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MYFLFAMILIES.COM

State of Florida
Department of Children and Families
CERTIFIES THAT

RECOVERY INSTITUTE OF SOUTH FLORIDA, INC.
1080 S.E. 3rd Avenue
Fort Lauderdale, Florida 33316
is Ueensed in ueordauee wltb Cbapter 397, Florida Statutes to provide substance abuse service11
for Adults for the following components:

Day or Night Treatment with Community Housing, Intensive Outpatient
Treatment, Outpatient Treatment
0912612014
Effective Date
R~ular

1706AD3SlS01

09/13/1015

Type ofLicense

License Number

Expiration Date

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MYFLFAMILIES.COM

State of Florida
Department of Children and Families
CERTIFIES THAT

RECOVERY INSTITUTE OF SOUTH FLORIDA, INC.
5540 Davie Road
Fort Lauderdale, Florida 33314
is licensed in accordance with Chapter 397, Florida Statntes to provide snbstance abuse services
for Adults for tbe following components:

Residential Detoxification (12 Beds)
Residential Level2 (16 Beds)
0912612014
Effective Date
RtEQiar
Type of License

1706AD35l50l
License Number

09/1312015
Expiration Date

 State of Florida

Department of Children and Families

Rick Sartt
Governor
Mike Carroll
Secretary

MYFLfAMIUES.COM

Dennis Miles
Regional Managing

12/10/2014

Director

Jon Mackler, CEO
Recovery Institute of South Fk>rida, Inc.
1080 S.E. 3rd Avenue
Fort Lauderdale, Florida 33316
Dear Mr. Mackler:
Please find attached the Regular License #1706AD352502 authorizing your agency to
provide Residential Detoxification and Residehtial Level 2 Treatment at 5540 Davie
Road. Davie, Florida 33314; and ReguJar license #1706AD352501 authorizing your
agency to Day or Night Treatment with Community Housing, Intensive Outpatient
Treatment, and Outpatient Treatment substance abuse services at 1080 S.E. 3rd
Avenue, Fort Lauderdale, Florida, 33316, respectively. The licenses are effective from
09/24/2014 through 09/23/2015 and carries all the rights and privileges afforded to all
substance abuse programs as defined in the Chapter 65D-30, Florida Administrative
Codes.
The Regular Licenses were Issued based upon a recent on-site monitoring visit of your
agency, the results of which are outlined in the attached site visit report. Please note
that deficiencies have been cfted in the site visit report which require that you submit a
Corrective Action Plan within 30 days of receipt of this letter

The SAMH Program Office must receive your applications for subsequent
licensure renewal sixty (60) days before the expiration date of the current
licenses.

Maritza Lopez
Licensure Specialist
Enclosures: License, report

cc: Licensure File

Substance Abuse and Mental Health Program Office
Southeast Region and Circuit 17
201 W. Broward Boulevard, Suite 511, Fort Lauderdale, Florida 33301

Mz.ssion: Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and
Advance PersoMl and Family Recovery and Resiliency

 DEPARTMENT OF CHILDREN AND FAMILIES
SUBSTANCE ABUSE AND MENTAL HEALTH PROGRAM OFFICE
SOUTHEAST REGION AND CIRCUIT 17
SUBSTANCE ABUSE LICENSURE SITE VISIT REPORT

SERVICE PROVIDER:

Recovery Institute of South Florida,
Inc.
!1080 S.E. 3rd Avenue
!Fort Lauderdale, Florida 33316

I
I

IE-MAIL:

jUonm@recoveryinstitute.com

I

jOWNER/PRESIDENT:

IITerry Livorsi

I

jCHIEF EXECUTIVE OFFICER:

I!John Mackler

I

!CHIEF FINANCIAL OFFICER:

I!John Mackler

!CLINICAL DIRECTOR:

I!Beatriz Dantzler, MA LCDC CAP

!AUTHORIZED AGENTS:

I!Midl~ne Vallon/ Maritza Lopez

jDATES OF VISIT:

1109-18-14
Maritza Lopez

REPORT PREPARED BY:

I
I
I
I

INTRODUCTION:
Recovery Institute of South Florida, Inc is a private, for-profit organization. Specializing
in the treatment of drug addiction, alcoholism and dual diagnosis, the ultimate goal is
the provision of effective quality treatment achieving long-term positive outcomes and
recovery. The agency utilizes a combination of both traditional and innovative therapies
in order to engage patients experientially.
PROGRAM COMPONENTS REVIEWED:
650-30.004 Common Licensure Standards
850-30.010 Standards for Outpatient Treatment
650-30.0091 Standards for Intensive Outpatient Treatment
650-30.0081 Standards for Day or Night Treatment with Community Housing
650-30.007 Standards for Residential Level 2
650-30.006 Standards for Residential Detoxification
REVIEW PROCESS AND VALIDATION METHODS:
This site visit report is based on licensing audit of program administration and
operational capability. The audit was conducted in order to ensure compliance with the
statutory requirements of Chapter 397, F.S. , and the regulatory standards outlined in
Chapter 650-30, F.A.C. The audit process included a review of client records and a
review of program administration and standards.

Recovery Institute of South Florida, Inc.

Page 1 of 15

 A performance-based rating system is used to evaluate the provider's Jevel of
compliance with the statutory requirements of Chapter 397, F.S., and the
regulatory standards outlined in Chapter 650-30, F .A.C.
The system requires providers to attain at least 80% compliance in all areas reviewed
during the inspection. Providers score one point for each required item contained in a
particular area. Providers lose a point if the item or any part of the item has been
omitted.
However, there may be instances where a provider has attained an 80% level of
compliance overall but it is in violation of a requirement related to health, safety, and
welfare of clients and staff. In such cases, the region will issue an interim license to the
provider or take other statutory action permitted in section 397.415, F.S.
SUMMARY OF FINDINGS:
OUTPATIENT TREATMENT CHART REVIEW:
CLIENT CHARTS: The authorized agent examined 1 client chart: OM
VALIDATION:
Recovery Institute of South Florida Program validated at 76.14%. A passing score is
80%. The Program scored 67 points out of a possible 88. The authorized agent
detected the following compliance issues:
RULE: Pursuantto65D-30.004 (12)(c) 1. r., F.A.C., Copiesofservice-related
correspondence, generated or received by the provider, when available ... . No
effort was made to solicit client's prior MH tx history.
• RULE: Pursuant to 650-30.004 (13) (a), F.A.C., The person conducting the
screening shall document the rationale for any action taken .... No rationale
provided.
• RULE: Pursuant to 650-30.004 (14) (b) 1. e., F.AC., Financial status ... Not fully
explored.
• RULE: Pursuant to 650-30.004 (14) (b) 1. f., F.A.C., Current living
conditions .. . Not fully explored.
• RULE: Pursuant to 650-30.004 (14) (b) 1. g., F.A.C., Past or current sexual
abuse or trauma ... Not fully explored.
• RULE: Pursuant to 650-30.004 (14) (b) 3., F.A.C., If the psychosocial
assessment was not completed initially by a qualified professional, the
psychosocial assessment shall be reviewedl countersigned , and dated by a
qualified professional within 10 calendar days of completion .... No QP evidentcompleted by BHT.
• RULE: Pursuant to 650-30.004 (14) (c), F.A.C., Such clients shall be
accommodated directly or through referral. ... Client appeared to have a strong hx
of MH issues that were not addressed.
• RULE: Pursuant to 650-30.004 (14) (c), F.A.C., A record of all services provided
directly or through referral shall be maintained in the client record ... Since
•

Recovery Institute of South Florida, Inc.

Page 2 of15

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provider does not have ACHA licensure, client could have been referred out for
MH issues.
RULE: Pursuant to 650-30.004 (15), F.A.C., Client file contains admission
justffication according to criteria .. .. Completed late on 5/28.
RULE: Pursuant to 650-30.004 (15), F.A.C., Client file contains
transfer/discharge justification according to criteria .. .. Completed late-client left
5/30, completed 6/26?
RULE: Pursuant to 650-30.004 (16) (b) 2., F.A.C., Applicable fees ... Not detailed
for this client.
RULE: Pursuant to 650-30.004 (16) (b) 6., F.A.C., General information about the
provider's infection control policies and procedures;... Not made known to client
upon placement.
RULE: Pursuant to 650-30.004 (17) (a), F.A.C., The expected dates of
completion .... Tx plan states 5/6, states this was completed 5/30? Extension of tx
plan goals not evident?
RULE: Pursuant to 650-30.004 (17) (a), F.A.C., The treatment plan shall be
signed and dated by the person providing the service .... Staff signed 6/6.
RULE: Pursuant to 650-30.004 (17) (b), F.A.C., Treatment plan reviews shall be
completed on each client. ... Not evident.
RULE: Pursuant to 650-30.004 (17) (b) 1., F.A.C ., For outpatient treatment,
treatment plan reviews shall be completed every 30 calendar days .... Not evident.
RULE: Pursuant to 650-30.004 (17) (a), F.A.C., The treatment plan reviews shall
be signed and dated by the person providing the service ... . Not evident.
RULE: Pursuant to 650-30.004 (17) (a), F.A.C., The treatment plan reviews shall
be signed and dated by the client. ... Not evident.
RULE: Pursuant to 650-30.004 (17) (c), F.A.C ., Progress notes shall be entered
into the client record documenting a client's progress or lack of progress toward
meeting treatment plan goals and objectives .... No clinical provisions were made
to help client remain "clean and not abuse substances" after Discharge.
RULE: Pursuant to 650-30.004 (22) (a), F.A.C ., The provision of other services
needed by the client following discharge, including aftercare .. .. No clinical
provisions were made to help client remain "sober" after Discharge.
RULE: Pursuant to 650-30.004 {29) (b), F.A.C., Providers shall provide a copy of
the telephone numbers to reach client placed in services ... . Update client
docs/posters to have correct SAMH contact info.

STANDARDS FOR OUTPATIENT TREATMENT SERVICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to detennine the level of compliance with section 650-30.010,
F.A.C ., for standards for Outpatient Treatment.
VALIDATION:
The Recovery Institute of South Florida Program validated at 100.00%. A passing score
is 80%. The Program scored 6 points out of a possible 6.

Recovery Institute of South Florida, Inc.

Page 3 of 15

 OUTPATIENT TREATMENT PROGRAM PRACTICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.010,
F.A.C. , for Outpatient Treatment practices. Program administration includes
requirements, which are not documented in the client record.
VALIDATION:
The Recovery Institute of South Florida Program Administrative Review validated at
91 .67%. A passing score is 80%. The Program scored 22 points out of a possible 24.
The authorized agent detected the following compliance issues:
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RULE: Pursuant to 65D-30.004(12)(a), F.A.C., Client/participant records shall be
kept secure from unauthorized access and maintained in accordance with 42
Code of Federal Regulations, Part 2 and ss. 397.50(7), F.S .... Update.EMR to
include scanned items.
RULE: Pursuantto 65D-30.004(29)(b), F.A.C. , district Alcohol, Drug Abuse, and
Mental Health Program Office ... Update.

INTENSIVE OUTPATIENT TREATMENT CHART REVIEW:
CLIENT CHARTS: The authorized agent examined 1 client charts: M.O 3
VALIDATION:
Recovery Institute of South Florida Program validated at 84.78%. A passing score is
80%. The Program scored 78 points out of a possible 92. The authorized agent
detected the following compliance issues:

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RULE: Pursuant to 650-30.004 (13) (a), F.A.C., The person conducting the
screening shall document the rationaJe for any action taken .... No rationale
provided by intake staff.
RULE: Pursuant to 650-30.004 (14) (b) 1. b., F.A.C., Level of substance abuse
impairment. .. not addressed.
RULE: Pursuant to 650-30.004 (14) (b) 1. d., F.A.C., Consequences of use,
and ... Not addressed.
RULE: Pursuant to 650-30.004 (14) (b) 1. e., F.A.C., Financial status .... Not
addressed.
RULE: Pursuant to 650-30.004 (14) (b) 1. f., F.A.C., Current living
conditions ... more detail needed.
RULE: Pursuant to 650-30.004 (14) (b) 1. g., F:A.C., Past or current sexual
abuse or trauma ... left unanswered.
RULE: Pursuant to 650-30.004(16)(b)2., F.A.C., Applicable fees ... no break
down per each clients insurance coverage.
RULE: Pursuant to 65D-30.004(17)(a), F.A.C., The tasks involved in achieving
those objectives ... does not reflect the lOP goals.
RULE: Pursuant to 65D-30.004(17)(b), F.A.C., Treatment plan reviews shall be
completed on each client. ... Not completed.

Recovery Institute of South Florida, Inc.

Page 4 ofl5

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RULE: Pursuant to 650-30.004(17)(b)1., F.A.C. , For intensive outpatient
treatment, treatment, treatment plan reviews shall be completed every 30
calendar days .... Not completed.
RULE: Pursuant to 650-30.004(17)(a), F.A.C .• The treatment plan reviews shall
be signed and dated by the person providing the service .. .. Not completed.
RULE: Pursuant to 65D-30.004(17)(a). F.A.C., The treatment plan reviews shall
be signed and dated by the client. .. .Not completed.
RULE: Pursuant to 650-30.004(17)(c}, F.A.C., Progress notes shall be entered
into the client record documenting a client's progress or lack of progress toward
meeting treatment plan goals and objectives .... progress or lack of progress in
meeting tx plan goals and objectives not always documented.
RULE: Pursuant to 650-30.004(22)(b), F.A.C. , A transfer summary shall be
completed immediately for clients who transfer from one component to another
within the same provider, and ... Completed late for entry to lOP.

STANDARDS FOR INTENSIVE OUTPATIENT TREATMENT SERVICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.0091 ,
F.A.C ., for standards for Intensive Outpatient Treatment.
VALIDATION:
The Recovery Institute of South Florida Program validated at 100.00%. A passing score
is 80%. The Program scored 11 points out of a possible 11.
INTENSIVE OUTPATIENT TREATMENT PROGRAM PRACTICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to detennine the level of compliance with section 650-30.0091,
F.A.C., for Intensive Outpatient Treatment practices. Program administration includes
requirements, which are not documented in the client record.
VALIDATION:
The Recovery Institute of South Florida Program Administrative Review validated at
90.32%. A passing score is 80%. The Program scored 28 points out of a possible 31.
The authorized agent detected the following compliance issues:
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RULE: Pursuant to 65D-30.004(12)(a), F.A.C., ClienVparticipant records shall be
kept secure from unauthorized access and maintained in accordance with 42
Code of Federal Regulations, Part 2 and ss. 397.50(7), F.S .... Update EMR to
include scanned item.
RULE: Pursuant to 650-30.004(12)(a)3., F.A.C., In those instances where
records are maintained electronically, a staff identifier code will be accepted in
lieu of a signature ... Update EMR to include scanned items.
RULE: Pursuant to 65D-30.004(29)(b), F.A.C., district Alcohol, Drug Abuse, and
Mental Health Program Office .. .Update.

Recovery Institute of South Florida, lnc.

Page 5 of 15

 DAY OR NIGHT TREATMENT CHART REVIEW
CLIENT CHARTS: The authorized agent examined 1 client chart: AP
VALIDATION:
Reoovery Institute of South Florida Program validated at 79.57%. A passing score is
80%. The Program scored 74 points out of a possible 93. The authorized agent
detected the following compliance issues:
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RULE: Pursuant to 650~30 . 004 (12) (c) 1. r., F.A.C., Copies of Service-related
Correspondence, generated or received by the provider, when available .... Client
denied repeatedly history and problems with SA, has been in tx for MH however
no effort was made to solicit docs from prior tx.
RULE: Pursuant to 650~30 . 004 (13) (a), F.A.C., The person conducting the
screening shall document the rationale for any action taken .... No rationale
provided by intake staff.
RULE: Pursuant to 650-30.004 (14) (b) 1. b., F.A.C. , Level of substance abuse
impairment. .. Client repeatedly denied SA problems and impairment.
RULE: Pursuant to 650-30.004 (14) (b) 1. e ., F.A.C., Employment history, and ...
Not fully explored-what nursing job?
RULE: Pursuant to 650-30.004 (14) (b) 1. f., F.AC., Peer relationships, and ...
Not fully explored.
RULE: Pursuant to 650-30.004 (14) (b) 1. f., F.A.C., Current living conditions ...
Not fully explored.
RULE: Pursuant to 650-30.004 (14) (b) 1. g., F.A.C., Past or current sexual
abuse or trauma ... Not fully explored.
RULE: Pursuant to 650-30.004(14)(c), F.A.C., Such clients shall be
accommodated directly or through referral. ... Client has extensive hx of MH tx-no
referral and cannot be accommodated directly.
RULE: Pursuant to 650~30.004(14)(c) , F.A.C., A record of all services provided
directly or through referral shall be maintained in the client record .... lf clients
with MH needs only are to be accommodated, provider may require certification
by the Agency for Healthcare Administration. Provider is encouraged to research
need for certification with AHCA
RULE: Pursuant to 650-30.004(15), F.A.C., Client file contains admission
justification according to criteria .. .. Completed late.
RULE: Pursuant to 65D-30.004(16)(b)1 ., F.A.C., A description of services to be
provided ... Update to include more detail regarding this component and step
down process, what to expect, length of stay, etc...
RULE: Pursuant to 65D~30.004(16)(b)2., F.A.C., Applicable fees .. . Update to
explain fees in client file-insurance breakdown/out of pocket deductible
RULE: Pursuant to 650-30.004(16)(b)6., F.A.C., General information about the
provider's infection contfol policies and procedures ... Not made known to the
client upon placement
RULE: Pursuant to 650-30.004(16)(c), F.A.C., An initial treatment plan shall be
completed on each client upon placement, unless an individual treatment plan is
completed at that time .. .. Completed 6/4 client admrtted 6/3 to detox?

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RULE: Pursuant to 65D-30.004(16)(c), F.A.C., The initial treatment plan shall be
signed and dated by clinical staff.... Staff signed 6/9?
RULE: Pursuant to 650-30.004(16)(c), F.A.C., The initial treatment plan shall be
signed by the client. ... Client signed 6/9?
RULE: Pursuant to 650-30.004(17)(c), F.A.C., Progress notes shall be entered
into the client record documenting a client's progress or lack of progress toward
meeting treatment plan goals and objectives .... Not all notes reflect client's
progress or lack of progress in meeting tx plan goals and objectives.
RULE: Pursuant to 65D-30.004(29)(b), F.A.C., Providers shall provide a copy of
the telephone numbers to reach client placed in services .... Update.
RULE: Pursuant to 65D-30.0081(2)(j)1., F.A.C., Managing clients with disorders
who are stabilized ... Not evident.

STANDARDS FOR DAY OR NIGHT TREATMENT WITH COMMUNITY HOUSING
SERVICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.0081 ,
F.A.C., for standards for Day or Night Treatment with Community Housing.
VALIDATION:
The Recovery Institute of South Florida Program validated at 100.00%. A passing score
is 80%. The Program scored 13 points out of a possible 13.
DAY OR NIGHT TREATMENT WITH COMMUNITY HOUSING PROGRAM

PRACTICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-.30.0081,
F.A.C., for Day or Night Treatment with Community Housing practices. Program
administration includes requirements, which are not documented in the client record .
VALIDATION:
The Recovery Institute of South Florida Program Administrative Review validated at
86.96%. A passing score is 80%. The Program scored 40 points out of a possible 46.
The authorized agent detected the following compliance issues:
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RULE: Pursuant to 65D-30.004(12)(a), F.A.C., ClienVparticipant records shall be
kept secure from unauthorized access and maintained in accordance with 42
Code of Federal Regulations, Part 2 and ss. 397.50(7), F.S .... Update EMR to
include scanned items.
RULE: Pursuant to 650-30.004(12)(a)3., F.A.C., In those instances where
records are maintained electronically, a staff identifier code will be accepted in
lieu of a signature .... Update EMR to include scanned item.
RULE: Pursuant to 65D-30.004(29)(b), F.A.C., district Alcohol, Drug Abuse, and
Mental Health Program Office ... Update-wrong DCF contact info.
RULE: Pursuant to 650-30.004(34) (g), F.A.C., Providers shall have written
plans for managing and preventing damage and injury arising from internal and

Recovery Institute of South Florida, Inc.

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external disasters .... Update policy to include all types of disasters and removal
and storage of meds.
RULE: Pursuant to 65D-30.004(34)(h), F.A.C., Provisions shall be made to
ensure that housekeeping and maintenance services are capable of keeping the
building and equipment clean and in good repair.... dust-ceiling fan, stove
drippings, oven, blinds, wall had dust, ants in bathroom.
RULE: Pursuant to 65D-30.004fj), F.A.C., Providers shall ensure that hazardous
materials are properly identified, handled, stored, used, and
dispensed ....... moving forward-since techs are not always going to stand guard
as clients are in laundry facility with chemicals then for client safety store
chemicals separately while clients perform laundry-administer amount needed.

RESIDENTIAL LEVEL 2 CHART REVIEW:
LOCATION OF SERVICES: 5540 Davie Road Floor #1, Davie, Fl 33314
CLIENT CHARTS: The authorized agent examined 1 client chart: AP
VALIDATION:
Recovery Institute of South Florida Program validated at 81.11%. A passing score is
80%. The Program scored 73 points out of a possible 90. The authorized agent
detected the following compliance issues:
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RULE: Pursuant to 650-30.004 (12) (c) 1. r. , F.A.C., Copies of Service-related
Correspondence, generated or received by the provider, when available .... No
effort made to obtain or solicit client tx history of MH.
RULE: Pursuant to 650-30.004 (13) (a), F.A.C., The person conducting the
screening shall document the rationale for any action taken .... No rationale
provided for admission.
RULE: Pursuant to 65D-30.004(14)(a)3.b., F.A.C., Further, the examination shall
be reviewed, signed, and dated by the physician in accordance with the medical
protocol established in ss. 650-30.004(7), F.A.C .... MD only initialed did not sign.
RULE: Pursuant to 65D-30.004(14)(a)4.a., F.A.C., Further, the results of the
laboratory tests shall be reviewed, signed, and dated during the assessment
process and in accordance with the medical protocol established in ss. 65030.004(7), F.A.C .... MD only initialed did not sign.
RULE: Pursuant to 65D-30.004(14)(a)6.a., FA. C., The results of both tests shall
be reviewed and signed and dated by the physician, or in accordance with the
medical protocol established in ss. 650-30.004(7), F.A.C., and filed in the client
record .... MD only initialed did not sign.
RULE: Pursuant to 650-30.004 (14) (b) 1. b., F.A.C., Level of substance abuse
impairment. .. For AP client repeatedly denied SA issues "two sips of wine" and
client also denied need for detoxification.
RULE: Pursuant to 650-30.004 (14) (b) 1. e., F.A.C ., Employment history,
·
and ... Not fully explored.
RULE: Pursuant to 650-30.004 (14) (b) 1. f. , F.A.C., Peer relationships,
and ... Not fully explored.

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RULE: Pursuant to 650-30.004 (14) (b) 1. f., F.A.C., Current living
conditions ... Not fully explored.
RULE: Pursuant to 650-30.004 (14) (b) 1. g., F.A.C., Past or current sexual
abuse or trauma .. .. Not fully explored.
RULE: Pursuant to 65D-30.004(14)(c), F.A.C., Such clients shall be
accommodated directly or through referral .... For AP client has extensive history
of MH, denied SA could have been referred to MH tx.
RULE: Pursuant to 65D-30.004(14)(c), F.A.C., A record of all services provided
directly or through referral shall be maintained in the client record ... . For AP
provider does not carry ACHA licensure and client not referred for MH support
which is what she truly needed.
RULE: Pursuant to 65D-30.004(16)(b)2., F.A.C., Applicable fees ... no
breakdown/out of pocket fees detailed
RULE: Pursuant to 650-30.004(16)(b)6., F.A.C., General information about the
provider's infection control policies and procedures ... not made known to client.
RULE: Pursuant to 650-30.004(17)(c), F.A.C. , Progress notes shall be entered
into the client record documenting a client's progress or lack of progress toward
meeting treatment plan goals and objectives. (Signed and dated) ... not all notes
reflect client's progress or lack of progress in meeting tx plan goals and
objectives.
RULE: Pursuant to 65D-30.004(29)(b), F.A.C., Providers shall provide a copy of
the telephone numbers to reach client placed in services .... Update.
RULE: Pursuant to 65D-30.007(3)(i)1., F.A.C., Managing clients with disorders
who are stabilized ... Mental health issues or history not being addressed
appropriately when it is clear client did not meet criteria for detox admission
according to MD.

STANDARDS FOR RESIDENTIAL LEVEL 2 SERVICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.007,
F.A.C., for standards for Residential Level 2.
VALIDATION:
The Recovery Institute of South Florida Program validated at 100.00%. A passing score
is 80%. The Program scored 10 points out of a possible 10.
RESIDENTIAL LEVEL 2 PROGRAM PRACTICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.007,
F.A.C., for Residential Level2 practices. Program administration includes requirements,
which are not documented in the client record.
VALIDATION:
The Recovery Institute of South Florida Program Administrative Review validated at
90.32%. A passing score is 80%. The Program scored 56 points out of a possible 62.
The authorized agent detected the following compliance issues:
Recovery Institute of South Florida, Inc.

