013, Respondent was required to submit

On or about May 9,

2013, Respondent provided a urine

specimen for use in the drug test. 7.

verified

On or about May 15, 2013, the Medical Review Officer for CFRH

that

Respondent's

test

drug

returned

positive

for

cannabinoids/THC. 8.

Cannabinoids are related to Tetrahydrocannabinols (THC).

Tetrahydrocannabinols marijuana, or cannabis.

(2012), THC is

a

(THC)

are

the

psychoactive

ingredients

in

According to Section 893.03(1), Florida Statutes

Schedule I controlled substance that has a high potential

for abuse and has no currently accepted medical use in treatment

in

Florida. Its use under medical supervision does not meet accepted safety

standards.

Department of Health v. Kyle Ahier, R.N. Case Number: 2013-08171

2

9.

informed

10.

On or about May 15, 2013, CFRH's

Respondent

that

drug

test

Review Officer

returned

positive

for

To date, Respondent has not provided a lawful prescription and

for using cannabinoidsfrHC.

legitimate medical 11.

his

l

Section 464M18(1)(h), Florida Statytes (2012),

subjects a

licensee to discipline, including suspension, for engaging in unprofessional

conduct, as defined by Rule 64B9-8.005(12), Florida Administrative Code, which defines unprofessional cOnduct to include testing positive for any drugs under Chapter 893, Florida Statutes (2012), on any drug screen

when the nurse does not have

a

prescription and legitimate medical reason

for using such drug. 12.

On

or about May 9, 2013, Respondent submitted to an

employer-ordered

drug

screen

which

returned

positive

for

cannabinoidsfrhC, drugs for which he did not have prescriptions and

a

legitimate medical reason for using. 13.

Respondent violated Section 464.018(1)(h), Florida Statutes

(2012), unprofessional conduct, by testing positive for hydromorphone

and/or hydrocodone, drugs under Chapter 893, Florida Statutes (2012), for

Department of Health v. Kyle Ahier, RN. Case Number: 2013-08171

3

which he did not have a prescription and legitimate medical reason for using such drugs. WHEREFORE,

the Petitioner

ly

requests that the Board of

Nursing enter an order imposing one or more of the

penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine,

of a reprimand,

placement of the Respondent on probation, corrective action, refund of

fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGN ED

this

day of

2013.

John H. Armstrong, MD, FACS Surgeon General and Secretary of Health

Mary S. Miller Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0780420 Telephone (850) 245 — 4444, ext. 8104 Facsimile (850) 245 — 4683

.us

/MSM PCP: PCP Members: Department of Health v. Kyle Case Number: 2013-08171

ler, R.N.

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is

0

NOTICE REGARDING ASSESSMENT OF COSTS

0

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this Pursuant to Section 456.072(4), Florida Statues, the Board assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline

0

Department of Health v. Kyle Ahier, R.N. Case Number: 2013-0817 1

5

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

-

/

¼_f

C4&

STATE OF FLORIDA

DEPARTMENT OF HEALTH INVESTIGATIVE REPORT Case Number 201308171

Date of Case; 7/06/12

Office: Orlando

Source: Central Florida Regional CHRIS TARAMASCO, RN, CNO 1401 West Seminole Blvd Sanford, Fl 32771

Subject: KYLE JAMES AHLER KJA, RN 581 Ranier St Palm Bay, Fl 32907 321-289-3150 (hm) Prefix;

License #:

1701

9343360

Profession: Registered Nurse

Report Date: 6/05/13

Board: NURSING

Type of Report: FINAL

Period of Investigation:

5/22/13- 6/05/13

Alleged Violation: Section 456.072(1)(z)(aa)(dd), 464.018(1)(h)Q)(o) FS: Being unable to practice with reasonable skill and safety; Testing positive for any drug; Violating any provision of this chapter; Unprofessional conduct; Violating any provision of this chapter or chapter 456.

.

Synopsis: This investigation is predicated upon receipt of a Complaint from CHRIS TARAMASCO, Chief Nursing Office of Central Florida Regional Hospital, stating KYLE JAMES AHLER, RN, tested positive on a drug screen, subsequent to violating the drug wasting policy, on 5/15/12, Exhibit

.

AHLER was flotified of the investigation by letter dated 5/22/13 and was provided a copy of the Case Summary and complaint documents, Exhibit DOH licensure records reveal AHLER first licensed as a RegistSNurse in June 2012 and has a clear and active license.

There is no patient involvement.

AHLER is not represented by an attorney at this time. AHLER denied the allegations during a phone interview on 5/29/13. He stated that he signed a contract with IPN, because he needs to continue to work.

)

Related Complaint: NONE Investigator/Date:

Approved By/Date:

Jack Bergquist, MMI (01-99) Medical Quality Assurance Investigator

Kim Haley, RN

Distribution:

C

Investigations Manager

HQ/ISU

07

i

'

c

r 1

DOH INVESTIGATIVE REPORT

CASE NUMBER: 201308171

TABLE OF CONTENTS I.

II.

INVESTIGATIVE REPORT COVER

I

TABLE OF CONTENTS

2

III. INVESTIGATIVE DETAILS

Summary of Records/Exhibits/Documents

Interview of CHRIS TARAMASCO, RN, CNO — source Interview of NANCY BAKEWELL, RN - witness Interview of KARLA WUEST - witness Interview of MYRTLE GREEN - wftness Statement from KYLE JAMES AHLER, RN — subject

3

4 4-5 5 6 6

IV. EXHIBITS

*1. Case Summary and attachments *2. Copy of the sublect notification letter, dated 5/22/1 3 •3 Copy of the status 30 letter to source

7-8 9-11 12

*4 Subpoena #A0080805 for AHLERS personnel documents from Central FL Reg Hospl3-21 22-36 Copy of AHLER'S personnel documents from Central FL Regional Hospital *6. Additional personnel documents from Central FL Regional Hospital 37-42 *7 Copy of Central FL Regional Hospital's Substance Use in the Workplace Policy 43-50 *8. Copy of IPN Investigator Communication Form 51-52 *9 Seminole County Clerk of Court Docket printouts for AHLER 53-55

1

*EXHIBIT5 CONTAIN INFORMATION WHICH IDENTIFIES PATIENT(S) BY NAME AND ARE SEALED PURSUANT TO SECTION 456.057(1O)(a), FLORIDA STATUTES ** THESE RECORDS ARE SEALED PURSUANT TO SECTION 456.057(1O)(a), FLORIDA STATUTES AND

COPIES OF SAME ARE NOT MAINTAINED

IN

THE ORLANDO INVESTIGATIVE OFFICE". 2

CASE NUMBER: 201308171

DOH INVESTIGATIVE REPORT

INVESTIGATIVE DETAILS

SUMMARY OF RECORDS/EXHIBITS/DOCUMENTS

) )

Exhibit

is Subpoena #A0080805 for

AHLERS personnel documents from Central Florida

Regional Hospital.

Exhibit KARLA

> > > >

>

AHLER'S personnel documents from Central Florida Regional hospital, provided by WUEST, contain the following: Medication Diversion Report indicating standard deviation of4 to 4.9 for February 2013. Medication Diversion Report indicating standard deviation of 5 or more for March 2013. Employee Counseling Form dated 4/2/13 for multiple high deviations in February and March 2013. Employee Counseling Form dated 5/8/13 for suspension for multiple high deviations in February and March and first week of April 2013 for Morphine, Hydrocodone and Hydromorphone. Employee also signed out narcotics for another nurse's patient, and signed out narcotics for a patient just prior to admission, using admitting orders. Employee had been counseled that continued appearance on RxAuditor would initiate a drug screen request. Drug screen scheduled for 5/8/13. Suspicious Event-Drug Related Reporting Form reveals the following: AHLER was hired as a new nurse on 8/06/12 No behavioral or attendance issues Drug screen positive for marijuana Diversion was not substantiated AHLER was terminated on 5/15/13

Exhibit

) ) ) )

is

Additional termination documents from KARLA WUEST, which includes confirmation of

Human a positive drug screen test from SETH PORTNOY, DO, the Medical Review Officer. of policy violation and the date termination as a Document notes the reason for Recourses termination as 5/18/1 3.

Exhibit

is a copy of Central Florida Regional Hospital's Substance use in the Workplace Policy, provided by KARLA WUEST.

Exhibit

is a copy of IPN Investigator Communication Form from Case Manager MYRTLE GREEN, indication that AHLER KJA is presently an active and compliant IPN participant.

Exhibit

Seminole Clerk of Court web site showing AHLER pled Nob Contendere to a 5/01/12 DUI arrest (592011MM006565A) and is scheduled for arraignment on the following charges from an arrest on 4/17/13 (case # 59201 3CFOO1 1 53A): > Altering/removing serial or ID number from a firearm > Carrying concealed firearm > Possess controlled substance without prescription (MDMA) > Use or possession of drug paraphernalia is print outs from

3

.

DOH INVESTIGATIVE REPORT

CASE NUMBER: 201308171

INTERVIEWS/STATEMENTS

INTERVIEW OF CHRIS CHRIS TARAMASCO, RN, CNO Central Florida Regional Hospital 1401 West Seminole Blvd Sanford, Fl 32771 407-321-4500

RN. CNO (Lic#

—

source

Attempts were made to contact TARAMASCO by phone on 5/22/13 and 5/23/13. On 5/23/13 AM, TARAMASCO'S assistant, ARLENE, said TARMASCO would be in meetings all morning and suggested call back after 3:00 PM. When a call was placed at 4:00 PM, ARLENE state TARAAMASCO was in another meeting that just stated. Another message was left on her answer machine. I

TARAMASCO returned the call at 4:30 and was interviewed. She said AHLER was a fairly new employee and that a couple of random Pyxis reports indicated that he was above the standard deviation. TARAMASCO stated AHLER was counseled by the Emergency Department Director, NANCY BAKEWELL, RN, concerning proper use of Pyxis and he seemed to improve. However, recently another nurse (name unknown) observed AHLER attempting to medicate one of his patients. TARAMASCO said the other nurse objected and stopped AHLER, saying, "what are you doing; you're not going to medicate my patient; Go waste that medicine". TARAMASCO said AHLER apparently failed to waste, as he charted that he administered the medication. TARAMASCO requested a drug screen. She said the Director brought AHLER to Employee Health for testing, but he left right after she left. TARAMASCO said the Director found AHLER attempting to open his locker, immediately after he left Employee Health. TARAMASCO said the Director walked AHLER back to Employee Health, where he gave a urine sample, which tested positive for THC.

)

Copies of the Drug Free Workplace, Pyxis use, and wasting policies and procedures were requested. TARAMASCO was informed that would like to interview NANCY BAKEWELL and the nurse whose patient AHLER attempted to medicate. I

INTERVIEW OF NANCY BAKEWELLI RN (Lic# Emergency Department Director Central Florida Regional Hospital 1401 West Seminole Blvd Sanford, Fl 32771 407-321-4500

-

witness

BAKEWELL said AHLER, she was unaware his last name on his nursing license is KJA. BAKEWELL said AHLER was hired as a new nursing school graduate and the hospital provided him six weeks on in-house training, before he was assigned to work in the hospital. She said initially, AHLER had problems jamming Pyxis and about two weeks after training, she noticed he failed to have another nurse witness wasting in Pyxis, though a witness was charted in the MAR.

BAKEWELL said she counseled AHLER concerning poor documentation, as he frequently failed to document the patient's response, subsequent to medication administration. She also said AHLER 4

DOH INVESTIGATIVE REPORT

CASE NUMBER: 201308171

administered medication to other nurse's patient. However, she stated that is not a problem by it self, as nurses are encouraged to help each other, especially when it gets busy and BAKEWELL said it busy at the time that AHLER administered medication to the nurse's patient who objected. BAKEWELL said they do not pair nurse into teams, as some hospital do, everybody assists when it gets busy. BAKEWELL identified the nurse who objected to AHLER'S administrating to his patient as TITO MERO, RN. She said MERO did not report the incident to her, but mentioned it to another nurse, who informed her. BAKEWELL corrected TARAMASCO'S version of events by stating that AHLER had actually administered the medication to MERO'S patient and properly charted it and the MERO did not administer the medication at the same time. BAKEWELL also stated that there were no further problems with AHLER'S wasting, all wasting was properly witnessed and documented. She also said there were no problems with patients failing to be relieved, subsequent to charted medications.

BAKEWELL said what bothered her was that AHLEk was the nurse who consistently administered pain medications to patients when several nurses were working on a patient. She said that is a red flag, combined with the fact that AHLER continued to medicate other nurse's patients and only marginally improved in documenting reassessment, after medication administration. BAKEWELL was asked which pharmacist reviewed Pyxis and came up with the above average deviations. BAKEWELL said she did the research, explaining nursing, not pharmacy, researches Pyxis use at Central Florida Regional Hospital. INTERVIEW OF KARLA WUEST Risk Manager Central Florida Regional Hospital 1401 West Seminole Blvd Sanford, Fl 32771 407-321-4500

—

witness

Two attempts were made to contact Risk Management on 5/23/13. The first call at 11:45 was not answered. The second call at 4:10 PM was answered by an answer machine, stating after hours, past 4:30 PM, would be returned the following day. A message was left requesting a return call. On 5/28/13 a subpoena for personnel records was sent to WEST, which included a note requesting she call the Orlando office.

Another attempt was made to contact WUEST by phone on 6/03/13. ARLENE answered the phone and said WUEST has routed all of her calls to her this date. After explaining that was checking on the status of some personnel documents that had subpoenaed, she said she would contact WUEST and let her know of my inquiry. I

I

WUEST called the Orlando office on 6/03/13. She agreed to fax the personnel file this date. WUEST was called after reviewing the personnel documents, as the chain of custody and lab results were missing, as well as the termination document. WUEST said she would try to obtain them from the Director of Human Resources, LINDA SMITH, tomorrow. WUEST was contacted after reviewing the additional documentation. She was asked for a copy The termination or resignation letter and any related statements. WUEST said the material she sent came from the corporate office. She said she would ask the Personnel Director for additional material. 5

DOH INVESTIGATIVE REPORT

INTERVIEW OF MYRTLE GREEN IPN Case Manager 904-270-1620

CASE NUMBER: 201308171

—

witness

An attempt was made to interview GREEN on 5/59/13. machine requesting she call the Orlando office. GREEN stated that ALHER had just submitted his application to IPN would not be illegible to contract with IPN for about a month,

A message was left on her answer returned the call later this date and this date. She explained that AHLER as he must be evaluated first.

ATTEMPED INTERVIEW OF KYLE AHLER — sublect CONTACT WITH MIKE AHLER - subject's father 581 Ranier St Palm Bay, Fl 32907 321-984-7199 (hm) A called place to AHLER'S phone number of record, on 5/28/1 3, was answered by MIKE AHLER, AHLER'S father, who stated KYLE no longer lives there. He offered to call KYLE and inform him that the Department was trying to reach him and give him my phone number.

INTERVIEW OF KYLE AHLER — subject 581 Ranier St Palm Bay, Fl 32907 321-289-3150 (hm) AHLER called The Orlando office on 5/29/13 and was briefly interviewed. AHLER denied being under the influetice of uuana while at work. He said he was surprised that he tested positive for marijuana. AHLER also denied the hospital's allegation that he improperly wasted a narcotic at work. However, AHLER said he signed a contract with IPN, because he has to continue to work as a nurse. AHLER provided his current phone number and stated that the above address is his permanent address.

6

;

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

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Rick Scott

Minion: To protect, promote & improve the health

John

Armstrong, MD, FACS

Slate Surgeon General & Secretary

H EA1]1—I Vision: To

.

Governor

be the Healthiest State in the Nation

NOTICE OF HEARING November 8, 2013 Case#: 201306738 To:

DEBORAH MARIE WOLFE 2121 SE 10TH TERRACE CAPE CORAL, FL 33990, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201306738

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

ida Dopartm.nt of Hosith Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 8501 245-4125 • FAX 850/ 245-4172

lorldasHnlth.gov TWI1TER:HealthyFLA FACEBOOK:FLDepartnentofHealth VOuTUBE: lldoh

Rick Scott

Minion:

Governor

To protect, promote & improve the health of all people in Florida through integrated

John H. Armstrong, MD, FACS

I

state, county & community efforts.

