Preview
Filing # 57868917 E-Filed 06/16/2017 01:17:05 PM
IN THE CIRCUIT COURT OF THE
11™ JUDICIAL CIRCUIT, IN AND FOR
MIAMI-DADE COUNTY, FLORIDA
CIVIL DIVISION
CASE NO.:
ISABEL LEVINE, as Personal
Representative of the Estate of
JOSE L. CLEMENTE, Deceased,
Plaintiff,
vs.
SENIOR HEALTH - TREASURE
ISLES, LLC. d/b/a TREASURE
ISLE CARE CENTER,
Defendant.
/
PLAINTIFF’S INITIAL REQUEST FOR PRODUCTION TO DEFENDANT,
SENIOR HEALTH - TREASURE ISLES, LLC. d/b/a TREASURE ISLE CARE CENTER
COMES NOW, the Plaintiff, ISABEL LEVINE, as Personal Representative of the Estate of
JOSE L, CLEMENTE, Deceased, by and through her undersigned counsel, and propounds the
attached requests for production, pursuant to F.R.C.P. §1.350, upon the Defendant, SENIOR
HEALTH - TREASURE ISLES, LLC. d/b/a TREASURE ISLE CARE CENTER, to produce copies
of the attached documents being requested, pursuant to the applicable rules of civil procedure, within
FORTY FIVE (45) days from the date of service hereof.
Note: The term “Facility” refers to: "TREASURE ISLE CARE CENTER”
The "Resident" refers to: "JOSE L, CLEMENTE"
The term “AHCA” refers to: “Agency for Healthcare Administration”
All words used in any gender shall extend to and include all genders.Page 2
Provide all insurance policies and declaration sheets (including umbrella and excess
policies), that may provide coverage to the Facility for the negligence that has been asserted
by the Plaintiff and all insurance policies and declaration sheets (including umbrella and
excess policies) that may provide coverage to any other entity(s) in addition to the Facility,
which was responsible for any care/treatment/supervision provided to the Resident while
he/she was a resident at the Facility, as required by Florida Statute §400.141(1)(s).
Provide all reservations of rights notices or denials of coverage notices for any insurance
policies identified Request for Production #1 and being asserted against this claim.
If a policy of insurance identified in Request for Production # 1 is a “shared policy,” and
there have been or are other pending claims being made on that policy, provide a list of the
names and addresses of the other claimants and/or their attorneys. If a settlement has been
made on a portion of the policy, provide the amount of the settlement and the remaining
money left on the policy.
If a policy of insurance identified in Request for Production # 1 is a “wasting policy,”
provide a summary of the remaining funds left on the policy, as of the answering of this
request for production.
If the facility does not have a policy of insurance that provides coverage for this claim,
provide any and all documents which show that the Facility has complied with the liability
insurance requirements set forth in Florida Statute §400.141.
If the facility does not have a policy of insurance that provides coverage for this claim,
provide any and all documents that show that the Facility has provided notice to the
Department of Elderly affairs that the Facility is not in compliance with Florida Statutes
and/or Florida Administrative Code.
Provide a complete copy of the facility’s licensure file as required by Florida Statute
§400.071(1)(e).
Provide laser color copy of all or portions of the original chart for the Resident while he/she
was a resident at the Facility, as designated by Plaintiffs counsel after having the
opportunity to review the chart. Please provide a date of availability, in writing, for the
Plaintiff’s attorney to review the original chart.
Provide a laser color copy of the complete administrative and/or financial file or files
prepared and/or maintained by the Facility concerning the Resident, including any contract(s)
between the Resident and the Facility, and any attachments to that contract(s), as designated
by Plaintiff's counsel after having the opportunity to review the administrative file. Please
provide a date of availability, in writing, for the Plaintiff’s attorney to review the original
chart administrative file.10.
11.
Page 3
Provide laser copies of any and all photographs that were taken of the Resident while he/she
was at the Facility.
Provide a complete and itemized bill(s) for any and all services, medical supplies,
pharmaceutical supplies, therapies, or any other goods or services for which the Facility
charged the Resident, or any third party payor on behalf of the Resident, while he/she was
a resident at the Facility, including but not limited to:
a.
b.