Page 9 of 15

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RULE: Pursuant to 650-30.004(12)(a), F.A.C., Client/participant records shall be
kept secure from unauthorized access and maintained in accordance with 42
Code of Federal Regulations, Part 2 and ss. 397.50(7), F.S.
• RULE: Pursuant to 65D-30.004(12)(a)3., F.A.C., In those instances where
records are maintained electronically, a staff identmer code will be accepted in
lieu of a signature.
• .RULE: Pursuant to 650-30.004(29)(b), F.A.C., district Alcohol , Drug Abuse, and
Mental Health Program Office ... Update.
• RULE: Pursuant to 650-30.004(34)(g), F.A.C ., The written plan shall incorporate
evacuation procedures .... Please update policy to include all types of disasters
and removal and storage of medications.
• RULE: Pursuant to 65D-30.004(34)(h), F.A.C., Providers shall ensure that
hazardous materials are properly identified, handled , stored, used, and
dispensed .... Kitchen staff explained there was a previous problem with rodents
however the visual of a giant rat trap sitting in the kitchen floor near the back
suggests it is still occurring.
• RULE: Pursuant to 650-30.004(34)0), F.A.C ., Providers shall ensure that
hazardous materials are properly identified, handled, stored, used, and
dispensed .. .. Laundry facility looks great, better organized , however,
detergents/chemicals are stored in the space and clients are not always
supervised.
RESIDENTIAL DETOXIFICATION CHART REVIEW:
LOCATION OF SERVICES: 5540 Davie Road Floor#1, Davie, F133314
CLIENT CHARTS: The authorized agent examined 2 client charts: LK, AP
VALIDATION:
Recovery Institute of South Florida Program validated at 75.93%. A passing score is
80%. The Program scored 82 points out of a possible 108. The authorized agent
detected the following compliance issues:
•

•

•

•

RULE: Pursuant to 650-30.004 (13) (a), F.A.C., The person conducting the
screening shall document the rationale for any action taken .... No rationale
provided by intake staff for files reviewed .
RULE: Pursuant to 650-30.004 (14) (a) 3. a., F .A. C., Further, the examination
shall be reviewed, signed, and dated by the physician in accordance with the
medical protocol established in ss. 650-30.004(7), F.A.C .... No MD signature
only initialed exams.
RULE: Pursuant to 65D-30.004(14)(a)4.a., F.A.C., Further, the results of the
laboratory tests shall be reviewed, signed, and dated during the assessment
process and in accordance with the medical protocol established in ss. 65030.004(7) .... MD only initialed labs for files reviewed.
RULE: Pursuant to 650-30.004 (15), F.A.C., Client file contains admission
justification according to criteria .... For LK -Client admitted 6/10 ASAM .

Recovery Institute of South Florida, Inc.

Page 10 ofl5

 •

•

•

•
•

•

•

•
•

•

•

•

done/signed 6/25?--For AP-client according to MD did not meet criteria for detox
admission.
RULE: Pursuant to 650-30.004 (16) (b) 2., F.A.C., Applicable fees ... Fee
breakdown not made clear for clients! clients should acknowledge and sign the
total out of pocket after deductibles and sliding scale totals
RULE: Pursuant to 650-30.004 (16} (b) 6., F.A.C., General information about the
provider's infection control policies and procedures .... Client exposure to possible
infections/communicable diseases not made known to client upon placement
RULE: Pursuant to 650-30.004 (17) (a) 5., F.A.C., A medical plan for
stabilization and detoxification ... . For LK not evident-For AP-Presenting problem
states: client complains of job harassment, anxiety, hx of domestic violence, no
alcohol; MD clearly states that client does not meet criteria for detox.
RULE: Pursuant to 650-30.004 (17) (a) 5., F.A.C., The treatment plan shall be
signed and dated by the client. ... For LK signed late.
RULE: Pursuant to 650-30.004 (17) (a) 5., F.A.C., If the treatment plan is
completed by other than a qualified professional, the treatment plan shall be
reviewed, countersigned , and dated by a qualified professional within 10
calendar days of completion ... For LK signed late.
RULE: Pursuant to 650-30.004 (17) (c), F.A.C. , Progress notes shall be entered
into the client record documenting a client's progress or lack of progress toward
meeting treatment plan goals and objectives. (Signed and dated) ... not all notes
reflect client's progress or lack of progress in meeting tx plan goals and
objectives
RULE: Pursuant to 650-30.004 (22) (a), F.A.C., The discharge summary shall be
signed and dated by a primary counselor... For LK done late-- Move to transfer
section.
RULE: Pursuant to 650-30.004 (29) (b), F.A.C., Providers shall provide a copy of
the telephone numbers to reach client placed in services .. .. Update
RULE: Pursuant to 650-30.006 (2) (a) 2., F.A.C. , Each client shall participate in
supportive counseling on a daily basis unless the client is not sufficiently
stable ...... .Although client was provided with supportive counseling, client
continued to deny issues with SA which is supported by MD's order stating client
did not meet criteria for Detoxification
RULE: Pursuant to 650-30.004 (12) (c) 1. r., F.A.C., Copies of Service-related
Correspondence, generated or received by the provider, when available ... . For
AP-no attempt made by clinical staff to obtain client prior MH tx history especially
since she denied SA problems .and MD stated she did not meet criteria.
RULE: Pursuant to 650-30.004 (14) (c), F.A.C., Such clients shall be
accommodated directly or through referral .... For AP client has extensive history
of MH, denied SA could have been referred to MH tx.
RULE: Pursuant to 650-30.004 (14) (c), F.A.C., A record of all services provided
directly or through referral shall be maintained in the client record .... For AP
provider does not carry ACHA licensure and client not referred for MH support
which is what she truly needed.

Recovery Institute of South Florida, Inc.

Page 11 of 15

 STANDARDS FOR RESIDENTIAL DETOXIFICATION SERVICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.006,
F.A.C., for standards for Residential Detoxification.
VALIDATION:
The Recovery Institute of South Florida Program validated at 81.25%. A passing score
is 80%. The Program scored 13 points out of a possible 16. The authorized agent
detected the following compliance issues:
•

•

•

RULE: Pursuant to 65D-30.006(2)(a)1., F.A.C., Stabilization services shall be
provided as an initial phase of detoxification .... Practice of placement in detox
have no prior history and no supplementary information from other clinical
sources. Lowest restive setting of treatment encouraged prior to resorting to
detox.
RULE: Pursuant to 65D-30.006(2)(a)2., F.A.C., Supportive counseling sessions
shall be of sufficient duration to enable staff to make reasonable decisions
regarding the client's need for other services .. .. Although client was provided with
supportive counseling, client continued to deny issues with SA which is
supported by MD's order stating client did not meet criteria for Detoxification.
RULE: Pursuant to 65D-30.006(2)(a)2., F.A.C., Services shall be directed toward
assuring that the client's most immediate needs are addressed and encouraging
the client to remain engaged in treatment and to follow up on referrals after
discharge .... Not evident-some clients admitted to detox program appeared to
have a strong MH history and not as much or no history with SA but MH was not
addressed.

RESIDENTIAL DETOXIFICATION PROGRAM PRACTICES REVIEW:
The authorized agent examined documentation submitted by the Recovery Institute of
South Florida program to determine the level of compliance with section 650-30.006,
F.A.C., for Residential Detoxification practices. Program administration includes
requirements, which are not documented in the client record.
VALIDATION:
The Recovery Institute of South Florida Program Administrative Review validated at
86.76%. A passing score is 80%. The Recovery Institute of South Florida Program
scored 59 points out of a possible 68. The authorized agent detected the following
compliance issues:
•

RULE: Pursuant to 65D-30.004(7)(a), F.A.C., For those components identified in
ss. 650-30.004(6), F.A.C., each physician wori<ing with a provider shall establish
written protocols for the provision of medical services pursuant to Chapters 458
and 459, F.S., and for managing medication according to medical and pharmacy
standards, pursuant to Chapter 465, F.S .... Protocol exists however, no
provision found which states LPN can override MD's decision to admit client to
detox when MD has already determined client did not meet criteria

Recovery Institute of South Florida, Inc.

Page 12 of 15

 •

•
•

•

•

•

•

•

RULE: Pursuant to 65D-30.004(12)(a), F.A.C., Client/participant records shall be
kept secure from unauthorized access and maintained in accordance with 42
Code of Federal Regulations, Part 2 and ss. 397.50(7), F.S .... Update EMR
policy to address.
RULE: Pursuant to 65D-30.004(29)(b), F.A.C., district Alcohol, Drug Abuse, and
Mental Health Program Office... Update.
RULE: Pursuant to 65D-30.004(34)(b), F.A.C., Provisions shall be made to
ensure that adequate space and equipment are available for all of the service
components of the facility, and the various functions within the facility ....
Although client's can be placed in a nearby bedroom, the observation of clients
placed in a small couch in the middle of an open room/hall way entrance seems
uncomfortable for the client
RULE: Pursuant to 65D-30.004(34)(g), F.A.C., The written plan shall incorporate
evacuation procedures .... Update policy to include all types of disasters and the
removal and storage of all types of meds.
RULE: Pursuant to 65D-30.004(34)(h), F.A.C., Providers shall ensure that
hazardous materials are properly identified, handled, stored, used, and
dispensed .... ...Kitchen staff explained there was a previous problem with rodents
however the visual of a giant rat trap sitting in the kitchen floor near the back
suggests it is still occurring?
RULE: Pursuant to 650-30.004(34)0), F.A.C., Providers shall ensure that
hazardous materials are properly identified, handled, stored, used, and
dispensed .... Laundry room looks great, less debris/loose items however,
administering and proper storage of chemicals and laundry detergent while
clients are washing is recommended.
RULE: Pursuant to 65D-30.006(2){a)1., F.A.C., Stabilization services shall be
provided as an initial phase of detoxification .... Practice of placement in detox
has no prior history and no supplementary information from other clinical
sources. Lowest restrictive setting of treatment encouraged prior to resorting to
detox.
RULE: Pursuant to 65D-30.006(2)(b), F.A.C., Clients requiring close medical
observation, as determined and documented by medical staff, shall be visible
and readily accessible to nursing staff.... Moving forward , clients under
observation are placed in front of nurse's station on couch but have very little
privacy during a d ifficult phase of tx.

HUMAN RESOURCES/ PERSONNEL RECORDS:
The authorized agent examined 3 personnel records to determine the level of
compliance with the licensing standards outlined in amended Section 65D-30.004(4)(a),
F.A. C., for the contents of personnel records. The authorized agent examined the
following records: G.T., T .T., S.T
VALIDATION:
Recovery Institute of South Florida, Inc. Florida validated at 93.59% for personnel
records. A passing score is 80%. Recovery Institute of South Florida, Inc. scored 73

Recovery Institute of South Florida) Inc.

Page 13 of15

 points out of a possible 78. The authorized agent detected the following compliance
issues:

•
•
•

RULE: Pursuant to 650-30.005 (3) (e), F.A.C., AU direct services staff working in
outpatient detoxification shall be trained in the outpatient detoxification protocol
prior to having contact with clients .... not in the file for all.
RULE: Pursuant to 650-30.004 (4) (a) 1., F.A.C. , The individual's current job
description with minimum qualifications for the position ... For S.T.-No license as
required by job require by job description.
RULE: Pursuant to 650-30.004 (4) (a) 5., F.A.C., A verified or certified copy of
degrees, licenses, or certificates of each employee ... For S.T .-No license as
required by job require by job description.

BACKGROUND SCREENINGS OF OWNERS, CEO, CFO:
The authorized agent examined documentation submitted by Recovery Institute of
South Florida, Inc. to detennine the level of compliance with the minimum licensing
standards outlined in ss. 65D-30.004(4){b), F.A.C., ss. 397.451(2), F.S., ss. 435.04(1),
F.S., and ss. 435.04(2)(a), F.S., for the background screening of owners, chief
executive officers, and chief financial officers. The authorized agent examined the
personnel records of the following records:
L.T, Owner, J.K, Executive officer
VALIDATION:
Recovery Institute of South Florida, Inc. validated at 66.67% for background screening.
A passing score is 80%. The screenings reviewed scored 8 points out of a possible 12.
The authorized agent detected the following compliance issues:

•
•
•

•

RULE: Pursuant to 650-30.435.04 (1), F.A.C ., Statewide criminal and juvenile
records checks through the Florida Department of Law Enforcement (FOLE) ... .
FBIIFOLE expired for T.L.
RULE: Pursuant to 650-30.435.04 (1), F.A.C., Federal criminal records checks
through the Federal Bureau of Investigation (FBI) .... FBI/FDLE expired for T.L.
RULE: Pursuant to 65D-30.397.451 (2), F.A.C., Employment history checks ....
Not in the file for T.L.
RULE: Pursuant to 650-30.397.451 (2), F.A.C., Checks of references ... Not in
the file for T. L.

SUMMARY AND LICENSING RECOMMENDATIONS
A site visit was completed at Recovery Institute of South Florida, Inc. on September 18,
2014. The agency had an overall performance score of 84.08%, scoring 713 points out
of a total of 848. The minimum standard score is 80.00%. The agency will be issued
Regular License for the Residential Detoxification, Residential Level2 Treatment, Day
or Night Treatment with Community Housing, Intensive Outpatient Treatment, and
Outpatient Treatment components. A corrective action plan for the compliance issues
noted above must be submitted within thirty (30) calendar days of receipt of this report.

Recovery Institute of South Florida, Inc.

Page 14 of15

 rComponent fProgram !Addre~ I
Outpatient
Treatment
Intensive
. Outpatient
Treatment
. Day or Night
· Treatment
with
Community
Housing.

City

~

I

License#

F
F:-

!Expiration.

Recovery 1080 SE
Institute 3rd
Ft.
1706AD352501 09M23-15
· of South ~venue Lauderdale 33316
·
Florida
Floor #1 ·
Recovery
Institute
of South
Florida

1080 SE
3rd
Ft.
1706AD352501 · 09-23-15
Avenue Lauderdale 33316
•
Floor #1

Recovery
Institute
·of South
Florida

1080 SE
3rd
Ft.
1706AD352501 . 09-23-15
Avenue . Lauderdale 33316
Floor #1

-

. r'-----'-'-·-·- -

Recovery 5540
Residential Institute Davie
'Davie 33314
·of South · Road
Level2
Florida · Floor#1
~
Recovery 5540
•
ntial Institute Davie
Davie 33314
!Detoxification of South Road
Floor#1
1Fiorida

r

Recovery Institute of South Florida~ Inc.

11706AD352502,09-23-1~:
1706AD352502,09-23-15

bate

Page 15 of 15

 Application for Licensure to
Provide

SUBSTANCE ABUSE
.SERVICES

1. Service Provider Name (If
RECOVERY INSTITUTE OF
3. Name of the Service Provider's OWner
TERRY LIVORSI

4. Point of Contact Email Address
jonm@recoveryinstitute.com

5. Mailing Address
1080 SE 3rd AVE., Fl #1
5a.

Code

FT
6. Street Address (if different than mailing address)
Sa. City

Sd. County

7. Circuit/Region

(Area Code & Number)

17
10. Please check the applicable box(es) below.

0

Publicly Funded Provider

181

Privately Funded Provider

0

Private Practitioner

0

Faith-Based Provider

0

Community Substance Abuse Coalition

11. Is the applicant accredited by a certifying organization approved
by the department? If so, please check the appticable box.

0

Commission on Accreditation of Rehabilitation Facilities (CARF)

0
D
0

Three-Year

0

One-Year

The Joint Commission
Council on Accreditation (COA)

Accreditation Expiration Date
Please submit the most recent accreditation survey report with

this
12. Is the agency incorporated with the State of Florida?

181

Yes

0

status.

13. Is the corporation for profli?
1:81 Yes
No

0

No

If Incorporated, please submit the names of the owner, board members, officers, and shareholders.

Email AQdress

Coordinator

An application without the applicable licensure fee as required under section 397.407, Florida Statutes and SSD-30.003(5), Florida
Administrative Code, will be returned to the applicant. An application for renewal of a regular license must be submitted to the
department no later than~ days before the license expires. A late fee of $100 per license shall be assessed for the late filing of an
application as required under section 397 .407(2) Florida Statutes. Please make check payable to the Florida Department of Children

C&F-SA Form 4024

1- 4

August24, 2012

 .. ..-

. II. PROGRAM COMPONENT INFORMATJO~t -~"::_].o::'_..Jt,~:~ ~-~-~ ~~~~-~~-:;:·~ ~·- ~-;~-*j'~
1. Name of Program (e.g., Adult Outpatient Treatment, Youth Residential Treatment, Outreach Prevention, etc.)
RECOVERY INSTITUTE OF SOUTH FLORIDA

2. Street Address
1080 SE 3 111 AVENUE, FL #1
3. Building Number, Room Number, Suite, etc.
r

4. City
FT. LAUDERDALE
7. CirculURegion
17
10. Current Ucense Number
1706AD352501
12. Name of Program Director

5. Stale Florida

6. Zip Code
33316
8. County
9. Telephone (Area Code & Number)
BROWARD
954-960-7091
11. Current Ucense Number Expiration Date {MMIDDIYY)
9/25/2014
13. Name of Clinical Director
STEPHEN M. HERZ LMHC,CAP
Type of Service Component (please ch eck only one service per component application):
14a. Addictions Receiving Facility:

14d. Residential Programs:

141. Aftercare Programs:

0

0
0

Addictions Receiving Facility
Bed capacity

Residential Detoxification

Bed Capacity

0

Bed Capacity

0

Level2

Bed Capacity

14j. Intervention Programs:

Level3

Bed Capacity

0

Case Management

Level4

Bed Capacity

D

General Intervention

LevelS

Bed Capacity

0
0

Employee Assistance Program

14e. Day or Night Treatment
Programs with Community Housing:

0 Day or Night Treatment Programs
with Community Housing

14k. Prevention Programs:

0
0
0

14b. Detoxification Programs:

0

Level 1

Outpatient Detoxification

0 Residential Methadone
Detoxification
Bed Capacity

Treatment Alternatives for Safer
Communities

14f. Day or Night Treatment
Programs:

0 Outpatient Methadone
Detoxification

0

Aftercare

Day or Night Treatment

0

Level 1 Prevention

0

Level 2 Prevention

141. Medication & Methadone
Maintenance Treatment Programs:

14c. Intensive Inpatient Treatment
Programs:

14g. Intensive Outpatient Programs:

D

14h. Outpatient Programs:

0 Medication & Methadone
Maintenance Treatment

IE!

0

0

Intensive Inpatient Treatment
Bed Capacity

Intensive Outpatient Treatment

Outpatient Treatment

15. DCF Contracted Bed Capacity (Residential, Inpatient,
Residential Detox. Addictions Receiving Facl!Jtles) 16
17. Hours during Which the program is open:
to

9pm

Tuesday

Bam
Bam

to

9 pm

Wednesday

Sam

to

9pm

Thursday

Sam

to

Friday

Sam

to

Monday

0
0

Satellite Maintenance

16. Ucensed Bed Capacity (Residential, Inpatient. Residential
Detox, Addictions Receiving Facilities) 16

1S. Please submit evidence of compliance for applicable areas below
(including the expiration date):

Closed

Fire and Safety

Closed

Health Standards

IZI

Yes

0

No

Date: 5122/14

Closed

Facility Inspection

181

Yes

0

No

9pm

0
0

Closed

Food Services

IZI

Yes

0

No

9pm

0

Closed

Zoning Compliance

181
181
181

Yes

D
D

No

Date: 6/08/11

Yes

No

Date: 1110/14

Yes

0

No

Date: 1/10/14

Saturday

Bam

to

9pm

Sunday

8am

to

9pm

0
0

Closed
Closed

Property Insurance
Professional Liability
Insurance

0
0

N/A

Date: 3/04/14

N/A

Date: 3/04/14

Please submit all approval documents with this application

C&F-SA Form 4024

2· 4

August 24.2012

·-

 20. Have all staff and volunteers who have direct contact with
clients under the age of 18 years been finger printed and
screened in accordance with section 397.451(1){a), Florida
Statutes?
0 Yes

19. Medication and Methadone Maintenance Treabnent
components, (i.e., programs which use methadone or other
medications for treating oplold addiction). Approved by:

0
0
0
0
181
J

J

Drug Enforcement Administration (DEA)
Substance Abuse and Mental Health Services
1\dminfstratfon (SAMHSA)
State Methadone Authority

0

No

I8J

Not Applicable

Board of Pharmacy
Not Applicable

Please submit the treatment resource affidavit with this
Please submit copies of approval documents with this
application
application.
21. Please check the client population, which have been targeted for services.

t8l
!81

White (Non-Hispanic)

181

Hispanic

I8J
0
I8J

Black (Non-Hispanic)

American Indian
None
Other (please describe) All Races

22. Please list any special population group targeted for services (e.g., healing impaired, pregnant alcoholics or addicts, youth,
criminal justice clients, etc.)

D
181

0
t8l
t8l
0
I8J
0

Women:

I8J
D

Hearing Impaired:

Adolescents:

181

Visually Impaired:

Homeless:

I8J
1.81
l8l
l8l

Older Adults:

Children:

Criminal Justice-Involved Adults:
Juvenile Justice-Involved Youth:
Pregnant and Post Parium Women:

HIV/AIDS:

Co~ccurring:

Intravenous Drug Users:
Other:

Please describe other group: Alcoholics, Men, Relapsers,
EAP Clients, Impaired Professionals

Pregnant and Post Parium Adolescents:

23. Services provided: Please check all major services provided on a regular basis either directly by the program or upon referral.
Provided D!rect!y by
Program

Provided by Written
Agreement or Referral

Not Applicable

Individual Counseling

l8l

0

0

Group Counseling

181

0

0

Famny Counseflng

1.81

0

0

Job Consulting and Placement

0

0

[81

Job Training

D

D

[81

Education Services

0

0

[81

Aftercare (Non·S1ructured)

I8J

General Health Care

l8l

0
0

Legal Services
Social Services (Welfare, Housing, etc.)

0
I81

D

Cultural/Recreational Programs

1.81

0

0
0
t8l
0
0

Other (Please Describe) Nutritional
Counseling

~

0

0

Program Services

C&F·SA Form 4024

0

3· 4

August24, 2012

 25. What is the maximum number of
clients that can be served in this
component on a given day?

24. Do you charge client fees? If so,
please attach a copy of the fee schedule
and fee policy.

181

Yes

0

26. What is your projected operating
budget for the component listed on this
application for the current year?45,000

20

No

27. Please list the complete names of agencies or practitioners you have written referral agreements, contracts, or subcontracts with
and check the type of business relationship:

0

a. lnsurdnce Compantes
Olher(Specify) Referrals

0

b Private Individuals
Referrals

0

c. HCAMS
d. EAP's

l8l

· 181

0

0

Agreement

0

0

Contract
Contract

0

D

Agreement

0

0

Agreement

D

0

h. Recovery Institute {Detox, RTC, PHP lOP)
Other{Speclfy) Referrals

0
0

Agreement

Contract

~ Other(Specify)

t8l Other(Specify) Referrals
C8l Other(Spedfy) Referrals

Subcontract
Subcontract

l8l

Subcontract

Subcontract

0

0

f. Christian Recovery Solutions (PHP,IOP,
Other(Specify) Referrals

0

Contract

Contract

e. Recovery Institute (Detox, RES,PHP, lOP)
Other(Specify) Referrals

g. Lighthouse .
Referrals

t8l

0

.Agreement

Agreement

0

Agreement

0

Contract

0

Contract

181

Subcontract

Subcontract
Subcontract

Other(Specify)

Agreement

0

Contract

0

I.

0

Agreement

0

Contract

0

Subcontract

0

Other{Specify)

j.

0

Agreement

0

Contract

0

Subcontract

0

Other{Specify)

Subcontract

28. Please list the sources of revenue you receive by name and check the type of funds, e.g., state funds, federal funds, fees, etc:

0
0

a. Insurance
b Private Pay
c. Other Fac~ities
agreements generated for services rendered

D
D
D
D
D

d.
e.
f.

g.

h.

C&F-SA Fonn 4024

State
Slate

0

State

0
State 0
State 0
State

State
State

0
0

D
0

Federal
Federal

0

0
0

Federal

Fees
Fees

0

Federal

0
0

Fees

Federal

D

Fees

Federal
Federal

Federal

4-4

0

Private

181

Fees

Private

0

0 Fees

0
0
0
0

D

D

Private

Fees

Fees

~ Other(Specify) Insurance

0

Private

Other( Specify)

181

Other(Specify) Fee

Private

0

Other(Speclfy)

Private

D

Other(Specify)

Private

0

Other(Spedfy)

Private

0
0

Other( Specify)
Other(Specify)

August24,2012

 29. Please further describe your program listed in item #1 on page 2. For counseling programs, this information should In c lude
the number of coun~ling sessions provided weekly, the duration of each counseling session, and the average length of
stay in the program.

The Outpatient Treatment Program will provide a minimum ot 6 hours ot services per week. These include, but are not limited to the
following: treatment planning, individual and group counseling as well as case management services as necessary. Group therapy
sussions will be twice per week for 21/2 hours each and individual sessions will be for 1 hour per week. If it is found that the client i<l
unsuccessful in obtaining treatment plan objectives, the client will be referred to a more intensive level of care. The average length of
stay will be 30 - 45 days.

C&F-SA Fonn 4024

4-4

August 24, 201 2

 Submission Date
(Month, Day, Year)

Application for Licensure to
Provide
~D Rfa~'Ti!U\I~IF:

New

ABUSE

~Renewal

I.op

0 Relocation
(Anticipated Relocation Date)

i. Service Provider Name (lfmultipl
RECOVERY INSTITUTE OF SOUT
3. Name of the Service Provider's 1
TERRY LIVORSI

4. Point of Contact Email Address
jonm@recoverylnstitute.com

5. Mailing Address
1080 SE 3rd AVE., Fl #1
5a.City
5b. State
Florida
FT. LAUDERDALE
6. Street Address (if different than mailing address)

oc. LIIJ Code
33316

5d. County
BROWARD

6d. County

6a. City

8. Telephone (Area Code & Number)
7. CircuiVRegion
954-960-7091
17
10. Please check the applicable box(es) below.

D

Publicly Funded Provider

181

Privately Funded Provider

D

Private Practitioner

D

Faith-Based Provider

0

Community Substance Abuse Coalition

11. Js the applicant accredited by a certifying organization approved
by the department? If so, please check the applicable box.

D

Commission on Accreditation of Rehabilitation Facilities (CARF)

0

The Joint Commil:sion

D

Council on Accreditation (COA)

D Three-Year 0

One-Year

Accroditati on Expiration Date

Please submit the most re<:ent accreditation survey report with
this
In accreditation status.
13. Is the corporation for profit?
12. Is the agency incorporated with the Stale of Florida?
12?1 Yes
0 No
l3l Yes
D No
If incorporated, please submit the names of the owner, board m&mbers, officers, and shareholders.