Vision: To be the Healthiest State in

State Surgeon General & Secretary

the NaUon

MEMORAND UM TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM: RE: SUBJECT:

Mary Miller, Assistant General Counsel

DATE:

Determination of Waiver

.

DOH v. Deborah Marie Wolfe, R.N. DOH Case Number 2013-06738

.

,

.

.

September 11. 2013

.

Enclosed you will find materials in the above-referenced case to be placed-on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of

-

Record:

Enforcement Address: Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s): Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address:

Fiorida Department of Health Office of the General Counsel ProsecuUon Services Unit 4052 Bald Cypress Way, Bin Tallahassee, FL Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX 850(245-4683

1701

Deborah Marie Wolfe 2121 SE 10th Terrace Cape Coral, FL 33990 2121 SE 10th Terrace Cape Coral, FL 33990 9333652 Rank: RN 436501

11/8/2011 No No No

464.018(1)(b),

FS

(2012)

None

July 18, 2013; Habgood & Kirkpatrick Pro Se

Department Of Health! Board Of Nursing

.com lealth

TWITTER:HealthyFLA VOUTUBE: fldoh

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENTOF HEALTH,

Petitioner, v.

CASE NO.

2013-06738

DEBORAH MARIE WOLFE, R.N.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER BY HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PetitiOner, Department of Health, by and through counsel, moves the Board of Nursing to find that Respondent has waived his/her right to elect a

method of disposition of the pending Administrative Complaint, to determine that no material facts are in dispute, to conduct a hearing not involving disputed

issues of material fact, and to enter a Final Order. As grounds therefore,

Petitioner states: 1.

18, 2013.

An Administrative Complaint was filed against Respondent on July

A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A. )

2.

Copiesof the Administrative Complaint, Explanation of Rights form,

and Election of Rights forms were sent to Respondent, via certified US mail

succethfuUy, on August 3, 2013 (7196 9008 9111 9326 5384). A copy of the

certified mail receipt is attached as Petitioner's Exhibit 3.

B.

Respondent has not filed with either the Department of Health or the

Board of Nursing, an Election of Rights form or other responsive pleading in this

s

case within the twenty-one (21) day period to dispute the allegations contained in the Administrative complaint.

4.

of affidavits

Exhibits

Rule 28-106.111(2),

C

and D.

Florida Administrative

Code,

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision.

.

Rule 28.106.111(4),

Florida Administrative Code,

provides in

pertinent part that: any person who received written hotice of an agency decision and who fails to file a written request for a 21 days waives the right to a hearing on such matters. •

6.

Respondent has been advised, by a copy of this motion sent to

his/her address of record, that

a

copy of the investigative file in this case. shall be

furnished to the Board to establish

a

prima fade case regarding the violations as

set forth in the Administrative Complaint.

7.

The Department has determined that there are no material facts in

dispute and has concluded that Respondent has waived his/her right to elect the method of resolution. 8.

The Department requests that this Motion and

a

hearing be placed

on the agenda for the next meeting of the Board of Nursing. WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived his/her right to elect a method of resolution Of this

matter, find that there are no material facts in dispute, hold

a

hearing not

involving material issues of disputed fact based on the information contained in

the investigative file, find that Respondent violated Chapters 456 and 464, Florida Statutes, as alleged in the Administrative Complaint, impose discipline in

accordance with the disciplinary guidelines, and enter a Final Order.

Respectfully submitted,

Armstrong, MD, FACS State Surgeon General and Secretary of Health_ H.

Assistant General Counsel Florida Bar No. 0780420 Department of Health Prosecution Services Unit 4052 Bald Cypress Way Bin C-65

Tallahassee, Florida 32399-3265 Telephone: (850) 245-1111 x8104 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE I HEREBY CERTIFY

that

a

,

true and correct copy of the foregoing Motion

for Determination of Waiver and for Final Order by Hearing Not Involving Disputed Issues of Material Fact has been furnished via U.S. mail this

day of Cape Coral, FL 33990.

/

to Deborah Wolfe, 2121 Southeast 10 Terrace,

Mary S. Mile) Assistant General Counsel

Respondent's address of record is 2121 Southeast

3.

Terrace,

Cape Coral, Florida 33990.

on or about April 25, 2013, the Indiana StateBoard of NursiAg

4.

acted against Respondent's nursing license by suspending her license to

practice

the State of Indiana for a minimum of two

as a registered nurse in

years.

.

The Indiana State Board of Registered Nursing is the licensing

S.

authority for the State of Indiana. Section 464.018(1)(b), Florida Statutes (2012), provides. that

6.

having

licenEe to practice nursing revoked, suspended, or otherwise

a

acted against by the licensing authority of another State constitutes

grounds for disciplinary action by the Board of Nursing. On or about April 25, 2013, the Indiana State Board

7.

of NUrsing

acted against Respondent's nursing license by suspending her nursing license in the State of Indiana for 8.

•

Based. on

the

a

minimum of two years.

foregoing,

Respondent

violated

n

464.018(1)(b), Florida Statutes (2012), by having her license to practice nursing revoked, suspended or otherwise acted against by the licensing

authority of another State.

DOH v. Deborah Wotre, RN Casc Number: 2013-06738

2

WHEREFORE, the Petitioner requests

that the Board of Nursing enter

an order imposing one or mare of the following penalties: permanent

revocation or suspension of Respondent's license, restriction of practice,

imposition of an administrative fine, issuance of

a

reprimand, placement of

the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and:any other relief that the Board deem&

appropriate.

SIGNED

this

day of

,

2013.

H. Armstrong, MD, FACS Surgeon General and Secretary of Health

John

)tti,+S rr(: Il,v

pK E LED

DEPARTMENT OF HEALTH

Mary S. Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Florida 32399-3265 Florida Bar Number 0780420 Telephone (850) 245 — 4444, ext. 8104 Facsimile (850) 245 — 4683

[email protected] .us

PCP: PCP Members:

•

Lfe,

DON v. Deborah RN. Case Number: 2013-O&73B

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented-by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board èhall assess costs related to the investigation and .:prosecutjon of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any Other discipline imposed.

DOH v. Deborah W&fe, RN. Case Number: 20L30673B

4

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93.1]. 9326 5384

TO:

Deborah Marie Wolfe, RN. 2121 Southeast 10th Terrace

Cape Coral, FL 33990 SENDER:

REFERENCE:

Postage

RETURN RECEIPT

l&3-067fl

i

Certified Pee

SERVICES

b

D Total Postage & Fees

user

POSTMARK OR DATE

Receipt for Certified Mar No Insurance Cowrags Pmvidsd Do Nc4 Use for International

2.

ArtIcle Number A.

—

1

7196 9008 1111 9326 5384

x

C Addressee

0. Is delivery address different frDrn item If YES, enter delivery 3.

Service Type

4. Restricled Delivery? (Extra Fee) 1.

—

CERTIFIED MAILTM

DYes

Deborah Marie Wolfe, R.N. 2121 Southeast 10th Terrace Cape Coral, FL 33990

•

C,

C,

r

C

Case No. -067385tip Pack, 'C-

Domestic Return Receipt

ENo

B

Article Addressed to:

PS Form 3811, January 2005

C Yes

1

Rick Scott

Mission:

Governor

To protea, promote & improve the health

k'luncia

John H. *nnstrong, MD, State Surgeon General &

HEALTH Vision: To be the Healthleststate

in

the Nathn

Affidavit of Non-Receipt

,

Sarah Starling

,

Seoelary

,

hereby certify in my official capacity as custodian

for the Board of Nursing's licensure files that the Board, as of

9/11/2013

has no evidence of an Election of Rights form or other responsivepleading requesting a

hearing prior to any agency action regarding Deborah Marie Wolfe, R.N.; which would affect the Subiect's substantial interests or rights.

$faJu* of RecordF Florida Board of Nursing Custodian

Before me, personally appeared

Sarah Starling

,

whose

id&itity is known to me personally and who, under, oath, acknowledges that his/her

signature appears above. Sworn to and subscribed before me thi.s

September

,

ii

day of

2013.

Notary Public Signatre My commission expires:

Florida Dspartn.ont of Hnlth Office of the General Counsel •

aMoa

www.FlorldasHealth.com

i

Rick Scott

Mission: .

To protect, promote & improve the

people state, county

Integrated

John H. Annstrong, MD, FACS

&comunay efforts.

,

State Suigeon General & Secretay

HEALTH Vision: To be the

Healthiest State

in

the Nathn

AFFIDAVIT

\

,

Deputy Clerk for the Department

Clerk's

in my official capacity as custodian for the Department Clerk's

Office,

records, that the Department Clerk's Office has not received an Election of Rights form

or other responsive pleading, which requests a hearing prior to any Department action

.

regarding Deborah Marie Wolfe, R.Na

Respondent's substantial interests or rights.

which would affect the

.

of Record Department Clerk's Office

whose identity is

Before me, personally appeared

known to me personally and who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this

Not

of_________________

13.

Pub Notary

Caisuian 0 Ef

Florida Department of Health Office of the General Counsel • Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 'Tallahassee, FL32399-1701 PHONE: 650/245.4444 FAX 850/245-4683

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14414?

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www.FI

EXHIBIT

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2013-06738

v. DEBORAH MARIE WOLFE, R.N.;

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW. the Department of Health, by and through

undersigned counsel, and moves the Board of Nursing for the entry

of

a

Final Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds• therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take-up- for consideration the above-styled disciplinary action and will enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel. costs related to the time spent by the attorney and other personnel working on the case, and any other incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

3.

.

The investigation and

prosecution of this case

has

resulted in costs in the total amount of $211.01, based on the

following itemized statement of costs:

*****

cost to Date

.

Hours

costs

Complaint:

i.io]

Investigation:

i.oo]

Legal:

0.901

Compliance:

.

Sub Total:

.

Prior Amount:

[

$54.90J

Yo

3.00

[

•

0.00

Expenses to Date: 'Total Costs to iDate:

$60.39!

•

I

1

I

$211.01

$211.01 J

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $115.29 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to. the

of costs, within ten (10) days of the date of this motion, specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based Upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $115.29 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section

Florida Statutes.

WHEREFORE, the Department of Health

requests that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $115.29.

3

-

•

DATED this

I#day of

2013.

Respectfully submitted,

Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265

#0780420.

(850) 245-4444x8104 Telephone (850) 245-4683 Fax

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess GOsts has been provided by U.S. Mail this day of

2013, to Deborah Wolfe,

2121 SE 10 Terrace, CapéCoral, FL 33990.

Mary S. Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTYOF LEON:

BEFORE ME, the undersigned authority, personally appeared SCOTT FLOWERS who was sworn and states as follows: 1)

My name is Scott Flowers.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Senior Management Analyst II (SMAll) for the Consumer Services and Compliance Management Unit for DOFI. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.-

I

I

I

4) As SMAll of the Consumer Services and Compliance Management

Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees. 5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-06738 (Department of Health v. DEBORAH

MARIE WOLFE) are TWO HUNDRED ELEVEN DOLLARS AND ONE CENT ($211.01). 6) The costs for DOH case number(s) 201 3-06738 (Department of Health

DEBORAH MARIE WOLFE) are summarized in Exhibit Summary Report), which is attached to this document. v.

1

(Cost

7) The itemized costs and expenses for DOH case number(s) 201306738 (Department of Health v. DEBORAH MARIE WOLFE) are

detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

EXHIBIT I

of 2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time, The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Scott Flowers, first being duly sworn, states that he has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knowledge and belief.

FURTHER AFFIANT SAYETH NOT.

Sthtt-Ft6Qvers, Affiani

State of Florida County of Leon Sworn to and subscribed before me this j day of by Scott Flowers, who is personally known to me.

2013,

Notary Signature

Name of Notary Printed

1'

.

Stamp Commissioned Name of Notary Public:

BERMDE1TE I.AWMDA WYES

BoMed Uni Tray rin

biSnc

C

2of2

/

Page

1

of

1

laillt Cost Summary Complaint Number: 20130673S

Subject's Name:

WOLFL, DEBORAH

*****

Investigation: Legal: Compliance: [

Cost to Date *****

Hours

H

I

1

I

IE

11 1

0.90(

Costs $60.39 $54.90 $95.72

3.00

$211.01

II

I

Total: Expenses to Date: Prior Amount: Total Costs to l)ate:

{Suh

I

I

so.ool

I

so.ool $211.01

ICSDETL.ASP

.

EXHIBIT

2.10

Sub Total

$5.49

$54.90

Cost

Sub Total

OA OA

0.90

0.40 0.50

$106.35 5106.35

$21 I.O1

$95.72

$42.54 553.18

$115.29

$54.90 $54.90

IPROSECUTION SERViCES UNIT

HA 107 HA52

1.00 1.00 0.10

I-IA 107

Cost

$54.90 $54.90

Staff Rate

ICONSUMER SERVICES UNIT

Staff Code Activity Hours

ReportDate

Medical Quality Assurance

25 28

2

78 77

I

201306738

Activity Description

REVIEWCASEFILE PREPAREORREVISEADMINISTRATIVECOMPLAINT

.

INITIAL REVIEW AND ANALYSIS OF COMPLAINT PREPARATION OF DESK INVESTIGATION SYNOPSIS OFFICE SUPERVISORY DUTIES

- FOR INTERNAL USE ONLY -

05/31/2013

05/31/2013

04/30/2013 05/23/2013 05/23/2013

Activity Date Activity Code

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFIDENTIAL***

itemizedeost

Page! of I

I

I

Total Expenses

SubTotal

Expense Date

Florida Department of Health

Staff Code

Report Date: 09/11/2013

MOA AmOUnt

Expense -

Expense Code Description

FOR INTERNAL USE ONLY--

Expense Code

Complaint

Time Tracking System Itemized Expense by Complaint

***CONFIDENTJAL***

I

of!

iternizedexpense

Page

,

Rick Scott Governor

To:protect,:promote.& Improve the health ofalFpeoplelh Florida thrcugh Integrated state, courity.& community efforts.

John H. Ann.trong,

HEALTH Vision: To be the

FAGS

State Surgeon General & Secretary

HealthIest State in the Walton

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health- A-02 (MM)

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Wolfe, Deborah

1

i

CASE NO: 2013-06738

RN.

DATE:

DATE OF PROBABLE CAUSE MEETING:

-

This matterwas broughtbefdre-a ProbabLe Cause Panel composed of:

:Lavigne Kirkpatrick and Mary K. Habgood

having received the investigative report and supplemental materials, On the date set forth above. The having carefully reviewed.said documentation and the recommendation of the agency/department, and having had the opportunity to. inquire of counsel, finds that:

Probable causeexists herein that the Subject violated the following statutes/rules: (464.Q1$(1)(b), F.S. (2012))

x

.

.

:

The panel.suggests imposing the following penalty: V6B, Costs, Administrative Fine $260,00 cause does not exist and the case should be closed with the flowing closure

i

lieu of a finding of probable cause, the above named licensee shall be issued address theconduct question:

:a

letter of guidance to

The.panet has. requested supplemental or additional information on the following:

1

Florida Department of Health

Office othe General Counsel • Prosecuflon Services unit FL 32399-1 701 cypresa:Way Bin C-65 4052 Express rnaltaddress: 2585 Merc$rnnls Row — SuIte 105 850/245-4683 PHONE:

Id

www, Flo rid as H esith , co m TWITTER:NeaIthyFt.A FACEBOOK:FLDepamnentofl-lealth

:fldoh

0

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

v

CASE NO.

2013-06738

DEBORAH MARIE WOLFE, R.N., RESPONDENTO

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and flies this Administrative Complaint before the Board of Nursing against Respondent Deborah Marie Wolfe, R.N., and in

support thereof asserts: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

a

registered nurse (R.N.) within the state of Florida, having been issued license number RN 9333652.

3.

Respondent's address of record is 2121 Southeast

th Terrace,

Cape Coral, Florida 33990. 4.

.

