After a death, state halts new admissions to ALF
TALLAHASSEE
After a resident who repeatedly left a Hialeah assisted living facility was found dead in November, the state’s Agency for Health Care Administration issued an emergency order halting admissions to the facility until further notice.
According to the order, which was issued Jan. 21, the resident was admitted to Pavilion Gardens in Hialeah on Nov. 13, 2019, without a health assessment but came in with prescriptions for medication generally used to treat schizophrenia. Three days later, the resident, who was not named in the order, left the facility.
According to the notice, the resident’s sibling was contacted but wasn’t able to find the relative. Law enforcement eventually found and returned the resident to Pavilion Gardens the next day. No healthcare providers were notified and the resident didn’t go through an evaluation, even though the facility’s policies require it, according to the notice.
The next week, the resident didn’t receive a prescription medication and on Nov. 23, was seen by a fellow resident scaling the facility’s fence at 2 a.m. It was reported to staff, but the resident couldn’t be found. A staff member was told by the facility administrator to wait until the next day to call the resident’s family and law enforcement.
The next day, the resident was found dead after falling from a four-story building, the location of which was not identified in the AHCA report.
Earlier in November, a resident at Pavilion Gardens left and has not returned to date. The administrator, Armando Godinez, told investigators “they want to leave, so they leave.” Citations issued by AHCA in 2015 and 2014 show multiple incidents where residents who left the facility were never reported missing to police.
The 40-bed facility on West 30th Street in Hialature leah is run by Godinez and his wife, Eugenia Godinez, according to state health records. It is the only facility that they own.
The AHCA report said the facility’s staffing schedule falls “far below” the hourly minimums dictated by state law, and that the facility’s staff “lack the minimum qualifications” needed to provide services in emergency situations.
According to state inspection records, AHCA responded to four complaints at the facility in 2018, with complaints ranging from bed bug infestations to peeling paint to rooms where the doors were not sufficient. Other complaints included failures to post emergency plans and lack of help from staff with dressing, bathing and administering medication to residents.
In a statement, a spokeswoman for AHCA wrote that the agency’s “foremost priority is ensuring the health and safety of the residents and patients in the facilities we regulate.”
When AHCA issues an emergency moratorium, it is hand delivered to the facility the day it is signed, and the order is posted at the facility.
During a moratorium on admissions, the facility cannot admit any new residents and any current resident admitted to the hospital during a moratorium must receive approval from AHCA before returning to the facility.
AHCA then determines appropriate sanctions, like fines or revoking of licenses.
Once the full report of the inspection is complete, AHCA will send a list of deficiencies, and the facility has to submit a plan of correction. During that time, AHCA can make site visits to decide whether the moratorium should be lifted.
During the duration of the moratorium order, AHCA also conducts monitoring visits.
Some advocates say incidents of this kind are troubling, and are critical of two bills moving through the Florida Legis
that they say would reduce oversight of ALFs by abbreviating required inspections.
The Senate version of the bill, filed by Stuart Republican Sen. Gayle Harrell, passed its first committee stop in November. The House version of the bill, filed by Rep. Michael Grant, RPort Charlotte, has not yet been heard.
But critics say the bills water down the inspection process by restricting the inclusion of long-term care ombudsman complaints from AHCA’s inspection evaluation process.
The bill also allows AHCA to use an abbreviated survey for an ALF that has had confirmed ombudsman complaints unless the complaints resulted in a violation. An abbreviated survey means a survey that is made up of observations and interviews. As it stands, an applicant for licensure renewal is eligible for an abbreviated survey if it doesn’t have any violations or confirmed ombudsman complaints.
Families for Better
Care, a nonprofit group focused on nursing homes and long-term care, is worried about the repercussions of the bill.
The group’s director, former ombudsman Brian Lee, said he fears what will happen when ombudsmen have less say and more facilities are eligible to receive the abbreviated surveys.
“This is not a Christmas gift, this is a lifetime membership to the best club in America,” he said. “No more AHCA hassle. And they are kicking the ombudsman out of this process. The law now guarantees them a seat at the table in the inspection process, in the reviews. … This bill is scary.”
Sandi Poreda, a spokeswoman for the Florida Senior Living Association, argued the contrary.
The ombudsman program often seeks to resolve issues that fall outside of the state’s regulatory process, she said.
For example if a complaint is made to an ombudsman against someone who may be taking advantage of a resident financially in an ALF, Poreda said, it doesn’t reflect a deficiency that should be taken into consideration during the survey process.
“Representative Grant and Senator Harrell’s proposal is forward thinking and friendly to seniors living in assisted living communities and supports their ability to use assistive devices and live more safely in their assisted living homes,” she added.
In a statement, a spokeswoman for AHCA said the agency has met with stakeholders and bill sponsors for both bills and “will continue to monitor these bills as they develop.”