A complete and itemized bill of the Resident.
All bills or statements submitted by the Facility to Medicare, or any fiscal
intermediary for Medicare, for supplies, therapies, or other ancillary charges covering
care, supplies, equipment, or other ancillary charges for the Resident.
Detail the specific nature of the charges, the specific services received, and
expenses incurred for such items of service, enumerating in detail the
constituent components of the services received within each department of
the Facility, including unit price data on rates charged by the Facility.
Specifically identify therapy treatment as to the date, type, and length of
treatment.
If the Facility has added to the price of any good or service provided to the
Resident beyond the price charged to the Facility for any good or service,
such as: pharmaceutical goods, supplies, therapies or any other good or
service, please identify clearly the original cost of the good or service and
separately state the amount of any service or handling charge.
All bills or statements submitted by the Facility to the Resident, his/her
power of attorney, guardian, or family for room and board, services, supplies,
equipment, or other items provided to the Resident, including co-payments
or deductibles.
All revenue reports and/or remittance advisories that reflect reimbursement
made by Medicare, Medicaid, private insurance, or any individual for room
and board, services, supplies, equipment, or other items provided by the
Facility to the Resident.
All statements, lists, or reconciliations of trust accounts, reflecting funds
received from the Resident, his/her power of attorney, guardian, or family or
held in trust for the benefit of the Resident.12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Page 4
If the Facility held money or property in safekeeping for the Resident, provide copies of the
quarterly statements provided to the Resident.
Provide a copy of the Facility’s policies and procedures governing the operation of the
Facility and the care and treatment of residents at the Facility during the period of the
Resident’s residency, as required by Florida Administrative Code 59A-4.106. In lieu of
producing the entire policy and procedure manual, the Facility may provide a complete index
ofall policy and procedure manuals that govern the care provided at the Facility, from which
the Plaintiffs counsel will designate certain portions for copying.
Provide copies of the fire safety inspections during the period of Resident’s residency and
required by Florida Administrative Code §59A-4.130.
Provide copies of the license issued pursuant to Chapter 400, Florida Statutes for the
operation of the Facility while the Resident was at the Facility and all licensure records
submitted to the Agency for Health Care Administration.
Provide copies of all other brochures and advertising materials used by the Facility during
the Resident’s residency.
Provide copies of all information given to Resident and/or family by the Facility pursuant to
Florida Administrative Code §59A-4.106.
Provide copies of the “standing orders,” if any, concerning the Resident during his/her
residency.
Provide the daily census of the Facility for the time period that the Resident was at the
Facility.
Provide daily census sheets for the wing and unit where the Resident resided during the time
he/she was at the Facility.
Provide all staff schedules for the time period that the Resident was at the Facility.
Provide all time cards for all employees who worked on the wing/unit where the Resident
lived during the Resident’s residency.
Provide any and all records of the Facility used or prepared for the purpose of calculating or
ensuring compliance with staffing requirements of assisted living facilities and established
by the State of Florida during the entire residency of the Resident, pursuant to the Florida
Administrative Code §59A-4.108.24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34,
35.
36.
Page 5.
Provide a copy of the Facility’s written Table of Organization.
Provide copies of any minutes of the Governing Body of the Facility prepared during the
time the Resident was at the Facility.
Provide copies of 24-hour report sheets and any communication books utilized by the staff
or employees of the Facility during the time period that the Resident was at the Facility.
Provide copies ofall electronic communications and/or information, including e-mails, voice
mail, Twitter, texts, faxes, records, orders, evaluations, etc. . ., stored in any manner and in
any format concerning the Resident.
If the Facility has a surveillance system in place, provide copies of all surveillance tapes
showing the Resident during his/her residency. In the alternative, provide a date and time,
in writing, for the Plaintiffs counsel to view the surveillance tapes.
Provide any and all records of accidents or unusual incidents concerning the Resident.
Provide copies of and all writings or documents in your possession reflecting any
investigations conducted by any state or federal agencies concerning the Resident.