Executive Officer
Rnancial Officer
17. Name of Staff Training Coordinator
NANCYZIFER
18. Name and professional license number of Medical Director (applies to addictions receiving facilities, detoxification, intensive inpatient
treatment, residential treatment, day or night treatment, and medication. and methadone maintenance treatment services.)
DR. ANTONIO DeFILit'PO
An application without the applicable licensure fee as required under section 397.407. Florida Statutes and 650-30.003(5), Florida
Administrative Code, will be returned to the applicant An application for renewal of a regular license must be submitted to the
department no later than §Q days before the license expires. A late fee of $100 per license shall be assessed for the late filing of an
application as required under section 397.407(2) Florida Statutes. Please make check payable to the Florida Department of Children
& Families.

C&F-8A FOOTI 4024

1-4

August 24,2012

 II. PROGRAM COMPONENT INFORMATIO

· ·~

.: ~ ~·,JJt:-, ::~;

·.

~.·~

·'4 ~!..."f.':~~-~~-.~

1. Name of Program (e.g., Adult Outpatient Treatment, Youth Residential Treatment, Outreach Preventlon, et c.)
RECOVERY INSTITUTE OF SOUTH FLORIDA

2. Street Address
1080 SE 3ro AVENUE, FL #1
3. Building Number, Room Number, Suite, etc.
4. City

5. State Florida

6. Zip Code
33316

8. County

9. Telephone (Area Code & N11t1ber)

FT. LAUDERDALE

7. Circuif/Region
17

954-960-7091

BROWARD

10. Current Ucense Number

11. Current License Number Expiration Date (MM/DDIYY)

1706AD352501
12. Name of Program Director

9/25/2014
13. Name of Clinical Director
STEPHEN M. HERZ LMHC, CAP

Type of Service Component (please check only one se!VIce per component application):
14a. Addictions Receiving Facility:

14d. Residential Programs:

141. Aftercare Programs:

0

Bed Capacity

0
0

14b. Detoxification Programs:

0

Addictions Receiving Facility

Residential Detoxification
Bed Capacity

0
0

Outpatient Detoxification

Residential Methadone
Detoxification
Bed Capacity

Level 1

Bed Capacity

D

Level2

Bed Capacity

14J. Intervention Programs:

0

Level 3

Bed Capacity

D

Case Management

0

Level4

Bed Capacity

0

Gener al intervention

0

Level5

Bed Capacity

D

Employee Assistance Program

14e. Day or Night Treatment
Programs with Community Housing:

0

0 Day or Night Treatment Programs
with Community Housing

14k. Prevention Programs:

Treatment Alternatives for Safer
Communltle.s

14f. Day or Night Treatment
Programs:

0 Outpatient Methadone
Detoxification

Aftercare

0

Day or Night Treatment

0

Level

0

Level 2 Prevention

1 Prevention

141. Medication & Methadone
Maintenance Treatment Programs:

14c. Intensive Inpatient Treatment

14g. Intensive Outpatient Programs:

Programs:

1.81

0

14h. Outpatient Programs:

0 Medication & Methadone
Maintenance Trea1ment

0

0

Intensive Inpatient Treatment
Bed Capacity

Intensive Outpatient Treatment

Outpatient Treatment

15. DCF Contracted Bed Capacity (Residential, Inpatient,
Residential Detox, Addictions Receiving Facilities)
17. Hours during which the program is open:
Monday

Bam

to

9pm

Tuesday

8am

to

9pm

Wednesday

Sam

to

9pm

Thursday

Sam

to

9pm

Friday

Sam

to

9 pm

0
0
0
0

0

Satellite Maintenance

16. Licensed Bed Capacity (Residential, Inpatient, Residential
Detox, Addictions Receiving Facilities)

18. Please submit evidence of compliance for applicable areas below
(Including the expiration date):

1.81

Yes

0

No

Facility Inspection

181

Yes

0

No

0

N/A

Date: 3/4/14

Closed

Food Services

~ Yes

0

N/A

Date: 3/4114

Closed

~ Yes

Property Insurance

~ Yes

Professional Liability

~ Yes

0
0
0
0

No

Zoning Compliance

Closed

Fire and Safety

Closed

Health Standards

Closed

Saturday

Sam

to

9pm

0

Closed

Sunday

Bam

to

9pm

0

Closed

Date: 5/22/14

No

Date: 6/8/11

No

Date: 1/10/14

No

Date: 1/10/14

Insurance
Please submit all approval documents with this application

C&F-SA Fonn 4024

2-4

August24. 2012

 19. Medication and Methadone Maintenance Treatment
components, (i.e., programs IMlich use methadone or other
medications for treating opioid addiction). Approved by:

20. Have all staff and volunteers who have direct contact with
clients under the age of 18 years been finger printed and
screened in accordance with section 397.451 (1 }(a), Florida
Statutes?

0
D

Drug Enforcement Administration (DEA)

D

Yes

Substance Abuse and Mental Healttl SeJVices

0

No

181

Not Applicable

D

Administration (SAMHSA)
State Methadone Authority

0

Board of Pharmacy

1:81

Not Applicable
Please submit the treatment resource affidavit with this
application

Please submit copies of approval documents with this
application.

21. Please check the client population, which have been targeted for SBJVices.

1:81

White (Non-Hispanic)

r8l

Black (Non-Hispanic)

181

Hispanic

181
0
r8l

American Indian
None
Other (please describe) All Races

22. Please list any special population group targeted for seJVices (e.g., hearing impaired, pregnant alcoholics or addicts, youth,
criminal justice clients, etc.)
HIV/AIDS:

Women:

181
0

D
181

Adolescents:

181

Visually Impaired:

Homeless:

r8l

Older Adults:

1:81

Criminal Justice-Involved Adults:

1:81

Co-occurring:

D
181

Juvenile Justice-Involved Youth:

181

Intravenous Drug Users:

Pregnant and PostPartum Women:

181

Other:

0

Pregnant and Post Parium Adolescents:

D

Children:

1:81

Hearing Impaired:

Please describe other group: Alcoholics, Men, Relapsers.
EAP Clients, Impaired Professionals

23. Services provided: Please check all major seJVices provided on a regular basis either directly by the program or upon referral.
Provided Directly by
Program

Provided by Written
Agreement or Referral

Not Applicable

lndMdual Counseling

[8l

0

0

Group Counseling

[8l

D

Family Counseling

r8l

0

0
0

Job Consulting and Placement

D

1&1

Aftercare (Non-Structured)

r8l

0
0
0

181

Education Services

0
0
0

0

General Health Care

181

0

D

Legal Services

0

181

0

D

Cultural/Recreational Programs

0
181
181

0

0

Other (Please Describe) Nutritional
Counseling

181

0

0

Program SeJVIces

Job Training

Social Services (Welfare, Housing, etc.)

C&F-SA FOITTl 4024

3· 4

r8l

August 24,2012

 24. Do you charge client fees? If so,
please attach a copy of the fee schedule
and fee policy.
~ Yes

0

25. What is the maximum number of
clients that can be served in this
component on a given day?

26. What is your projected operating
budget for the component listed on this
application for the current year?4,330,000

30

No

27. Please list the complete names of agencies or practitioners you have written referral agreements, contracts, or subcontracts with
and check the type of business relationship:

D

a. Insurance Companie!>
Other(Specify) Referrals

D

b Private Individuals
Referrals

0

c. HCAMS

D

Agreement

D

D

Contract

0

Contract

Agreement

e. Recovery lns1ltute (Detox, PHP, lOP)
Other(Specify) Referrals

D

181

Subcontract

181

Subcontract

Other(Specify)

181 Other(Specify) Referrals
0 Contract 0 Subcontract 181 Other(Speclfy} Referrals
0 Agreement 0 Contract D Subcontract 181

Agreement

0

d. EAP's

D

Agreement

Contract

D

f. Christian Recovery Solutions (PHP,IOP

Subcontract

0

Agreement

Contract

D

Subcontract

1.81 Other(Speclfy) Referrals

0

g. Ughthouse
Referrals

Agreement

0

Contract

0

D

Subcontract

181

Subcontract

Other{Specify)

h. Recovery Institute (Detox, RTC)

D

0
D

i.
j.

0

Agreement

Contract

D
0

Agreement
Agreement

181

Other{Specify) Referrals

Contract

0

Subcontract

0

Other(Specify)

Contract

D

Subcontract

0

Olher(Speclfy)

28. Please list the sources of revenue you receive by name and check the type of funds, e.g., state funds, federal funds, fees, etc:

0

a. Insurance

c. Other Facllftles
agreements genernted for services rendered

D
0
0
0
0

d.
e.
f.

g.
h.

C&F-SA Form 4024

State

0

b Private Pay

State

0

0

D

State

Federal
Federal

D

State

0

Federal

State
State

0
0

State
State

0
0

Federal

0

Fees
Fees

0

181

Fees

Private
Private

0

Fees

0

Private

Federal

0
0

Fees

0

Fees

0

Federal

Fees

D

Federal

0
0

0
0
0
0

Private

Federal

4- 4

Fees

Private
Private
Private

~ Other(Speclfy) Insurance

0

Private

0
0
0
0
D

Other(Speclfy)

181

Other(Specify) Fee

Other(Speclfy)
Other(Specify)
Other(Specify)
Other(Speclfy)
Other(Specify)

August 24,2012

 29. Please further describe your program listed In item #1 on page 2. For counseling programs, this Information should Include
the number of counseling sessions provided weekly, the duration of each counseling session, and the average length of
stay in the program.

The Intensive Outpatient Treatment Program provides a minimum of 10 hours of services per week. These include, but are not
1 limited to the folowing: treatment planing, lndMdual and group counseling and case management seNices as necessal)'. Group
I' the,·apy sessions meet three limes per week for three hours each and Individual sessions are for one hour per week. Group therapy
sessions consist of both process and and educational topics germane to life skill development and recovel)'. Psychiatric assessment
and ongoing mental health seNices are provided to assist clients as needed.
The average length of stay will be 30-45 days

..

~·

.•.-----"'~

31. Date (Mo?th, Oa , Year)

i--(1-f
(

\~

C&F-SA Fo1m 4024

4-4

August 24, 2012

 Application for Licensure to
Provide

SUBSTANCE ABUSE
SERVICES

(If multiple locations enter CORPORATE HEADQUARTERS name)

SOUTH FLORIDA

3. Name of the Service Provider's Owner

4. Point of Contact Email Address
jonm@recoveryinstitute.com

TERRY LIVORSI

DA;:'f.--:--:,;-:,::;:
V:=Jb==H=r==::---1

5. Mailing Address

1080 SE 3rd AVE., Fl #1

City
5b. State
LAUDERDALE
Florida
6. Street Address (if different than mailing address)

Zip Code

16

6a. City

8. Telephone (Area Code & Number)

7. CircuiflRegion
17

954-960-7091
10. Please check the applicable box(es) below.

0

Publicly Funded Provider

181

Privately Funded Provider

0

Private Practitioner

0

Failh-Base<i Provider

D

Community Substance Abuse Coalition

12. Is the agency incorporated with the State of Florida?
181 Yes
0 No
If Incorporated, please submit the names of the owner,

11. Is the applicant aet
by the department? If

:Jproved

0

Commission on Accreditation of Rehabilitation Facilities (CARF)

0

The Joint Commission

0

Council on Accreditation (COA}

0

Three-Year

0

One-Year

Accreditation Expiration Date
Please submit the most r~ent accreditation survey report with
this
chan
fn accreditation status.
f 3. Is the corporation for profit?
18i.' Yes
0 No
members, officers, and shareholders.

Financial Officer
Training Coordinator

18. Name and professional license number of Medical Director (applies to addic1ions receiving facilities, detoxification, intensive inpatient
treatment, residential trealment, day or night treatment, and medication and methadone maintenance treatment services.)
License#
An application without the applicable licensure fee as required under seclion 397.407, Rorida Statutes and 65D-30.003(5}, Florida
Administrative Code, will be retumed to the applicant. An application for renewal of a regular license must be submitted to the
department no later than 60 days before the license expires. A late fee of $100 per license shall be assessed for the late filing of an
application as required under section 397.407(2) Florida Statutes. Please make check payable to the Florida Department of Children

C&F-SA Form 4024

1- 4

August 24. 2012

 II. PROGRAM COMPONENT INFORMATIO

._ .• '£···:-:l"·;\\
... • •'
r--.~

.,.l~·;:p·~:,;

../"

.,-.. . . . , .... ,

,,o,·!"-t.;,! ....

..

~~ ~ .... .....~~ ~~

~-l""_. ~J .~r\~

1. Name of Program (e.g., Adult Outpatient Treatment, Youth Residential T reatment, Outreach Prevenllon, etc.)
RECOVERY INSTllUTE OF SOUTH FLORIDA
2. Street Address
1080 SE 3"' AVENUE, FL #1

3. Bu~ding Number, Room Number, Suite, etc.
5. State Florida

4. City

6. Zip Code

FT. LAUDERDALE

33316

8. County

7. Circuit!Region
17

9. Telephone (Area Code & Number)
954-960-7091

BROWARD

10. Current License Number

11 . Current License Number Expiration Date (MMIDDIYY)

1706AD352502

9125/14

12. Name of Program Director

13. Name of Clinical Director

STEPHEN M. HERZ LMHC, CAP
Type of Service Component (please check only one service per component application):
14a. Addictions Receiving Facility:

14d. Residential Programs:

14/. Aftercare Programs:

0

0
0
0
0
0

Level 1

Bed Capacity

0

Level2

Bed Capacity

14j. Intervention Programs:

Level 3

Bed Capacity

0

Case Management

Level 4

Bed capacity

0

General Intervention

Level S

Bed Capacity

0
0

Employee Assistance Program

14e. Day or Night Treatment
Programs with Community Housing:

181 Day or Night Treatment Programs
with Community Housing

14k. Prevention Programs:

14f. Day or ~lght Treatment

0

Level 1 Prevention

0 Outpatient Methadone
Detoxification

Programs:

0

Level

14c. Intensive Inpatient Treatment

14g. Intensive Outpatient Programs:

Programs:

0

Addictions Receiving Facility

Bed Capacity
14b. Detoxification Programs:

0

Residential Detoxification
Bed Capacity

0
0

Outpatient Detoxification

Residential Methadone
Detoxification
Bed Capacity

0

0

Intensive Inpatient Treatment
Bed Capacity

to

5pm

Tuesday

Bam

to

Spm

Wednesday

8am

to

Spm

0
0
0

2 Prevention

141. Medication & Methadone
Maintenance Treatment Programs:

14h. Outpatient Programs:

0 Medication & Methadone
Maintenance Trea1ment

0

0

Intensive Outpatient Treatment

Outpatient Treatment

17. Hours during which the program is open:
Bam

Treatment Alternatives for Safer
Communities

Day or Night Treatment

15. DCF Contracted Bed Capacity (Residential, Inpatient.
Residential Detox, Add ictions Receiving Facilities)

Monday

Aftercare

Satellite Maintenance

16. Licensed Bed Capacity (ResidentiaJ, Inpatient, Residential
Detox, Addictions Receiving Facilities)

18. Please submit evidence of compliance for applicable areas below
(Including the expiration date):

Closed

Fire and Safety

Closed

Health Standards

l8l

Yes

0 No

Yes

0
0

No

0

N/A

Date: 3/4/14

No

0

NJA

Date: 3/4/14

No

Date: 6/8111

Yes

0
0

No

Date: 12129/14

Yes

0

No

Date: 2119/14

Closed

Facility Inspection

l8l

[gl Yes

Thursday

Bam

to

Spm

0

Closed

Food Services

Friday

Sam

to

Spm

0

Closed

Zoning Compliance

[gl Yes

Saturday

Sam

to

Spm

0

Closed

Property Insurance

Sunday

Sam

to

5pm

0

Closed

l8l
181

Professional Liability

Date: 5122/14

Insurance
Please submit all approval documents with this application

C&F-5A Fonn 4024

2-4

August 24.2012

 20. Have all staff and volunteers who have direct contact with
clients under the age of 18 years been linger printed and
screened in accordance with section 397.451(1){a), Florida
Statutes?

19. Medication and Methadone Maintenance Treatment
components, o.e., programs which use methadone or other
medlcaUons for treating opioid addiction). Approved by:

0
0
I

Drug Enforcement Administration (DEA)
Substance Abuse and Mental Health Services
Administration (SAMHSA)

0
0

Board of Pharmacy

l8l

Not Applicable

0
0

No

181

Not Applicable

Yes

State Methadone Authority

Please submit the treatment resource affidavit with this
application

Please submit copies of approval documents with this
application.

21. Please check the client population. wflich have been targeted for services.

Black (Non-Hispanic)

181
0

None

Hispanic

1'81

Other (please describe) All Races

181

White (Non-Hispanic)

181
181

American Indian

22. Plel!se llsi!i.!'IY.. s~cial populatic-!Q.9fOJ!P.ta!@ted_for ~~rvices (e.g., hearing impaired, pregnant alcoholics or addicts, youth,
criminal justice clients, etc.)
. ---·--·--··- - - - · ·-· ·•· ··•
• ·
----- - - - -

0

Children:

181

Women:

181
0

0

Adolescents:

[8J Visually Impaired:

l8l
181

Homeless:

181

Older Adults:

Criminal Justice-Involved Adults:

1'81
l8l
181

Co-occurring:

0
181
0

Juvenile Justice-Involved Youth:
Pregnant and Post Partum Women:
Pregnant and Post Parium Adolescents:

HN /AIDS:
Hearing Impaired:

Intravenous Drug Users:
other:

Please describe other group: Alcoho!lcs, Men Relapsers,
EAP Clients. Impaired Professionals

23. Services provided: Please check all major services provided on a regular basis either directly by th e program or upon refena l.
Provided Directly by
Program

Provided by Written
Agreement or Referral

Not Applicable

Individual Counseling

181

D

0

Group Counseling

l8l

0

Family Counseling

Aftercare (Non-Structured)

181
0
0
0
!81

General Health Care

181

0
0
0
0
0
0
0

Legal Services

0

0

Social Services (Welfare, Housing, etc.)

18'1

0

Culb.Jrai/Recreational Programs

181

0

0
0
181
0
0

Other (Please Describe) Nutritional
Counseling

1'81

0

0

Program Services

Job Consulting and Placement
Job Training
Education Services

C&F-SA Form 4024

3· 4

0
181
181
181

August 24, 2012

 24. Do you charge client fees? If so,
please attach a copy of the fee schedule
and fee policy.
~ Yes

0

26. What Is your projected operating
budget for the component listed on this
application for the current year?2,583,000

25. What is the maximum number of
clients that can be served In this
component on a given day?
30

No

27. Please list the complete names of agencies or practitioners you have written referral agreements, contracts, or subcontracts with
and check the type of business relationship:

0

a. lnsurana! Companies
Other(Specify) Referrasl

0

b Private Individuals
Referrals

0

c. HCAMS

0

Agreement

0

Agreement

0

d. EAP's

0

Agreement

0

Agreement

0

Contract

0

Contract

0

Contract

0

Contract

181

Subcor.tract

181

Subcontract

Other(Speclfy)

[8l Other(Speclfy) Referrals

Subcontract

18] Other(Speclfy) Referrals

Subcontract

e. Recovery lnstiMe (Detox,RES, IOP,OP)
Other(Specify) Referrals

0

Agreement

0

Contract

0

Subcontract

f. Christian Recovery Solutions (PHP.IOP,
~ Other(Specify) Referrals

0

Agreement

0

Contract

0

Subcontract

t8l

D

g. Ughthouse
Referrals

0

Agreement

0

Contract

[g) Other(Specify)

Subcontract

h. Recovery Institute (Detox, RTC)

0

0
0

i.
j.

0

Agreement

0

Contract

0
0

Agreement
Agreement

Subcontract

Contract
Contract

0
0

1:81

Other(Specify) Referrals

0
0

Subcontract
Subcontract

Other{Specify)
Other(Specify)

28. Please list the sources of revenue you receive by name and check the type of funds, e.g., state fu nds, federal funds, fees, etc:

0

a. Insurance

0

b Private Pay
c. Other FaCilities
agreements generated for services rendered

g.

0
D
0
D

h.

0

d.

e.
f.

C&F-SA Fonn 4024

State
State

0

0
0

State

Federal
Federal

0

State

D

Federal

State

D

Federal

State

Federal

State

D
0

State

D

Federal

Federal

4-4

0
0

Federal

0
D
0
0
0

Fees
Fees

D

Fees
Fees

0

Fees
Fees

Private

[8:1 Private

Fees

0
D
0
0

Fees

0

0

~ Other(Spec/fy) Insurance

0

Private

Other{Specffy)

IZI

Other( Specify) Fee

Private

0

Other(Specify)

Private

D
D

Other( Specify)

0
0

OthertSpeclfy)

Private
Private
Private

Other(S pecify)

Other(Specify)

August24,2012

 29. Please further describe your program listed in item #1 on page 2. For cou nseling programs, this Information should Include
the number of c ounseling ses sions provided wee kl y, the d urat ion o f each counselin g session, and the average length of
stay in the program.

The Day/NJght Treatment with Community Housing Program provides a m inimum of 25 hours of services per week. These include
Individual, Group and Family counceling sessions. The minimum daily involvement In the clinical experience by the client is 5 hours
per day. The group experience consists of a number of therapeutic cpportunities. Including but not limited to, Substance Abuse
Education, Life Skills trainings, Anger management. Communication skills trainings, Relapse Prevention, Problem Solving and
Decision Making, Relationship Skills and Symptom Management. Individual counseling sessions lasting a minimum of 1 hour per
week is provided.Clients are also provided and/or referred fo r services reganding Physical and Mental Health issues. Add itionally, all
clients receive medication management and monitoring where applicable and attendance at 12 Step meetings daily. Famfly
conferences are scheduled based on the Individual needs of the client and family. All clients are provided with case management
services.
The average length of stay is 30-60 days.

C&F--SA Fonn 4024

4- 4

August 24, 2012

 Submission
(Month, Day, Ye

Application for licensure to
Provide

SUBSTANCE ABUSE
SERVICES

1. Service Provider Name (Jfmultipla locations enter CORPORATE HEADQUARTERS name)
2. Federal ID #
RECOVERY INSTITUTE OF SOUTH FLORIDA
84-1703525
3. Name of the Service Provider's Owner
4. Point of Contact Email Address
TERRY LIVORSl
jonm@recoveryinstitute.com

5. Mailing Address
1080 SE 3m AVE., Fl #1
Code

5d. County
BROWARD

6a. City

6c. Zip Code

6d. County

7. Circuit/Region
8. Telephone (Area Code & Number)
17
954-960-7091
10. Please check the applicable box(es) below.

9. Fax Telephone (Area Code & Number)
954-533-4053
11 . Is the applicant accredited by a certifying organization approved
by the department? If so, please check the applicable box.

6. Street Address (If different than mailing address)

0

Publicly Funded Provider

181

Privately Funded Provider

0

Private Practitioner

0

Faith-Based Provider

0

Community Substance Abuse Coalition

0

Commission on Accreditation of Rehabilitation Facilities (CARF)

0
0

The Joint Commission

0

Three-Year

0

One-Year

Council on Accreditation (COA)

Accreditation Expiration Date

Please submit the most recent accreditation survey report with
cha
status.
13. Is the corporation for profit?
C8J Yes
0. No

12. Is the agency Incorporated with the State of Florida?
~Yes
0 No
If incorporated, please submit the names of the owner, board members, officers, and shareholders.

Email Address

Executive Officer

16. Name of Chief Financial Officer
JON MACKLER
17. Name of Staff Training Coordinator
NANCY ZIFER
18. Name and professional license number of Medical Director (applies to addictions recoiving facilities, detoxtflcatlon,lntenslve Inpatient
treatment, residentiallrealmenl, day or night treatment, and medicalion and methadone maintenance treatment services.)
DR. ANTONIO DeFILIPPO
License i# ME63070
An application without the applicable licensure fee as required under sectlon 397.407, Florida Statutes and 650-30.003(5), Florida
AdministratiVe Code, will be returned to the applicant. An application for renewal of a regular license must be submitted to the
department no later than m2 days before the license expires. A late fee of $100 per license shall be assessed for the late filing of an
application as required under section 397.407(2) Florida Statutes. Please make check payable to the Florida Department of Children
&Families.