On or about April 25, 2013, the Indiana State Board of Nursing

acted against Respondent's nursing Hcense by suspending her Uicense to

practice as

5.

a

registered nurse in the State of Indiana for a minimum of two

State Board of Registered

The

the

authority for the State of Indiana. 6.

Section 464.018(1)(b), Florida Statutes (2012), provides that

having a license to practice nursing revoked, suspended, or otherwise acted against by the licensing authority of another State constitutes

grounds for disciplinary action by the Board of Nursing. 7.

On or about April 25, 2013, the Indiana State Board

of Nursing

acted against Respondent's nursing license by suspending her nursing license in the State of Indiana for a minimum of two years. 8.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(b), Florida Statutes (2012), by having her license to practice nursing revoked, suspended or otherwise acted against by the licensing

authority of another State.

l

v. Deborah Wolfe, RN. Case Number; 2013-06738

2

WHEREFORE, the Petitioner requests that the Board

of Nursing enter

an order imposing one or more of the following penalties: permanent

revocation or suspension of Respondent's license, restriction of practice, imposition of art administrative fine, fissuance of a reprimand, placement of

the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and any other relief that the Board deems

appropriate.

SIGN ED

this

day of John

2013.

Armstrong, MD, FACS Surgeon General and Secretary of Health H.

Mary S. Miller Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number. 0780420 Telephone (850) 245 — 1114, ext. 8104 Facsimile (850) 245 — 4683

.us

PCP: PCP Members:

DOH V. Deborah Wolfe, R.N. Case Number: 2013-06738

3

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested; NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

DOH v. Deborah Wolfe, RN. Case Number: 2013-06738

4

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

/ 4

HEALTH

INVESTIGATR/E REPORT Office:

Date of Complaint:

CONSUMER SERVICES

4/29/13

201306738 Source:

Subject:

DEPARTMENT OF HEALTH Board of Nursing

DEBORAH MARIE WOLFE, 2121 SE

Case Number:

othTerrace

Cape Coral, FL 33990 (239) 738-9623 Prefix:

License #:

Profession:

Board:

Report Date:

RN

9333652

Registered Nurse

Nursing

5/23/13

Period of Investigation:

Type of Report:

5/2/13-5/23/13

FINAL

Alleged Violation:

55. 456.071(1 )(fl(dd); 464.018(1 )(b)(o) F.S.: License disciplined

by Fed/other state.

Synopsis: This investigation is predicated on a complaint and the receipt of documents indicating WOLFE'S RN

license has been disciplined by Indiana State Board of Nursing. Documents show that on 4/25/13 (RN 9333652) was Indefinitely Suspended due to being unable to practice safely by reason of alcohol or other substance abuse. (Exhibit. #1).

WOLFE was notified of this complaint by letter sent on 5/2/13. (Exhibit. #2). A review of DOH computer licensure records on 5/23/13 revealed WOLFE'S licensure status is currently CLEARJACTIVE. No patient(s) was/were identified thus patient notification was not required.

WOLFE does not appear to be represented by counsel as of the date of this report No response has been received as of this date.

Related Case:

None Approved By/Date:

Investigator/Date:

Leo Paulson

IO7) 5/23/13

Government Analyst Distribution:

Pagel

Shane Walters OMC Manager

I

Legal/Consumer Services Unit

47 — C,

:

CASE NUMBER 201306738

DOH INVESTIGATIVE REPORT

I.

. III.

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

TABLE OF CONTENTS

INVESTIGATIVE DETAILS Summary of Records

Statement of complainant (Source)

.

1

2

3

3

EXHIBITS

1)

UCF with attachments

2)

Copy of notification Letter

4-12 13

Page 2

CASE NUMBER 201306738

DOH INVESTIGATIVE REPORT

INVESTIGATIVE DETAILS SUMMARY OF RECORDS Exhibit #1: Documents indicating WOLFE'S RN license has been disciplined by Indiana State Board of Nursing. Documents show that on 4/25/13 (RN 9333652) was Indefinitely Suspended due to being unable to practice safely by reason of alcohol or other substance abuse.

STATEMENT OF COMPLAINANT

—

Source

Investigator Paulson received documents indicating WOLFE'S RN license has been disciplined by Indiana State Board of Nursing. Documents show that on 4/25/13 (RN 9333652) was Indefinitely Suspended due to being unable to practice safely by reason of alcohol or other substance abuse.

Page

3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

*0

,

Rick Scott

Mission To protect, promote & improve the health

John H. Armstrong,

FACS

State Surgeon General & Secretary

Vision: lobe

the Healthiest State in the

NOTICE OF HEARING

November 8, 2013 Case#: 201209103 To:

RYAN KENNETH REYNOLDS P.O. BOX 80866 CHARLESTON, SC 29416, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

17011201209103

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Fiorida Department of Heaith Division of Medical Quality Assurance' Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Taliahassee, FL 32399-3252 PHONE: 8501245-4125 • FAX 850/ 245-4172

www.FlorldasHeaith.gov TWIITER:HealthyFLA

B00K:FLoepartientoff-feami YOUTIJBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve The health

of all people in Flonda through integrated

John

state, county & community efforts.

HEALTH Vision: To be

H Armstrong, MD, FACS State Surgeon General & Secretary

the Healthiest State in the Nalion

NOTICE OF HEARING

November 8, 2013 Case#: 2012-09103 To:

RYAN KENNETH REYNOLDS 900 KING STREET, #39B CHARLESTON, SC 29403, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE

FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

/2012-09103

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

5,

2013

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting.

,

Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner, Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information.

For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance' Board of Nursing 4052 Bald Cypress Way, Bin C-Q2 'Tallahassee, FL 32399-3252 PHONE: 850/ 245-4125 • FAX 8501 245-4172

www.FlorldasHealth.goy

TWITTER:HealthyFLA YOUTIJBE: fldoh

Rick Scott

Mission

Governor

To protect promote & improve the health of all people in Florida Through integrated state, county & community efforts.

John H. Armstrong, MD, FACS State Surgeon General & Secretary

Vision: To be The Heaithiest State in the

Nation

MEMORAND UM TO:

Joe Baker, Jr., Executive Director, Florida Board of Nursing

FROM:. RE: SUBJECT:

Judson Searcy, Assistant General Counsel

,

DATE:

Determination of Waiver

.

DOH v. Ryan Kenneth Reynolds, R.N. DOH Case Number 2012-09103

September 16, 2013

Enclosed you will find materials inthe aboye-referénced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard. Subject: Ryan Kenneth Reynolds P.O. Box 80866 Subject's Address of Record: Charleston, SC 29416

Enforcement Address:

P.O. Box 80866

Subject's Additional Address: Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s): Prior Discipline: Probable Cause Panel: Subject's Attorney: Complainant/Address: .

Fiorida Department of Heaith Office of the General Counsel • Prosecuton Services Unit 4052 Bald Cypress Way, Bin C-65 • Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX 850/245-4683

Charleston, SC 29416 900 King Street #39B Charleston, SC 29403 9274706 Rank: RN 365449

3/14/2008 No No No

464.018(1)(b),

FS

(2011)

None

October 22, 2012; Kemp & Herrera Pro Se

Department Of Health/Board Of Nursing

www.FioridasHeaith.com TWITTERHealTh FLA FACEBOOK:FLDepartrnentoff-fealth YOUTUBE fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner,. CASE NO.

v.

2012-09103

RYAN KENNETH REYNOLDS, R.N.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of Order in the above-styled cause on

a

a Final

date and time that has been determined

and noticed by the Board. As grounds therefore Petitioner states: An Administrative Complaint was filed against Respondent on

October 23, 2012. A copy of said Administrative Complaint is attached hereto as Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were sent to Respondent via certified US mail on

April 23, 2013 (7196 9008 9111 8827 3790). Service on Respondent via certified

mail was not successful.

A copy of the certified mail receipt and envelope is

attached as Petitioner's Exhibit B. 3. Thereafter, Petitioner requested personal service on Respondent, which

was completed on July 25, 2013. The affidavit of personal service is attached as

Petitioner's Exhibit C. 4.

Rule

28-106.111(2),

Florida Administrative

1

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the deCision. 5.

Rule 28.106.111(4), Florida Administrative Code, providesthat:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as PetitiOner's Exhibits D and 7.

E.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 8.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima fade case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests that the Board find

that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final

Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Assistant General Counsel Fla. Bar No. 0098772 Florida Department of Health Office of the General Counsel #C65 4052 Bald Cypress Way, Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 x8100 Facsimile: (850) 245-4683 Email: [email protected]

CERTIFICATE OF SERVICE

true and correct copy of the above and day of provided by U.S. mail this 2013, to Ryan Reynolds, 900 King Street, Apt

I HEREBY CERTIFY that foregoing

has

been

a

39B, Charleston, SC 29403.

Wdson

Msistant General Counsel

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER, v.

CASE NO.

2012-09103

RYAN KENNETH REYNOLDS, R.N.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

.

Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Ryan Kenneth Reynolds, R.N., and in

support thereof alleges: 1.

.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

tImes

material

to

this

Administrative

Complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9274706.

7

EXHIBIT

3.

Respondent's address of record

:South Carofina 29416. 4.

Box 80866, Charleston,

.

The South Carolina Board. of Nursing

is

the licensing authority

of the practice of nursing in the state of South Carolina. 5.

Respondent's South Carolina nUrsing license is RN 105509.

6.

On- or about; June 1, 2012, Respondent voluntarily surrendered

his South Carolina nursing license to the South Carolina Board

of Nursing

for alleged violations of South Carolina laws. 7.

Section 464.018(1)(b), Florida Statutes (2011),. provides that

having a license to

nursing revoked, suspended,: or. otherwise

of licensure, by the licensing authority of

acted against, including

anpther state, territory, or country constitutes grounds for disciplinary .

action. 8.

Respondent

had

.s.a

to, practice' nursing

license

.

revoked,

suspended, or otherwise acted against by the licensing authority of another

state, territory, or country by voluntarily' surrendering his South Carolina nursing license to the South Carolina Board of Nursing. 9.

Based

on

the

foregoing,

Respondent

464.018(1)(b), Florida Statutes (2011),. by having

DOH v. Ryan K. Reynolds, RN. Case Number 2012-09103

. .

a

violated

Section

license to practice

2

nursing revoked, suspended, or otherwise acted against, including the

denial of licensure, by the licensing authority of another state, territory, or country.

DOH v. Ryan K. Reynolds, R.N. Case Number 2012-09103

3

WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposihg one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial. education and/or any

er

relief that the

Board deems appropriate.

SIGNED

this

day of

.

John H. Armstrong, MD State Surgeon General a.nd Secretary of Health

•

•

•

Assistant General Counsel Fla. Bar No. 0098772 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee,+L 32399-3265 Telephone: (850) 245-4640 Facsimile: (850)245-4683 Email: [email protected]

ED DEPARTMENT OF HEALTH DEPUTY CLERK

DATE

nrr

2 3 2012

PcP. PCP Members:

DOH v, Ryan K. Reynolds, R.N. Case Number 2012-09103

12 B.

acenty &

31'èrrera.

•

4

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented' by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENTOF COSTS

Respondent is plated on notice that Petitioner has' incurred costs. related to the investigation and prosecution of this matter. Pursuant toSection 456.072(4), Florida Statutes, the Board shall assess costs related to the investiöation and of a disciplinary matter, may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

'

DOH v. Ryan K. Reynolds, Case Number 2012-09103

RN

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Ryan K Reynolds, RN

: •

2012-09103 ab—StipPk Sent 4/23/13 .

REFERENCE:

.

.

Ryan K Reynolds Box Charleston, SC29416

D.

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POSTMARk OR DATE

Receipt for

Certified Mar. No Insurance Coverage Provided

ONMUflflM-an,IMaM

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iassee, Florida 32399-3265

?cution Services Unit Bald Cypress Way, Bin #C65

DA DEPARTMENT OF

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0004252168 APR23 2013 MAILED FROM ZIRGODE

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J. Al

Cannon,

Sheriff, Charleston County

Special Operations Department 100 Broad Street

LEGAL

Charleston, Sc 29401-2206

PM

2013 AUG —9

AttQrney Or Party Without Attorn ey: FLORIDA DEPARTMENT OF HEALTH 4052 BALD CYPRESS WAY TALLAHASSEE, FL 32399 Att For: DEPARTMENT OF HEALTH

Telephone No. 850-245—4444

.

Court Use Only

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Name and Address of Court: OUT OF STATE COURT

SHERIFF NO. CIOT-13007426-OOlI

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.

.

.

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Plaintiff:

DEPARTMENT OF HEALTH

.

Defendant: RYAN KENNETH REYNOLD

PROOF OF SERVICE

.

I,

Time

.Hearinq Date

(CIVIL OTHER)

I

Case Number 2012—09103

ALCANNON,JR.,ESQ., SHERIFF in and for said County and State, do hereby

J.

certify that

I

have received the annexed:

ADMINISTRATIVE COMPLAINT, NOTICE OF RIGHTS, NOTICE OF REGARDING ASSESSMENT OF COSTS, SETTLEMENT AGREEMENT, VOLUNTARY RELINQUISHMENT OF LiCENSE, ELECTION OF.RIGHTS, EXPLANATIONOF RIGHTS

on the 25th day of JULY, 2013, and that I served the same on the 29th day of JULY, 2013, at the hour of 12:14PM within the County of CHARLESTON, State of SOUTH CAROLINA,

as follows on:

PERSON SERVED: REYNOLD, RYAN KENNETH BY DELIVERING TO THE DEFENDANT(S) OR PERSON(S) NAMED ABOVE, A COPY. IAddress Served: I

900 KING STREET APT: 393 CHARLESTON, SC 29403

Service By SHERIFF'S FEES

**

GREEN, B.

Charges

TOTALS **

00 PY

Ltbniui9 NOTARY PUBLIC SOUTH CARQJJINA MY

COMMISSION EXPIRES:

**

NO CHARGE

**

I

am a SOUTH CAROLINA SHERIFF, I certify that the foregoing is true and correct.

and

AL CANNON,JR.,ESQ., SHERIFF COUNTY OF CHARLESTON STATE OF SOUTH CAROLINA J.

DATE:

Rick Scott Governor

MIssiOIt To proted, promote &improve the health

John H. AnnetrOfla, MD, FACS

To be the Healthiest State

the

Affidavit of Non-Receipt

,

,

William Spooner

,

hereby certi& in my official capacity as

Board, as of custodian for the Board of Nursing's licensure files that the

9/17/2013

,

has no

evidence of an Election of Rights form or other

responsive pleading requesting a hearing prior

Kenneth Reynolds. interests or rights..

agency action regarding Ryan

which would affect the Subject's substantial

ofRecdds Florida Board of Nursing Custodian

Before me, personally appeared

William Spooner

l ,

whose identity is

his/her signature known to me personally and who, under, oath, acknowledges that appears above. Sworn to and subscribed before me this

September

,

2013.

Notary Public Signature

sel ,

My commission expires:

Plodda Department of Health - -

-

day of

17

I!!

I

TD

Mission:

I

Rick Scott

I

Governor

To proted, promote & improve the health of all people in Florida through integrated county & community efforts.

John N. Armstrong, MD, FACS

., HEALTH

VIsion;

State Surgeon General & Seaatary

To be the Heafthlest Stats in the Navon

AFFIDAVIT ,

Deputy Clerk for the Department

Clerk's

certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Ryan Kenneth

R.N.;

which would affect the

Respondent's substantial interests or rights.

Department Clerk's Office Before me, personally appeared

whose identity is

known to me personally and who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this

My Commission Expires:

tay of

ANGELA

0

SAftioji

Notary Public Slim of My £aplr.s

sip

Florida Dopartment of Hsalth Office of the General CounselS Prosecution Services Unit 4052 Bald Way, Bin C-65 Tallahassee, FL 32399-1701 PHONE: 85W245-4444 • FAX

.4683

E?cpkrnhcr

I 2017

,2013.

STATE OF FLORIDA DEPARTMENT OF HEALTH •

DEPARTMENT OF HEALTH,

Petitioner,

)

CASE NO. 2012-09103

v. RYAN KENNETH REYNOLDS, R.N.,

Respondent.