Provide copies of all inspection reports for the 5 years prior to the resident’s stay at the
facility.
Provide copies of any management contracts in effect during the time the Resident was at the
Facility.
Provide copies of all reports, correspondence, or other writings generated by or on behalf of
any management company or consultant to the Facility concerning the care and treatment of
residents during the Resident’s residency.
Provide copies of any and all resident family council (or similar entry) minutes, or other
documents which record the discussions, agenda, or determinations of the council created
during the residency at issue.
Provide any and all reports or data compilations that concern the status or condition of
residents and were prepared by and sent to corporate officers or supervisors during the
residency in question.
Provide a blank copy of the Facility’s standard incident report form.37.
38.
39.
40.
41.
42.
Page 6
Provide written job descriptions for all staff, employees, agents and apparent agents at the
Facility during the time that the Resident was at the Facility.
Provide copies of any and all in-service training and attendance sheets for all in-service
training provided at the Facility during the time that the Resident was at the Facility.
Provide a list of all videos and teaching materials used for in-service training programs
during the time that the Resident was at the Facility.
Provide a list of all employees of the Facility during the time the Resident was at the Facility.
Provide any and all documentation, (i.e. personnel files), maintained at the Facility for each
employee of the Facility who provided any care or service to the Resident at the Facility,
including but not limited to the following information:
a. any and all applications for employment;
b. copies of any and all documentation obtained by the Facility about the
employee from any third source such as employment verification information
from other employers, reports from any law enforcement or state
administrative agency or any abuse reporting agency where such document
is not privileged by the state or Federal law creating the abuse reporting
agency;
c. copies of any and all licensing certification for the employee;
d. any and all documents which would contain disciplinary information of the
employee by the Facility, including letters of reprimand, complaints by
outside persons, or letters of reprimand;
e. any and all documents submitted by or recorded by Facility, concerning
complaints registered by another employee concerning employee;
f. any and all performance evaluations completed for the employee;
g. any and all forms, letters, or notes relating to termination of the employee’s
service at the Facility, including writings completed by the employee or any
other member of the Facility’s staff or administration.
Provide any and all turnover reports which delineate the turnover rate for employees of the
Facility during the time that the Resident was at the Facility.43.
44,
45.
46.
47.
48.
49.
50.
Page 7
Provide copies of any and all budgets and budget worksheets, including any original budgets
and all amendments to budgets, prepared for the operation of the Facility for the calendar
years the Resident was at the Facility.
If the resident was seen by a home health aide, or outside healthcare provider, provide copies
of any and all records in the Facility’s possession, evidencing same.
Provide any and all documents in the Facility’s possession that memorialize or verify the
Resident’s fall(s) including, but not limited to photographs, witness statements, incident
reports, surveillance tapes, medical records, etc. . .
Provide copies of any medical records of the Resident, in the Facility’s possession, which
address, reference, or deal with the Resident’s fall, injuries suffered as a result of the fall or
medical treatment obtained as a result of injuries suffered in the fall.
If the Resident suffered a fall with resulting injuries, while a resident at the Facility, and the
Resident required additional medical treatment and or physical therapy as a result of those
injuries, provide copies of all medical records and medical bills that show the additional
treatment and charges associated with those injuries.
Provide copies of all nursing staffing information as required under 42 C.F.R. §483.30(e) for
the one year prior to the Resident’s stay and the Facility and the 6 month period after the
Resident’s stay at the facility.
Provide copies ofall roster/sample matrix forms (CMS-802) prepared during the Resident’s
stay at the Facility.
Provide copies of all daily aide assignment sheets created during the Resident’s stay at the
Facility, redacted to protect the identities, but not the care requirements, of other residents.
[CERTIFICATE OF SERVICE ON NEXT PAGE]Page 8
CERTIFICATE OF SERVICE
WE HEREBY CERTIFY that a true and correct copy of the foregoing was attached to and
served with the Summons and Complaint herein.
DATED this_16th day of June, 2017.
FORD, DEAN, & ROTUNDO, P.A.