C&F-SA Form 4024

1-4

August24, 2012

 U. PROGRAM COMPONENT INFORMATION ·:·r·~·

::q: ·..· ,!·~~··.,.· ·. ~

' ?....i ;

'·~f.·.·~.~~~~

1. Name of Program (e.g., Adult Outpatient Treatment, Youth Residential Treatment, Outreach Prevention, etc.)

RECOVERY INSTITUTE OF SOUTH FLORIDA
2. Street Address
5540 DAVIE ROAD

3. Building Number, Room Number, Suite, etc.
~·~-----------------r~~~=-~----------~~-------------------------~

4. City

5. State Florida

6. Zip Code

7. CircuiVRegion

8. County

9. Telephone (Area Code & Number)

17

BROWARD

DAVIE

33314

954-960-7093
11. Current Ucense Number Expiration Date (MMIDDIYY)

10. Cu rrent License Number
1706AD352502

9/2512014

12. Name of Program Director

13. Name of Clinical Director
STEPHEN M. HERZ LMHC, CAP

Type of Service Component (please check only one service per component application):

14a. Addictions Receiving Facility:

14d. Residential Programs:

141. Aftercare Programs:

0

0
181
0

0

Addictions Receiving Facility
Bed capacity

14b. Detoxfflcatlon Programs:

0

0
0

Residential Detoxification
Bed Capacity

0

Bed Capacity
16

Bed Capacity

Outpatient Detoxification

14j. Intervention Programs:

Bed Capacity

0

Case Management

Levef4

Bed Capacity

D

General Intervention

Level 5

Bed Capacity

0

Employee Assistance Program

0 Treatment Alternatives for Safer
Communities

Programs with Community Housing:

0 Day or Night Treatment Programs
with Community Housing

Bed Capacity

14k. Prevention Programs:

14f. Day or Night Treatment
Programs:

0

Outpatient Methadone
Detoxification

0

Day or Night Treatment

0

Intensive Inpatient Treatment
Bed Capacity

0

Level 1 Prevention

D

Level 2 Prevention

141. Medication & Methadone
Maintenance Treatment Programs:

14g. Intensive Outpatient Programs:

14c. Intensive Inpatient Treatment
Programs:

Aftercare

Level3

14e. Day or Night Treatment

0 Residential Methadone
Detoxification

0

Level 1
Level2

D

Intensive Outpatient Treatment

14h. Outpatient Programs:

Medication & Methadone
Maintenance Treatment

0

0

Outpatient Treatment

16. Licensed Bed Capacity (Residantial, Inpatient, Residential
Detox, Addictions Receiving Facilities) 16

15. DCF Contracted Bed Capacity (Residential, Inpatient.
Residential Detox, Addictions Receiving Facilities) 16
17. Hours during which the program is open:

Satelltte Maintenance

18. Please submit evidence of compliance for applicable areas below
(induding the expiration date):
Yes

0

No

Facility Inspection

~ Yes

0

NJA

Date: 3/4/14

Closed

Yes

No

0

N/A

Date: 3/4/14

Zoning Compliance

'181
181

Property Insurance

181'

Yes

Professional Llablllly

t8l

Yes

0
0
0
0
0

No

Food Services

Monday

12am

to

11:59

0

Closed

Fire and Safety

Tuesday

12am

to

11 :59

Closed

Health Standards

Wednesday

12am

to

11:59

Closed

Thursday

12am

to

11 :59

0
0
0

Friday

12am

to

11:59

0

Closed

Saturday

12am

to

11:59

Closed

Sunday

12am

to

11:59

0
0

Closed

181

Yes

Date: 5122/14

No

Date: 6/8/11

No

Date: 12/29/13

No

Date: 2/1 9/1 4

Insurance
Please submit all appr oval doc uments with this application

C&F-SA Fotm 4024

2-4

August24,2012

 19. Medication and Methadone Maintenance Treatment
components, (i.e., programs V>Jhich use methadone or other
medications for treating opioid addiction). Approved by:

0

Drug Enforcement Administration (DEA)

0
0

Substance Abuse and Mental Health Services
Administration (SAMHSA)
8tate Methadone Authority

0

Board of Pharmacy

20. Have all staff and volunteers who have direct contact with
clients under the age of 18 years been linger printed and
screened in accordance with section 397.451 (1 )(a), Florida
statutes?
D Yes

0
181

No
Not Applicable

18) Not Applicable
Please submit the treatment resource affidavit with this
application

· Please submit copies of approval documents with this
application.

21. Please check the client population, which have been targeted for services.

I

181
181
181

181
0
!8l

White (Non-Hispanic)
Black (Non-Hispanic)
Hispanic

American Indian
None
Other {please describe) All Races

22. Please list any special population group targeted for services (e.g., hearing impaired, pregnant alcoholics or addicts, youth,
criminal justice clients, etc.)

0

Children:

0

HIV/AIDS:

~ Women:

0

Hearing Impaired:

0
181
181

Visually Impaired:

Homeless:

0

Juvenile Justice-Involved Youth:

0
l8l
!8l
!8l
181

Adolescents:
Criminal Justice-Involved Adults:

~ Pregnant and Post Partum Women:

0

Pregnant and Post Partum Adolescents:

Older Adults:
Co-occurring:
Intravenous Drug Users:
Other:

Please describe other group: Alcoholics, Men, Retapsers,
EAP Clients, Impaired Professionals

23. Services provided: Please check all major services provided on a regular basis either directly by the program or upon referral.
Provided Directly by
Program

Provided by Written
Agreement or Referral

Not Applicable

Individual Counseling

~

0

0

Group Counseling

t8l

0

Family Counseling

t8l

0

D
D

Job Consulting and Placement

0

0

181

Job Training

0

0

Education Services

0

0

l8l
181

Aftercare (Non-Structured)

12?,1

D

0

General Health Care

t8l

0

Legal Services

0

Social Services (Welfare, Housing, etc.)

t8l

0
0
0

Cultural/Recreational Programs

181

0

0
0

Other (Please Describe) Nutritional
Counseling

181

0

0

Program Services

C&f ·SA Form 4 024

3- 4

l8l

August 24. 2012

 25. What is the maximum number of
clients that can be served in this
component on a given day?

24. Do you charge client fees? If so,
please attach a copy of the fee schedule
and fee policy.
~ Yes

0

26. What is your projected operating
budget for the component listed on this
application for the current year?1,551 ,000

16

No

27. Please list the complete names of agencies or practitioners you have written referral agreements, contracts, or subcontracts with
and check the type of business relationship:

0

a. Insurance Companies
Other(Specify) Referrals

0

b Private Individuals
Referrals

0

c. HCAMS

I

I

d. EAP's

0

Agreement

0

Agreement

0

Contract

e. Recovery Institute (Detox, PHP,IOP,OP)

1181

0

Contract

Contract

0

Contract

0

Agreement

D

Agreement

0
0

0

181

Subcontract

!8l

Subcontract

lZ1

Subcontract

0

Agreement

!8:1

Subcontract

Other(Specify)

Other(Specify) Referrals

Other(Specify) Referrals

Contract

0

Subcontract

OU"'(Specif') Refe..al'

0

f. Christian Recovery Solutions (PHP,IOP ,OP)
Subcontract
181 Other(Specify) Referrals
g.

0

Agreement

0

Contract

0

Subcontract

h.

0

Agreement

Contract

0

Agreement

j.

0

Agreement

D
D
0

Subcontract

i.

0
0
0

Contract
Contract

0

Agreement

Contract

0
0
0
0

Subcontract
Subcontract

D

Other(Specify)
Other(Specify}
Other(Specify)
Other(Specify)

28. Please list the sources of revenue you receive by name and check the type of funds, e.g., state funds, federal funds, fees. etc:

D
0

a. Insurance
b Private Pay
c. Other Facilities
agreements generated for services rendered

D
0
D
0
0

d.

e.
f.
g.

h.

C&F-SA Form 4024

State
State

0
State
State
State
S1ate
State

0
0

State

D
0
0
0
0

Federal
Federal

0

D
0

Federal

Fees
Fees

0

Federal

D
0

Fees

Federal

0

Fees

Federal

0 Fees

Federal

D

Federal

4·4

Fees

Fees

0
0

Fees

0
0
D
0
D

Private
Private

0

Private

Private
Private
Private
Private

~ Other(Specify) Insurance

0

Private

D
D
0
D
0

Other(Specify)
~ Other(Spedfy) Fee

Other(Spedfy)
Other(Specify)
Other(Specify)
Other(Specify)
Other(Specify)

August24.2012

 29. Please further describe your program listed in item #1 on page 2. For counseling programs, this information should Include
the numb~r of counseling sessions provided weekly, the d uration of each counseling s ession, and the average length of
stay In the program.
The Residential Level 2 program Is a 16 bed facility that serves both men and women, 18 years of age and older. Admission criteria
for this level of care is based on the American Soclety of Addiction Medicine Patient Placement Criteria.
The program Is In operation seven days per week, 24 hours per day, with overnight staff providing direct care and supervision of
clients. Our staff is composed of a multidisciplinary team of professinnal~ that includes medical, alcohol/substance abuse counselors,
mental health professionals, Clinical management, administrative and support staff.
Each client is assigned a primary therapist that W<lfks with them to assess their needs for treatment, develop an Individualized
treatment plan and continues to review the clienrs progress on an on-going basis. There are group and individual counseling session
focusing on the cfients individual needs.
Clinical, medical and mental health issues provided include, but are not limited to: individual, group and family therapy, education
about the disease of addiction, life skills, relapse prevention training, medication management and monftorlng. Additional activities
also include gym attendance, art therapy, yoga, and attendance at various 12 step meetings. Family therapy is scheduled based
upon the individual needs of the client and their family. Case management services are provided to all clients. Clients receive a
minimum of 10 hours of therapy per week and 1 hour of individual therapy per week.
The average length of stay in the level 2 program Is 5-30 days.
31. Date (Mon1h, Day, Year)

C&F-SA Form 4024

4- 4

August 24, 2012

 Application for Licensure to
Provide

SUBSTANCE ABUSE
SERVICES

Pmovirloc>r

Name (If multiple location~> enter CORPORATE HEADQUARTERS name)
OF SOUTH FLORIDA
4. Point of Contact EmaH Adc
jonm@recoverylnstitute.com

5b. State
Florida
6. Street Address (if different than mailing address)

Code

6a. City

6d. County

7. Circuit/Region
17
10. Please check the applicable box(es) below.

0

Publicly Funded Provider

181

PriVately Funded Provider

0

Private Practitioner

11. Is the applicant accredited by a certifying organization approved
by the department? If so, please check the applicable box.

0

0

Faith-Based Provider

0

Community Substance Abuse Coalition

Commission on Accreditation of Rehabilitation Facilities (CARF)

0
0
0

Three-Year

0

One-Year

The Joint Commission
Council on Accreditation {CDA)

Accreditation Expiration Date

Please submit the most recent accreditation survey report with
this
status.
12. Is the agency incorporated with the State of Florida?
13. Is the corporation for profit?
l8l Yes
0 No
l8:l Yes
0 No
If incorporated, please submit the names of the owner, board members, officers, and shareholders.

Email Address

Training Coordinator
18. Name and professional license number of Medical Director (applies to addictions receMng facilities, detoxification. Intensive inpatient
treatment, residential treatment, day or night treatment, and mecftcation and methadone maintenance treatment services.)
DR. ANTONIO DeFILIPPO
Ucense # ME63070
An application without the applicable licensure fee as required under section 397.407, Florida Statutes and 650-30.003(5), Florida

Administrative Code, will be returned to the applicant. An application for renewal of a regular license must be submitted to the
department no later than ~days before the license expires. A late fee of $100 per license shall be assessed for the late filing of an
application as required under section 397.407(2) Florida Statutes. Please make check payable to the Florida Department of Children
Fem

1- 4

August 24, 2012

 J

,r··PROGRAM COMPONENT INFORMATIO

-

I,

..

·-·

. •,.·. t"" .. ~ t

,

~
·.. 'l.' ..
. "·:\· 't"
1. Name of Program (e.g., Adult Outpatient Treatment, Youth Residential Treatment, Outreach Prevention, etc.)
RECOVERY INSTITUTE OF SOUTH FLORIDA
2. Street Address
5540 DAVIE ROAD
3. Building Number, Room Number, Suite, etc.
f

~

I• •

'

i--- -

4. City

~

.;,

·--·

5. State Florida

r

.. •;

.;

\

~

~;

t

.

.. · :

t

••1,. -~

~

' • • <I

6. Zip Code

33314

DAVIE
7. CircuiURagion

8. County

17
10. Current License Number
1706AD352502
12. Name of Program Director

BROWARD

9. Telephone (Area Code & Number)
954-960-7093

11. Current License Number Expiration Date (MWDDJYY)
9/25/14
. ~. ~ ·".
13. Name of ClinttaiJ)irector
STEPHEN M. HERZ LMHC,CAP
Type of Service Component (please check only one service per component application):
14d. Residential Programs:
14a. Addictions Receiving Facl/lty:
141. Aftercare Programs:

0

Addictions Receiving Facility
Bed Capacity

14b. Detoxification Programs:

~ Residential Detoxification
12

0
0

Bed Capacity

Level1

Bed Capacity

0

0

level2

Bed Capacity

14j. Intervention Programs:

0

level3

Bed Capacity

0
0

Level4

Bed Capacity

0
0

Level S

Bed Capacity

Outpatient Detoxlftcation

0

Day or Night Treatment

0

Intensive Inpatient Treatment
Bed Capacity

11:59

0

Closed

Fire and Safety

Tuesday

12am

to

11:59

0

Closed

Health Standards

Wednesday

12am

tQ

11:59

0

Closed

Thursday

12am

to

11:59

0

to

11:59

Sunday

12am

to

11:59

Satellite Maintenance

18. Please submit evidence of compliance for applicable areas below
(including the expiration date):

to

12am

Level 2 Prevention

16. Licensed Bed Capacity (Residential, Inpatient, Residential
Detox, Addictions Receiving Facilities} 12

12am

Saturday

0

0

Outpatient Treatment

Monday

0
0
0

level 1 Prevention

0

17. Hours during which the program Is open:

11:59

0

14h. Outpatient Programs:

Residential Detox, Addictions Receiving Facilities) 12

to

Employee Assistance Program

0 Medication & Methadone
Maintenance Treatment

Intensive Outpatient Treatment

15. DCF Contracted Bed Capacity (Residential, Inpatient,

12am

General Intervention

141. Medication & Methadone
Maintenance Treatment Programs:

14g. Intensive Outpatient Programs:

14c. Intensive Inpatient Treatment
Programs:

Case Management

14k. Prevention Programs:

14f. Day or Night Treatment
Programs:

0 Outpatient Methadone
Detoxification

Aftercare

Treatment Alternatives for Safer
Communities

0 Day or Night Treatment Programs ·
with Community Housing

Bed Capacity

Friday

0
0

14e. Day or Night Treatment
Programs with Community Housing:

Residential Met!1 adone
Detoxifica tion

0

0

~ Yes

0

No

Facility Inspection

~ Yes

0

No

Closed

Food Services

~ Yes

0

No

Closed

Zoning Compliance

l8'J

Date: 6/8111

Property Insurance

~ Yes

0
0

No
No

Date: 12/29113

Professional Liability
Insurance

~ Yes

0

No

Date: 2119/14

Closed
Closed

Yes

Date: 5/22/14

0
0

N/A

Date: 3/04/14

N/A

Date: 3/04/14

Please submit all approval documents with this application

C&F-SA Form 4024

2-?

August24,2012

 20. Have all staff and volunteers who have direct contact with
clients under the age of 18 years been finger printed and
screened In accordance with section 397.451(1)(a), Florida
Statutes?
0 Yes

19. Medication and Methadone Maintenance Treatment
components, (i.e., programs which use methadone or other
medications for treating opioid addiction). Approved by:

jgJ Drug Enforcement Administration (DEA}

0
D
181
D

0

Substance Abuse and Mental Health Services
Administration {SAMHSA)
State Methadone Authority

No

18] Not Applicable

Board of Pharmacy
No! AppUcable

Please submit the treatment resource affidavit with this
Please submit copies of approval documents with this
application
I application.
1 21. Please check the client population, which have been targeted for services.

I

jgJ White (Non-Hispanic)

181

American Indian

lB:I

Black (Non-Hispanic)

0

None

181

Hispanic

1.'81 Other (please describe) All Races

. 22. Please list any special population group targeted for services (e.g., hearing impaired, pregnant alcoholics or addicts, youth,
criminal justice clients, etc.)

!
I
I

I
I

0
l8l

Women:

0

Adolescents:

181
D
0

f8l

Homeless:

18] Older Adults:

IZ!

Criminal Justice-Involved Adults:

181

0

Juvenile Justice-Involved Youth:

[81 Intravenous Drug Users:

181
0

Pregnant and PostPartum Women:

181

Children:

HIV/AIOS:
Hearing Impaired:
Visually Impaired:

Co-occurring:

Other:

Please describe other group: Alcoholics, Men, Relapsers,
EAP Clients, Impaired Professionals

Pregnant and Post Partum Adolescents:

23. Services provided: Please ch&ek all major services provided on a regular basis either directly by the program or upon referral.
Provided Directly by
Program

Provided by Written
Agreement or Referral

Not Applicable

Individual Counseling

1:81

D

0

Group Counseling

181

0

Family Counseling

181

0

0
D

Job Consulting and Placement

0

181

0

181

Education Services

D
D
0

181

Aftercare (Non-Structured)

l8l

General Health Care

[81

0
0
0

Legal Services

D

Social Services (Welfare, Housing, etc.)
Cultural/Recreational Programs

l8l
l8l

Other (Please Describe) Nutritional
Counseling

l8l

Program Services

Job Training

C&F-SA Form 4024

.
3· 4

0
0
0

0
0
181
0
0

D

0
August 24, 2012

 24. Do you charge client fees? If so,
please attach a copy of the fee schedule
and fee policy.

181

Yes

0

25. What is the maximum number of
clients that can be served in this
component on a given day?

26. What is your projected operatfng
budget for the component listed on this
application for the current year?l, 113,000

12

No

27. Please list the complete names of agencies or practitioners you have written referral agreements, contracts, or subcontracts with
and check the type of business relationship:

D

a. Insurance Companies
Other(Speclfy) Referrals

0

b Private Individuals
Referrals

0

c. HCAMS

d. EAP's

0

0

Agreement

0

Agreement

0

e. Recovery Institute (PHP, lOP)
I Other(Speclfy}
Referrals

0

0

0

0

Agreement

Agreement

0
0

Agreement

0

h.

0

Agreement

i.

0

j.

0

181

Other(Specify) Ref-errals

1:81 Other(Specify) Referrals

0

Contract

0

Agreem ent

0

Contract

~ Other{Spedfy)

Subcontract

Subcontract

0

181

Subcontract

Subcontract

Agreement

f. Christian Recovery Solutions (PHP,IOP,OP)
Subcontract
1ZJ Other(Specify) Referrals
g. Lighthouse
Referrals

0

Contract

0

Contract

0

Contract

Contract

0

Agreement

0

Agreemer.t

Subcontract
Contract

181

Subcontract

0

Other(Specify)

Subcontract

0

Other(Speclfy)

Contract

0
0

Subcontract

Other(Specify)

Contract

0

Subcontract

0
0

Contract

181

Other(Specify)

28. Please list the sources of revenue you receive by name and check the type of funds, e.g., state funds, federal funds, fees, e1c:

0
0

a. Insurance
b Private Pay
c. Other Facllltles
agreements generated for services rendered

State
State

D

D

0

State

Federal
Federal

0

d.

0

State

0

Federal

e.

0
0
0
0

State

Federal
Federal

State

0
0
0

State

0

Federal

f.
g.
h.

C&F...SA Form 4024

State

Federal

4-4

0
D

Federal

0
0
0
0
0

Fees
Fees

0

0

Private

~ Private

Fees

0

Fees

0

Private

Fees

0

Private

Fees

0

Private

Fees

0

Private

Fees

0

Private

I8l
0

Private

0
0
0
0
0

Other(Speclfy) Insurance
Ottler(Specify)

181

Other(Spedfy) Fee

Other(Speclfy)
Other(Specify)
Other(Specify)
Other(Specify)
Other(Specify)

August 24,2012

 t

29. Please further describe your program listed in item #1 on page 2. For counseling programs, this Information should incl ude
the number of counseling sessions provided weekly, the duration of each counseling session, and th e average length of
stay In the program.
Rer..overy Institute's Detox program is a 12 bed facility that serves both men and women, 18 years and older. Admission criteria to
this level of care is based on the American Society of AddicHon Medicine Patient Placement criteria.

l

The program operates seven days a week 24 hours per day. The Detox staff is composed of a multidisciplinary team of professionals •
that includes medical personnel, substance abuse afld mental health ~;ouns9lors, clinical management, administrative and support
1 staff. The overnight staff provides direct care and monitoring for medical needs and safety.
Each client is assigned a primary therapist that works with them to assess their needs for further treatment, develops an
individualized treatment plan and continues to review the client's progress on an on-going basis. The clients attend group sessions
daily for 4 hours per day and individual counseling sessions at least 2 times per week, focusing on their individual needs. Family
counseling is provided as needed. Meals and snacks are prepared in house following the guidelines of a State of Florida registered
and licensed nutritionist.
The average length Is stay in the Detox Program is 5- 10 days.

the Chief Executive Officer (Original signature only)

31. Date (Month, Day, Year)

1-11---IL{.../

C&F-SA Fonn 4024

4-4

August 24, 2012

 /. t

··-·-···--------·-----------·--··--...-------·--·-..--~---·

Tawn of Davie
Fir:& RescU. O.partmelrt
fit$ Prevention & Lffit Safety
U~f

Clnu111• DIWe
DIIYI!'o Pl.. ~l:U

0 .~ .

·.

gra~
Otbtr~
.·'

,...-...,... ·.

...

. G«t•··
NFP~

0

Servic:e E;)di.SJ..j<>

n

lntlaO Elclteq' .
9CIIIct EMil' . ;ey ~~

0

0
'Q

.
t.ag ~ .

0

FOC'Sijjn Requhd

Qhal~ .~
0 ~a-Reqond
o~Pot1l'- Fn~- .·o t=OO~
0 !Mia~~~ , ·~ E<diro1Jv1thu< 0 FDC Cell MIHiliQ

0
0
0

Ab!IIIS ~twll bu "

&!!S~D~M~
I!* t.ocked

d Mhts ·ReQuwod
D

0

Poll~·· ..oJ
~ Hoaw c ! 11011 Ato:Os
M'I'A101

.~ itP"Q IIlii '"
of lila reporl.
• rl:'!
Prtnl Nam J:sL

,..•

~'12

I.

E'l .s~ ·

0

. .

,.'...

..;,g ·ft~·.