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW the Department of Health, by and through

undersigned counsel., and moves the Board of Nursing for the entry

of

a

Final Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the fQllowing: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter a Final Order therein. 2.

•

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or

discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on -the case, and any other expenses incurred by the department for the case. The board, or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs• and any written obiections

.

The investigation

3.

prosecution of this case has

and

resulted in costs in the total amount of $585.86, based on the

following itemized statement of costs:

*****

-

Hours

-

I

Complaint:

Investigation: Legal:

Isub Total: Expenses to Date:

Cost to Date Costs

l

1

t.ooIJ

-

-

so.oo

$553.11

6.601

$32 75 --

Prior Amount: -

Total costs to Date:

-

1 1

1

$0.00 585 86

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $199.04 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

•

•

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideratiOn of the affidavit attached as Exhibit A and any

timely-filed written objections. S.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $199.04 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and

is in accordance w!th

Section 456.072(4), Florida Statutes. WHEREFORE, the Department of Health

requests that the

Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $199.04.

3

of

DATED this

2013.

Respectfully submitted,

Seárcy General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar # 0098772 (850) 245-4444 x8100 Telephone (850) 245-4683 Fax

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day of

2013, to Ryan Reynolds, 900

King Street, #39B, Charleston, SC 29403.

/u,dson

Ssistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON:

BEFORE ME, the undersigned authority, personally appeared ELISA M. FLOYD who was sworn and states as follows: 1)

My name is Elisa M. Floyd.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am a Regulatory Program Administrator (RPA) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275.

I

I

I

4) As a RPA of the Consumer Services and Compliance Management

Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida health care licensees.

of today, DOH's total costs for investigating and prosecuting DOH case number(s) 201 2-09103 (Department of Health v. RYAN KENNETH REYNOLDS) are FIVE HUNDRED EIGHTY-FIVE DOLLARS AND EIGHTY-SIX CENTS ($585.86).

5) As

6) The for DOH case number(s) 2012-091 03 (Department of Health v. RYAN KENNETH REYNOLDS) are summarized in Exhibit 1 (Cost

Summary Report), which

is

attached to this document.

7) The itemized costs and expenses for DOH case number(s) 201209103 (Department of Health v. RYAN KENNETH REYNOLDS) are detailed in Exhibit 2 (Itemized Cost Report ahd Itemized Expense

Report and receipts), which

is

attached to this document.

8) The itemized costs as reflected in Exhibit 2 are determined by the

following method: DOH employees who work on cases daily are to keep track of their time in six-minute increments (e.g., investigators

EXHIBIT I

of 2

and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Elisa M. Floyd, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of her knOwledge and belief.

FURTHER AFFIANT SAYETH NOT.

ETisa M. Floyd,

()

State of Florkia County of Leon

Sworn to and subscribed before me this_______ day of by Elisa M. Floyd, who is personally known to me.

2013,

4! S Name of Notary

Printer

Stamp Commissioned Name of Notary Public:

2

of 2

TOWANDA B. BURN EU

# EE 838342 Expires September 25,2016

l'age

I

of

1

Complaint Cost Summary

H

Complaint Number: 201209103 Subject's Name:

REYNOLDS. RYAN

***** Cost to Date Uours

Complaint: lilvestigation:

Total: Expenses to Date: Prior Amount: Costs to Date:

}

1.

.901

Costs 51

1 6.60

ICSDETL.ASP

5553.11

$32.75 $0.00

9/17/2013

l

13

Expense Date

09/17/2013

Florida Department of Health

Total Expenses

PROSECUTION SERVICES UNIT

8

Staff Code

Report Date:

$32.75

$32.75

$32.75

Amount

Expense

.

PAYMENT FOR INFORMATION AND EVIDENCE

Expense Code Description

FOR INTERNAL USE ONLY--

497000

Expense Code

Complaint 201209103

J'\4

FIB EN TI AL

Time Tracking System Itemized Expense by Complaint

N

*** CO

Medical Quality Assyrance

I

of

itetmzedexpense

Page

I

.

Rick Scott Governor

John H. Armstrong, MD State Surgeon General

: MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS

TO;

Department of Health

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

Ryan Kenneth Reynolds, R.N.

DATE OF PROBABLE CAUSE MEETING:

CASE NO.: 2012-091 03 DATE: October

22,2012'

This matter was brought before a Probable Cause Panel composed of

Barbara Kemp and Mary Jane Herrera

1

having received the investigative report and supplemental On the date set forth above. The materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that:

xx

Probable cause exists herein that the Subject violated the following statutes/rules: Section 464.018(1)(b), FS (2011) The panel

imposing the foflbwing penalty: Costs and V2

cause does not exist and the case should be closed with the flowing closure code:

•

•

.

the above named licensee shall be' issued a letter of lieu, of a finding of guidance toaddress the conduct in question:

..

The panel has requested supplemental or additional information on the following: Other

!9G

I

L2

Prosecution Services Unit 4052 Bald Cypress Way, Bin C65 Tallahassee, Florida 32399-1701 Phone: (850) 245-4640 - Fax: (850) 245-4683 ' http://www.floridashealth.com

/

_________________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITION ER, v.

CASE NO.

2012-09103

RYAN KENNETH REYNOLDS, R.N.,

RESPONDENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Ryan Kenneth Reynolds, R.N., and in

support thereof alleges: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a licensed registered nurse (R.N.) within the state of Florida, having been issued license number RN 9274706.

3.

Respondent's address of record is P.O. Box 80866, Charleston,

South Carolina 29416. 4.

The South Carolina Board of Nursing is the licensing authority

of the practice of nursing

in

the state of South Carolina.

5.

Respondent's South Carolina nursing license is RN 105509.

6.

On or about June 1, 2012, Respàndent voluntarily surrendered

his South Carolina nursing license to the South Carolina Board of Nursing

for alleged violations of South Carolina laws. 7.

Section 464.018(1)(b), Florida Statutes (2011), provides that

having a license to practice nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action. 8.

Respondent

had

a

license

to practice

nursing

revoked,

suspended, or otherwise acted against by the licensing authority of another

state, territory, or country by voluntarily surrendering his South Carolina nursing license to the South Carolina Board of Nursing. 9.

Based

on

the

foregoing,

Respondent

464.018(1)(b), Florida Statutes (2011), by having

DOH v. Ryan K. Reynolds, R.N. Case Number 2012-09103

a

violated

Section

license to practice

2

nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state, territory, or country.

DOH v. Ryan K. Reynolds, R.N. Case Number 2012-09103

3

WHEREFORE, the Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNEDth1s

dayof

201

John H. Armstrong, MD State Surgeon General and Secretary of Health

MICHAEL G. LAWRENCE, JR. Assistant General Counsel Fla. Bar No. 0011265 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65

Tallahassee, FL 32399-3265 Telephone: (850) 245-4640 Facsimile: (850) 245-4683 Email:

@doh.state.fi.us

js/M G L PC P:

PCP

Members:

DOH v. Ryan K. Reynolds, R.N. Case Number 2012-09103

NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

DOH v. Ryan K. Reynolds, RN. Case Number 2012-09103

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

September 12, 2012 Mr. John P. Beck

Division of Medical Quality Assurance Consumer Services Unit-Compliance Management Team 4052 Bald Cypress Way, Bin C-76 Tallahassee, FL 32399-3251

Complaint #201209103 •Dear Mr. Beck,

am responding to the letter I received from you, in regards to the complaint filed against myself with the Florida Department of Health. From what! can understand from your letter the complaint states that I voluntarily surrendered my South Carolina Nursing License in order to avoid investigation of a possible narcotics violation or drug statutes. This is completely false. I have spoken to the Compliance Supervisor at the South Carolina Board of Nursing and I have been assured that nowhere in my voluntary surrender agreement is it mentioned that this was to avoid investigation, nor was that reported to NURSYS. I

voluntary surrender of my license was the result of a complaint filed against me in Texas, where I was working as an agency nurse under a multi-state compact license. The Texas Board of Nursing contacted South Carolina and the Department of Investigations for South Carolina demanded that I surrender my license until the Texas Board had concluded their investigation of the complaint. The Texas Board investigation and found no evidence of my being a threat to the concluded public and closed the investigation. I have attached a copy of the letter from the Texas Board. I am currently in the process of reinstating my South Carolina license and should be done with the process by the end of this year. •The

r

hope this response helps to clarify the situation. If you have any further questions please do not hesitate to contact me. Thank you in advance for your attention to this matter. I

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2O9TanglewoodAve Charleston, SC 29407

843.822.1982

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Texas Board of Nursing 333

lupe

Phone: (512) 305-7400

Street, Ste. 3-460, Austin, Texas 78701 Fax: (512) 305-7401

www.bon.texas.gov

Katherine A. Thomas, MN, RN Executive Director

December 13, 2011 Ryan Kenneth Reynolds P.O. Box 80866 Charleston, South Carolina 29416

Dear Mr. Reynolds: The investigation conducted by this office has been completed. A review of the evidence indicates no further action is needed to protect the public at this time.

However, a certified copy of the South Carolina Order, regarding your license to practice nursing in that jurisdiction, will be maintained in your permanent record in Texas and available to the public upon request.

If you have any questions or concerns, you may contact me at (512) 305-6831.

ames S. Smelser Investigator .JS

]

ss

11/2010.670

Members of the Board

in,

Kristin Benton, MSN, RN President Deborah Bell, CLU, ChEC

gen

Patricia Clapp, BA Tamara Cowan, MSN, RN Shari Crosby, JD, SPUR Marilyn Davis, BSN, RN, MPA rnchard Gibbs, LVN Atsilenc Dallas Sugar Land Maaqnite Kathy Leader-Horn, LYN Mary as. LeBeck, MSN. RN Josefena Liajan, PhD, RN Beverley Jean Ntatstl, LVN Mary Jane Salgado, MEd Katblein Shlpp, MSN, RN, Grassbuq FNP Weatberford El Paso Bryan San Antonio Lubbock

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CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FLORIDA DEPARTMENT

INVESTIGATIVE REPORT Office:

Date of Complaint:

CONSUMER SERVICES

June 19, 2012

Subject:

License 4:

RN

9274706

:

Period of Investigation:

June 20, 2012 through September 10, 2012

201209103 Source:

RYAN KENNETH REYNOLDS P. 0. Box 80866 Charleston, SC 29416 Prefix:

Case Number:

DOH/Board of Nursing

Profession:

Board:

Report Date:

Registered Nurse

Nursing

September

Type of Report:

FINAL

Alleged Violation: § 464.018(1 )(b)(o), F.S.: The following acts constitute grounds for denial of a s.

10,

456.072(2): (b) Having a license to practice nursing revoked, suspended, or otherwise acted against

license, or disciplinary action, as specified in

This investigation is predicated on the receipt of a complaint (Exhibit # 1, UCF and attachments) from (DOH/Board of Nursing) source, alleging that, RYAN KENNETH REYNOLDS has a license to practice nursing revoked, suspended, or otherwise acted against including the denial of licensure by the licensing authority of another state, territory, or country. On May 31, 2011, the State of South Carolina accepted the Voluntary Surrender of RYAN REYNOLDS license in lieu of being investigated by the Board of Nursing for South Carolina. REYNOLDS was under investigation for "narcotics violation or other violation of Drug Statutes".

REYNOLDS was notified of this complaint through three letters, one dated June 20, 2012, and the other two dated August 29, 2012. Two notifications were sent to the address of record with DOH, one by regular mail and the other by certified mail. The third notification sent to REYNOLDS was sent to an address found in Accurint, and was sent by certified mail. (Exhibit #2) DOH computer information was reviewed September 10, 2012 (Exhibit. #3). It reflects RYAN KENNETH REYNOLDS is duly certified/licensed to practice as a Registered Nurse in the State of Florida; his certificate s in a ClearlActive status. No patient(s) was/were identified, thus patient notification was not required.

RYAN KENNETH REYNOLDS is not represented by counsel as of the date of this report. RYAN REYNOLDS has not responded to the allegations. If a response is received from REYNOLDS, forwarded to the case file. Related case None

Investigator/Date: September 10, 2012

John Beck (HA-57) Government Analyst Distribution:

I

Approved By/Date:

Shane Walters OMC Manager

Consumer ServiCes Unit/Prosecution Services Unit

/

9

SEP

1.

0

2012

it

will be

-

DON INVESTIGATIVE REPORT

I.

II.

III.

CASE NUMBER 201209103 TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

1

TABLE OF CONTENTS

2

INVESTIGATIVE DETAILS Summary of Records

Statement of RYAN KENNETH REYNOLDS

IV.

3

-

subject

EXHIBITS 1)

UCF and Attachments

2)

Copy of notifications sent to REYNOLDS

4, 5

6-11

Page 2

DOH INVESTIGATIVE REPORT

CASE NUMBER 201209103

INVESTIGATIVE DETAILS SUMMARY OF RECORDS

(Exhibit#

This is the Case Summary, and a document from the State of South Carolina indicating REYNOLDS voluntary surrender of his license. 1)

INTERVIEWIRESPONSE of RYAN KENNETH REYNOLDS - (subject) Address of Record P. 0. Box 80866

Charles, South Carolina 29416 RYAN KENNETH REYNOLDS has not responded to the allegations. REYNOLDS was notified of this complaint through three letters, one dated June 20, 2012, and the other two dated August 29, 2012. Two notifications were sent to the address of record with DOH, one by regular mail and the other by certified mail. The third notification sent to REYNOLDS was sent to an address found in Accurint, and was sent by certified mail. (Exhibit # 2)

gator follows:

:

An Accurint address check of REYNOLDS indicates a different address as RYAN REYNOLDS 349 Clarmont Road Willowick, Ohio 44095-4773

Page 3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

r

a

Minion:

U

To protect, promote & improve The health

of at

peo$

in

flohdathrouhintegrated

Rick Scott Governor -

John H. Armstrong, MD, FACS State Surgeon Generai & Secretary

H EAJ.]}I Vision: To be the

Healthiest State in the Nafion

NOTICE OF NEARING November 8, 2013 Case#: 201301786 To:

OPAL MELANE JOINER 3200 RIFLE GAP RD.#1 346 FRISCO, TX 75034, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5, 2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201 301786

Place:

letree by Hilton

100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

.

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in,

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

Florida Department of Heaith Division of Methcal Ouabty Assurance • Board of Nursing 4052 Bald Cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 8501 245.4125 • FAX 85W 245-4172

lof

www.FiorldasHeaith.gov 1TTER:HeaIthyFLA Health VOUTUBE: fldoh

Rick Scott

Mission:

Governor

To protect, promote & improve the health of all in Florida through integrated state, county & communUy efforts.

John H. Annstrcng, MD, FACS

U

State Surgeon General & Secretary

HEALTH Vision: To be the Heaithiest State in

ME

the Nation

MORAN

FROM:

Joe Baker, Jr., Executive Director, Florida Board of Nursing Mary Miller, Assistant General

RE:

Determination of Waiver

SUBJECT:

DOH v. Opal Melane Joiner, R.N. DOH Case Number 2013-01786

DATE:

October 17, 2013

TO:

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of

Opal Melane Joiner, R.N. 3200 Rifle Gap Rd.

Record:

#1346 Frisco, TX 75034

Enforcement Address:

3200 Rifle Gap Rd.

#1346 Frisco, TX 75034

Subject's License No: Licensure File No: Initial Licensure Date: Board Certification: Required to Appear: Current IPN/PRN Contract: Allegation(s):

9206201

Rank: ARNP

294655

8/19/2003 No No No

Section 464.018( 1)b), F.S.(2012)

Prior Discipline: Probable Cause Panel:

None June 20, 2013 Mary K. Habgood and Sandra L. Walker

Subject's Attorney:

Pro Sc

Complainant/Address:

Department of Health/Board of Nursing

Florida Department of Health Office of the General Counsel • Prosecution SeMces Unit 4052 Bald Cypress Way, Bin 0-65 • Tallahassee, FL 32399-1701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 FAX 850/245-4683

www.FlorldasHeafth.com

leaIthyFLA

ceparljrentofl-jeatfrj VOUTUBE: fldoh

_I STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEAL.