Attorneys for Plaintiff
Turnberry Plaza, Suite 600
2875 NE 191* Street
Aventura, FL 33180
Tel: (305) 670-2000
Fax: (305) 670-1353
Bill@forddean.com
Zee@forddean.com
Service@forddean.com
™ a .
By: i C “
WILLIAM A. DEAN, B.C:S.
Florida Bar No.: 118354
Preview
Filing # 57868917 E-Filed 06/16/2017 01:17:05 PM IN THE CIRCUIT COURT OF THE 11™ JUDICIAL CIRCUIT, IN AND FOR MIAMI-DADE COUNTY, FLORIDA CIVIL DIVISION CASE NO.: ISABEL LEVINE, as Personal Representative of the Estate of JOSE L. CLEMENTE, Deceased, Plaintiff, vs. SENIOR HEALTH - TREASURE ISLES, LLC. d/b/a TREASURE ISLE CARE CENTER, Defendant. / PLAINTIFF’S INITIAL REQUEST FOR PRODUCTION TO DEFENDANT, SENIOR HEALTH - TREASURE ISLES, LLC. d/b/a TREASURE ISLE CARE CENTER COMES NOW, the Plaintiff, ISABEL LEVINE, as Personal Representative of the Estate of JOSE L, CLEMENTE, Deceased, by and through her undersigned counsel, and propounds the attached requests for production, pursuant to F.R.C.P. §1.350, upon the Defendant, SENIOR HEALTH - TREASURE ISLES, LLC. d/b/a TREASURE ISLE CARE CENTER, to produce copies of the attached documents being requested, pursuant to the applicable rules of civil procedure, within FORTY FIVE (45) days from the date of service hereof. Note: The term “Facility” refers to: "TREASURE ISLE CARE CENTER” The "Resident" refers to: "JOSE L, CLEMENTE" The term “AHCA” refers to: “Agency for Healthcare Administration” All words used in any gender shall extend to and include all genders.Page 2 Provide all insurance policies and declaration sheets (including umbrella and excess policies), that may provide coverage to the Facility for the negligence that has been asserted by the Plaintiff and all insurance policies and declaration sheets (including umbrella and excess policies) that may provide coverage to any other entity(s) in addition to the Facility, which was responsible for any care/treatment/supervision provided to the Resident while he/she was a resident at the Facility, as required by Florida Statute §400.141(1)(s). Provide all reservations of rights notices or denials of coverage notices for any insurance policies identified Request for Production #1 and being asserted against this claim. If a policy of insurance identified in Request for Production # 1 is a “shared policy,” and there have been or are other pending claims being made on that policy, provide a list of the names and addresses of the other claimants and/or their attorneys. If a settlement has been made on a portion of the policy, provide the amount of the settlement and the remaining money left on the policy. If a policy of insurance identified in Request for Production # 1 is a “wasting policy,” provide a summary of the remaining funds left on the policy, as of the answering of this request for production. If the facility does not have a policy of insurance that provides coverage for this claim, provide any and all documents which show that the Facility has complied with the liability insurance requirements set forth in Florida Statute §400.141. If the facility does not have a policy of insurance that provides coverage for this claim, provide any and all documents that show that the Facility has provided notice to the Department of Elderly affairs that the Facility is not in compliance with Florida Statutes and/or Florida Administrative Code. Provide a complete copy of the facility’s licensure file as required by Florida Statute §400.071(1)(e). Provide laser color copy of all or portions of the original chart for the Resident while he/she was a resident at the Facility, as designated by Plaintiffs counsel after having the opportunity to review the chart. Please provide a date of availability, in writing, for the Plaintiff’s attorney to review the original chart. Provide a laser color copy of the complete administrative and/or financial file or files prepared and/or maintained by the Facility concerning the Resident, including any contract(s) between the Resident and the Facility, and any attachments to that contract(s), as designated by Plaintiff's counsel after having the opportunity to review the administrative file. Please provide a date of availability, in writing, for the Plaintiff’s attorney to review the original chart administrative file.10. 11. Page 3 Provide laser copies of any and all photographs that were taken of the Resident while he/she was at the Facility. Provide a complete and itemized bill(s) for any and all services, medical supplies, pharmaceutical supplies, therapies, or any other goods or services for which the Facility charged the Resident, or any third party payor on behalf of the Resident, while he/she was a resident at the Facility, including but not limited to: a. b. A complete and itemized bill of the Resident. All bills or statements submitted by the Facility to Medicare, or any fiscal intermediary for Medicare, for supplies, therapies, or other ancillary charges covering care, supplies, equipment, or other ancillary charges for the Resident. Detail the specific nature of the charges, the