,....,

Fn~&}Rim

0
0
.0

C!<I\U1 'HoocJa)'llllm
~~~ami:

•

lm~ofAll!1
.
.

.

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 ~

PoUcyNumber 2S9M06549
COMMON POLICY DE(fLARATIONS
Rftnewal of. 28980 0632 a

i

THE BURLINGTON INSURANCE COMPANY

-"

IFG

IU">
Home Office: Burlington, Nolth CeroUna
Adminl9tr.ltr..OffJCe:238 Inter nat I onal Road, l!lur I i ngt OR, t«; 27215 Claim sOffics: 238 ntemational Road, Burlington, NC 27215

Item 1. Name<llnsured and Mailing Address
:> ¢.;...-:·:<.:~";· Ir,..;t:..L'-~L~

L

~"'..;\:~

C J.~r

Co.U3e;
ll.iuk Placement Ser\'i~es, Inc.
2400 B. Commercial Blvd.

l 'J•

~:o. llox 1446
POJPPano Beaoh

:n.

3~061

Code:

suite 728
Tort Lauderdale,
33308
YL
0289

Surplus Lines Broker License No.:
Effective Date: 0 2/191 2 o14 Expiration Date:02119120l5
at 12:01 A.M., standard Time at your maiJing address shown above.
Item 3. In return fur ttle payment of the premium, and subject to all the terms of this polity, we agree with you to
provide the insurance as stated in this policy. This policy consists of the following coverage parts for Which a
preplium Is indicated. Where no premium is shown, there Is no coverage.
Coverage Part(s)
Premium

Item 2. Policy Period

commercial

$

Liability

~eneral

1,585.00

$

$
$

$
$

I
J

iiil

~

r
,,,I

Total Polley Premium or Deposit Premium

s

1,585.00

Total Other Charges

$

353 ~3 ()

$

1,938.3()

Otller Charges (if applicable)
Policy Fee
In.speot:ion i'ee
Surplus Lines Tax
St~in9 ot!ice Wee
Florida Hurr Cat rund

35.00
200 • oo
91.00

I Total Amount
Due•
.

3.6'1

23-66

0

s

• Premium is:
F:lat . Ji] Auditable
Policy Minimum Premium
In the event you cancel tttisJ'_olicy, we will retaln2 5\ Minimum :Earned ~remimn
tteru 4 . Forms and Endorsements applicable to this policy: See "lis1ing of FonT\3 and Endor&ementa" (IFG.J-0150)
Item fl. Form of Business.

Q lndtvldual
0 Limited Liability Company
0 Trust

0

0

Partnership

Joint Venture

1Kl

Other Organtzation,lncl ud!ng a Corporation
Corporation
Busine~ Description: CH~:~.ic, l!u.sin~ .. s Center I Rebeb Residence
Producinq_ Aqent : Frank Pettineo, 2430 Bast commercial Blvd.
Fqrt Lauderdale J'L 33308
<

lliESE DEClARATIONS TOGETHER WITH IHE COMMON POLICY CONDffiONS AND COVERAGE FORM(S) AND ANY
811DORS94ENi(S), COM PLE"fE THE ABOVE NUMBERS) POLICY.

SURPLUS LINES

INSURERS~"

POLICY RA TEB AND FORMS ARE NOT

APPROVED BY ANY FLORIDA REGULATORY AGENCY.
'TNs Insurance Is issued pursuant to the FloF1da Surplus Lines &aw.
Pll:t."SOJlS insured by surpfU9 lines camers do not have the proteatlon of
Che Flof"lda bls.urance ~uaranty Act to the extent of any right of rec·owry
~r 1he obtigaoon of an insolvent unlicensed insurer.
~

Countersigned:
Date:
-------------bsueOata: 02/2()/14
IFG-1-0101 0204

By:

INSURED

0

h.~-,.0

----------~~~~~-------------------------Authorized Representative
Page 1 of 1

RPS Ft. Lauderdale (RPSSC)

 ..

Policy Number 2 8 9ao o 655 o
COMMON POLICY DECLARATIONS

•

Renewal of: 2 8 980 o 63 21

THE BURLINGTON INSURANCE COMPANY

IFG Co~nies*

Admlnls!!"i!tMIOffll:e:2:S8 Inter nat I onol

Hom • Ofllce: Bwflngton, North Carouna
Road,, Bur I i ngt on, NC 27215 Claims Office: 2381ntemational Road, Burfonglon, NC 27215

Item 1. Named Insured and Mailing Address
cr

1·~.:to

.Jn ;.-:..;.::•:(::y

s

..

Co. Use:

Rist Placem~nt Serv.l.ces,· Inc.
2400 J. Co:mmArcia.l Blvd.
Suite 728
.Fort Lauderdlsle,

''U\~

1080 8E 3 rd Avenue
Lauderdale
i'L
33316
~ort

3330S

i'L

0289

Code:

SUrplus Lines Broker License No.:

Item 2. Policy Period

Effective Date: o 2/191 2 o 14 Expiration Date:02/19/2015
at 12:01 A.M., Standard Time at your mailing address shown above.
Item 3. rn return for the payment of the premium, and subjeot to aU the term5 of this policy, we agree with you to
provide the insu~nce as stated In this policy. This policy consists of the fo flowing coverage part5 for which a
premium Is lnd~ated, Where no premium is shown, there is no coverage.
Coverage Part(s)
Premium
Commercial

$

General Li4lbi1ity

1,585.00

$

$
$

$

$

Toter Policy Premium
OtherCilarges (f appllcahfe)
Policy l'ee
In~rpection li'e4'1
Surplu• Line~ Ta~
St~inq Office ~ee
Florida Hurr cat Fund

35.00
200. o~
91.00
3. 64
23.66

or Deposit Premium

$

1,5115.00

Total Other Charges

's

353.30

J: Total Alftount Due* .

l, 93 8. 3 0

.

$
• Premjum is: 0 Flat Ji] Audltable
Policy Minimum Premium
In the event you cancel this poHcy, we will retain2st Minl:wWil Earned Premium
Item 4. Forms and Endorsemef)ts applicable to tltis policy: See "listing ot Forms and Endorsements" (IFG-!-0150)

g

Individual
. U Partnership
0 Joint Venture
Limited liabirrty Company
I!] Other Organization, Including~ Corporation
CorporatiQn
Trust
Business Description: CliDic. Business Ceuter/Rehab Residence
Producinq Aqent : l'cank Pftttioeo 2430 E. CoJIIlllercial Blvd. Fort Lauderdale FL 33308
TiiESE DECLARATIONS TOOETHER WITH TilE COMMON POI..ICY CONDmONS AND COVERAGE FORM(S) ANO ANY
ENOORSEMENT(S), COM.PLETETHE N30VE NUMBERED POLICY.
Item~.

Form of Business.

0
0

SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT

APPROVED BY ANY FLORIDA REGULATORY AGENCY.
Thts Insurance Is Issued pursuant to fhe Flortda Surpl~s Lines raw_
Persons insured by sutpJu:s lines earners dO not have tile protl!!etton of
tne Florida Insurance Guaranty Act to Ule extent of any right of recovery
fol' the obligation of an insolvent unlicensed insurer.
Countersigned:
Date:
----------------------------Issue Olll.e:
D2/2 o /ld
IFG-1-0101 0204

)\
0~
By: ------~~~~-~~~----~~------------­
Authorized Representative

INSURED

Page 1 of 1

RPS Ft. Lauderdale (RPSSC)

 3.

(NO FLAT CANCEllATfON)

DECLARATIONS
A.ttaching to and forming part of

POLICY NUMBER: HAH14-0033

.Ai..UED H't:AL TH PROFESSIONAL AND GENERAL LIABILITY INSURANCE
This ln6UT811Ce Is effected wilh Certain UNDERWRITERS AT LLOYD'S OF LONDON (not incorporated).

THIS IS A ClAIMS--MADE PRO~SSIONAL AND GENERAL UABILrrY INSURANCE POLICY.

PLEASE READ CAREFUlLY.
Item 1

N~meclln,suled: ~COveiY

lnsijtut- of South FlortdafCflristlan Recovery SoJuUons
Mailing Address: 1080 SE Srd Avenue
Fort tauGiert*lle, A. 33316

.ftem 2 Polley Period:
fti ception: Janu~ry 10, 2014
Termination: January 10, 2015
both days at 12.01 a.m. local standard time atthe address shown in Item 1. above
~tmac:tiva

Date:

.

ta) f'ROFESSIONALl,.IAI;\IILITV: .Janu~ '10; 2014
(b} GENERAL UASlllfY:
Januaty 10, 2014
~ stltll apply ('nly·to ~ aairns ,-.,~ pyrsuant1o !tee. tenns and c:Ohcillals of th.e. Ppliey wl9in.g out otPIOOtaional ser.otces
deailied heraln lntf ped<nnei'J sub'lllque~~' to the date aballe, or an Aa:lde~ happening alter.

Uml fJI.I,.laiJiflf;v:
{ll) PROFE$10NAL UABLLITY: .$1,000,000 E~ Cl8,im
(b) GENERAL LIABILITY:
$1,000,000 Each Claim

$3,000,000
$3,000,000
Included

Aooregate -Includes Claims E:x~nses.

Included

Personal&. Advertising l njU'ry
Fil9 Legal UElbii{y

$50,000
$6,000

~regate

-Includes Claim:! Expenses.

Pro~uct Completeji O~ra~ons

Medica1 Payments

Dedudlble:

(a) PROFESSIONAL UABIUT'Y: ~ooq Each Claim- incfudes C::faJJTis E;perises.
.(.b) GENERAL LIASIUTY:
$'5,000 Each Claim - inC:h.lde5 Claims Scpenses.
Pnn*un; ~.71f3

The PNIT'-'in flllldtl respect mthe eflire Policy Periotl of lnsurwrce'Jllu$ taxes and fellS a.s apJflcable. which sflal b~: payable In U l at
!ncep(ion d'!hiS lnilur'lltuse n deSIQo~ In Item 2 of!tee Dedaraams

ttem7 Not~@ Of Clillth To:

M&nde.s & ~ount L~P
750·se-.enth Aven ~,~e.

NewYe>rk., NY 1.0019
Attn: James A McGuire
ja.mes..mog·ui~me('ld!:Mi.COil'l

P~al fiervic:es: Alcohol & Drug RehabllltatiotT Services

NOtice of Eladlon:
~ tlf Nalit·e of lnsuretl'W ~ncdliltioll, and ReCipient of Ndice
~ and pnlll"i..rm fa E,ne11ded Repating Period~:

ar lnsur.ed's ll'lrentiOn to pu rthasc EXtentled R~ll Pertad

Hurrbusure LL.C
!29 Seuentb $fre,et, Sulb ~3
Garden City, NY' 1153(1
Hem 10 s~ of Suit:

Mendes & MoYnt, LLP

750 se~th. Avenue
New Vorl<, NY 10019
~ss·ue data:

FebruaryS, 2014

Au~-·~·""""- 4 ~

Declaration offHuntersure LLC. Limited Binding Authority, Agreement No: 807o2BB014530d

It Is understood '8Jld agreed thai any reference In the attached Wording to "Policy" shall be deemecJ to read Certifit;811a.

HAH-Dec001

Page 1 of 1

 CITY OF FORT LAUDERDALE
FI~E

RESCUB DBPART!'.E.."IIT

FIRE PREVENTION BUREAU

www.tortlauderdale . gov
523 N.W. 2nd Str eet
Fort LauderCale, FL 33311- 9108
OFFICE: (954 I 828 - 637')
FAX: {954)928-5338
INSPECTION REPORT
INSPECTOR CONTACT INf.'OR.tt.AT!ON:
INSPECTION OJ\TE: OS/~2/2 0 14
~DDRESS:

TETREAULT 954 560-4086

' 1080 SE 3 AVE

OCCUPANT:CHRISTIAN

ZONE: 300

P.~COVERY

SOLUTIONS

ACCOUNT:

2 3053739

VIOLATION (S)

9000

TO WIT:

~o

fire violations found at this time.

CORRECTIVE: ACTION:

Approved for COiltinued use.

INSPECTION TYPE: ANJ1
INSPECTION RESULT {~·Passed, F•Failed,

C~Cancelled,

I •Inco~plete l :

NOTE: A RF. - INSPECTION WILL BE MADE:
NO VIOLATI ONS AT THlS TIM&
PROMPT ACT ION SHALL BE TAKEN TO CORRECT ABOVE INDICATBD VIOLATIONS.
IF CORRECTIONS ARB l~OT ~8 UI?ON RE-INSPECTION, AN ADDITIONAL
RE-.U!SPgC:l'ION FEE WJLI. BB CHARGED FOR EACH SUBSEQUENT I NS?3CTION.
PERMITS Mi\Y BB REQU.tREO TO CORRECT VIOLATIONS.
CJU\~GEO

FOR EACH su·J:3!1QUENT

SIGNATURB: NA

INSl'ECTION.

P

 CITY OF

FORT LAUDERDL-U,E

June 8, 2011

Dr. Barbara Gibson
Recovery Institute of South FL, Inc.
1080 SE 3nt Avenue, 1st Fir
Ft. Lauderdale, FL 333 I 6

RE:

1080 SE 3ni Avenue

Parcel ID~ 0215010260

Dear Dr. .Gibson:
We have reviewed our records with respect to the current zoning ofthe above referenced property
And can confirm that it is zoned ROC (Planned Residential Office District).

Please feel free to co.atact me at 954-828-5913 if you require additional ~stance in this regard.

Enclosures
TB/yb

•

DEPARTMENT OF PLANNJNG AND ZONING
700 N.W- 19TH AVEI'IUE. FORT lAUP£RDALE, FlORIDA 33311
BUJU>ING SERVICEs:C954l 82&-5t9f • . 'PLANNING a ZONING SERVICES:(954) ~1•20NING COUNTER:C954l SZ&-5203
E:I>U.U.. OPPOII"TUtUTY EMPI..On!ll

WWW.fOrti&Udenfale.gGV

Pmwn:D ON REC"FC&ZD P'AHJt

0

 _,

,.

__.-.,._&._. .,.OJW_.,

ew . ,
**' ..,..,. §I Af~ OF FLORIDA

......,.....r

i!ll!l!bt!}:

DEPARTMENT OF HEALTH
ANNUAL SANITATION CERTIFICATE
Group Care ~ Residential Treatment Facility (AHCA)

PIM
HEAllli
BrOiWaidtounly

Issued To: Recovery Institute
5540 SW 64 Avenue
Davie, FL 33314

Audit Control#:

06·810~2293534

.....":M~u:Q

19

South EH

florkla Dapar1men1 of Health -Sroward County
780 SW 24 Street
Fort Laudefda!e, Fl33315

(Non-Transferable) DISPlAY CERTIFICATE IN A CONSPICUOUS PLACE

STATE OF FLORIDA
DEPARTMENT OF HEALTH
ANNUAL FOOD SANITATION CERTIFICATE

South EH: (954) 467·4700 X 4211

Food Hygiene • Residential Treatment Facility (AHCA} ~ Full Service

iiiOIJmdCounty'

OG-51-Q0207

Licensed Capacity

1080 SE 3rd Avenue

HEAlTH

£

x

September 2014

Permit Number

Fort Lauderdale, FL 33316

AM

~,

Permit Expires o.o....»r-~

Mailed To: Recovery Institute of South Fla

Prgm: 51
ORIGINAL· CUSTOMER

.•

South EH: (954) 467-4700 4211

Audit Control#:
Issued To: Recovery Institute (Institute, Recovery)
5540 SW 64 Avenue
Davie, FL 33314

06-BJ0-2324169

September 2014

Permit Number

06-48..00211

Not Availalbe

Mailed To: Recovery Institute of South Fla
1080 SE 3rd Avenue

Fort Lauderdale, FL 33316

Progm: 48

South EH

ORIGINAL • CUSTOMER

(Non-Transferable) DISPLAY CERTIFICATE IN A CONSPICUOUS PLACE

Florida Department of Health • Broward County
780 SW 24.S!reet

Fort lauderdale, Fl33315

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CERTIFICATE

OF liABILITY

J9/17/2014

IlliTE~

~~~URANCE

THlS ceRllRCATE IS ISSUED AS A MATTeR OF INFORMATlON ONLY .A!C> COI-IFERS N9 RlGI1TS uPoN THE CERTIFICATE HOl.De~ Tl1lS
CER'TIPICATE DOE! NOT AfFIRMATIVELY OR NEGATIVELY Allll!HO, !XTENO OR ALTER THE COVERAGe AFfORDED a'l THE POUCJES·
SE\.OW. TI-llS CERTIACATE OF INSURANCE DOES NOT C'ON$mUTf! A CONTRACT 8GlWEEN THE ISSUING lNSURI!.R(S). AlllliORIZEO
FIEPRESSHTATIVE OR PR.OOU~ AND THI! CI!RTIFICATI!. J-l!ll~R.
,. :
IMPORTANT; II die unilcala lloldlr a. an A.DOmONAt. INSUR!:O, lne pglicy(lu$) mill& II* tMCira.cl 'If SUBR0<3ATTON IS WAJVS), &ulljtel to
tbe tern. and condllbns ollllo pollc;)', certb> p~OII m.y ~»ire en tndori1111111t. A slallin~ 0<1 #1111 certlllc:!._ cJo. not coofcr righls lo lilt
certlfleal• hcJjdQr tn 11ec of $UCh ondo.........-d(e~
~!"';
PROOI.JCeA

Pettineo I~urance Agency, I.na
2430 E. Co:amercial Blvd.
Ft. Lal.lo&J:tdale, FL 33308

~:JS:
IIISURERA:

Christian Recovery Solutions

l.liSli!ED

l~4-493-89§j!

-:.. ...... 954-~93-9424

--

·- ------

~-·'··
INSVREI\C :

1080'SE 3rd Avenue
Fort Laudardalu, FL 33316
954-960-7091

llloii!JI

~-I*IG--

'l'he Burl.ington Insu:cance Co.

INSIJFIER 0 :

INSUAER E.:
I~F:

CERTIFICATE NUMSER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE: POliCIES OF INSURANCE LlSTEO BElOW HAVE B€EN ISSIJa> TO THE 1t.!$URSO HAMED ABOVE FOI:t TilE ~ICY PI:RIOO
INDICATED. NOTWmfSTAM)IHG 1\HY REQtM£MI!H'r, TEIW OR CONOmON OF ANY COHTAAC'r OR <>mER DOCUMENT WITH f!ESPECT TO WHCH THIS
CERTIFICATE MAY B~ ISSUED OR W.Y PERTAIN', THE' I}ISUAAHCE Af'FQROEO BY THE POLICIES OESCRlOEO HI:REIN IS SIJBJECT ro Al.l 11:11: TERMS,
. EXE_~USIONSANO CONDIT~(»iS OF SUCH POLICIES.liMITS SHOWN ~MY tiA\11: D€EN REOVCF.O BY f'AI[)Cl,A!MS..

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2/19/2014 2/19/2016

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Cl!Seflll>'riON OF ~"'III.I!l-

OE5CRIPTION Of OI'ERA'OOr«S/I..OCI\TION81VSIIIClES fAit,ociiACORD 101,Aa"lio><ro!AIIm.U Scl*"'!l>, iltW>IeOj)-illrO<Illrall)

Property AddrG$e;
1080 SE 3rd Ave., Fort Lauderd3le, FL 33316
2901 SW 1?tll St., Fort Lauderdale, FL 33312
2915 sw 17th St., Fort Lauderdale, FL 33312

CANCt:LLATJON

CERTJFJCATE HOLDER

Proof of Insurance

SfiOIJll) AJ(Y OF THE IIOOVE DE3C!WED f'OUCIES llE CANCELlED Bf.I'ORE.
THE EXPIAATION l>.r\TE 111ERF.OF, NOl1CE WU OC Of.ilVI:RCD IN
ACCORDANCE Willi T'HE POUCY PRO\IISiotiS.

C 1988·2D10 ACORD CORPORATION. All righ1s ruerved .

AGOR025(20Hl/OO)

The ACORD name end logo are regiSle~ mai1CS of ACORO

 OAT£(100'11)!1/YYYY)

URANCE

CERTIFICATE OF LIABILtTY I

9/17/2014

n-IlS CERTIFICATE IS IS41UI:O AS A MATTER OF INFOAAIATION ONLY AND CONFERS N() RIGHTS UPON THE CF.RTIRCATE HOLOER. lNIS

CERTifiCAT£ DOE$ MOT AI'FIRMAT!III!J..Y OR r~EGATIVELY AMEMD, EXTEHO OR ALTER THE COVERAGE .AfFORDED BY THE POUCIES
lll!l.OW. THIS CER'l1FICATI! Of INSURANCE DOES NOT CONSTIT\Ilf A CC»>TRACi 8ETWEEJol THE LSSUING INSURER($), AUlHORIZ&J
R,El>FU:SENTAtM! OR PRODUCER, AND Tl!E Cl!ORTIFICAT£.
must bt tndor:.ecl. If
to
~my require an endon-ltll. A ~t 011 U\!5 ce~llute doN not confat ~hi$ to lllf

PIIOOUCM

Pettirteo I~urance Agency, Inc
2430 E. Comm&rcial Blvd .
Ft. Lauderdale, FL 33308

1080 SE 3rd Avenue
Fort La.uderdala, FL 33316
954-960- 7091
COVERAGES
' CERTIFICATE NWBER'
REVISION NUMl3ER:
THIS IS TO C£RllFY TK<\T THE POLICIES Of INSURI\NC£ Llr:>TEO BElOW HAVE 8£91 IS&IEO TO THE IN$lJRiiO NAMED AIIOvt FOR THE POUCY PEN)OO
tNOfCA-reo. N01WITHSTANOING ANY REQUIREMeNT. YERM OR CONDmON OF NN COtfl'RACT OR OTl'lER DOCUMENT Wlni RESPa;T TO WHfGH THIS
~Rl'iFICATf MAY AS. ISSI,IEO OR MAY PeATAIN, 'THE INSUAANCE AFFOROEO BY' T14E I'OUCJt:S O£SCRIBeO HEREIN IS $l.IBJECT TO /Ill 1Ht; TEI'IMS,
~UJSfOI.IIS ANO OOHOITIONS OF SUCft POUCU:S. UMITS SHOWN Mo\Y tiAVE SEEN ReDUCF-D BY PMJ CI.AIIAs.
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DESCRIP'nOf>l OF OPER/.1101191 lOCATIONS/ YEHIC\.6S ~ AC0R:U 101,- - SchodUb, lfnoore- ito rc¢ec0

Property Addraao:
1080 SB 3rd Ave. , Fort I4ouc:l$rdaJ.e, FL 33316
2901 SW 17th St. , Fort Lauderdale, n. 33312
2915 SW 17th St. , Fort Lauderdale, FL 33312

CANCELLATION

CERTIFICATE HOlDER

Proof of Insurance

SHOULD MY OF THE A/JOVE OESCmSeO I'OUCIES BE CAHCEUt:O BEFORE
l1iii EXPIMllON OJ,TE Tli£REOF, HO'TICE WLt DIZ O£lMni:O IN
ACCORDANCE WITH THe POUCY PROVISIONS.

@

ACOfW26(201Q/06}

1588·201 0 ACORD CORPOAATlON. .AI right& rese!Yed.

Tile ACORD r~amc and logo are T1!9istered maJ1ca of ACORD

..

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 Us;erld:

FOOD SERVICE

HanfsooTB

STATE OFA...ORJOA

l>EP:AATMEKr OF HEALTH .

Geocoded

P.URPo~E

I8J ~;.m

FILE COPY

COUNTY HEALTH DEPARTMENT
FOoD SERVICE
IMSPECTION REPORT

D

o·~STRi:cr. o

i<B)(&I.:Cnoli

~~Or-01~
cJ cni!VJ.it'f CJ OO!tS:lLTAlDt

~: ResidentiaH·~~entl"acllity{Aif~l

•

. 6·~ D. ~<iroe~
NAME
.4t)~S:S'

RE~lTS:·

Recovety institute
• 5:)40-SW:~.Av£\nu·e.

• :~ ,.;;;O;..;;av..;.;i:.;;.e_ _ _ _ _ __

t8l SatisfJ.do.sv
D Jncom~
D tinsattstadoly
0 OUT OFS.OsiNESS-

·""CdtltiBueil on Page..z-

· Pf:!.ONE:_(954) <f67-47G9.eX.

FA.Xt. (954) 4:67-4.204 ..

tM.TE: .;3.(412014

4219

I

 STATE OF FLORtDA

DEPARTMENT OF HEALTH

COUNTY PUBliC .HEALTH UNIT
FOO<f Estafmshment
Name~. Recovery Institute····

Date:

.:

Q310':4J2U14

Cc)mmeri11(~d . ln·m~~pns· (Conli~il~ fmrR Page- 1}:

f~ky. net ~.mar\<ed~·.~ d ~. Jfl;!~ >i4 hours F'Oodmusf!»~ ~in~ ~bG:ve lhetlo9r.

OH'"~oliS'

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P'age2

 --- --- --:.._ ·· -· -· --·- ··- BEVEO?Me..:!~ER-!.F~... . . -?J.f~~G & ZONiNG D!V!S!ON
~""'91 OR.-\NGE DRivE • DAVIE. FLORIDA 33314-3399

-~

.PHoNE: 954.i'97.1103. FAX:. 9S<!-'97.~ '! ~WW.OAVIE-fl..GOV

December 1~ 2009

·nr:aaibiia ·&ii&Oii
R«evay JaafjtdeofSomh Florida
. 1080 SH 3"" AlleDDe, I~ FJr
~ Ft. I.auderdMc;. P.L 333~6

BE:

5540 SlY tU Av. (DaYie Rd.)

folio# 0/3$--()2-039

Dear D. CJ<ibsoo:

P1ease allow this letter to ·serve ~ -verificatio.n of th~ zoning. and land U9e o£ thepropetty l~ at 554D SW 64 Ave.·· 'Ihe propertY. is ~ned Community Facility (CF).
The underlying~ ~is. Resi~/Oflice on the Western portiOn oi the lot, which
is the ·~. :o£ .the. pan=el;.·aru( the Futw:e Land Use is Special Classification
~ 2 D.~./acre on the ~ easteaw¢ portion Which is approximafely: the
e~.30feet of the p2ircel.

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Permitted i:.ses in the area include-'the follDwfng:
ron Code
land
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Nu!Slng Home

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Prisals, Jails, Oclcntlcn

N

Private Oubs

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Wafar, Wastewasr Treelmen!
P =Permitted by right in ~district.
N =:Not permitted .in this district.
•=Conditionally ~tted subject to detailed use regulations (section 12~34).
Permitted uses, specified under each zoning district, are intended to express the intent
and purpose of that distr:id:. All uses are subject to General RegulatiOns, section 12-33
and Detailed Use Regulations, section 12~34 of this Article.
..
(Ord. No. 91~33, 9-4-91;-0rcL No. 92-3, § 1, 1-:-2-92; Ord. No. 92-17, § 1,5-6-92; Ord. No.
92-26, § 1, 7-1-92; Ord. No. 96-4, § 3, 2-21-96; Orci No. 96-24, § 1, 6-.5-96; Ord. No. 96-36,
§ 1, g.:..21-96; Ord. No. 97-9, § 1, 1-22-97; Ord. No. 97-12, § 2,2-5-97; Ord. No. 97-71, § 1,
12-10-97; Ord. No. 98-33, § 1, 7-15-98; Ord. No. 2000-15, § 1, 5-17..00; Ord. No. 2000-29, §
4, 7-19..()0; Ord. No. 2002-()()6, § 1,.3-6-02; Ord. No. 2002-038, § 1, 12-4-02; Ord. No. 200310, §·1, 5-7-03; Ord. No. 200~38, § 1,·9-17-03i Ord. No. .2004-012, § 1,4-21-04)

source: htto://mmricodi.rom/resoyrces/gatel.wy.asp?oid=10630&sid=9

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The maximl.U-:n ni:.Ullber of additional residential facilities that can be built depends ~.pen
~e- ~pedal Reside,y,to/ Facility Cate0ory classification nurnber (see tf:-e Broward County
Future Land Use Plan -1989, upd~.ted 2005; Section .:W-B; B-1 (11))
~ttp: //www.brow~rd.org-/p.Lu-u""tine-council/1989 land use olan/bcluo /b!23permitte

duses.odf

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·an:cl'~I5aVie Future Land Use·(F.ttl.) de..J')Sity req-uirement of 5D,.U./acre (TOD §1134 (W)) in the curreltt RIO F.L.U. classification.
=_

Expansion or a ~ge in the use of the p~erty would require ~ submittal to the
OCcupational Licensing Division re£lecting thls. Please contact Sandy 'Saikley, ~er
of Qccupational Licensing at (954). 797-1 VB.

&sidert.tilll cm-e focilities (/or mental health seruices} is how the Town Code of Ordinances
classifies residential live-in programs for drug or alcohol treatments (§12-503). Please
cohsult §12-34 (Z) for information on Specil11 Residential Facilities. A eopy is includeti !or
your c:onveniertce (below):
Town of Davie Code of Ordinances, chapter 12, Land ~elopment CDde; Article ill,
Division~ (Detailed Use Regulati~ns)

§12-34
-

.

(Zj Special Residentitzl Facilities:
(I) : All nursing, convalescent and rest fadHti.es} or residential or life , care
faciliti.e.s, are subject to density limitations of the Town of Davie Comprehensive
Plan:
(2) No residential care or life care fac:ili.ty shall be located closer than twenty-five
hundred (2,500) feet from any other ~ establishment, measured from ·the
nearest point of one establ.ishment to the nearest point of the other establishment
in a straight line. The applicant shall furnish a certified survey from a land
:mrveyar registered in the S~te of Florida, i.11.dicating the distance between the
proposed establishment and any other si.milar establishment.
(3) No residential care facility shall be designed to accommodate more than
thirty~five (35} full-fune residents, unless otherwise specified (see deiinitions},
exclusive of staff accommodal:ions.
(4) No nursing, convalescent, or rest facility shall be designed to a~mrnodate
more than forty (40) full-time residents, exclusive of staff accommo~~(S) No sponsored housing facility or life care facility shall exceed a maxiquun of
one hundred (lOO) dwelling or residential units or a density of ten (10) dwelling
or residential units per acre, whichever is less, and a ma.x.imum parcel size of ten
(10) gross acres.

(6) The maximum parcel size for a residential care facility, exoept a life care
facility, shall be two and erie-hill {2 1/2) gross acres in all districts except ·the

PCF District, notwithstaru:ling ariy other requirements of this Code.

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· ~ ·· - · -· - · · -· ·

Upon receipt of a.Tt originallct'"u:a from the State of Florida Departme..'1t of Childrei1. &
Families, District 10 Office, written by Van Jones, Substu"tee Ab~ UcensingSpecial.ist,
to ~p Bacher(s) (~~)~ .Pn. November 11, 2006, the letter says that mey- will-aHow 19
_h.~ "up.onreceipt..otaU--r.equired-doat:men.tati~ mandated--by-qrapter 6SD:30·rtC>nda
Administrative Code." :This number of beds is below the pe..rmitted density for the site
;~ determined by staH ~ the Town Attorney'S: Office of 14 bedrooms (2 resid~ p~­
J~.droom:.time.s. 14--.h-edr-Qems-~~·- -teSi-de:nts) a-crording ·to--the ·T--own ·ot DaVfe
P>mprehensive Plan-Ftiture Land Use Plan. The proposed 19 reSidentS is well-below
i;he niax:i:mum permitted\~ty on the site.
\
SI}.ould you have any q~ons or need additidnal information, pieasJ feel free to
contact me at 954-797-1008. Office hours are 8:30AM to 5 P.M Monday-Friday.