Petitioner, v.

CASE NO.

2013-01786

OPAL MELANE JOINER, R.N.,

Respondent. MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT

IIONER,

the Florida Department of Health, by and through the

undersigned counsel, hereby moves the Board of Nursing for entry of a Final Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

3, 2013.

An Administrative Complaint was filed against Respondent on July

A copy of said Administrative Complaint is attached hereto as

Petitioner's Exhibit A. 2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were sent to Respondent via certified US mail on:

August9, 2013(7196 9008 9111 9326 7494).

Service on Respondent via certified mail was not successful. A copy of the

certified mail receipt and envelope

is

attached as Petitioner's Exhibit

B.

3. Thereafter, Petitioner requested personal service on Respondent, which

was completed on September 23, 2013.

The affidavit of personal service is

attached as Petitioner's Exhibit C. 4.

Rule

28-106.111(2),

Florida

Administrative

Code,

provides

in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. •

5.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits D and

E.

7.

Based upon the foregoing, Respondent has waived the right to

dispute

materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board. 8.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima fade case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final

Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

Respectfully Submitted,

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Mary M4Ikr Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar #0780420 (850) 245-4444 telephone (850) 245-4683 facsimile

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that has been

a

Lday of

true and correct copy of the above and

by U.S. mali this

,

2013,

to: Opal Melane Joiner, R.N., 3200 Rifle Gap Road, #1346, Frisco, Texas 75034.

Mary S. Assistant General Counsel

,

STATE OF FLORIDA

DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

OPAL MELANE JOINER,

.,

CASE NO.

2013-01786

ADMINISTRATIVE COMPLAINT

COMES NOW, Petitioner, Department of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent Opal Melane Joiner, R..N., and in

support thereof asserts: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

a

registered nurse (R.N.) within the state of Florida, having been issued license number RN 9206201,

3.

Respondent's address of record is 3200 Rifle Gap Road, #1346,

Frisco, Texas 75034.

On or about January 17,

4.

2013, the Texas Board of Nursing

against Respondent's nursing license by placing her license to

acted

practice as a registered nurse in the State of Texas on probation for two years with terms and conditions.

The Texas Board of Registered Nursing is the licensing authority

5.

for the State of Texas. 6.

having

Section 464.018(1)(b), Florida Statutes (2012), provides that a

license to practice nursing revoked, suspended, or otherwise

acted against by the licensing authority of another State constitutes

grounds for disciplinary action by the Board of Nursing. 7.

On or about January

17,

2013, the

Texas Board of Nursing

acted against Respondent's nursing license by placing her nursing license in

the State of Texas on probation fortwo years with terms and conditions. 8.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(b), Florida Statutes (2012), by having her license to practice nursing revoked, suspended or otherwise acted against by the licensing

authority of another State. DOH v. Opal Joiner, tN. Case Number: 2013-01786

2

WHEREFORE,

the Petitioner req uests that the Board of Nursing enter

an order imposing one or more

of the following penalties:

revocation or suspension of Respondent's license, restriction of practice,

imposition of an administrative fine, issuance of a reprimand, placement of

the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and any other relief that the Board deems

appropriate.

SIGNED this

day of

, 2013.

John H. Armstrong, MD, FACS Surgeon General and Secretary of Health

Mary S. £4Jèr Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0780420 Telephone (850) 245 — ext. 8104 Facsimile (850) 245 — 4683

,

CLERK

PCP:cJu.a. zs, PCP Members:

v. Opal Joiner, P.N. Case Number:

1786

zois

NOTICEOF RIGHTS

Respondent has the ngbt to request

a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represents by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested.

NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to anyother discipline Imposed.

DON v. Opal )oiner, R..N. Case Numben 201301786

4

PHONE: 850/245-4444

4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399.1701

Florida Department of Health Office of the General Counsel Prosecution Services Unit

Frisco, TX

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Opal Joiner 3200 Rifle Gap Rd #1346 Frisco, TX 75034

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10/16/2013

COLLIN COUNTY

Ty

OFFICE OF THE SHERIFF

4300 Community Avenue

McKinney, TX 75071

Terry G. Box, Sheriff

) )

AFFIDAVIT OF SERVICE

c-.j

CASE: 201301786

Department Of Health vs. Opal Melane Joiner,R.N.

-n

The State of Texas County of Collin

.,

rn

r

)

Before me, the undersigned authority, a Notary Public in arid for the State of Texas, on this day personally appeared Shonda Norton, who first being duly sworn, upon his oath deposes and says:

of twenty one years and of sound mind. I hold the office of Deputy Sheriff for the Collin County Sheriff's Office and have personal knowledge of every statement herein made, and I am fully I

am over the age

1

competent to test as to the matters stated herein.

of September, 2013, our office received a COMPLAINT-OUT OF COUNTY, issued out of the Department Of Health Services, for the State of Florida, County of Tallahassee to be delivered to: Joiner, Opal Melane, at 3200 RIFLE GAP RD #1346 FRISCO TX 75034, in Collin County, Texas On the 20th day

This Said document was served (delivered) on the 23rd day of September, 2013, at 1:06 PM at 3200 RIFLE GAP RD #1346 FRISCO TX 75034, Collin County, Texas by Deputy Shonda Norton, who is a licensed peace officer in and for the State of Texas and is employed by the Collin County Sheriff's Office in Collin County, Texas.

Every statement in this, my affidavit, is true and correct. Further affiant sayeth not

TERRY 0. COL

OX, SHERIFF IJNTY, TE*AS

Deputbk'erifIhonda

Subscribed and sworn to before me on the 23rd day of September, 2013.

Alisha Riggs, Notary Public In and for Collin

I AUSHA 0100$ No4syPtic

N

Commission Expires: 07/02/20

STATE OF 1EXAS

17

EXHIBIT Sheriffs Office (972)547-5100. Metro (972) 424-4797. FAX (972) 547-5304 Detention (972) 424-I 433. FAX (972) 547-5301

II

.e

Mission:

mcii Scoft

I

Governor

To promote & improve the health of all In Florida through Integrated state, county & community

, I,

John H. *nnstrong,

MD, FACS

State Surgeon Geneml & Seaetary

Vision: To be the Healthiest State in the Nation

hereby certify in my official capacity as

William Soooner

custodian for the Board of Nursing's licensure files that the Board of Nursing as

of

10/16/2013

has no evidence of an Election of Rights form or

other responsive pleading requesting a hearing prior to any agency action regarding CASE NAME, OPAL MELANE JOINER. R.N., CASE NUMBER

which would affect the Subject's substantial interests or rights.

Custodian of Records Florida Board of Nursing

Before me, personally appeared

identity is known to me

William Soooner

Dersonallv

•(type

of

whose

identification)

and

who, under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this 16 day of

October

2013.

Notary Public

Floflds Dspartm.nt of Hsalth Office of the Gene rat Counsel• Proseajilon Unit 4052 Bald Cypress Way, BIn C-65 . Tallahassee. FL 32399.1701 Express mall address: 2585 Row — SuIte 105 PHONE: 850f245.4444• FAX 650t245-4683

salth.com FLA

FACEBCOKFLDeparfrnantofrIeaffJi VOUTUBE: fidoh

____

Minion:

Rick Scott I

I

of all peope In Flodda through state, county & efforts.

AEALTH Vision: lobe the Heilthlest

Governor

John H. Annstrong, MD, FACS Stale Surgeon Genemi

&

Seottary

State in the Nation

AFFID AVIT

eputy Clerk for the Department Clerk's Office, hereby certify in my official capacity as custodian for the Department Clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case Name, OPAL MELANE JOINER, R.N., Case

Number 2013-01786,

which would affect the Respondent's substantial interests or rights.

Custodian of Record Department Clerk's Office Before me, personally appeared

identity

is known to

me by personally known (type of identification) and who, under oath, acknowledges that his/her signature appears above.

Sworn to and subscribed before me this

2013.

My Commission Expires:

Florida Department of Health Office of the General Counsel Proseojton Sewces Unil 4052 SaId Cypress Way, Bin C-65 Tallahassee FL 32399-1701 Express mall address: 2585 Merchants Row— Suite 105 PHONE: FAX 850/245.4583

1

.

I

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, V.

OPAL MELANE JOINER,

Respondent.

,

) CASE NO.

I

2013-01786

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES NOW, the Department of Health, by and through the

undersigned counsel, and moves the Board of Nursing for the entry

of

a Final

Order assessing costs against the Respondent for the

investigation and prosecution of this case in accordance with Section

456.072(4), Florida Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of

Nursing will take up for consideration the above-styled disciplinary

action and will enter 2.

a Final

Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1, 2001, pursuant to this section or disc!p!ine through fh& order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited to. salaries and benefits of personnel, costs related to the time scent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board. or the department when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

.

.

The investigation

3.

and

prosecution of this case has

resulted in costs in. the total amount of $509.75, based on the

following itemized statement of costs: I

I

I

complaint: ILegal:

Compliance:

1 1 0.00]

to Prior Amount: Total Coststo Date;

j

Costs

l 0.00

[

iSub Total:

)1

I

Hours

5.30

$424.75]

J[

_____________________________

$5Q975

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $233.23 as evidenced in the attached

affidavit. (Exhibit A). 4a

Should the Respondent file written objections to the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of

the costs to which the objections are made, the Petitioner requests

that the Board determine the amount of costs to be assessed based upon its consideration of the affidavit attached as Exhibit A and any

timely-filed written objections. 5.

Petitioner requests that the Board grant this motion and

assess costs in the amount of $233.23 as supported by competent,

substantial evidence. This assessment of costs is in addition to any

other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the

Respondent in the amount of $233.23.

3

____________,

DATED this

SE

2 day of

Respectfully

&r

,

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

l

—

Mary S. MUter Assistant General Counsel Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar #0780420

(850) 245-1114 telephone (850) 245-4683 facsimile

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that

a

true and correct copy of the

foregoing Motion to Assess Costs has been provided by U.S. Mail this day of

2013, to:

Opal

Melane

Joiner,

R.N.,

3200 Rifle Gap Road, #1346, Frisco, Texas 75034.

Mary S. Miller Assistant General Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTYOF LEON:

BEFORE ME, the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for TheConsumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses, respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin 0-75 Tallahassee, Florida 32399-3275.

I

I

0k

I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time TraOking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida

health care licensees.

I

5) As of today, DOH's total costs for investigating and prosecuting DOH case number(s) 2013-01786 (Department of Health v. OPAL MELANE

JOINER, R.N.) are FIVE HUNDRED TWENTY DOLLARS AND THRITY-NINE CENTS ($520.39).

6) The costs for DOH case numbers 201 3-01786 (Department of Health

OPAL MELANE JOINER, R.N.) are summarized in Exhibit Summary Report), which is attached to this document.

v.

1

(Cost

7) The itemized costs and expenses for DOH case numbers 201 3-01 786 (Department of Health v. OPAL MELANE JOINER, R.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

I

of2

keep track of their time in six-minute increments (e.g.. investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report)

Share Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained therein are true and correct to the best of his knowledge and belief. FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant

State of Florida County of Leon

\1

day of Sworn to and subscribed before me this known to me. personally who is Walters, Sha by

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of2

2013,

Page

1

of I

Complaint Cost Summary Complaint Number: 201301786

_ Subject's Name:

[

L

JOINER, OPAL MELANE Cost to Date

Hours

Costs

Complaint:

1.90

Investigation: Legah Compliance:

0.80

Sub

S.40J

2.70 0.00

lExpenses to Date:

Prior Amount:

Total Costs to Date:

l.us/IRMOOTIMETRAKJCSDETL.Asp

1

S104.31

S287.16

l1 $0.00

S435.39

$85.OOj

10/17/2013

0.60 0.60 0.30 0.40 0.80

2.70

Sub Total

2.70

HLL7OA

Sub Total

Florida Department of Health

0.10

HLL70A

10

1.50 1.00

HLL7OA HLL7OA

$106.35 $106.35 $106.35

106.35

.

$54.90 $54.90 $54.90 $54.90

IPROSECUTION SERVICES UNiT

F1A62

F-1A62

HA62 HA62 HA62

$54.90

Staff Rate

CONSUMER SERVICES UNIT

Stall Code Activity Hours

Report Date 10/17/2013

Medical Qoolily Assmance

Division ol

$287.16

$10.64 $159.53 $106.35 $10.64 28 79 25

25

REVIEW CASE FILE

Page

itemizedeost

REVIEWCASEFILE PREPAREORREVISEADMINISTRATIVECOMPLAINT STIPULATION

- FOR INTERNAL USE ONLY -

05/14/2013 05/16/2013 07/10/2013 10/14/2013

REPORT PREPARATION

REVIEW CASE FILE

$148.23

.

INT REVIEWCASEFILE

25 78 76

03/07/2013 04/24/2013 05/02/2013

$16.47 $21.96 $43.92

Activity Description

INITIAL REVIEW AND ANALYSIS OF COMPLAINT

25

78

Activity Code

01/28/2013 02/13/2013

Activity Date

201301786

$32.94 $32.94

Cost

Complaint

Time Tracking System Itemized Cost by Complaint

***CONFIDENTIAL***

1

of

I

I

I

_______In _______Other _______Probable _______ _______________

Rick Scott

Minion: To pmmote & Improve the health of alipeople in Fior4da through hitegrated state, wunty & cernmunity efforts.

John

H. Annetrong, MD, FACS State Surgeon General & Secretary

Vision: To be the Healthiest State hi the NatIon

MEMORANDUM OF PROBABLE CAUSE PANEL FINDINGS TO:

Department of Health- A-12 (MM)

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT: Joiner, Opal Melane, RN.

CASE NO: 2013-01786

DATE OF PROBABLE CAUSE MEETING:

DATE: 6-20-13

This matter was brought before a Probable Cause Panel composed of:

Mary K. Habgood and Sandra L. Walker

On the date set forth above. The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department and having had the opportunity to inquire of counsel, finds that: x

Probable cause exists herein that the Subject violated the following statutes/rules: (464.018(1)(b}, F.S. (2012)) The panel suggests imposing the following penatty:

code:

TX

Costs

cause does not exist and the case should be closed with the flowing closure

lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the following:

CAUt9 PANEL

Florida Department of Health Office of the General Counsel' Prosecrition Services Unil 4052 Bald Cypress Way, Bin 0.65 • Tallahassee, FL 32399-1701

Express mall address: 2585 RowPHONE: 850/245-4444 'FAX 850/2454683

lits 105

www.FlarMasHsslth.com flER:HealthyffLA YOWUSE: fldoh

/

STATE OF FLORIDA DEPARTMENT OF HEALTK

DEPARTMENT OF HEALTK,

PETITIONER,

CASE N©.

v.

201341786

OPAL MELANE JOINER, R.N., RESPON DENT.

ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department

of Health, by and through its

undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent Opal Melane Joiner,

and in

support thereof asserts: 1.

Petitioner is the state department charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At all times material to this Complaint, Respondent was

a

registered nurse (R.N.) within the state of Florida, having been issued license number RN 9206201.

Respondent's address of record is 3200 Rifle Gap Road, #1346,

3.

Frisco, Texas 75034. On or about January 17, 2013, the Texas Board of Nursing

4.

n

acted against Respondent's nursing license by placing her license to

practice as a registered nurse in the State of Texas on

for two

years with terms and conditions.

The Texas Board of Registered Nursing is the licensing authority

5.

for the State of Texas. Section 464.018(1)(b), Florida Statutes (2012), provides that

6.

having

a

license to practice nursing revoked, suspended, or otherwise

acted against by the licensing authority of another State constitutes

grounds for disciplinary action by the Board of Nursing. 7.

On or about January 17, 2013, the

Texas Board of Nursing

acted against Respondent's nursing license by placing her nursing license in

the State of Texas on probation for two years with terms and conditions. 8.

Based

on

the

foregoing,

Respondent

violated

Section

464.018(1)(b), Florida Statutes (2012), by having her license to practice nursing revoked, suspended or otherwise acted against by the licensing

authority of another State. DOll v. Opal Joiner, RN. Case Number 2013-01786

2

WHEREFORE, the Petitioner requests that the Board an order imposing one or more of

of Nursing enter

the following penalties: permanent

revocation or suspension of Respondent's license, restriction of practice,

imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and any other relief that the Board deems

appropriate.