specific services received, and expenses incurred for such items of service, enumerating in detail the constituent components of the services received within each department of the Facility, including unit price data on rates charged by the Facility. Specifically identify therapy treatment as to the date, type, and length of treatment. If the Facility has added to the price of any good or service provided to the Resident beyond the price charged to the Facility for any good or service, such as: pharmaceutical goods, supplies, therapies or any other good or service, please identify clearly the original cost of the good or service and separately state the amount of any service or handling charge. All bills or statements submitted by the Facility to the Resident, his/her power of attorney, guardian, or family for room and board, services, supplies, equipment, or other items provided to the Resident, including co-payments or deductibles. All revenue reports and/or remittance advisories that reflect reimbursement made by Medicare, Medicaid, private insurance, or any individual for room and board, services, supplies, equipment, or other items provided by the Facility to the Resident. All statements, lists, or reconciliations of trust accounts, reflecting funds received from the Resident, his/her power of attorney, guardian, or family or held in trust for the benefit of the Resident.12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Page 4 If the Facility held money or property in safekeeping for the Resident, provide copies of the quarterly statements provided to the Resident. Provide a copy of the Facility’s policies and procedures governing the operation of the Facility and the care and treatment of residents at the Facility during the period of the Resident’s residency, as required by Florida Administrative Code 59A-4.106. In lieu of producing the entire policy and procedure manual, the Facility may provide a complete index ofall policy and procedure manuals that govern the care provided at the Facility, from which the Plaintiffs counsel will designate certain portions for copying. Provide copies of the fire safety inspections during the period of Resident’s residency and required by Florida Administrative Code §59A-4.130. Provide copies of the license issued pursuant to Chapter 400, Florida Statutes for the operation of the Facility while the Resident was at the Facility and all licensure records submitted to the Agency for Health Care Administration. Provide copies of all other brochures and advertising materials used by the Facility during the Resident’s residency. Provide copies of all information given to Resident and/or family by the Facility pursuant to Florida Administrative Code §59A-4.106. Provide copies of the “standing orders,” if any, concerning the Resident during his/her residency. Provide the daily census of the Facility for the time period that the Resident was at the Facility. Provide daily census sheets for the wing and unit where the Resident resided during the time he/she was at the Facility. Provide all staff schedules for the time period that the Resident was at the Facility. Provide all time cards for all employees who worked on the wing/unit where the Resident lived during the Resident’s residency. Provide any and all records of the Facility used or prepared for the purpose of calculating or ensuring compliance with staffing requirements of assisted living facilities and established by the State of Florida during the entire residency of the Resident, pursuant to the Florida Administrative Code §59A-4.108.24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34, 35. 36. Page 5. Provide a copy of the Facility’s written Table of Organization. Provide copies of any minutes of the Governing Body of the Facility prepared during the time the Resident was at the Facility. Provide copies of 24-hour report sheets and any communication books utilized by the staff or employees of the Facility during the time period that the Resident was at the Facility. Provide copies ofall electronic communications and/or information, including e-mails, voice mail, Twitter, texts, faxes, records, orders, evaluations, etc. . ., stored in any manner and in any format concerning the Resident. If the Facility has a surveillance system in place, provide copies of all surveillance tapes showing the Resident during his/her residency. In the alternative, provide a date and time, in writing, for the Plaintiffs counsel to view the surveillance tapes. Provide any and all records of accidents or unusual incidents concerning the Resident. Provide copies of and all writings or documents in your possession reflecting any investigations conducted by any state or federal agencies concerning the Resident. Provide copies of all inspection reports for the 5 years prior to the resident’s stay at the facility. Provide copies of any management contracts in effect during the time the Resident was at the Facility. Provide copies of all reports, correspondence, or other writings generated by or on behalf of any management company or consultant to the Facility concerning the care and treatment of residents during the Resident’s residency. Provide copies of any and all resident family council (or similar entry) minutes, or other documents which record the discussions, agenda, or determinations of the council created during the residency at issue. Provide any and all reports or data compilations that concern the status or condition of residents and were prepared by and sent to corporate officers or supervisors during the residency in question. Provide a blank copy of the Facility’s standard incident report form.37. 