Sincerely,

·

·

f~1So-~
Philip &c::hen;
!llanner I -

P.ZC

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...

 TOWN OF DAVfE
BUSINESS TAX REC~IPT

First-Class Mail

PRSRT
US Postage

6591 S\\ ",u. St
Davie, FL 33314

PDS .

Name and Location of Business Tax Receipt

RECOVERY INSTITUTE OF SOUTH F
5540 SW 64 AVE
Davie, FL 33314

License Type:

ACLF (Group Homes)

Licensed For & Quantity;

ACLF Group Homes

1

License #:

30800

Phone#:

2672780743

Effective Date:

10/1/2013

Expiration Date:

9/3012014

·~~~~roo
RECOVERY INSTITUTE OF SOUTH FLORIDA
RECOVERY INSTITUTE OF SO. FLORIDA INC
PO BOX 290430

Restrictions:

,

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I

,.
•

DAVIE Fl, 33329

 r;;::===========·,.-. ' COMMO N POLICY DECLARATIONS :::--·-==========::=;"1

Jl SCOTTSDALE INSURANCE CO~ANY<>

Renewal of
CPS1707973

Home Office:
One Nationwide Plaza • Columbus, Ohio 43215
Administrative Office:
8877 North Gainey Center Drive • Scottsdale, Arizona 85258

Po lley Number

CPS1906018

1-800-423-7675
A STOCK COMPANY
---------------ITEM 1. Named Insured and Mailing Ad dress
1lAVtE RF.COVF:R y CENTER' L •,c ·
1080 S.W. 3RD AVE. 2ND FLOOR
FORT LAUDERDALE
FL
33 31.4
I

Agent Name and Address
RISK PLAC~M£NT SERVICES, INC .

THIS INSURANCE IS ISSUED
PURSUANT TO THE FLORIDA SURPLUS
LINES LAW. PERSONS INSURED BY
THE SURPLUS LINES CARRIERS DO
NOT HAVE THE PROTECTION OF THE
FLORIDA GUARANTY ACT TO THE
EXTENT OF ANY RJGtfT OF RECOVERY
FOR THE OBLIGATION OF AN
INSOlVENT UNLICENSED INSURER.

2400 E. COMMERCIAL BLVD.

f728
AgentNo.:
09004
Program No.:
Al
33308
To: 12/2.9/2014
Term; 365 DAYS
From: 12/2 9 I 2 o13
12:01 AM., Standard Time at them aiin g address shoWn in ITEM 1.

FORT LAUDERDALE, FL
ITEM 2. Policy Period

Business Description:

ME·DICAL OFFIC:ES/HEALTH CARE FACI LI'I''l'

ln return for the payment of the premium , and subject to all the terms of t his policy, we agree with you to provide the
insurance as st~ted in this policy, This policy consists of the following coverage parts for wnich a premium is ind icated .
Where no prel"('lium is !?hown, there is no coverage. This premjum may· be subject to adjustment.
Premium s ummary

Coverage Part(s}
Commercial General Liability Coverage Part

$

6 274

Commercial Property Coverage Part

s

1 9i4

Comrnercial Crime And Fidelity Coverage Part

$.

NQT COVERED

Commercial Inland Marine Coverage Part

$

NOT

COVERED

Commercial Auto Coverage Part

$

NOT

COVERED

Professional Liability Goverage Part

s

~~res Agent :

NO'f COVERED
$ __________________

$ __________________

..

JiJneS'Q'Nflii,·J> #Ai96572 2400 E.Olrrmert:ie! BlVd.
Ste#728, f'ort r.at.ideroole,Kmaa

Total Policy Premium: $ ____---'9"-'-"l..,.ll..::.B..:..·.::...D.::...D_ _
POLICY FEE $ __________3~5~.0~0~---

IKSPECTION FEE $ ________~1~0~0~·~00~---

sti\Plt1Sl.HS .

SU~PLUS

ltSIJRfRS' Pctid'

Riffis'AIIl roRMS

L:NES TAX $ __________4~1~6~-~1~5~---

STAMPING OFFICE FEE $ __________.1..::.6~·.::...6~5_ __ _

BVANYflORIOA
ARUIOT APPROVED

FLORID~

RfGUlATORV AXillCY.

HURRICANE CAT FUND $ ________~1~0~8~·~20~---

EMPA : $4 . 00 + CITIZENS : $83.23

$----------~8~7~.2~3~--­

Policy Total: $
Form(s) and Endorsement(s) made a

;:>~rt

B 951.23

of this policy at time of issue:

SEE SCHEDULE OF FORMS AND ENDORSEMENTS

A000706B: PETTINEO INSURANCE AGENCY, INC.
0
1 - - .... ······"'
FRANK PETTINEO 2430 E. COMMERCIAL ELVD.
FT . LAUDERDALE, FL 33308
JQONE ILL I JS 12/30/2 013
THIS COMMON POLICY DECLARA110N A ND THE SUPPLEMENTAL DEClARATION(S), TOGETHER WITH
THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AN D ENDORSEMENTS, IF ANY,
COM PLETE THE ABOVE N UMBERED POLICY.

OPS-D-1 (8-10)

INSURED

opsdl j . tap

RPS Ft. Lauderdale (RPSSC)

 ..
Policy Number

289S006S49

CO MMON POLIC Y DECLARATIONS
Renewal of: 28 9BOO 632 o

IFG Componie~

THE BURLINGTON INSURANCE COMPANY

Home Office: Burlington, North Carofina
Administrative Office: 238 I nt &r nat i anal Road, Bur II ngt on, riC 2n15 Claims Office. 238lnternational Road , Burlington, NC 27215

Item 1. Named Insured and

Mailin~

Address

Co. Use:

Recovery Institute of South Florida

IP.o.

Bo.x 1446

"'oropano Beach
•L
33061

Code:

Ri:;k Placement Service s,
2400 E. Comrnercla l Blvd.
Suite 726
Fort Lauderdale,
FL
33308
0289

Inc.

Surplus Lines Broker License No.:
Item 2. Policy Period

Effective Date: 02/19/2 014 Expiration Date:02/19/2 015
at 12:01 A.M .• Standard Time at your mailing address shown above.
Item 3. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to
provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a
premium is indicated. Where no premium is shown, there is no coverage.
Coverage Part(s)
Premium
$

commercial General Liability

1,585.00

s
$
$

$
$

Total Policy Premium or Deposit Premium

$

1,!'185 .00

Total Other Charges

$

353.30

200 · o~ J Total Amount Due*
91.00
3.64
23 .66

$

1,.938.30

Other Charges (if applicable)
Policy l!ee
Inspection Fee
Suz:plu.s Lines Tax
Stamping O(fice Fee
Floz:ida Hurr Cat Fund

35.00

• Premium is: 0 Flat !il Auditable
Policy Minimum Premium
$
In the event you cancel this policy, we will retainz 5% Minimum Earned Premi urn
Item 4. Forms and Endorsements applicable to this policy: See "Listing of Forms and Endorsements" (IFG-1-0150)
Item 5. Form of Business.

0
0
0

Individual
Limited Liability Company
Trust

0
00

Partnership
D Joint Venture
Other Organization, includ ing a Corporation

Co ::po ration

Business Description: Clinic, Busin ess Center I Rehab Res idence
Producinq Aqent : Frank Pctlineo, 2430

Eas~

commercial Blvd.

Fort Lauderdal e ,

FL 33308

THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE FORM(S} AND ANY
ENDORSEM ENT(S), COM PLETETH E ABOVE NUMBERED POLICY.

SURPLUS LINES INSURERSt POUCY RATES AND FORMS ARE NO·T
APPROVED BY ANY FLORIDA REGULATORY AGENCY~
ThJs Insurance Is fssued pursuant to the Ffonda Surplus Lines law.
Persons insurec by surpllJs nnes ·earners do not halre th·e protection ·of
the Florida lnsurance Guaranty Act to the extent of any right of re~overy
for the obligation of an insolvent unlicensed insurer.
Countersigned:

"

By:
-----------------------------Date:Dale:
Issue
02/20/14
IFG -1.0101 0204

INSURED

0

)._.... ..<:_ J. I

--------~~~~~----~~----~-------------­
Authorized Representative
Page · of 1

RPS Ft. Lauderdale (RPSSC)

 \!~0

I

FLAT CANCELlATION}

DECLARATIONS
POLICY NUMBER: HAH14-0033

Attaching to and forming part of

ALLIED HEALTH PROFESSIONAL AND GENERAL LIABILITY INSURANCE
This Insurance is effected wit]l Certain UNDERWRITERS AT LLOYD'S OF LONDON (not incorporated).
THIS IS A CLAIMS~MADE PRO.FESSIONAL AND GENERAL LIABILITY INSURANCE POLICY.
.
PLEASE READ CAREFULLY.
Item 1 Named Ln.sured: Recovery Institute of South Florida/Christian Recc;>very Solutions
Mailing A-ddress: 1080 SE 3rd Avenue
Fo·rt Lauderdale, FL 33316

ttem 2 Policy Period:
l.nception: .January-10, 2014
Termin?.tion: January 10. 2015both days at 1'2.01 a.m. local standard time at the a'ddress shown in lfeml above

Item 3 t{etroaetlve ·oate:
(a) PROFESSIONAL LIABIUTY:
(b) GENERAL UABlLITY:

J~uary10, 20121
Janu~ry 10, ~014

Coverage. shaJI.ttpply oofy to thO$!! Claims report.ed pursuant to thetetm:s and conditions of the. Pdfcy arlsihg out,¢ Prof~ss19!1aJ Services
deso1tied ber.ein and .performed subsequent to the dille aboye, or an Accident· happening after:

ltam 4 llmit of Liability:
(a) PROFESSIONAL LIABI U"JY:, S1",0.00,000 Each Claim
{b) GENERAL UABILITY:
$1 ,000,000 Each ClaJm

$3,000,000
$3,000;DOO
lncJude.d

Included
$50,00U
$5,000

Item 5 D'eductible :
(a) PROFESSIQNAL LIABILITY:

.(bj GENERAL LIABILITY:
Item 6 Premium: $2Z,713

Aggregate - Includes Claims Expanses.
Aggregate -lnel.udes Claims Expenses.
Pi'qduc.t ComP.l~t~q Ope.~tioris
P~rsonal & .Actverti~lng 1njury
Fire--Leg~l

Liab.flitv'

Medical Payments

$5,000. Each Claim - fnci!J.d~s .Claims 13\penses:
$5,000 Each Claim- includes Claims.Expenses.

.

.

The prerriilim paid-in respect of the entire POlicy P.enod of tnsu~ nee plus tax:es lilld fees as.uppfi"cable, whiCh shall be payable In fUll at
l.nceptioo ofthi!t Insurance as designated in Item. 2·ofl!le DeJ:h;u<iticils

Item 7 N·otJce·otclaifu To:

Mendes·&

~ount,

1.,1.-P

750 sev:~n~~- Avenue.
.NawYo~ t'l'f 1'0019
Attn: James A Mc"Guire
jamas..rncguirEi.@men.~ ,com

Item 8 Profes$.iQnal Se.rvlce$~ Alcohol.& Drug RE!ha:Qjiitatiqh SeNices

lte:m 9 Notice.of Election:
R.eelplent of Notlc'e of Insured~ Cahcelli!rl1on, and Re~piehttlf Notice of lhsured'slntehtibn to.purcl\"ase ExtEfltled Reporting Period
COIIef'l!ge· anp premium roretended ~~poltihg Period C-QVerag·e.:

H.unteJsure L.LC

229 Sevanth Str~t. Suite 303
Garden City, NY 11530"

ltem 10 Service of Suit:

Mendes & Mo1:1n~ LLP

75d Seventh Avenue
New York, NY l0019
Issue da:te: F~bruary 9, 2014

U{:
Authorised Signatory:

I

.u"" /,.__

L·_,.--.. ·-~.

Declaration off Huntersure LLC. Limited Binding Authority, Agreement No: B0702BB014530d
It is understood and agreed that any reference In the attached wording to " P91icy''·shall be dee.med to read q·ertifl c-ate.

HAH-Dec001

Page · of 1

 Policy i

·ber: 8 7 0 2 9 3 50 9 0 2 013

Federated
National

FLOOD POLICY DECLARA'riONS

lnsn.rance

Federated National Insurance COmpany

COMPANY

050101

Type: Renewal
Policy Period:
Form: General

01/12/2013

For payment status, call: (888) 245·7274
These ~eclarations are effective

04/12/2014

as of: 04/12/20 13 a t 12:01 AM

Producer Name and Mailing Address:

Insured Name and Mailing Address:

DAVIE RECOVERY CENTER LLC
5540 SW 64Ta AVE
DAVIE, FL 33314·6006

PE'rTINEO INSURANCE AGENCY DIC

2430 E COMMERCIAL BLVD
PORT LAUDEROALE, FL 33308·4040

Agent/Agency#: 07600 · 00826- ooo
Reference#:
Phone#: (9541493·9424

Processed by:

Insured Property Address:

Coverage Limitations May APply, Refer .to Your
Flood I nsurance Policy for Details.

S540

Flood Insurance Processinq Center

P.O. Box 2057

sw 64TB AVE

DAVIE, .FL 33314· 6006

Kalispell MT 59903 · 2057

Building Description:
Premium Payor: Insured
Rated ~one: AHB
Current Zone:
Community Number: 12 0035 0304 F
Community Name: PAVIE, TOWN OF
Grandfathered:

Non-Residential
Two Floors

Pr e·Pirm Construction

Replacement Cost:
Number of Units:

Slab On Grade

Program Type: Regular
~e

Coverage

i'.uld.rng
Oontonts·

500,000

Dedu~

Ra.tes
.::!30 I

.080

Discount

1,000

Sub Total
663.00

$500,000
1

Prem.ium Cakula.tion

PMmtum Subintal

663.00

lcC P.ram-Jum

tr.anl:ents

4. 00

em.~ Diseo\!<nt
F'sd~al

L!lle<Wton..

Poltcy Fee:

.

100.00
40.00

ProbalJon SUl'eb~·
&daree.me.nt Amount .

T«>tal .Rtemium Paid:
First Mortgage:

.00

.oo
607.00

Third Mortgage:

FIRSTBANK PUBR~ RI CO
dba PIRSTB.ANK l!LORIDA ISAOA
9795 SO. D!XlE HIGHWAY
Miami, FL 33156
Loan #: 4 8 1 655412

Second Mortgage:

Fourth Mortgage:

·This Declaration Page, in conjunction with the policy, constitutes your Flood Insurance Policy.
In WITNESS WHEREOF, we have signed this policy below and hereby enter into this Insurance Agreement.

ytep-CfV'---.. ~~~
President
870293509 OJ013

03/13/2013

Federated National IneQrance

Secretary
Co~y

rNIDSCJ.C'l'_lR OX'P_000006155549

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115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895-954-831-4000
VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30,2014

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321-3 644
Rece .lpt #·'CLINICS/HOSPITALS
Business Type: !CLINICS/HOSPITALS)

DBA:
Business Name· RECOVERY INSTITUTE OF SOUTH
. FLORIDA

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Owner Name: IU:COVERY INST I TUTE OF SOUTH FLORIDA Business Opened:I0/17 /2006
Business Location: 1080 SE 3 AVE
State/County/Cert/Reg:
FT LAUDERDALE
Exemption Code:
Business Phone:

...
Rooms

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Machine~

'IEmploy&e.&.
.:B
.

Seats

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Professionals

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For Vending Business Only

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Vending Type:

Number of Machines:

Tax Amount

Transfer Fee

81.00

0. o.o...:

Prior Years

NSF Fee
0 •..00 ....

• .

8 10

·..

. 0.0'()

Collection Cost

Total Paid

0.00

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89.10

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THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT
WHEN VAliDATED

This tax is levied for the privHege of doing business within Broward County and is
non-regulatory In nature. You must meet all County and/or Municipality planning
and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location. This receipt does not indicate that the business Is legal or that
it is in compliance with State or local laws and regulations.

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Mailing Address:
Receipt #02B-13-00000486
Paid 10/15/2013 89.10

RECOVERY INSTITUTE OF SOUTH FLORI D.
1080 SE 3 AVE
PORT LAUDERDALE, FL
33315

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2013 - 2014

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:¥''::".:

:nY OF

FORT LAUDERDALE

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June 8. 2011

Dr. Barbara Gibson
Recovery Institute of South FL, Inc.
1080 SE 3ro Avenue. 1st Fir
Ft. Lauderdale. FL 33316

RE:

1080 SE3ni Avenue
Parcel ID: 0215010260

Dear Dr..Gibson:

We have·reviewed our records with respect to the current zoning ofthe above referenced property
And can confirm that it is zoned J{OC (Planned .Residential Office District).
Please feel free to contact me at 954-828-5913 ifyou require additional ~istance in this regard.

· Enclosures
TB/yb

II

DE:PARTMENT OF PLANNING AND ZONING
700 K.W. t9TH AVENUE. FORT l.AU~£RDAU, Fl.OIUOA 333f l
UUJtolNG SERVICSS:C9'54) 82&-St91•. PLANNING &: ZONlNG SE1MCES:(954) ns-sost •ZONir.G COUHTER:C954l 828-5203

£0\JJ\1.. OH'OtmJHITY EMPI.~

WWW.fOrtfaUcferdafe.goV

PRINTED ON

~ I"Af'Elt

v

 RECOVERy INSTITUTE OF SOUTH FLORIDA INC.
OPERATING ACCOUNT

3309
07/09/2014
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'thousand five hundred forty-three and 75/100**"--"*****"*••••.....--_.....,..,...,....,.................................._ •........,

--------------------------------------------------------------- ~~~
I
s
Department of Children & FamiJles

License renewal

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----------------------------------~

 RECOVERY INSTITUTE Of SOUTH FLORIDA

per 6Sd-30

detox

$375.00

rtc

$350.00

day/night w/ community housing

$300.00

10p

$300.00

outpatient

$300.00

total amount due

less: 5% discount

$1,625.00
($81.25)

$1,543.75

 <JRisF

~ ~ ~aWYWt"-''1"'

Reeovery JDJtitute of South Florida
Table of Organization

MHC'a
1\.npisl
Peer Sappo!T

Toch

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BHAI!aistant

SUpmiJot

llc:aidence
Semcca
SUpervilar

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y op 11111Nol0r

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HI 7."£w...e.-. 9'Jh. . &r.I..AI"INfth, ~IN.tJ8-4U.9
(61o} 17U!JU9f. (Gio} MJ.-6171·

September5, 2014
~fB of Aorids
.
Department of Children and FamifJeS

Substance Abuae and Mental Hf)fllth P.rogram Office
Southeast Region and Circuit 17
201 W. Broward Blvd., Suite 511

Fort Laud8J"dafe, Fl33301

,.

Re: Recovery Institute of South Florida. Inc.
Jam the accountant for the Recovery Institute of South Florida. Inc. oUr professJonal
relationship began in 2008.
The corporation has been profitable and experienced e)dreme financial viability. The
~rporation has 1he history and ablltty to continue to achieve I1B operating objectives and

fulfill ita mission over the long term.
If any additional inforr:nation is required, please do not hesitate to COI)1act me directly.

Sincerely,

-~~~I

c,..-c_

MargaretJ. Capone
Certtfied Public Aocounlant

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September 18, 2014
State of Florida
Department of Children and Families
Substance Abuse and Mental Health Program Office
Southeast Region and Circuit 17
201 W. Broward Blvd., Suite 511
Fort Lauderdale, FL 33301
Re: Christian Recovery Solutions, Inc.
I am the accountant forChristian Recovery Solutions, Inc. Our professional relationship
in2008.

~an

Th~ corporation

has experienced financial viability. The corporation has the history and
ability to continue to achieve Its operating objectives and fulfill its mission over 1he long
term.
If any additional infortnation is required, please do not hesitate to contact me directly.