SIGNED

this

day of John

20fl.

Armstrong, MD, FACS Surgeon General and Secretary of Health H.

Mary S. Miller Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Florida Bar Number 0780420 Telephone (850) 245 — 4444, ext. 8104 Facsimile (850) 245 — 4683

Mary_Miller2©doh.state.fl.us

PCP: PCP

Members:

DOH v. Opal Joiner, R.N. Case Number: 2013-01786

3

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing

0

NOTICE REGARDING ASSESSMENT OF COSTS

0

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this Pursuant to Section 456.072(4), Florida Statutes, the Board shala assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

DOH v. Opal Joiner, R.N. Case Number: 2013-01786

4

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

FLORIDA DEPART MENT

REPORT Date of Complaint:

Office:

CONSUMER SERVICES

Case Number: RN 201 3-01 786

2/13/13

Subject:

Source:

OPEL JOINER, RN 3200 Rifle Gap Road, #1 346 Frisco, TX 75034

DOH/BOARD OF NURSING

Prefix:

License #:

Profession:

Board:

Report Date:

:

9206201

Registered Nurse

Nursing

5/2/13

1701

Period of Investigation:

Type of Report:

2/14/13— 5/2/13

FINAL

Alleged Violation: 456.072(1)(f)(dd), 464.O16(1)(b)(c) F.S.: Raving a license revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state; violate statute/rule/conviction/failing to report

This investigation is predicated on the receipt of complaint and copy of an Agreed Order from Texas Board of Nursing dated 1/17/13 stating JOINER'S Texas RN license was placed on probation (Ex. #1, UCF and attachments).

JOINER was notified of this complaint by letter dated 2/14/13 (Exhibit #2). A certified letter was sent on 3/5/13 and was returned by the Postal Service marked "unclaimed." Accurint shows the same address for JOINER as JOINER'S address of record.

A check of DOH computer licensure records dated 5/2/13 revealed JOINER'S licensure status is currently Clear/Active, No patient(s) was/were identified thus patient notification was not required.

JOINER does not appear to be represented by council. Investigator BATES has not received a response from JOINER. Related Case:

None Approved By/Date:

Investigator/Date:

Diane Bates (HAG2) 5/2/13 Government Analyst I

Distribution:

Shane Walters OMC Manager

.

MAY 0 2 2013

Prosecution Services/Consumer Services Unit

Pagel C,

:

DOE! INVESTIGATIVE REPORT

. II.

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

1

TABLE OF CONTENTS

2

INVESTIGATIVE DETAILS Summary of Records

Ill.

I

Statement of Texas BON(Source) Statement of JOINER(Subject)

IV.

CASE NUMBER RN 201 3-01 786

3

3 3

EXHIBITS 1)

UCF with attachments

2)

Copy of notification Letter

4-25 26-29

Page 2

DOH INVESTIGATIVE REPORT

CASE NUMBER RN 201 3-01 786

INVESTIGATIVE DETAILS SUMMARY OF RECORDS Exhibit #1 documents from Texas Board of Nursing stating JOINER'S license has been disciplined

STATEMENT OF MAINE BOARD OF NURSING

—

Source

2/13/13 receipt of a complaint and copy of an Agreed Order from Texas Board of Nursing dated 1/17/13 stating JOINER'S Texas RN license was placed on probation (Ex. #1, UCF and attachments).

STATEMENT OF OPAL JOINER, LPN 3200 Rifle Gap Road, #1 346 Frisco, TX 75034

—

Subject

A response has not bee received, If a response is received it will be forwarded to Prosecution Services.

Page 3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

C

t

C

Rick Scott

Mission:

Governor

To protect, promote & improve the health

John H. Annstrong, MD, FACS

OH

State Surgeon General & Secretary

I

Vision: To

be the

Healthiest State

in the Nation

NOTICE OF HEARING

November 8, 2013 Case#: 201307887 To:

ELLINDA ANNE JONES WHITE 225 PLEASENT STREET POMONA PARK, FL 32181, FL

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

/201307887

Place:

Doubtletree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board.

Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be

considered at the Board meeting, except at the discretion of the Board Chair. Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of

Nursing office at (850) 245-4125 or via email at

Florida Department of Health Division of Medical Quality Assurance • Board of Nursing 4052 Bald cypress Way, Bin C-02 • Tallahassee, FL 32399-3252 PHONE: 8501 245-4125 • FAX 850/ 245-4172

.Hnith.gov

TWITTER:HealthyFLA FAcEBOOK:FLDeparhnentof Health VOUTUBE: fldoh

Rick Scoet

Mission:

i

Governor

To protect, promote & improve the health of people in Florida through integrated

John H. Armstrong, MD, FACS

state, county&comrnunityefforts.

State Surgeon General

H EALTH Vision: To be

&

Seuetary

the Healthiest State in the Nathn

MEMORANDUM TO: FROM: RE: SUBJECT:

DATE:

l

Joe Baker, Jr., Executive Director, Florida Board of Lucy Schneider, Assistant General Counsel

Determination of Waiver

DOH v. Ellinda Anne Jones White, L.P.N. Case Number 2013-07887

October 18, 2013

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of Record: Enforcement Address:

's

License No:

Ellinda Anne Jones White, LP.N. 225 Pleasant Street Pomona Park, FL 32181 225 Pleasant Street Pomona Park, FL 32181

889241

Rank:

PN

Licensure File No: Initial Licensure Date: Board Certification: Required to Appear' Current IPN/PRN Contract:

26117

Allegation(s): Prior Discipline:

Section 456.072(1)(q), F.S. (2012)

Probable Cause Panel:

September 16, 2013 Denker & Habgood

Subject's Attorney:

Pro Se

Complainant/Address:

Department of Health/Compliance Management Unit

Florida Dep.rtment of Hoaith Office or the General Counsel • Proseculion Services Unit 4052 Bald Cypress Way, Bin C-65 • Tallahassee, FL 32399-1 701 Express mail address: 2585 Merchants Row — Suite 105 PHONE: 850/245-4444 • FAX 850/2454683

12/7/1987 None No

None

None

www.FiorldasHeaith.com TWflTER:HealthyFLA FACEEOOK:FLDepar%-nentofl-lealth VOUTUBE: fldoh

STATE OF FLORIDA BOARD OF NURSING

9

DEPARTMENT OF HEALTh,

v.

CASE NO.

2013-07887

ELLINDA ANNE JONES WHITE, L.P.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states: 1.

An Administrative Complaint was filed against Respondent on

September 16, 2013. A copy of said Administrative Complaint is attached hereto as Petitioner's Exhibit A.

i

2.

Copies of the Administrative Complaint, Explanation of Rights form,

of Rights form were successfully served on Respondent via certified

and Election US

on: September 23,2013 (7196 9008 9111 1387 0902). A copy of the

certified mail receipt is attached as Petitioner's Exhibit B. 3.

Rule

28-106.111(2),

Florida Administrative

Code,

provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. •

4.

.

.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 6.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time. Copies of affidavits supporting the same are attached hereto as Petitioner's Exhibits C & D. 7.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

8.

Respondent has been advised by way of this Motion, that

a

copy of

the investigative file in this case will be furnished to the Board, establishing

a

prima fade case regarding the violations as set forth in the Complaint.

s

WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter disCipline upon

a

Final Order imposing whatever

license that the Board deems appropriate.

FACS

and Secretary of Health

Lu"

Schneder'

As stant neral Counsel Fla. o. 0815349

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email:

@flhealth.gov

CERTIFICATE OF SERVICE REBY CERTIFY that a true and correct copy of provided by U.S. mail this 2013, to: Elli Street, FL 32

eral Counsel

and at 225

,

___________________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

or

—

CASE NO.

2013-07887

ELLINDA ANNE )ONES WHITE, L.P..N., RESPONDENT.

ADMINISTRATIVE COM PLAINT Petitioner, the Florida Department of Health, by and through the undersigned counsel, files this Administrative Complaint before the Board

of Nursing against Respondent, Ellinda Anne Jones White, L.P.N., and

in

support thereof states: 1.

Petitioner is the state agency charged with regulating the

practice Of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

tines material to this Administrative Complaint,

all

Respondent was

a

licensed practical nurse (L.RN.) within the state of

Florida, having been issued license number PN 889241.

3.

Respondent's address of record is 225 Pleasant Street, Pomoma

Park, Florida 32181.

4.

On or about July 10, 2012, a Final Order was filed in connection

with Department of Health citation number 2012-06439, that affected Respondent's license to practice nursing. 5.

The above referenced Final Order required Respondent to pay

a

fine in the amount of $250, and costs in the amount of $122.00, by on or

about August 10, 2012; and to submit proof of twenty-two (22) hours of general continuing education credits, and two (2) hours of Prevention of Medical Errors continuing education credits, by on or about October 30,

2012. 6.

Respondent failed to submit payment of the $250 fine and the

$122 in costs by on or about August 10, 2012; and failed to submit proof

of twenty-two (22) hours of general continuing education credfts, and two (2) hours of Prevention of Medical Errors continuing education by on or

about October 30, 2012, as required by the Final Order entered in citation number 2012-06439. 7.

Section 456.072(1)(q), Florida Statutes (2012), provides that

violating a lawful order of the department or the board, or failing to comply

Departn,fl of Health v. Ellinda Anne Case Number 2013-07887

E

White LP.N.

2

with

a

lawfully issued subpoena of the department constitutes grounds for

disciplinary action. 8.

As set

forth above, Respondent violated a lawful order of the

department by failing to submit payment of

a

fine and costs, and proof of

completion of the continuing education courses required by the Anal Order entered in citation case number 2012-06439. 9.

Based

the

on

foregoing,

Respondent

456.072(1)(q), Florida Statutes (2012), by violating

a

violated

Section

lawful order of the

department or the board. WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, Imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the

i"

Board deems appropriate.

SIGNED

this

t

day of

2013.

John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Departhieit of Health v. Ellinda Anne Jones Case Number 2013-07887

I..P.N,

3

FILED DEPARTMENT OF HEALTH DEPUTY CLERK

of Health DON Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65

CLERK i4nge(Saflt€r5 DATE SEP 1 6 2013

Tallahassee, Florida 32399-3265 fla. Bar No. 0815349 Telephone: (850) 245-'llll, ext 8159 Facsimile: (850) 245-4683

LS/ PCP: September 16, 2013 PCP Members: Habgood &

Denker

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine withesses and to have subpoena and subpoena duces tecum issued on his or her behalf If a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Departnent of Health v. Eilinda Mne nones White LP.N. Case Number 2013-07887

4

________

719L 9008 9111 1387 0902 TO:

Cassandra/Schneider Date Mailed 9/20/2013 2013-07887 SENDER: •

REFERENCE:

y

White, Ellinda

PS Form 3800,

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10/15/2013

______________________(type ______________________________

Rick Scott

ion:

Governor

To protect promote of at people In

&

Ida

state,

&

improve the health through Integrated efforts.

John K. Annstrona, MD, FACS State Surgeon General & Seaetary

HEALTh Vision: To be the Healthiest Slate in the Nation

1,

hereby certify

Sherri

,

in

my official capacity as custodian

of Nursing for the Board of Nursing's ilcensure files that the Board 10/15/2013

as of

other has no evidence of an Election of Rights form or

action regarding CASE responsive pleading requesting a hearing prior to any agency

NAME: Eltinda Anne Jones which would affect

L.P.NI. CASE NUMBER: 2013-07887

stantial interests or rights

Records Custodian Florida Board of Nursing

identity is known to me

whose

Sherri Sutton-Johnson

Before me, personally appeared

of identification) and

oersonallv

who,

under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this

15

day of

October

,

2013.

Notary Public

ida Depaflrnent of HnIth

Unit Office of the General Counsel • Pioseajtion 4052 Bald Cypress Way, Bin C-65 •Taltahassee, FL 323991701

-

EXHIBIT

lealth

www.Fiorldasiieaith.com TWIflR:HeathyFtA

Mission:

Rick Scott

Ta protect, promote & improve the health of all people in Florida through integrated state. & community efforts.

HEALTH

,

Governor

John H. *nnstrong,

MD, FACS

Slate Surgeon General & Secretary

Vision; To be the Healthiest Stale in the

Clerk for the

Clerk's Office, hereby cert'fy in my official capacity as custodian for the Department.clerk's records, that the Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding

Ellinda Anne Jones White, L.P.N., Case Np: Respondent's substantial interests or rights.

which would affect the

Custodian bVRecord Department Clerk's Office Before me, personally appeared

\

nersonally known (type of identification signature appears above.

and who, under oath, acknowledges that his/her

Sworn to and subscribed before me this

identity

day of

is known to me by

2013.

Notaiv Public

i

RFNAfl COMsY - Stat, Fioadi Nov a. 20t6

My Commission Expires:

Notary Public My Comm.

SE

Fiends Department of Health Office or the General Counsel- Prosecution Unit 4052 Bald Cypress Way, Bin C-85 . Tallahassee, FL 22399-1701 Express mail address: 2585 Merchants Row — Sufte PHONE: 8501245-4444 • FAX 850/2454683

105

lm

coin

YOQTLJBE: fldoh

_________________________________I

STATEOF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH,

Petitioner, v.

)

CASE NO.

ELLINDA ANNE JONES WHITE, LP.N.,

Respondent.

2013-07887

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW the

Department of

Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of Final Order assessing costs against the Respondent

a

for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter a Final Order therein. 2.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the and prosecution include, but are not limited to, salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the deoartment for the case. The board, or the department when there is no board. shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written obiections

gation

.

3.

The investigation and prosecution of this case has resulted in

costs in the total amount of $253.06, based on the following itemized

statement of costs: ***** Cost to Date *****

[

Hours [

Investigation:

Costs 0.401

1

Expenses to Date: IPrior Amount:] Total Costs to Date:

.401

1 1

$54.90j

i.o0I L

$253.06 $0 00

$0.00

$253.06

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $93.52 as evidenced in the attached affidavit.

(Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $93.52 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $93.52.

3

DATED th

Respectfully Submitted,

John H.

FACS

:retary of Health

er

L

eral Counsel

Flt-Bafljo. 0815349 Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265

Telephone: (850) 245-4444 Facsimile: (850) 245-4683

@flhealth.gov

Email:

CERTIFICATE OF SERVICE I HEREBY CERTIFY

that

a

true and correct copy of the foregoing

Motion to Assess Costs has been furnished via U.S. mail to Ellinda Anne Jones White, L.P.N., at

25 Pleasant Street, Pomona Park, FL 3218k, on 2

Lu

n

sistan

3.

ider eneral Counsel

4

AFFIDAVIT OF FEES AND COSTS EXPENDED STATE OF FLORIDA COUNTY OF LEON: the undersigned authority, personally appeared SHANE WALTERS who was sworn and states as follows:

1)

My name is Shane Walters.

2)

am over the age of 18, competent to testify, and make this affidavit upon my own personal knowledge and after review of the records at the Florida Department of Health (DOH).

3)

am the Operations and Management Consultant Manager (OMCM) for the Consumer Services and Compliance Management Unit for DOH. The Consumer Services Unit is where all complaints against Florida health care licensees (e.g., medical doctors, dentists, nurses,

I

I

respiratory therapists) are officially filed. have been in my current job position for more than one year. My business address is 4052 Bald Cypress Way, Bin C-75 Tallahassee, Florida 32399-3275. I

4) As OMCM of the Consumer Services and Compliance Management Unit, my job duties include reviewing data in the Time Tracking System and verifying that the amounts correspond. The Time Tracking System is a computer program which records and tracks DOH's costs regarding the investigation and prosecution of cases against Florida

health care licensees.

DOll's total costs for investigating and prosecuting DOH case number(s) 2013-07887(Department of Health v. ELLINDA ANNE JONES WHITE, L.P.N.) are TWO HUNDRED FIFTY-THREE DOLLARS AND SIX CENTS ($253.06).

