59A-36.023 Administrative Enforcement | FL

Facility staff must cooperate with agency personnel during surveys, complaint investigations, monitoring visits, license application and renewal procedures and other activities necessary to ensure compliance with Part II, Chapter 408, F.S., Part I, Chapter 429, F.S., Rule Chapter 59A-35, F.A.C., and this rule chapter.

(1) Abbreviated Survey.

(a) An applicant for license renewal who does not have any class I or class II violations or uncorrected class III violations, confirmed long-term care ombudsman program complaints, or confirmed licensing complaints within the two licensing periods immediately preceding the current renewal date, is eligible for an abbreviated biennial survey by the agency. For the purpose of this rule, a confirmed long-term care ombudsman program complaint is a complaint that is verified and referred to a regulatory agency for further action. Facilities that do not have two survey reports on file with the agency under current ownership are not eligible for an abbreviated inspection. Upon arrival at the facility, the agency must inform the facility that it is eligible for an abbreviated survey, and that an abbreviated survey will be conducted.

(b) Compliance with key quality of care standards described in the following statutes and rules will be used by the agency during its abbreviated survey of eligible facilities:

  1. Section 429.26, F.S., and Rule 59A-36.006, F.A.C., relating to residency criteria;
  2. Section 429.27, F.S., and Rule 59A-36.013, F.A.C., relating to proper management of resident funds and property;
  3. Section 429.28, F.S., and Rule 59A-36.007, F.A.C., relating to respect for resident rights;
  4. Section 429.41, F.S., and Rule 59A-36.007, F.A.C., relating to the provision of supervision, assistance with the activities of daily living, and arrangement for appointments and transportation to appointments;
  5. Section 429.256, F.S., and Rule 59A-36.008, F.A.C., relating to assistance with or administration of medications;
  6. Section 429.41, F.S., and Rule 59A-36.010, F.A.C., relating to the provision of sufficient staffing to meet resident needs;
  7. Section 429.41, F.S., and Rule 59A-36.012, F.A.C., relating to minimum dietary requirements and proper food hygiene;
  8. Section 429.075, F.S., and Rule 59A-36.020, F.A.C., relating to mental health residents’ community support living plan;
  9. Section 429.07, F.S., and Rule 59A-36.021, F.A.C., relating to meeting the environmental standards and residency criteria in a facility with an extended congregate care license; and
  10. Section 429.07, F.S., and Rule 59A-36.022, F.A.C., relating to the provision of care and staffing in a facility with a limited nursing services license.

(c) The agency will expand the abbreviated survey or conduct a full survey if violations which threaten or potentially threaten the health, safety, or welfare of residents are identified during the abbreviated survey. The facility must be informed when a full survey will be conducted. If one or more of the following serious problems are identified during an abbreviated survey, a full biennial survey will be immediately conducted:

  1. Violations of Rule Chapter 69A-40, F.A.C., relating to firesafety, that threaten the life or safety of a resident;
  2. Violations relating to staffing standards or resident care standards that adversely affect the health, safety, or welfare of a resident;
  3. Violations relating to facility staff rendering services for which the facility is not licensed; or
  4. Violations relating to facility medication practices that are a threat to the health, safety, or welfare of a resident.

(2) Survey Deficiency.

(a) Before or in conjunction with a notice of violation issued pursuant to Part II, Chapter 408, F.S., and Section 429.19, F.S., the agency shall issue a statement of deficiency for class I, II, III, and IV violations which are observed by agency personnel during any inspection of the facility. The deficiency statement must be issued within 10 working days of the agency’s inspection and must include:

  1. A description of the deficiency;
  2. A citation to the statute or rule violated; and
  3. A time frame for the correction of the deficiency.

(b) Additional time may be granted to correct specific deficiencies if a written request is received by the agency before the expiration of the time frame included in the agency’s statement.

(3) Employment of A Consultant.

(a) Medication Deficiencies.

  1. If a class I, class II, or uncorrected class III deficiency directly relating to facility medication practices as established in Rule 59A-36.008, F.A.C., is documented by agency personnel pursuant to an inspection of the facility, the agency must notify the facility in writing that the facility must employ or contract the services of a pharmacist licensed pursuant to Section 465.0125, F.S., or registered nurse as determined by the agency.
  2. After developing and imprementing a corrective action plan in compliance with Section 429.42(2), F.S., the initial on-site consultant visit must take place within 7 working days of the notice of a class I or class II deficiency and within 14 working days of the notice of an uncorrected class III deficiency. The facility must have available for review by the agency a copy of the license of the consultant pharmacist or registered nurse and the consultant’s signed and dated review of the corrective action plan no later than 10 working days subsequent to the initial on-site consultant visit.
  3. The facility must provide the agency with, at a minimum, quarterly on-site corrective action plan updates until the agency determines after written notification by the consultant and facility administrator that deficiencies are corrected and staff has been trained to ensure that proper medication standards are followed and that such consultant services are no longer required. The agency must provide the facility with written notification of such determination.

(b) Dietary Deficiencies.

  1. If a class I, class II, or uncorrected class III deficiency directly related to dietary standards as established in Rule 59A-36.012, F.A.C., is documented by agency pursuant to an inspection of the facility, the agency must notify the facility in writing that the facility must employ or contract the services of a registered or licensed dietitian, or a licensed nutritionist.
  2. The initial on-site consultant visit must take place within seven working days of the notice of a class I or II deficiency or within 14 working days of the notice of an uncorrected class III deficiency. The facility must have available for review by the agency a copy of the license or registration of the consultant dietitian or nutritionist and the consultant’s signed and dated review of the facility’s corrective action plan, if a plan is required by the agency, no later than 10 working days after the initial on-site consultant visit.
  3. If a corrective action plan is required, the facility must provide the agency with, at a minimum, quarterly on-site corrective action plan updates until the agency determines after written notification by the dietary consultant and facility administrator, that deficiencies are corrected and staff has been trained to ensure that proper dietary standards are followed and consultant services are no longer required. The agency must provide the facility with written notification of such determination.