Sincerely,

~~~~ ~~
Margaret J. Capone
Certified Public Accountant

 ~

FLO,.JDA DEPARTMEN .

~,~ OF CHILDREN AND FA\IliLIES
~-

Rick Scott
Gov&mor
David E. Wilkins
Secretwy

MYFLFAMIUES.COM

RESULTS VALID AS OF: 01130.12014

Letter issued: January 31.2014

RECOVERY INSmtrrE OF SOUTII FLORIDA

P.O. BOX 290430
DAVIE, FL 33329

Dear Director:

RE: MACKLER, JONATHON
D.O.B. 08/31/1961 - SSN: XXX-XX-4488

THIS DOCUMENTS THE FINAL RESULTS ~lF A CRIMINAL HISTORY RECORDS CHECK Rr.CEIVED
BY THE DEPARTMENT, REQUIRED BY FLORIDA STATUTE FOR THE BELOW SfATI:D PROGRAM.
IF THERE IS A FLORIDA PUBLIC RECORD, IT WILL BE A1TACHED.

PROGRAM AREA: 01· SAMII Propams
The Department ofCbt1dren and Families received the complete criminal history records fur the above named
appliamt. Noddagwas foaJld In tbe Departmcat'1 nview tnt disqaaJifies tile iDdiviclul from serving in the
program or pro&ssion for whidl. this screening was requested and is~ by law. In some simaticos. as
specified in the Jaw controlling your program, results may be used for other positions.

••e•••••••••••••.. •••••••••..••••••••••••••I&IP()JlT~•••••••••••..••.. ••••••••• ..••••••..•...••••••..
I'I..FASE BE ADVJSED THAT LOCAL LAW .INJ'ORCEMENT CHECKS WERE NOT INCLUDED IN 'l1IE
DETERMINATION I PROCESS.

........................................................................................................
Once this determination is received, the submitting employer has tbe final decision regarding employment

selec:tionlhiring.
Criminal history records information received by 1he Department foe the purpose of adoption will be provided in
compliance with appropriate state and :federal laws.

This saeening runains valid for five years providing the applicant does not have a 90 day break in service and is
in compliance with re-screening rcquiremeDls and updates as required by the regulatory authority oftbe program.
However, the~ is no longer valid if'there is an arrest for a disqualifying offense after the "Results Date"
found above.

Sberek:a Korokous
Screening Coordinator

1317 Winewood Blvd., Bldg 2. Room 306, Tallahassee, FL 32399

Mission: Protect the Vulnerable, Promote Strong and Econom.icaDy Self..Sufficient Families, and
Advance Personal aod Faoilly hcovery sod Resilieocy

 Broward Shcrlrrs Office Records Division
2601 West B•·oward Boulevard
Fort Lauderdale, FL 33312
(954) 831-8700

Date:

March 7, 2014

Subject:

JON MACKLER

w

Race:

M

Sex:

DOB:

08-31-61

Based on the above information, a check of the Broward Sheriff's Office Records was completed.
The records of this agency reflect the following:
NO ARREST RECORD

[8]

ARREST RECORD ATTACHED:

0

a

To obtain statewide background check, contact the Florida Department of Law Enforcement at:
Internet:
http://www.fdle.state.fl.us/criminalhistory or
FDLE - User Services Bureau/Public Records
P.O. Box 1489
Tallahassee, FL 32302
Phone: (850) 41 0-81 09
To obtain Clerk of the Court records on dispositions and court information, please contact the Clerk
of Court directly at one of the following locations:
Internet: http://www.clerk-17th-flcourts.org/bccoc2/pubsearch/public_search.asp
Central Courthouse- 201 S.E. 6th Street, Fort Lauderdale, FL 33301
North SateJiite Courthouse - 1600 . illsboro Blvd., Deerfield Beach, FL 33442
South Satellite Courthouse- 355 Holl ood Blvd., Hollywood, FL 33021
West Satellite Courthouse- 10
. p· e Isl d Road, Plantation, FL 33317
CHECK COMPLETED BY:
"Check not valid without signature and CCN.

CCN:

5294

 AFFIDAVIT OF GOOD MORAL CHAkACTER
State of Florida

Countyof

Before me this day personally appeared

aor-J l

fv1Ac.4:t~

(Appllcant"s/Employee' s

~
who, being duly

t!::.:nt:~

sworn, deposes and says:

I have not been arrested with disposition pending or found guiHy of, regardless of adjudication, or entered a
plea of nolo contender or guilty to or have been adjudicated delinquent and the record has not been sealed or
e>epunged for, any offense prohibited under any of the following provisions of the Florida Statutes or under any

similar statute of another jurisdiction for any of the offenses listed below:
Section 393.135
Section 394.4593
Section 415.1 11
Section 741.28
Section 762.04
Section 782.rn
Section 782.071
Section 782.09
Chapter784
Section 784.011
Section 784.03
Section 7ff7.01
Section 787.02
Section 787.025
Section 787.04(2}
Section 787.04(3}

Section 790.1 15(1)
Section 790.115(2) (b)
Section 794.011
Fonner Section 794.041
Section 794.05
Chapter796
Section 798.02

Chaptar800
Section 806.01

Section 81 0.02
Section 610.14
Section 810.145
Chapter812
Section 817.563
Section 825.102
Section 825. 1025
Section 825.103
Section 826.04

Section 827.03
Section 827.04
Fonner section 827.05
Section 827.071
Section 843.01

Relating to:
sexual misconduct with certain developmentally disabled dlents and reporting of such sexual miscondUct
sexual misconduct with certain menfal health patients and reporting of such sexual misconduct
adult abuse, negled. or exploitaHofl of aged persons or disabled awlts OJ failt.J'8 to report of such abuse
criminal ofi:nses that constHute domestic violence, whether committed fn Florida or another jurisdiction
mumer
·
manslaugtter. aggravated manstaughter of an elderly persoo or msabled adult. or aggravated manslaughter
of a child
vehicular homicide
killing an unbOm qtic;f( dlUd by inJI6Y to the mother
assault, batt.e:y, and culpable negligence, lf1he offense was a felony
assault, if the victim of offense was a minor
battely, ifthe victim of offense was a minor
kidnapping
false imprisonment
ltring or enticing a child
taking, enticing, or remoVing a child beyond 1he state linits with criminal intent penclng custody proceeding
canylng a dlfld beyond the state lines with crlminallntent t.o avoid prodUcing a child at a cusiDdy heat1ng or
deliVering the child to the designated pe~Wll
extllbiting firearms or weapons within 1,000 feet of a school
posseaing an elecbic weapon or device. desaructiYe device, or other weapon on school property
sexual' batlery
prohibited acts of persons in familial or custodial authority
un~ sexual activity with certain minors

prostitution
lewd and lascivious behavior
lewdness ~d indecent exposure
arson
bwglary
voyeLITism, if the offense is a felony
video voyeurism. if the offense is a felony
theft andl'or robbefy and related ctfmes, it a felony offense
traudaent sale of controlled sub&tances, if ltle offense was a felony
abuse, aggravated abuse, or neglect ofan elderty person or dfsabled adult
lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult
~oo of disabled adLdts or elderly persons, if the offense was a felony
incest
child abuse. aggravated child abuse, or neglect of a Child
conbibuli!g to the delinquency or. dependency of a child
negligent treatment of chldren
sexual pertonnance by a child
resisting arrest with Violence

CONTINUED ON NEXT PAGE
CF 11148, Aug ~01 0 (Obaoletas '"''lllouc e<IIUons wllic:l't may not be used)

Page 1 of 3

 Section 643.025

depriving a law enforcement, correctional, or correctional probatloi. .iicer means of protection or

Section 843.12
Section 843.13

aiding in an escape
aiding in the escape of juvenile inmates in correctional institution
obscene literature
encouraging or recruiting another to join a criminal gang
drug abuse prevention and control only if the offense was a felony or If any other person involved in the
offense was a minor
sexual misconduct with certain forensic dients and reporting of such ·sexual conduct
inflicfjng cruel or Inhuman treatment on an inmate resulting In great bodily harm

Ghapter647

Section 874.05(1)
Chapter893
Section 916.1075
section 944.35(3)
Section~AO

Section 944.46
Sectiorl 944.47
Section 985.701
Section 985.711

communication

·

escape
harboring, concealing, or aiding an escaped prisoner
introduction of contraband into a correctional facility
sexual misconduct in juvenile justice programs
cootraband introduced into detention facilities

THE FOLLOWING APPLIES ONLY TO THOSE APPLICANTS FOR MENTAL HEALTH POSITIONS

In addition to the Chapter 435, F.S., listed offenses, the following offenses are also applicable for ·Mental
Health Persooner screened pursuant to section 394.4572, F.S., defined as program directors, professional
clinicians, staff members, or volunteers working in a public or private mental health program or facility who
have direct contact With individuals held for examination or admitted for mental healttl treatment. The
additional offenses apply only to "Mental Health Personnel., as detennined pursuant to Section
408.809, F.S. as listed below:
Relating to:
Chapter.408
Section 408.8065{3)

Section 409.920
Section 409.9201
Section 817.034
Section 817.234
Section 817.505
Section 817.568
Section 617.60
Section 817.61
Section 831.01
Section 631.02
Section 831.07
Section 831.09
Section 831.30
Section 831.31

felony offenses oontain&d in Chapter 408
offers service or skiDed service wl1ttout valid fioense when licensure ls required, or kn<Mingly files a false or
misleading license or license renewal appticatlon, a submits false or miSleading ilformation related to
application
Medicaid provider fraud
Medicaid fraud
fraudulent acts through mail, wire, radio, etec:tromagnetic, ph.otoeJectroruc. or photooptlcal systems
fa.lse and fraudulent insurance daims
patient brokering
criminal use of personal iden1ification lnfonnalion
obtaining a credit card through fraudulent means
fraudulent use of credit cards, Ifthe offense was a felony
fofgeiy
uttering forged Instruments
forglllJ bani( biis, checlcs, drafts or promissoJY notes
uttsring forged bank bills, checks. drafts, or promissory notes
fraud In obtaining medicinal drugs
the sale, manufacture, delivery, or possession wfth the Intent to sell, manufacture, deliVer anyCOU1terfeit
controUed substanoe, If the offense was a felony.

I also affirm that I have not been designated as a sexual predator pursuant to s. 775.21; a career offender
pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless the requirement to register as a
sexual offender has been removed pursuant to s. 943.04354.
·
I understand that I must acknowledge the existence of any appHcable aiminal record relating to the above lists
of offenses induding those under any similar statute of ~nother jurisdiction, resardless of whether or not those
rec rds have been sea
or
. Further, I understand that, while employed .or volunteering at
·.
~ tw-1
In any position that requires background

screening a
condition of employment, I must immedjately notify my supervisor/employer of any arrest and
any changes m my criminal record invoMng any of the above listed provisions of Florida Statutes or similar
statutes of another jurtsdiction whether a misdemeanor or felony. This notice must be made within one
business day of such arrest or charge. Failure to do so could be grounds for termination.

CONTINUED ON NEXT PAGE
CF 16-4Q, Aug 201 o (ObiiOiates premuoo eclilionol wftic:ft mar not be usee!)

Page 2 of3

 I

true and correct that my
record does not contain any of the above listad offenses. I understand. under penalty of pe~ury, all
employees in such positions of trust or responsibility shall attest to meeting the requirements for qualifying for
employment and agreeing to inform the emploYer immediately if arrested for any of the disqualifying offenses.
I also understand that it is my responsibility to obtain clarification on anything contained in this affidavit which I
do not understand prior to signing. I am aware that any omissions, falsifications, misstatements or
misrepresentations may disqualify me from employment consideration and, if I am hired, may be grounds for
1 attest that I have read the above (.;Clrefully and state that my attestation hert..

termination or denial

.i

pti n at a later date.

SIGNATURE OF AFFI

Above OR Below, DO NOT Sign Both lines
To the best of my knowledge and belief, my record contains one or more of the applicable disqualifying
acts or offenses fisted above. I have placed a check mark by the offense(s) contained in my record. · (If
you have previously been granted an exemption for this disqualifying offense, please attach a copy of the letter
granting such exemption.) (Please circle the number which correspond~ to the offense(s) contained in your

___

record.)

....,...

SIGNATURE OF AFFIANT:_ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __

to and subscribed before me

this_::}_ day of U,Y//

j

.

. J!f-·

~

20

IDA

(Print, Type, or

Public)

(Ch~one)

,? Affiant personally known to notary
OR

0

Affiant produced identification
Type of identification produced:._ _ _ _ _ _ _ _ _ _ __

CF 1c;..c11, Aug 2010 (O~oletes previous odltions

""''ell may

riOt be """d)

Page 3 of 3

 JON L MACKLE~ FACh-'"J
H 732.617.8866 I

4 Quebec Woods Court

Manalapan, New JetSey 07726

c 732.239.3746

E: jonmack:let@optooline..net

of\

. . ,. M...

t~ JJ7'\ j\j)JNJif
years of diverse management ~e in~ ~etitive arid complex
EXECUTIVE SUMMARY

J

I

Hcalthc.are Executive with twenty
eilvironments. Decisive, energetiC, .resu.l~ oriented leader with an outsrnnding record of business development, revenue
generation and expense reduction through innovative programs. Consistent record of achievement in all aspects of day-

t<><hy~;~~'~"Jfcilitytw=o=d~.

\~ -~.)<>"~~~~PROFESS!ONALEXPERIBI>!CE

,,,Mn,u.- , M- . ~A »·
p \~~i~Jw

ADVANCED ORTHOPEDICS & SPORTS MEDICINE-_FREEHOlD, NEWJE;RSEY
Chit:fn--.·
· Oilicer
·
...,~-ttng
.
.
AOSMI.js a ~;Dulti-specialty practice with 25 providers, Slocations, $55M revenue. ·
• BuSiness de;ve!-opment; Ci:eated 4 sei:vice lines, ·a dded 9 providers and 3 satellite offices, that .resulted' in $2M net

profit, in neady two ye:us.

.

.

.· ·.

.

• .Humao reso.ur;ces: Des.igned/im.plemented Hiring fot: Excellent Prognun tnat in~uded ttain~g xn.an.agers on
.intervieWing skills and p.rcigressive disdp:l.ine, .instituted Employee Engagement Sw:Vcy and Action Plans. Reduced
t:u.tnovet to 3%.

·

.

.
..
• Quality: Des:igned/implemented . Qoauty. C<mncil that inclUded Scot:ecttds, Patient· SatisfaCtion Truti2cive and
improved :indicatots /process. throUghout organiZation. ·
· ·. ·
·.
.
.
·
·
. • Financial: Created Cost CentErs and Budgei:s for departmeO~· satellites
anc:i1l.a..t:y services.

and

INN?YATIONALLEADE~HIPf 'INC.- MANALAPAN, ~J:gRsEY .
P.resident/CEO

8Lu"'Y\

(!!0 •

·.

·

2009..;; PRESENT
.

.

Innovational I=detship, ~ is 2 hcal~e management and coo_sultillg fian focaaed. 011 assisting bospiWs. pbysitian·pnctices, :and Other
:hcalthCllie. o~tiO?S- Innovational Leade.tShip. provides 2SSeSS!D~Ili of
opca.ti.ons md fuiancial pcrfoanance, S)'Stem redc:oigll; md
program design/implementation: AdditiQoal savices io.clude st:mtegic/ b~siness planniog, iD.terim ~t and billi!lg/collecting ~ for ·
physicWl pmctice&..
.
.
.
. .. .

bosmess

• ProVided comprehensive assessment of a mnlti-site cardiology pncti~ that n:suJt.ed in redesigning woi.kflows,
improved accountability, est:abli.sh.itlg enh.an'ced revenue/ expense cost st:tuctu:te and enhanced billing/c:Oliectiqris.
• Purrued and engaged to ewlua.te feasibility of 25 .orthopedic sW:geons, ·creating a ·Group Modd. Developed and
compietcd- a comprehensiVe Pmct:i.c~ Assessment Tool, Business· Plan; ..Marketing P.b.o, and.Fmandal ?.rofottna.S. ·
;. Eng2ged by multi-site; 35 physicia.Os, Urology Group.
.
.
·
.
• Established office operations for a Batiatric Surgeon with two weeks' notice - icko.tified
secui:ed space,
D:egotiated lease; recruited and ttairicd office staff, established administrative and clinical opera,tions of physician
p.I:2Ctice. ~n~t ~o functioned as f/t Pnctice Aamini.s~or · duriog multi-~onth recrllit:t:D.ent process.
Surgeon annualized. sritgicalases of 350 and 5,000 offi,cc Visits.
.
.
.
• Assiste~ Vasculac SU:rgery, Urology and Dental p:rit~ces with operational assessmentS and improvemenn; to
Olalhting, business development, human .reso~es, volume .and practice opera~ons.
·
• Provided Interim CEO role to a Long Te:an Acute oire flospital · . .
• Pw:sued to lead Business D~elopment functions that resulted m highest volume/financial perl'o.tmance in hospital's
history. CEO resigned shortly thereafter and Corporate President aSked to ~ ~~· ~ ~. _/)
.

and

.·

U·7'Je¥~

SELEcr MED~CAL CORPO~TION- MECHANICSBURG, PENNSYLV~lf:::;:
Corporate lntet:t.m Chid..Execuf!Ve DJlicer . .
·
.
~--

=

2007-2009
·
.

Select .M.ecliC2l Cotp~on (SMC) is a $2.1B for-profit org:mizatioD that c:nc:ompasses 89 lqog
aOlle cue hospitals, 5 medical rdi2hhtioo
hospil:al.s and 985 outpatient centets ·in 37 states. RcpQrting to the President/SMC, .t:eSpOI1Siblc for ail aspects of heispital opcr:2tioo foe 2.5Signed
hospiml(s) - operations, clini.oal services, medical slllff lcla.tioas, piogram development, new business development, human :raourccs and opCr..ting
budgds. Served 10 different hospitals (ooe ~~being .ccspoo.sible for 3 hospibls). .LTACHs save ctit:ially ill patients.
• Improved tat:gets for quality, Enab.cial perfo.anatlce, employee ~ent, p2tient satis&ction and

census.

• Con:ected 100% o f deficiencies for two hospitals tha.t were on a CMS Decertification Ttack.

 JONLMACKLER,FACHE
H: 732.617.8866 I C: 732239.374{)

Page 2

• Assigned .responsibility to open first acute medical .rehabilitation hospitaL Collaborated with design/ construction
tean:i. recruited staff and physicians, implemented policies and programs. secw:ed clinical and non-clinical contr:acts
and prepared for licenslire surveys.
·
·
• Recognized by Division Presidents to quickly assess defici~cies in hospitals, compose and implement conective
actions while obtaining results.
• Created and proposed a Patie.t:tt Satisfaction ~~e for the Corporation.
• Created and proposed a ~tehensive scorecard to objeccivdy meas~ keys areas of hospital operations -Human

Reso=,Seroice, Quality, Growdund F=cial P~ .

~YHEALni

SYSTEMJlice President/Operations
:

·

. :-\'

J) ~. . )~.tJ:cf,

VOORHEES,NEWJERS~ ~~Nf)~J.-1.-\.~(?.
. .

b~s,

·

fl/

\'

2006-2007
.

ce.n~ ~~~for

Kennedy Health Sys10n .is a health system that eocompasses 3 hospi.t:ala, 600 Jicc1=.d
130 SNF
and ·14<11ellite
2
hospit:als '\Vith ·opetQtWg certifioite of 400 beds, ADC.- 250, ED visits - 65,000, Admiss.ioQ.S - J.9.500. . System teSJX>O.Slbil.ities inclodod Serv:ice
· Excdlence Initi:a.tivc:, T.abo.a.to.ty, ·Pathology, <Audiac Cath Lab, BehaviOral Health .Ser:via:s that includes .60 inpatient beds, Health Information
M:in2gemenr, Barlat:ck Sur:gety Progom. ;E'nrironinenllll Setvices (EVS), 1~rommucicatioo, ?J.ao.t Opo::atiollS and~ T~n and
· &mrity. .Ovea:ight for Contxacted Setvitts - Physical ~ :md Reb3biiitatioo, LiDeo, and Food/Notrilioo.· .Responsible for. 635 · FI'Es,.
:
·
·
·
·
.
·
·
·
.
Opeming BUdget: $51M and Capibl Budget- $4M.

• DeSigned and led a. system-wide Emergency.Department Throughput Initiative. that :resulted .jn a vokuni ~~e of
."1:2«'/o;·~educti~ of 000/1) in Bypass and DivertS, LOS - 30%, .LeftWrthcmt Treatment·- 34%. E:.i:catt LOS ..: 16%;H61ds
- 4:2«'/o•. Initiative n:Sulted in in6:emen~ rcvepue of $6M and Patient Satisfaction n the 9Qtb perc.enc¥.
· · ..
• Implemmted.w iopatieilt ~ Witiative that iesclred hl a 6% io~e in.~~. .
.
• Supported an $8M .faality ren<>W.tion an.d modcioiza~ p~ ~ ~ ho~pitals· .and auxiliaty buildings..
• Iniplementcd cost reductions·ptOg:tams that .tesnlted in $1.6M savings: ·· · · · ·
o .Converted EVS to.Sdf-Op at all faC:ili.ties that reSulted in ~c~t' hospitai Q~~ an~ savingS of $470K .
··.Requested by Presid~t/CEO to design and lead a system-wide Serna: Excelleric~ Ioitia~e, that ~tc;d in a 10
·point improvement fo,r, Inpatient Serv:ices~ patient sa:tisnacti.on scores;
.·
. · ·.. .
· . · · ..
· ·.
• In~ed wdiac catheteri2ation vohlme k; excee.d DP.fl :teqaU:enients and avoiding loss ofl.ab D~tion.
• Managed an.d~part!D.~ts .wi._thln budge~ wpjle expanding S~eS.in Laboratory.l;\C:havio.tal Health ~d Therapy.

KESSLER INSTITUTE FORRE.HABruTATION-: WEST OR..Al'/GE, NEWJERSEY

2002:_2006

Vice President Basiiless Developn:u:nt and ChidMuketing 0Ric~(2/2004 ~ 8/'JiXJ6)
Kessl.e:r Institute fQI: B.ehllbilrtation ·(KIR) is a:fur-profit Division of Select Medioil. Col:pow:iari that encOmpasses 4 aam: medical rehaholjNrion
hosp.itals with 322 l>eds. KJ1.l. has been .I1Dkcd 2Dd.best ~ hospillll in the' United Stm:s br US N11Dii etJJd W"6rld Rlport, far mote thM a decade.
~to the Pn:siclcot/K(R, m;poiosib1e for msinagemmt ofS:Ym:m'; business developmen~·tnarket stmregy, client .rdations and mado:ring.

• hltte2sed two ID2jot service .lipe's ~in 2005 "?S:W04; Stroke services- 18%, Brain fujuty: ~ 12%, Orthopedics5o/o; p~ormance .tesu.lted .in..$8M ofinctc:Ole!i.tal ~ue.
.
·
• Increasedcomplia:nce by 11% in one year, to the CMS 75% Rule, that .resulted in avoiding 60_FIE layoffs.
• Increased Matketing Dmsion's Employee Engagement Score frOm 3~8 to 4.3 (25 fold statistically significant increase):'
• Directed ~ting relations activities
devdoi>meot of.refeo:al netwo.tk among hospitals in NY/NJ /PA..
• Negotiated a $65Kreductioo. in p.roductiop and display ?fa~ coJ:D.J:D.etcial, ~played in T'.unes Sqtiru:e, NY.
• Promoted by Preside.o.t/KiR to function as Kessler's o~y dual-tole Vu:e President
• Implemented a multi-level CEU Ptognun that resulted iO m~re than 100 extemal preseotatio~ per year.
• G.rew marketing staff from 12 to 23 professiooa!S.

and

Vice President A.dministrarion
East Orange Hospital/~ .&st. ~ NewJeisey(1/2IJ02 - 9/2005)
Reporting to P.ccside.at/KIR, function liS CEO for a ·78 bed acute medical tchabiliwioa bo3pital, providing .tieot =d outpatient semce.:
(0/1!). Responsible for 300+ FfEs, $48M revenue and a $23M expense budget.

 JON L. MACKLER, FACHE
H: 732617.8866 I C: 732.239.3746
I

Page 3

• Financial pe.tfo.anaoce: 2004 - exceeded net profit budget by 1.3M In 2005 - exceeded budget tevenue ta.tgets by

$4.7M and $1.1M less than expense budget.
• Gallup Employee Engagement: 2004 - secured a 93% comp~etion rate (highest .in organization), 2005 - secured a
94% completion rate w.d attained highest engagenient scores ·a nd ~ea~t imp.rov~en.t in KJR (3.7 to 4.3).
• Reci:uited, mentored and developed high perfo.tm.ance leadership Team. - 7 key positions placed
• Sq>port Services - executed .system imp:tovements .that resul~ed in a statistically significant increase Jn patient
satisfaction scores and $85K savings.
• Nursing- supported.stabilization of positions in departrilent. Engaged stuff in customer service that resulted in the
highest Press Ganey score .in 3 years. Reduced bonus shifts .in 2002/2003 that resulted in:a $250K savings.
• . Provided 0/P Services to Adult Day Healthca.re CenteJ:S ~t :resulted in $220K of increme.nt:al rev~tie·in fust year.
~ At :request ofP.resi.deat/KIR, cbelopedand implemented system-wide Customer Service Ioitiative that reSulted in
a statistically significant increases to KIR and East On.nge HospimJ?s patient satis&.ction scotts, in first yeat. .·
• Increased patient sai:isfaciion at Bast Orange Hospital .from system· l~west to 2ftd place in fitst year. Io.~eased
employee ~eat from 3<d place to 1st pla.ce, incr_easing by 3 poims in 1st ye.:U. .
• Opened Gift Shop from.{) to 7 days/week that ~ed m ·$9<JK .in.qement:al re'venue .in ~t y~· ~f operation..
• Community..involveri:l.e.nt - City cleanup day,. food and coat drives,__disaster drills and health fiW:S.

a

N ORTHSHOREUNIVERSITY H OSPITAL-MANHA.SSET,NEWYOR.K

Aclzni!Jist:t::ativc DireaO.r, North Shore.Ciirdiovast:viai.~d·_Thqn:dc·s~· P.C

1999-2001
. .

NSUH is a 751 bed tr.rtWy &cility ~ the~ &cility within the ·15 hospital. Nodh Shore '- Long ~ Jewilb Health System.. .
Responsible for e»:tdiac ftt'ld thoracic SWgt::ry divisions and private practice. Divisi.oos perfoon 2,000 umual cas~ pei: year with.. sUperior clinical
.results ";'ld rmnue io ac:.e.sS ·of$20M.
··· ·
·
· ·
·

New program ·development - .composed bus~s plans, secured . funding. and implemented a Suxgical Robotia
Prognm and Tra.asmyocatdial Revascularization Pro~ . Negotiated conttac_t:S that resulted in a $350K savings
and $275K cost avoidance.
• Generated $180K ofincremental reveaue as l:i2 Q.S. sites to participate in m. FDA Surgical Robotic Clinical Trial.
• Managed private practice des:ign .p roject that .resulted in reduced expenses of $200K ·
.
...
.
o

A.LHALI..A. NEW YORK

WEsTCHESTER MEDICAL CENTER -V
Admlriistrator, Wed-end
.

.

WMC is aiCgiooalacadem3c·tatiary ceo.t'crwilh 530beds, 400 SNF beds

• Fooction as

agent fQr President/CEO ofWMC

• Responsible for all hospital operatio.ns - 6 Centers

.

· 1994.:... 2002

·

and a 109 bed cbilcfm:t's hospital.
.

of Excellence,
Ptess Relations and llisk Management.
. ..
.

ST. BAR.NABA.s HOSPITAL- BRONX, NEW YORK

1998--1999

.ABsistfJ.Ilt Vice PreSident
..
.
..
.
.
St Barnabas is an acu~ care bospi.tll with 450 lied&, 200 SNF beds and a managed care ~tio.o. :Responsible forVarious depatt:ll1l:Ot.6 and
6pCci2l projects.
.
.
.
• Eliminated $270Kexpease by tedes.igning Transpormtio.o. Sei:v:i.cc, that resulted in cnb.an'ced servic;e..~.
• Avoided ~.$325K expense 1D the Nursing Home by aeruting a·business plan and r~ttuCtlttttig service for the Adult

Day Healthcare Prograai.

·

·

e Assigned -with the.planning of a 40,000 sq. ft. ~toty care facility.