38. 39. 40. 41. 42. Page 6 Provide written job descriptions for all staff, employees, agents and apparent agents at the Facility during the time that the Resident was at the Facility. Provide copies of any and all in-service training and attendance sheets for all in-service training provided at the Facility during the time that the Resident was at the Facility. Provide a list of all videos and teaching materials used for in-service training programs during the time that the Resident was at the Facility. Provide a list of all employees of the Facility during the time the Resident was at the Facility. Provide any and all documentation, (i.e. personnel files), maintained at the Facility for each employee of the Facility who provided any care or service to the Resident at the Facility, including but not limited to the following information: a. any and all applications for employment; b. copies of any and all documentation obtained by the Facility about the employee from any third source such as employment verification information from other employers, reports from any law enforcement or state administrative agency or any abuse reporting agency where such document is not privileged by the state or Federal law creating the abuse reporting agency; c. copies of any and all licensing certification for the employee; d. any and all documents which would contain disciplinary information of the employee by the Facility, including letters of reprimand, complaints by outside persons, or letters of reprimand; e. any and all documents submitted by or recorded by Facility, concerning complaints registered by another employee concerning employee; f. any and all performance evaluations completed for the employee; g. any and all forms, letters, or notes relating to termination of the employee’s service at the Facility, including writings completed by the employee or any other member of the Facility’s staff or administration. Provide any and all turnover reports which delineate the turnover rate for employees of the Facility during the time that the Resident was at the Facility.43. 44, 45. 46. 47. 48. 49. 50. Page 7 Provide copies of any and all budgets and budget worksheets, including any original budgets and all amendments to budgets, prepared for the operation of the Facility for the calendar years the Resident was at the Facility. If the resident was seen by a home health aide, or outside healthcare provider, provide copies of any and all records in the Facility’s possession, evidencing same. Provide any and all documents in the Facility’s possession that memorialize or verify the Resident’s fall(s) including, but not limited to photographs, witness statements, incident reports, surveillance tapes, medical records, etc. . . Provide copies of any medical records of the Resident, in the Facility’s possession, which address, reference, or deal with the Resident’s fall, injuries suffered as a result of the fall or medical treatment obtained as a result of injuries suffered in the fall. If the Resident suffered a fall with resulting injuries, while a resident at the Facility, and the Resident required additional medical treatment and or physical therapy as a result of those injuries, provide copies of all medical records and medical bills that show the additional treatment and charges associated with those injuries. Provide copies of all nursing staffing information as required under 42 C.F.R. §483.30(e) for the one year prior to the Resident’s stay and the Facility and the 6 month period after the Resident’s stay at the facility. Provide copies ofall roster/sample matrix forms (CMS-802) prepared during the Resident’s stay at the Facility. Provide copies of all daily aide assignment sheets created during the Resident’s stay at the Facility, redacted to protect the identities, but not the care requirements, of other residents. [CERTIFICATE OF SERVICE ON NEXT PAGE]Page 8 CERTIFICATE OF SERVICE WE HEREBY CERTIFY that a true and correct copy of the foregoing was attached to and served with the Summons and Complaint herein. DATED this_16th day of June, 2017. FORD, DEAN, & ROTUNDO, P.A. Attorneys for Plaintiff Turnberry Plaza, Suite 600 2875 NE 191* Street Aventura, FL 33180 Tel: (305) 670-2000 Fax: (305) 670-1353 Bill@forddean.com Zee@forddean.com Service@forddean.com ™ a . By: i C “ WILLIAM A. DEAN, B.C:S. Florida Bar No.: 118354