5) As of today,

6) The costs for DOH case numbers 2013-07887 (Department of Health v. 1

ELLINDA ANNE JONES WHITE, L.P.N.) are summarized in Exhibit (Cost Summary Report), which is attached to this document.

7) The itemized costs and expenses for DOH case numbers 2013-07887

(Department of Health v. ELLINDA ANNE JONES WHITE, L.P.N.) are detailed in Exhibit 2 (Itemized Cost Report and Itemized Expense Report and receipts), which is attached to this document. 8) The itemized costs as reflected in Exhibit 2 are determined by the following method: DOH employees who work on cases daily are to

I

of2

keep track of their time in six-minute increments (e.g., investigators and lawyers). A designated DOH employee in the Consumer Services Unit, Legal Department, and in each area office, inputs the time worked and expenses spent into the Time Tracking System. Time and expenses are charged against a state health care Board (e.g., Florida Board of Medicine, Florida Board of Dentistry, Florida Board of Osteopathic Medicine), and/or a case. If no Board or case can be charged, then the time and expenses are charged as administrative time. The hourly rate of each employee is calculated by formulas established by the Department. (See the Itemized Cost Report) 9) Shane Walters, first being duly sworn, states that she has read the foregoing Affidavit and its attachments and the statements contained

therein are true and correct to the best of his knowledge and belief. FURTHER AFFIANT SAYETH NOT.

Shane Walters, Affiant State of Florida County of Leon Sworn to and subscribed before me this Lo day of by Shane WaIters, who personally known to me.

Name of Notary Printed

Stamp Commissioned Name of Notary Public:

2

of 2

Oc*ntcax

2013,

ragc

I

ui

I

Cost Sub

s

Complaint Number: 201307887 Name:

m,

I

L I

ELLfNDA ANNE JONES

Cost to Date bours Costs 1.00

521.96]

]

]

Lcom&ianee:

l

Sub Total: Expenses to Date: Prior Amount: Costs to Date:

I

1

1.501

o.so] *)'r********

Si

516.66]

3.40 $0.00]

1 I______________

EXHIBIT

I___._I0/1

6/2013

0!

10/16/2013

Stall Rate

0.50

Sub Total

1.40

0.10 0.40 0.20 0.20 0.10 0.40

$54.90 $54.90 $54.90 $54.90 $54.90 $54.90

$33.33 $33.33

1.50

Sub Total

Florida Department of Health

Total Cost

0.30 0.40 0.30 0.20 0.20

HLL94B HLL94B HLL94B HLL94B

$106.35 $106.35 $106.35 $106.35 $106.35

IPROSECUTION SERVICES UNiT

8

Sub Total

HA23 HA23

I-1A23

-1A23

HA23 HA23

ICONSUMER SERVICES UNIT

0.40 0.10

I3 13

IC0MrUANCE MANAGEMENT UNIT

Staff Code Activity flours

Report Date

MQA

Medicol QuclEly Asstrance

S253.06

SI 59.54

$31.91 $42.54 $31.91 $21.27 $21.27

$76.86

$5.49 $21.96 $10.98 $10.98 $5.49 $21.96

16.66

$13.33 $3.33

Cost

90

28 89

28

25

76

144

144

144

144

144

142

124

Activity Code

Activity Description

PROBABLE CAUSE PREPARATION POSTPROBABLECAUSEPROCESSING

PREPAREORREVISEADMINISTRATIVECOMPLAINT PREPARE OR REVISE ADMINISTRATIVE COMPLAINT

REVIEW CASE FILE

IVE

CSU INVESTIGATIVE WORK CSU INVESTIGATIVE WORK CSU INVESTIGATIVE WORK WORK CSU CSU INVESTIGATIVE WORK REPORT PREPARATION

PROCESSING MAIL, FAXES OR CORRESPONDENCE PREP AND SCAN CASE FILES

- FOR INTERNAL USE ONLY --

09/20/2013

11/2013

08/12/2013 08/12/2013 08/13/2013

06/18/2013 06/21/2013 06/27/20 13 07/01/2013 08/07/2013

13

06/18/20 13 06/18/2013

Activity Date

Complaint 201307887

Time Tracking System Itemized Cost by Complaint

CO NF ID E NT JAL

temizedeost

Page

1

of2

I

I

I

i

10/16/2013

I

Florida Department of Health

StafiCode Activity Flours

ReportDate

Medical Qucirly Msurance

Staff Rate Cost

—

Activity Code

-

Complaint

FOR INTERNAL USE ONLY

Activity Date

ONF IDE NT JAL

201307887

Activity Description

Time Tracking System Itemized Cost by Complaint

C

itemizedcost

Page2of2

Total Expenses

SubTotal

Expense Date

lO/16/20L3

Florida Department of Health

Code

Report Date:

f

t'Vk

Divisionol Medical Quolily A$su,ance

Amount

Expense

Expense Code Description

Complaint

- FOR INTERNAL USE ONLY -

Expense Code

CONFIDENTIAL "ca

Time Tracking System Itemized Expense by Complaint

***

1

of!

itemizedexpense

Page

Rick Scott

Mission: To protect promote & improve the

Governor

heat

2

of all people in Florida through integrated

slate,

&

cemmunity

'U

6 201 1

H.

FWRIDA:BOARD

Vision: To

Armstrong, MD, FACS

State Surgeon General & Secretary

in the Nation

MEMORANDUM OF PROBABLE CAUSE TO:

Department of Health- A-OS (LS)

FROM:

Board of Nursing, South Probable Cause Panel

SUBJECT:

White, Ellinda Ann Jones, L.P.N.

DATE OF PROBABLE CAUSE MEETING:

CASE NO: 2013-07887 DATE: September16, 2013

This matter was brought before a Probable Cause Panel composed of:

Ann-Lynn Denker and Mary K. Habgood On the date set forth above. The panel, having received the investigative report and supplemental materials, having carefully reviewed said documentation and the recommendation of the agency/department, and having had the opportunity to inquire of counsel, finds that x

Probable cause exists herein that the Subject violated the following statutes/rules: (456.072(1)(q), F.S. (2012) The panel suggests imposing the following penalty: Costs, V5F

Probable cause does not exist and the case should be closed with the following closure code:

t

lieu of a finding of probable cause, the above named licensee shall be issued a letter of guidance to address the conduct in question:

The panel has requested supplemental or additional information on the following:

a

RSON,

Florida Department of Health Office of the General counsel. Prosecubon Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701

Express mail address: 2585 Merchants Row PHONE: 650/245-4444 • FAX

-4683

—

Sulfa 105

www.FloridasHealth.com

TWITTER:HealthyFL.A VOUTUBE: ffdoh

_____________________________________I

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

PETITIONER,

0

CASE NOQ

2013-07887

ELLINDA ANNE JONES WHITE, LP.N., RESPONDENT.

ADMINISTRATIVE COMPLAINT Petitioner, the Florida Department of Health, by and through the undersigned counsel, files this Administrative Complaint before the Board

of Nursing against Respondent, Ellinda Anne Jones White, L.P.N., and

in

support thereof states: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2.

At

times

all

Respondent was

a

material

to

this Administrative

Complaint,

licensed practical nurse (L.P.N.) within the state of

Florida, having been issued license number PN 889241

Respondent's address of record is 225 Pleasant Street, Pomoma

3.

Park, Florida 32181. On or about

4.

ly 10, 2012,

a

Final Order was filed

with Department of Health citation number

connection

that affected

Respondent's license to practice nursing. The above referenced Fin& Order required Respondent to pay

5.

a

fine in the amount of $250, and costs in the amount of $122.00, by on or

about August .10, 2012; and to submit proof of twenty-two (22) hours of general continuing education credits, and two (2) hours of Prevention of Medical Errors continuing education credits, by on or about October 30,

2012. Respondent failed to submit payment of the $250 fine and the

6.

$122 in costs by on or about August 10, 2012; and failed to submit proof

of twenty-two (22) hours of general continuing education credits, and two (2) hours of Prevention of Medical Errors continuing education by on or

about October 30, 2012, as required by the Final Order entered in citation number 2012-06439. Section 456.072(1)(q), Florida Statutes (2012), provides that

7.

violating

a

lawful order of the department or the board, or failing to comply

Department of Health v. Case Number 2013-07887

Anne Jones White L.P.N.

2

______

with

a

lawfully issued subpoena of the department constitutes grounds for

disciplinary action. 8.

As set forth above, Respondentviolated a IawfuB order of the

department by faffing to submit payment of a fine and costs,

1

aid proof

of

completion of the continuing education courses required by the Final Order entered in citation case number 9.

Based

on

the

foregoing,

Respondent

violated

Section

Florida Statutes (2012), by violating a lawful order of the

department or the board. WHEREFORE, the Petitioner respectfully requests

that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate.

SIGNED this

day of

,

2013.

John H. Armstrong, MD, FACS State Surgeon and Secretary of Health

Department of Health V. Ellinda Anne Jones Whfte L.P.N. Case Number 2013-07887

3

Lucy Schneider Assistant General Counsel Florida Department of Health DOH Prosecution Services Unit 4052 Cypress Way, G=65 Tallahassee, Florida 32399-3265 Fla. Bar No. 0815349 Telephone: (850) 245-4444, ext: 8159 Facsimile: (850) 245-4683

LS/ PCP: PCP

Members:

NOTICE OF RIGHTS

Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested NOTICE REGARDING ASSESSMENT OF COSTS

Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investiSation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

,

Department of Health Ellinda Anne Jones White L.P.N. Case Number 2013-07887

4

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

INVESTIGATIVE REPORT /16/2013

Subject: ELLINDA ANNE JONES

L,P.N.

License 889241

Source: FLORIDA DEPARTMENT OF HEALTh

Compliance Management Unñt

225 Pleasent Street Pomona Park, FL 32181 Prefix: LPN

Case Number LPN 201 3-07887

Date of Complaint:

Office: CONSUMER SERVICES

#:

Period of Investigation: 05/21/2013 through 08/07/2013

Profession: Licensed Practical Nurse

Board: Nursing

Report Date: 08/07/2013

Type of Report: FINAL

Alleged Violation: 55. 456.072(1)(k)(q)(dd) and 464.01 8(1)(l)(o), F.S. Failure to perform statutory/legal obligation; Violate lawful order of the Board; Violate statute/rule Synopsis: This investigation is predicated on the receipt of a complaint from the FLORIDA DEPARTMENT OF HEALTH stating WHITE has failed to pay a fine in the amount of $250.00 and costs in the amount of $122.00, due 08/10/2012, and has failed to submit proof of completion of twenty-two (22) hours general continuing education and two (2) hours of Prevention of Medical Errors continuing education, due 10/30/2012, as required by Citation Number 201206439, filed 07/10/2012. (EXHIBIT #1) WHITE was notified of this complaint by certified letter, dated 05/21/2013. The notification was sent to the mailing address of record. Forwarded with this letter were copies of the Case Summary and the initiating documents. WHITE was again notified of this complaint by certified letter, dated 06/28/2013. The notification was sent to the mailing address of record. Forwarded with this letter were copies of the Case Summary and initiating documents. Domestic Return Receipt (green card) reflects this notification was received by WHITE on -4 07/1212013. (EXHIBIT #2)

)

DOH licensure information was viewed on 08/07/2013. It reflects WHITE is duly licensed to practice Licensed Practical Nurse in the State of Florida with a Clear, Active status.

a

C C

No patient involvement, thus patient notification not required.

WHITE is not known to be represented by counsel in this matter as of the date of this report. WHITE has not responded to notification of this complaint as of the date of this report.

0

r.,

C)

Related Case: 2012-06439

Investigator/Date:

Approved By/Da

Anita M. Hill (HA23) 08/07/2013

Nicole

Distribution: Prosecution Services Unit/Consumer Services Unit

ingleton, OMC

anager Page

1

CASE NUMBER LPN 201 3-07887

REPORT

DOH

TABLE OF CONTENTS

INVESTIGATIVE REPORT COVER PAGE

TABLE OF CONTENTS

I 2

INVESTIGATIVE DETAILS

III.

Summary of Records

3

Interviews/Statements: Interview/Statement of the FLORIDA DEPARTMENT OF HEALTH ANNE JONES WHITE, L.P.N Interview/Statement of

3 3

EXHIBITS 1)

Case Summary & Initiating Documents

2)

WHITE's Notification Letters

4-7

8-12

Page 2

CASE NUMBER LPN 201 3-07887

DOH INVESTIGATIVE REPORT

INVESTIGATIVE DETAILS

INTERVIEW/STATEMENT OF THE FLORIDA DEPARTMENT OF HEALTH

Address of Record:

iance Management

Source

Unit

On 05/16/2013, Investigator Hill received the FLORIDA DEPARTMENT OF HEALTH's complaint stating WHITE has failed to pay a fine in the amount of $250.00 and costs in the amount of $12200, due 08/10/2012, and has failed to submit proof of completion of twenty-two (22) hours general continuing education and two (2) hours of Prevention of Medical Errors continuing education, due 10/30/2012, as required by Citation Number 201 2064391 filed 07/10/201 2. (EXHIBIT #1) INTERVIEW/STATEMENT OF ELLINDA ANNE JONES WHITE. LPN Subject

Address of Record:

225 Pleasent Street Pomona Park, FL 32181

WHITE has not responded to notification of this complaint as of the date of this report.

Page 3

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

CONFIDENTIAL AND EXEMPT MATERIALS

One or more pages have been removed from this document for security reasons Scroll down to see the available pages or advance to the next document if all pages have been removed. SOME OR ALL PAGES IN THIS DOCUMENT ARE PATIENT RECORDS AND/OR DOCUMENTS THAT IDENTIFY THE PATIENT BY NAME AND ARE EXEMPT FROM PUBLIC RECORDS LAWS. 456.057 - Ownership and control of patient records; report or copies of records to be furnished.— 10)(a)All patient records obtained by the department and any other documents maintained by the department which identify the patient by name are confidential and exempt from s. 119.07(1) and shall be used solely for the purpose of the department and the appropriate regulatory board in its investigation, prosecution, and appeal of disciplinary proceedings. The records shall not be available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the department or the appropriate board.

a

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Rick Scott

Mission:

Governor

To protect, promote & improve the health of all people in Floñda Through integrated

John H. Armstrong, MD, FACS

stale, county & community efforts.

State Surgeon General

HEALTH Vision: To be the

Hejithiest State

&

Secretary

in the Nation

NOTICE OF HEARING November 8, 2013 Case#: 2013-04553 KATI-IRYN ELIZABETH DEIST 3400 FRANCES STREET, APT. 6 ERIE, PA 16510, FL

To:

YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December

Time:

8:30am

Type:

Determination of Waiver

Re:

/2013-04553

Place:

letree by Hilton

5,

2013

100 Fairway Drive Deerfield Beach, FL 33441 954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information. For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at If you have any

,

ida Department of Health Division of Medical Quality Assurance' Board of Nursing 4052 Bald Cypress Bin C-02 'Tallahassee, FL 32399-3252 PHONE: 850) 245.4125 'FAX 8501 245-4172

lealth

www.FiorldasHeaith.gov TWITTER:HeaithyFLA VOUTUBE: tldoh

/

Minion:

Rick Scott Governor

To protect, promote & improve the health

John H. Armstrong, MD, FACS Stath Surgeon General & Secretary

H EALTH Vision: To be the Heaithiest State

in

the Nathn

NOTICE OF HEARING

November 8, 2013 Case#: 201304553 To:

KATHRYN ELIZABETH DEIST

5920W COMMONWEALTH AVE CHANDLER, AZ 85226, FL YOU ARE HEREBY NOTIFIED THAT THE BOARD OF NURSING WILL CONSIDER YOUR CASE AT THE FOLLOWING MEETING: Date:

Thursday, December 5,2013

Time:

8:30am

Type:

Determination of Waiver

Re:

1701/201304553

Place:

letree by Hilton 100 Fairway Drive Deerfield Beach, FL 33441

954-427-7700

Informal hearings, informal waivers and informal licensure hearings are heard individually by the Board. Respondents have the opportunity to address the Board but attendance is not mandatory unless otherwise indicated. Should you plan to attend, please arrive approximately 15 minutes prior to the beginning of the meeting to sign in.

After the conclusion of the meeting, the Board will file a final order stating the facts of the case and the outcome voted on by the Board. A copy of the order will be sent to the respondent, typically within 30 days of the board meeting. Do not send additional materials to the Board office at this time. Additional material will not be considered at the Board meeting, except at the discretion of the Board Chair.

Requests for continuance must be received in the Board Office at least 7 days in advance of the meeting and are subject to approval by the Board Chair or designee. Any request due to medical conditions must be accompanied by a statement from a Physician or Advanced Registered Nurse Practitioner. Requests for continuances can be mailed to the board office or faxed to (850) 412-2208. Please include your full name and contact information.

For questions regarding meeting location directions, contact the hotel at the number listed above under "Place." If you have any further questions regarding the upcoming board meeting, please contact the Florida Board of Nursing office at (850) 245-4125 or via email at

Florida Department of Health DMsion of Medical Quaf ity Assurance • Board of Nursing 4052 Bald Cypress Way, Bin 0-02 • Taliahassee, FL 32399-3252 PHONE: 8501 245-4125 • FAX 650/ 2454172

www.FiorldasHeaith.gov TWiTFER:HeatthyFLA FAOEBOOK:FLDepartmentoHealth vouluBE: fldoh

Rick Scott

Mission;

Governor

To protect, promote & irnprove the health of all people in Flodda through integrated state, county & community efforts.

I

John H. Armstrong, MD, FACS

I%AU

HEALTH

State Surgeon General

&

Secretary

vision: To be the Heafthlest State in the Nation

MEMORANDUM

l

TO: FROM: RE: SUBJECT:

Joe Baker, Jr., Executive Director, Florida Lucy Schneider, Assistant General

DATE:

October 23, 2013

of

Determination of Waiver v. Kathryn Elizabeth Deist, R.N. DOH Case Number 2013-04553

Enclosed you will find materials in the above-referenced case to be placed on the agenda for final agency action for the December 5, 2013 meeting of the board. The following information is provided in this regard.

Subject: Subject's Address of Record: Enforcement Address:

Kathryn Elizabeth Deist, R.N. 3400 Frances Street, Apt 6 Erie, PA 16510 5920 W. Commonwealth Ave Chandler, AZ 85226

Subject's License No: Licensure File No:

9171674

Initial Licensure Date:

9/18/2000

Board Certification: Required to Appear:

None

Current IPN/PRN Contract: Allegation(s):

No

Rank:

RN

256302

No

Prior Discipline: Probable Cause Panel:

Section 464.018(1)(b), F.S. (2012) None

September 16, 2013 Denker & Habgood

Subject's Attorney:

Pro Se

Complainant/Address:

Department of Health/ Board of Nursing

Fiorids Dopautment of Hosith Office of the General Counsel • Prosecution Services Unit 4052 Bald Cypress Way, Bin C-85 Tallahassee, FL 32399-1701 Express mail address: 2585 Merthants Row — 105 PHONE: 850/245-4444 • FAX 850/245-4683

Ite

.aith.com

TWITTER:HeaithyFLA

oepartrnentotHealth YOUTUBE: fldoh

STATE OF FLORIDA BOARD OF NURSING

DEPARTMENT OF HEALTH,

Petitioner, v.

CASE NO.

2013-04553

KATHRYN E. DEIST, R.N.,

Respondent.

MOTION FOR DETERMINATION OF WAIVER AND FOR FINAL ORDER AFTER A HEARING NOT INVOLVING DISPUTED ISSUES OF MATERIAL FACT PETITIONER, the Florida Department of Health, by and through the undersigned counsel, hereby moves the Board of Nursing for entry of a Final

Order in the above-styled cause on a date and time that has been determined and noticed by the Board. As grounds therefore Petitioner states:

s 1.

An Administrative Complaint was filed against Respondent on

September 16, 2013. A copy of said Administrative Complaint is attached hereto as

Exhibit A.

2.

Copies of the Administrative Complaint, Explanation of Rights form,

and Election of Rights form were successfully served on Respondent via certified US mail on:

September 25, 2013 (7196 9008 9111 1387 0889). A copy of the

certified mail receipt is attached as Petitioner's Exhibit B. 3.

Rule

28-106.111(2), Florida Administrative Code, provides in

pertinent part that: persons seeking a hearing on an agency decision which does or may determine their substantial interests shall file a petition for hearing with the agency within 21 days of receipt of written notice of the decision. 4.

Rule 28.106.111(4), Florida Administrative Code, provides that:

Any person who received written notice of an agency decision and who fails to file a written request for a hearing within 21 days waives the right to request a hearing on such matters. 5.

Respondent has not filed an Election of Rights form, or any other

responsive pleading, with Petitioner or the Board of Nursing within the required

twenty-one (21) day period of time.

Copies of affidavits supporting the same

are attached hereto as Petitioner's Exhibits C & D. 6.

Based upon the foregoing, Respondent has waived the right to

dispute any materials facts contained within the Administrative Complaint.

Therefore, there are no disputed issues of material fact to be resolved by the Board.

7.

Respondent has been advised by way of this Motion, that a copy of

the investigative file in this case will be furnished to the Board, establishing a prima facie case regarding the violations as set forth in the Complaint. WHEREFORE, Petitioner respectfully requests

that the Board find that

Respondent has waived the right to dispute any materials facts contained within

the Administrative Complaint and enter

a

Final Order imposing whatever

discipline upon Respondent's license that the Board deems appropriate.

John H. Armstrong, MD, FACS State S eon General and Secretary of Health

Lucy Sch eider sistant

eneral Counsel

No.0815349 Florida Department of Health Office of the General Counsel Fla.

4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-4444 Facsimile: (850) 245-4683 Email:

CERTIFICATE OF SERVICE

I

HEREBY CERTIFY that a true and correct copy of the above and been provided by U.S. day of 2013, to: at 3400 Frances Street, #6, Erie, PA 16510.

er 'eral Counsel

,,

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Pti V.

CASE NO.:

2013-04553

KATHRYN E. DEIST,

RESPONDENT.

iVE I

COM PLAINT

Petitioner, the florida Department of Health, by and through the undersigned counsel, files this Administrative Complaint before the Board

of Nursing against Respondent, Kathryn

E.

Deist, R.N., and in support

thereof states: 1.

Petitioner is the state agency charged with regulating the

practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter

f

456, florida Statutes; and Chapter 464, Florida Statutes. 2.

At

all

times

material

to

this

Administrative

Complaint,

Respondent was a registered nurse (R.N.) within the state of Florida, having been issued license xiumber RN 9171674.

3.

Respondent's address of record is 3400 Frances Street,. Apt. 6,

Erie, Pennsylvania, 16510.

Other known addresses for Respondent are:

5920 West Commonwealth Avenue, Chandler, Arizona 85226; and 7776

Dutton Road, Harborcreek, Pennsylvania 16421-1116. 4.

The Arizona State Board of Nursing is the licensing authority for

nurses in the State of Arizona. 5.

At

all

times

material to

this

Administrative

Respondent was licensed by the State of Arizona as

a

Complaint

registered nurse

possessing license number 115035. 6.

On or about March 8, 2013, the Arizona State Board of Nursing

issued a Consent Agreement that constituted formal disciplinary action

against Respondent's Arizona nursing license. 7.

Section 464.018(1)(b), Florida Statutes (2012), provides that

having a license to practice nursing revoked, suspended, or otherwise acted against, induding the denial of licensure, by the licensing authority of

another state, territory, or country constitutes grounds for disciplinary action. 8.

As set forth above, Respondent had a license to practice

nursing revoked, suspended, or otherwise acted against, including the Dwarthient of Health V. Kathryn CaseNumbe 2013-04553

E. DeiSt.

RN. 2

denial of licensure, by the licensing authority of another state, territory, or

country, when on or about March 8, 2013, the Arizona State Board of Nursing took formal

disciplinary action against Respondent's nursing

license. 9.

Based

on

the

foregoing,

Respondent

64.018(1)(b), Florida Statutes (2012), by having

a

violated

Section

license to practice

nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority

of another state, territory, or

country. WHEREFORE,

Petitioner respectfully requests that the Board of

Nursing enter an order imposing one or more of the following penalties:

permanent revocation or suspension of Respondent's license, restriction of practice, Imposition of an administrative fine, issuance

of

a

reprimand,

placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the

—

Board deems appropriate.

SIGNED

•

this

day of_______________ 2013. John H. Armstrong, MD, FACS State Surgeon General and Secretary of Health

Department of Heajth V. Kathryn E. Deist, R.N. Case Number 2013-04553

3

I

Lucy Schn Assistant

ener Counsel

florida Department of Health Prosecution Services Unit 4052 Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265

FILED DEPARTMENT OF HEALTH DEPUTY CLERK CLERK

L6

er

2013

ld

0815349 Telephone: (850) 245-4444, ext: 8159 Ha. Bar No.

Facsimile: (850) 245-4680

PCP

Members:

NOTICE OF RIGHTS Respondent has the right to request a hearing to •be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represents by counsel or other qualified representájjve, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS

Respondent

is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter.

Pursuant to Section 456.072(4),. Florida Statutes, the Board shall assess costs related to the investigation and prosecution of disciplinary matter, which may include attorney hours and costs,a on the Respondent in addition to any other discipline imposed.

Departmentofl4earmv. Kathryn Case Number 2013-04553

E.

Deist,

tN,

4

t...

9111 1387 DM9

3

I

Stip Pack

Date Mailed 9120/2013

SENDER:

REFERENCE:

Deist, KathrY PS Form 3800 Janue

RETURN RECEIPT SERVICE

S

Deist Icathtyhi 6. Street, #6 3400 16510 Erie, PA

2005

Postage Certified Fee

Return Receipt Fee Restricted Delivery

Total Postage & Fees

POSTMARK OR DATE

USPSS

Receipt for Certified Mall"' NO

Insurance coverage Provided

InternatiOnal Do Not Use toe

2.

Article Number A. Received by Please P,lnt Clearly)

II

C.

Ellulill

0. Date of Delivery

Signatu

?]I% 9008 9111 1387 0889

h

3.

SeMce Type CERTIFIED

4.

Restricted Delivery? (Extra Fee)

Is

From item 1? if YES, enter delivery address below:

flves

Article Addressed to:

o C) -4 I.

E.

3433 Fraii':es Screet, #6

E-C. RA

i C,

rt,rn-

—

Stip

2013-04553

'9 C-

PS Form 3811,

January 2005

Domestic Return Receipt I

,

Rick Scott Mission:

Governor

To protect promote & inipruve the heath of all people in Fietida through integrated slate, county & community oftorts.

John H. Annstrong. MD, FACS Gaemi

State

HEALTH

& Seaeta,y

Vision: To be the Healthiest State in the

,

:

I

hereby certify in my official capacity as custodian

Joe BakenJn

for the Board of Nursing's licensure files that the Board of Nursing as of 10/18/2013

,.

has no evidence of an Election of Rights form or other

responsive pleading requesting

NAME: Kathryn E. affect the Subject's

a

hearing prior to any agency action regarding CASE

CASE

2013-04553

which would

orrits.

inte

\J..Lustodian of Rec4ds

ls

Florida Board of Nursing

Before me, personally appeared

Joe

nersona lv

identity is known to me

I

whose

(type of identification)

and

who,

under, oath, acknowledges that his/her signature appears above. Sworn to and subscribed this 18

day of

October

,

2013.

Notary Public

Fladda Department of Health • Prosecution SeMces Unit of the Generil 32399-1701 4052 Bald Cypress Way, Bin C-65 Tallahassee,

ft

.com TWITTER:HealthyFLA

ACEBOOK:Fepamnenfofiieattti

fl

Minion: To protect, promote & improve the health ol all people In Florida through integrated state, county & community efforts.

Rick Scott Governor

John H. Armstrong, MD, FACS

, HEALTh

Vision: To

State Surgeon General & Secreiary

be the Health jen State hi the NaUon

AFFIDAVIT

Deputy Clerk for the Department Clerk's Office, hereby certify in my official capacity as custodian for the Department Clerk's records, that the L)

Department Clerk's Office has not received an Election of Rights form or other responsive pleading, which requests a hearing prior to any Department action regarding Case Name: Kathryn E. Deist. R.N.. Case No: whIch would affect the Respondent's substantial interests or rights.

Custodian of Record Department Clerk's Office

lly

Before me, personally appeared

whose identity is known to me by

known (type of identification) and who, under oath, acknowledges that his/her signature appears above.

ofEU4OhQtr

Sworn to and subscribed before me this

Notary Public My Commission Expires:

AMY C. %

?

.,

2013.

U

y

RA CO1ra,lJnJQn#0D941628

wcm?r

Florida Department of Health Office of the General CounselS Proseailion Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-1701 Express nail address: 2585 Merchants RoN — Suite 105 PHONE: 850)245-4444 • FAX 850)245-4683

.com

TWflTER:HeaIthyFL.A YOUTIJBE: fldoh

STATE OF FLORIDA DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH,

Petitioner, v.

)

CASE NO.

KATHRYN E. DEIST, RJ'l.,

Respondent.

2013-04553

MOTION TO ASSESS COSTS IN ACCORDANCE WITH SECTION COMES

NOW

the

Department of

Health,

by

and

through

undersigned counsel, and moves the Board of Nursing for the entry of a Final Order assessing costs against the Respondent for the investigation

and prosecution of this case in accordance with Section 456.072(4), Florida

Statutes. As grounds therefore, the Petitioner states the following: 1.

At its next regularly scheduled meeting, the Board of Nursing

will take up for consideration the above-styled disciplinary action and will

enter

a Final

2.

Order therein.

Section 456.072(4), Florida Statutes, states as follows:

In addition to any other discipline imposed through final order, or citation, entered on or after July 1,

2001, pursuant to this section or discipline imposed through final order, or citation, entered on or after July 1, 2001, for a violation of any practice act, the board, or the department when there is not board, shall assess costs related to the investigation and prosecution of the case. Such costs related to the investigation and prosecution include, but are not limited salaries and benefits of personnel, costs related to the time spent by the attorney and other personnel working on the case, and any other expenses incurred by the department for the case. The board. or the deøartment when there is no board, shall determine the amount of costs to be assessed after its consideration of an affidavit of itemized costs and any written objections

,

3.

.

The investigation and prosecution of this case has resulted in

costs in the total amount of $353.83, based on the following itemized

statement of costs:

*****costtonate*****

]

I

Hours jComplaint: Investigation:

]

]

Costs

j

1.10]

i.so] I

0.00

0.00

1

Sub Total: Expenses to Date: Prior Amount: Total Costs to Date:

$353.83 $0 00]

H

so.oo $353 83

2

Therefore, the Petitioner seeks an assessment of costs against the Respondent in the amount of $151.74 as evidenced in the attached

affidavit. (Exhibit A). 4.

Should

the

Respondent

file

written

objections

to

the

assessment of costs, within ten (10) days of the date of this motion,

specifying the grounds for the objections and the specific elements of the costs to which the objections are made, the Petitioner requests that the Board determine the amount of costs to be assessed based upon its

consideration of the affidavit attached as Exhibit A and any timely-filed

written objections. 5.

Petitioner requests that the Board grant this motion and assess

costs in the amount of $151.74 as supported by competent, substantial

evidence. This assessment of costs is in addition to any other discipline

imposed by the Board and is in accordance with Section 456.072(4), Florida Statutes.

WHEREFORE, the Department of Health requests that the Board of Nursing enter a Final Order assessing costs against the Respondent in the

amount of $151.74.

3

DATED

day of

(r2

2013

Respectfully Submitted,

John H. State

MD, FACS nd Secretary

of Health

Sch eider A istant eneral Counsel o.

F

081534

Florida Department of Health Office of the General Counsel 4052 Bald Cypress Way, Bin #C65 Tallahassee, FL 32399-3265 Telephone: (850) 245-1111 Facsimile: (850) 245-4683 Email:

CERTIFICATE OF SERVICE I HEREBY CERTIFY

that

a

true and correct copy of the foregoing

Motion to Assess Costs has been furnished via U.S. mail to Kathryn Deist, R.N,