• Acquired and instituted a Mobile M.ammogr.aphy Unit Progtiun. .
TRANSCARE NEWYORK, INC.- LONG ISLAND CITY, NEW YORK
RegionalDirector
.

1997-1998
.

.cans= is the th.it:d 12rgest mediad tc~nsport:arion prov:ider in the U.S. .Responsible for a Division of 80 vehicles, 175 FIEs and a $1M operating

T

budget.

• · Reduced AIR by 150% in six months that resulted in $1.2M of additional cash flow.

 JON L. MACKLER, FACHE'
H: 732.617.8866 I C: 732239..3746

Page 4

• Increased .ambulance and ambulette volume by 10% that resulted in $550K of incremental revenue.
• Reduced $875Kio. opeutin_g expenses and $230K in vendor expenses.
• Improved DOT semi-annual passing inspection rate from 58% to 95%, exceeding New Yotk State standards.
e Neg6t:iated and C<)Ottacted with a managed care o.rganization covering 375,000 lives.
• Redcced ambulance and ambulette accident rate by 60%.

WINTHROP UNIVERSITY HOSPITAL-MINEOLA, NEW YORK

1995-19.97

.A.dmini.str.aive Director Tborscic, Csrdi:zc and- Vszscolar SargeryDivisio..tJS
Wnttbrop is a U.oivet:sity Hosp.i:t:al with 591 beds. .Respoosible for 3 maj01: surg1ca1 divisions, pc:rfaaning 2,500 a.oowll cases pe.r y~ ru~d 70 FfEs•
.Wodred directly with C~2irmao, other Division staff 110.d CEO. Managed opet:ating budgets .in e:xcas of$7M ao.d c:tpiralliudgets of $500K.

• Assisted in the recruitmmt of a cardiotbo.racic surgeori who iocteas.ed volume by 37%, in:cluded acquirillg $1M of
.capil21 equipment, buil.diOg a third open heart..room and recruiting slllff·in 23 d:a:ys.
• Assisted and supported 30% TCV Surgety ~ .resulringW. $12M of inczemenbli revenue..
• N~ Prop devdopmeot Implemented Arti.ficial Heart De:vices:Progcam - 3ni non ttanspla.nt cetiterin U.S., 1"
in New York St:l.te;_Cardiac Assist Devices; Minimally Invasive Cardiac Suigcry and a NUtse Pract:!tioner Serric~ • Instituted and managed a.nnuat $215K mru:keting and advertising catn.paign. .
o Managed p.dvatc p.taetice i:clocation project (negot:iat:il)g lease and io·i:.er.facingw/builder, architect·and designer).
• De.v~ global" ronttacts for open hem: ~-err
• Esf2.Qiished an outpatient Wound Care Center.

an

.

· ··

CATHOLIC MEDICAL CENTER--QuEENs, NEW YORK

··

.

.

1992-1~5

CMC is a4 h~ sjsu:a1 (Mary Tmf!W711ate, 5-t.Jo~h'~ StJohn~ alldSt. Matys). 3-SNFs and.ahame are~cy.

Maty.lmtmlculate.HospitiJ,]:rr.nai~ New York :

.

Ma!y Tmmaculate has 260 beds, Level I Tauma Center, malliple Amhul2roxy'Cate Cenb:i:s liOd. a Can.cec Center. ·

~t~D~ctoz:(199<J.--1995) :
. . . .. . .
.
Jkspottsibiliti indudod the Emi:tgency DepnrtD'Ient, Ambalaocc (2m .1argeo>t #911 Setvica in.NYq, -TOUlspOl"i.mion, Ambulatory Care Centers- 4,
Community Pbys:ici:lo Network, Program. for the Disabled. Priaiitty :c~. Gmnt· Inirilltives. Soci:ll Ser:viccs, Utilizati.on Review (UR), D.iscbarge
Plarmiog (DP) mdHealth~ ~ · ·
: ·
· · .. . · ·

Reduced .tticompkte and deliitquent medical.r~ by 44% ~d ~edoce~ Acrounts Receivable by..$23M . .
Developed pediatric serv.i-ce for foster care that .i:~d in $110K of iocrem~tal..rev~ue fo:r the·op D~t
-Restroctnred DR 1f?-d DP D.Cpartments that :resulted io implX?ved _systems and FI'B expense reduced $145K
Conceptualized, designed and impiemented a Physician Recruitment Service w.ith.aistiDg resqurces that reSulted in ~35
inqemental admissions and Jl.lM of increm~llll. .revenue in fusf6 months ~?f operation. .
.
• .Submitted and·received.$375K.ingrant funding. · .

•
:. ·•
.•
•

A.ssist:znt to the Executive I>.irec_tor (1993 -1994)

bf

.

. .

..

Rcsponstbli: for Soc:W Services, Utiliz3ti00 Review and ~ Plall!ling Depattme.ot:l._: ·
• Developed ~d implemented a PecW.ttlc: Spec:ial Care.Uoit and HIV UWt

.

• Coordination of CQI, Operational R.es.b:uc~ MIS Initiatives.and. othe:t projects assigned by Executive Director.

C~len.·on. ~f Institutional P.olicy Review Documen
· t of ACG~ f~ CMC's 6"Re5ide.oq7 P.rog:ca~~s
. .
Catholic Medicsl Ce.D~ ofBrooklyn .and Queens, Ivc.,JJl.llJsuca, New Yo.z:k
() .11 ~ ·
'
•

Adm.inist;ra.tivr Residcnt(1992 -1993) ·

. · .

f'JtSt Administ:ra.tive ~cntrecmited fromNewYock Univemty. Responsibilitil:s .included~ projects.

~~

.

·

• Conceived, designed and implemented a Discb..a.rge, Planning Process that %educed LOS by 1.7 days at ::M2l:y.
Immaculate Hospital; resulting in $4M of additional revenue and elimjnated the need for an Emetgcncy Department
Holding Area (11 beds).
• Requested by President/CEO to implement Discharge Planning P~ at ·cMC's hospitab.

 JONL.MACKLER,FACHL
H: 732617.8866/ C: 732.239.3746

Page S

• Proposed and completed an Ambulance T.wispo:i:tatioo Analysis that resulted in an expense reduction of$625K
• Completed an MRI Feasibility Analysis an·d developed a Certificate of Need submission.
.

MONTGOMERY HOSPTI'AL- NORRISTOWN, PENNSYLVANIA
Paramedic Supe.rvisor/Trainiog ODicer.

1983-1990

Montgomery H~'PilaHs a 240 bed hospital Responsible for 35 employees and supervised field operations.
" Conceived, proposed ·aa9. tt:npidn.ented an Invasive pto"cedure tt:airung ~culum for Montgomery County, _
Pennsylvania Pa.tamedics (250)- Chest Decompression and Needle Cricothyrotomy.
• Designed and unplemented a Quility Assurmce P.rogram and ~
EMS Training Program·.

an

EDUCATION

Master ofPublic HC3lth AdministratiO.f!, Program in Health P.olicy tUJ.d Mao.sgt:wCL!t, tj92
NewX"ork UnivetS:ity, Robert F. Wagner Gtachttte SchpoJ o:fPt:iblic Service- New York, New York
·
·
Bachelor ofSderiee; Heil./thEducation, 19~9
Temple University. College of{.Jeath Prof~s.ions ~P~adelphia, P.ennsylv-anla .

AWARDS
• Cbaimlan's Awatd,.Scl.ect .Medical Corporation, Employee Engagement, 2005. .
o Chairman's AWa.td, Sdect MediCal Corporation, Outsun:ding'Perfo~a of theY~
, • D~opment Achievement Awatd, The ~can Heart .Ass~on, NY/NJ/CT Region, for _recogoitiqn of
volunteer service and fund .raising. of$250K for Annual Gili, 2001.
.
.
• Highest Award fot A~evement. the Dale Camegie ~tioo, Loog Is4D.d -Nevi otkRegi~ 1997.

20M. ··

Y

• Pai.-amedic,.Commoowealth ofPeonSy~ 1983- Present
-

.
.

.

.

·PROFESSIONAL
. AFFILIATIONS/MEMBERSHIPS
.
• Etren.zik, Director .~£ Medical Consulting Services, 2010·- 2011. '
• OrthoOne, ~ Consultant. 2009 - 2010.. ·
• Crohn~s and Colitis Foundation of .America, Bomi ofTrustees, 2007- 2009: ·
• Mettqp<)liWl Healt;hcate Administratoa' ,Association, Board of Trustees_. ·2001 - 2002.
• Adjunct Fa.culty, St. John's UniverSity, College of Profes.sional Studies; Prop in Health Seroc~ Adininlstra:tion,
•'Fmanci21 Adttrinl.stration of Healthcire Insritut:ions". 2001 - ·2002. · ·
·
·
• American Heart 'Assodaticin, NY and NJ Regions,·BOard of Trustees and various Committees, 1998 - 2002.
o;o Dale Carnegie Intematioo4 tP,e Dale Camegie Co~e, Gtachute Leader and Instructor Candidate, 1997 ~ .200i .
• · Adj~ct F2culty, New Yo~ University, Adult~ Program. "Healthcare Fka.ncial Man.agcmeor', 2000.
• Administrative and Einaocial C~ulta11.t to Th~ocardiosystems, In~, Boston, 1'999: .

• Amet:iCari. Coil~ ofHealthi::are Exectitives, FelloW.
• Marlboro First Aid Squad, Member.

 Rick Scott

State of Florida

Department of Children and Families

December 17. 2013

Govemor
Esther Jacobo
/nt8r1m Secretal)f

Michael P. Carron
Regional Managmg
Director

Recovery Institute of South Florida
Attn: Administrator/Director

P.O. Box 290430
Davie, Florida 33329
RE: Terrence Brian Livorsi

Result valid as of: 12/12/2013
Dear AdminiStratorfD!rectar:
The Dopartment of Children and Families {DCF) previously.granted Terrence Brian Llvorsl,
a OCF exemption from dlsqualificatfon on September 22, 2008,for a disquanfylng offens'i). The
previous DCF exemption is being continued for the ~!lTent screening det&l'rt'llnation by the
Department. No subsequent disqualifying offenses were ider.-tifled on the results that our offJCe
received and determined.
Pjease be advised that vou are stilt reguired to determine efigtblfiU' based on the Logf
Law 1'$Std1s tf1at vour facility diresrtly I'QCeives; !he local law backgtound chocks pre not
Included in our determination process.
A standard clearance letter will not be issued since a disqualifying offense exists.
Pursuan~ to Florida Statute Chapter 435.07(5). "Exemptions granted by one agency shall·be
considered by scb$equent agencies, but are not binding on the subsequent agency"

The granting of an exemption does not imply a recommendation for, or against. licensure or
employment. It only establishes minimal eligibility for consideration. The final decision
regardlng licensure or employment rests with the reg;.»atory/agency authori!y and the employer
after they consider all available Information and the established standards of that agency or

employer.
Sincerely,

Marcia Weller, Director
SunCoast Region
Background Screening Unit

Suncoast Region. 9393 North Florida Avenue. Tampa, Florida 33612-7907
Mission: Protect the Vulnerable, Promote Strong and Economically Self-Sufflc!ent Faml!les, and
AdVance Personal and Family Recovery and Resrlienay

 ·-

Brolf.ard Sheriff's Offlce R.tcord.s DlvwOB
UOl West Bra111ud Boukvard
Fort Lauderdllle. FLJ33l2
(954) 831-87110

Date:

September 15,2010

Subject:

TERRY LIVORSI

Race:

w

M

Sex:

DOB:

l0/05/1954

Based on the above i:nfuzmation, a check of the BrowardSherifrs Office Records was completed.
The rec::ords of this agency reflect th~ following;
NOARRESTQCORD

.~

~TUCO~AITAOmD:

0

To obtain a statewide backgroulld deck, contact the Florida Department ofLaw Enforcenient at:
Internet:
httn://www.fdl~.state.fl.us/criminalbistory or
·
FDLE- User ~ces Bureau/Public Records
P.O. BoX: 1489
Tall8hasSee. FL.32302
PhQne; (85()).410-8109

To obtaiii·Clerk of the Court ~cords on dispositions and court information, pleas~ contact the Clerk
of <;:ourt dllectly at one of."~;he fullow.ing locations:
.
Internet: llttp://www.clem-17th-fleourts.~ccoc21puhsearchlpublic_search.asp
Central Courthouse- 201 S:E. (ih street, Fort Laude:Idale, FL 33301 ·
North Satellite Courthouse -1 0 W. ·
oro Blvd., Deerfield Beach, FL 33442
South Satellik C~onse ~ 5 0 Ho
Blvd., Hollywood~ FL 33021
West Satellite CourthoUse - 00 . Pine I
d Road, Plantation, FL 33317
CHEcK COMPLETED BY:
*Cheek not valid without .sigrwfure and CCN.

CCN:

--~1:..::438=0_ _

*

 MEMO TO THE FILE

FROM: Margaret S. Phiambofis
DATE: January 22, 2014
TO: Recovery Institute, Terry Livorsi, Dr. Barbara Gibson, Nancy Zifer, John
Lichtenberg and Kathleen Quigley
RE:

Weekly Telephone Conf erence Calf

Present on th is weekly conference call were Terry, Nancy Zifer, Barbara Gibson,
Kathleen Quigley, John Lichtenberg and myself.
1. An announcement will go out from Terry. Kathleen and Barbara will draft the
announcement, letting the staff know that Barbara will be moving into her new
role as Director of Program Development for CRS.
2. A separate announcement will go out regarding Jon Mackler's starting in the
position of Executive Director, when we learn his start date.
3. Everyone had very positive feedback on Jon Mackler's visit to the facility on
Monday and Tuesday. John Lichtenberg and Barbara were very complimentary
Nancy will have an opportunity to spend more time with Jon Mackler at his next
visit.
4. Nancy said that the ad for an E)(ecutive Director in the HFMA periodical has
already been paid for. They will hold that for one year and we can place another
ad within that timeframe.
5. Kathleen said that Jon is very excited about joining the organization and he is
looking forward to working with everyone here.
6. Nancy will send Jon the new employee packet. She will also make
arrangements to be fingerprinted and to have a high level background check,
which will·be required of the Executive Director. Margaret will send Jon a noncompete agreement on the agreed upon terms for his signature prior to starting
his employment.
7 Nancy has discussed with Matt, the insurance broker for the Willow Grove office,
the comparative costs for Aetna coverage as compared to keeping the Blue
Cross Blue Shield coverage for the Pennsylvania office. Matt forwarded quotes
for Aetna and IBC. The IBC is much more reasonable and the Willow Grove
office will continue with that coverage.
8. Matt is excited about the opportunity to obta in quotes for the employees in
Florida, comparing the Humana coverage to other available coverage in Florida.
Page 1 of 3

 Recovery Institute of South Florida, Inc.

PRIVATE PAY
PHP Treatment:
30days

$11,800.00

•

Phannacy:

j() to

60 days .

60to90days

1 week

$2~125.00

1 week

$1,750.00

2 weeks

$4,250.00

2 weeks

$3,500.00

3 weeks

$6,375.00

3 weeks.

$5,250.00

30days

ss,5qo.oo

:30 days

$1,000.00

Please advise all clients to have money for their pharmacy costs
upon admission.

With Phannacy Insurance:
No Phaimacy Insurance:

$250.00 to start
$500.00 to start

INSURANCE
Partial Day
Individual Sessions
Group Sessions
Con-joint I Family

$990.00 per day
$225.00 per session
$125.00 per ses8ion
$125.00 per hour

..

 ---·-·------

Recovery Institute of South Florida, Inc.

PRIVATE PAY

lOP Treatment:
3 nights a week

Pharmacy:

$3,000.00, due at admission

Please advise all clients to have money for their pharmacy costs

upon admission.

With Pharmacy Insurance:
No Pharmacy Insurance:

$250.00 to start
$500.00 to start

INSURANCE
Intensive Outpatient
Individual Sessions
Group Sessions
Coa:joint I Family

$715.00 per day
$225.00 per session
$l25.00 per session
$125.00 per hour

 RECOVERY INSTITUTE OF SOUTH FLORIDA
POLICY AND PROCEDURES
mLE
NUMBER

CLIENT'S FINANCIAL RESPONSJBJLITY
CL-1:28

SUBJECT

CliNICAL

EFFECTIVE DATE

08/25!08

REVIEW AND APPROVAL

PAGE(S)

REVIEW DATES

REVISION OATES

1 OF2

PURPOSE:
It is the policy of Recovery Institute of South Florida to require clients to be financiafiy
responsible for their treatment costs. At times funds may become available to provide

client assistance.

SCOPE:

This policy applies to all clients of The RECOVERY INSTinJTE OF SOUTH FLORIDA.

RESPONSIBILITY:

 It is the responsibility of the CFO and/or designee to implement this policy and procedure.
It is also the responsibility of the CFO to disseminate this information to employees under

their direction.

POLICY:
1. Provide a Fee schedule for services provided upon initial intake.
2. Provide clients the opportunity to negotiate lower rates based on income and
need.
3. Clients or pf,Jrticipants are required to initiate the request for lower fees. It is not
the responsibility of RISF to offer reduced fees.
4. Clients will be requested to provide proof of income and complete a Fee
Reduction Request prior to approval of reduced fees.
5. Upon completion and receipt of the Fee Reduction Request by finance staff,
each case will be reviewed to determine the appropriate amount of reduction, it
any.
6. Fee reduction will become effective at the time of approval. Initial fees for
assessment and -treatment planning will not be reduced without approval of the

CFO.

 Policy Number 289B006550
COMMON POLICY DECLARATIONS

•

Renewal of: 28 9B oo6321

IFG Companies•

TH E BURLINGTON INSURANCE COMPANY

Home Office: Burlin gton, North Carolina
Admin istrative Office: 238 I nt er nat i onal Road, Bur I i ngt on, NC 27215 Clai ms Office: 2~ lntemal!onal Roa d, Burlington, NC 27215

Item 1. Named Insured and Mailin~ Address
~hristian

Recovery Solutions

1080 SE 3rd Avenue

~ort Lauderdale

~L

33316

Code:

Co. Lise·
Risk Placement Services, I nc.
2400 E • commercial Blvd.
Suite 728
Fort Lauderdale ,
FL
33308
0 289

Surplus Lines Broker License No.:
Effective Date: o21 1 91 2 o1 4 Expiration Date: 02/1912015
at 12:01 A.M., Standard Time at your mailing address shown above.
Item 3. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to
provide the insurance as stated in this policy. This policy consists of the fo !lowing coverage parts for which a
premium is indicated. Where no premium is shown, there is no coverage.
Coverage Part(s)
Premium
Item 2. Policy Period

$

Commercial General Liability

1,585 .0 0

$

$
$
$

$
Total Policy Premium or Deposit Premium

$

1,585.00

Total Other Charges

$

353 . 30

Total Amount Due•

$

1,938.30

Other Charges (if applicable)
Policy Fee
Inspection.l?ee
surplus Lines Tax
Stamping Office Fee
Florida Hurr Cat Fund

35 .00

2oo·. oo

91.00
3.64

I

23. 66

$
Policy Minimum Premium
0 Flat llQ Auditable
In the event you cancel this policy, we will retain25% Minimum Earned Premium
Item 4. Forms and Endorsements applicable to this policy: See "Listing of Forms and Endorsements" (IFG-1-0150)

* Premium is:

Item 5. Form of Business.

D

0
0

Individual
Limited Liability Company
Trust

Business Description: Cli.nic, Business
IProduci nq Aqent : Frank Pett i neo,

0

0

Partnership

Joint Venture

If] Other Organization, including a Corporation
Corporat ion

Cen te rl~ehab

Residence
2 4 3 0 E. Commercial Blvd., Fort Lauderdale,

FL 33308

THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDmONS AND COVERAGE FORM(S) AND ANY
ENOORSEM ENT(S}, COMPLETE THE ABOVE NUMBERED POLICY.

SURPLUS LJNES INSURERSr POUCY RATES AND FORMS ARE NOT
APPROVED BY ANY FLORIDA REGULATORY AGENCY..
Tbfs insurance Is Issued pursuant to the Florida SurpiUis Lines taw.
Persons Insured by surpius Unes carriers do not have the protection ilf
the Florida fnsuranee Guaranty Act to the exte-nt of any right of recovery
for the obligation of an insol\lent unricensed insurer.

1'\

Countersig ned:
Date: ----------------------------JssueDate:
02120114
IFG -1..0101 0204

0

J---....>L.i..

By:--------~~·~--~~-·------------------------Authorized Representative

INSURED

Page 1 of 1

RPS Ft. Lauderdale (RPSSC)

 Recovery Institute of South Florida, Inc.

PRIVATE PAY
PHP Treatment:
30 days
$11,800.00

Pharmacy:

30 to 60 days

60 to 90 days

1 week

$2,125.00

1 week

$1,750.00

2 weeks

$4,250.00

2 weeks

$3,500.00

3 weeks

$6,375.00

3 weeks

$5,250.00

30 days

$8,500.00

30 days

$7,000.00

Please advise all clients to have money for their phannacy costs
upon admission.

With Pharmacy Insurance:
No Phannacy Insurance:

$250.00 to start
$500.00 to start

INSURANCE
Partial Day
Individual Sessions
Group Sessions
Con·joint I Family

$990.00 per day
$225.00 per session
$I 25.00 per session
$125.00 per hour

 ll'·.
I

RECOVERY INSTITUTE OF SOUTH FLORIDA
POLICY AND PROCEDURES
TITLE

NUMBER

CLIENrS FINANCIAL RESPONSIBILITY
Cl-1~28

SUBJECT

EFFECTIVE OATE

CLINICAl

08 / 25 / 08

REVIEW AND APPROVAL

PAGE(SJ

RE.VIEW DATES

REVISION OATES

1 OF2

PURPOSE:
It Is the policy of -Recovery lnstitut~ of South Florida to require clients to be financiariy

responsible for their treatment costs. At times funds may become available to provide
client assistance.

SCOPE:

This policy applies to all clients of The RECOVERY INSTITUTE OF SOUTH FLORIDA.

RESPONSIBIUTY:

!
I
I

 It is the responsibility of the CFO and/or designee to implement this policy and procedure.
It is also the responsibility of the CFO to disseminate this information to employees under
their direction.

POLICY:

1. Provide a Fee schedule for services provided upon initial intake.

2. Provide clients the opportunity to negotiate lower rates based on income and
3.

4.
5.
6.

need.
Clients or participants are required to initiate the request for lower fees. It is not
the responsibility of RJSF to offer reduced fees.
Clients will be requested to provide proof of income and complete a Fee
Reduction Request prior to approval of reduced fees.
Upon completion and receipt of the Fee Reductio.n Request by finance staff,
each case will be reviewed to deten:nine the appropriate amount of reduction, if
any.
Fee reduction will become effective at the time of approval. Initial fees for
assessment and1reatment planning will not be reduced without approval of the
CFO.

 Recovery Institute of South Florid. Inc.

PRIVATE PAY
Detox Treatment:
$600.00 per day

Pharmacy:

$3,600.00 for 6 days, due at admission

Please advise all clients to have money for their pharmacy costs upon
admission.

With Pharmacy Insurance:

$250.00 to start

No Pharmacy Insurance:

$50.00 to start

Insurance
Detox
Individual Sessions
Group Sessions
Con/ Family
Residential
PHP
lOP

$1,799.00 per day
$ 250.00 per session
$ 125.00 per session
$150.00 per session
$1,568.00 per day
$1,090.00 per day
$788.00 per day

 RECOVERY INSTITUTE OF SOUTH FlORIDA
POLICY AND PROCEDURES
TITLE

NUMBER

CLIENT'S FINANCIAl RESPONSIBILITY

CL-1:28
EFFECTIVE DATE

SUBJECT

CLJNICAL

08/25 / 08

REVIEW AND APPROV~L

PAGE(S}

1·0F2

- .

REVIEW DAlES

REVISION DATES .

PURPOSE:

It is the policy .of -Recovery lnSti:tu.te of South Fiorida to require

.

.

.

respOnsible for their treatment costs.
..

.

clien~
.

to. be. financially

At times funds may become avail?ble to provide

client assistance.
'

SCQPE:

This policy applies to all clients of The RECOVERY INSTITUTE OF SOUTH FLORIDA.

RESPONSIBILITY:

 It is the responsibility of the CFO and/or designee to implement this policy and procedure.
It is also the responsibility of the CFO to disseminate this information to employees under
their direction.

POLICY:
1. Provide a Fee sc!ledule for services provided upon initial intake.

2. Provide clients the opportunity to negotiate lower rates based on income and
need.
3. Clients or participants are required to initiate the request for lower fees. It is not
the responsibility of RISF to offer reduced fees.
.
..
be requested to provide proof of income and complete a Fee
Reduction ~eqi.Jest prior to approval.of redu~ fees.
5. Upon oompletion and.receipt of the Fee 'R~uctiori . Request by finance staff,
each case will be reviewed to deterr.nitie the appropriate amount of reduction, if
any.
.
.
.
6. Fee reducti9n wit! become· effective at the time of·approval. Initial fees for
assessment and-treatrrienl planning will not be reduced without apProval of the

4. Clients will

cro.

·

·

·

·

·

··

·

 Recovery Institute of South Florida, Inc.

Outpatient Treatment:
Individual Sessions:

$250.00

Group Sessions:

$125.00

 RECOVERY INSTITUTE OF SOUTH FlORIDA
POLICY AND PROCEDURES
Tm.E

NUMBER

CLIENT'S FINANCJAL RESPONSIBILITY

Cl-1:28
SUBJECT

EFFECTIVE DATE

CUNJCAL

08/25/08

REVIEW AND APPROVAl

PAGE(S)

REVIEW DATES

REVISION DATES

1 OF2

PURPOSE:
It is the policy of Recovery Institute of South Florida to require clients to be financialiy
responsible for their treatment costs. At times funds may beoome available to provide

client assistance.

SCOPE:

This policy applies to all clients of The RECOVERY INSTITUTE OF SOUTH FLORIDA.

RESPONSIBILITY:

 It is the responsibility of the CFO and/or designee to implement this policy and procedure.

It is also the responsibility of the CFO to disseminate this information to employees under
their direction.

POLICY:
1. Provide a Fee schedule for services provided upon initial intake.

2. Provide clients the opportunity to negotiate lower rates based on income and
need.

3. Clients or participants are required to initiate the request for lower fees. It is not
the responsibility of RJSF to offer reduced fees.
4. Clients will be requested to provide proof of income and complete a Fee
Reduction Request prior to approval of reduced fees.

5. Upon completion and receipt of the Fee Reduction Request by finance staff,
each case will be reviewed to determine the appropriate amount of reduction, if
any.
6. Fee reduction will become effective at the time of approval. Initial fees for
assessment and-treatment planning will not be reduced without approval of the
CFO.

 State of Flotfda

Department of Children and Families

BlVIAIDS EDUCA'110N CONFIRMATION

c~
t

12......,~o£.Si,.,U,Qx;:h
ZhJUr
oo HIV/AIDS .

............... .....
~ tlla~~ oftiU alpniudoa ba\le campllllted ;;~

cNtiatian

com.

by the PJorida ~ otehihna 4 Pmlliea.

tt il ~ tblt ptoOfof4llldJ. -~·a11f!mdwv.e is requirecl fiJI' audl~ and tbllt It is 1bc I'C8p0Diibility oftbe

liCIII8icl flmriilcr m uiaiataia alliYiGW 1be el1ladoaal dooameDIMioa rdi:Paced bcreio m11 in ICCiion 38t.D03s,
Florida~- Aidiliooally. I dlo a1film dJit ~q>ri.ae·mvJAn:JS ectuc:.tiGo will be p:vvided to peados
~ liltW:es b.al upoo ~ CO@Ili6..; liad ada lew& G!fiNtionine

Pr1iltlllt tx> s,_..16J.003S(l), F ..S.. tlw Depw tJivt:nt oj"Cif&Hft & F-ut.. lhllll nqt11rw t10
QllfjJ/oyeo rmtl dmltb qfjildlilia ~ fllltW C7Mpr 191, F.S. to
a~~

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~ ~pr~ cliiti«d ~ fllfll JIIWllf1I'IIHHI qf
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llppt'tiJ1rlole ~ 11114attilullJe tNnr,p.. &rdJ t1Utrrldicn sM/1 irtt::lJt4e ~ ""CinW!M Plurit/d
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~ applicahl• to hwwJn ~COIIIUII!lbJgtmtl ~ ritpdrtbe tlre~tl/1111'
tutink to Jilt fiJI..., -..m, lft!IJ~lrl- ~ Utla puntlillfl to~- 38l.OIH tiM 1&4_.15• .Nr
~ 'lrAo "-~the -.lat:qtkm61 etnne ~ill tJrU ~ u rKll r~ to repmt
tlr.txllll'ltt apM dltzlr/lbfl~ ID D llifl.rDIIfoctliJp lieaU«JJ1111kr cltDpt4r 393, ~ 394,
~ J95, t:hapltlr _397. pmt 0. part 'i1I, tlf' part.Itt1{clrt1ptltr 400, , port I ofchtzpter 129.

hTifltlnl to I«<ID11 J:BI.OOU(2)t.fodlllia
illllf

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edllctltkl11t1lcorrn&

NDw cmplo)lecS irbal COiilpllla two (2) hwrl ofBrv/AIDS tiaiDDg widtbl cbo &It 611l0111bs of eiuploymall.
I lllldcrslliDd tbO .tequiumcas ~ in 1lil docum.eu~ ad I reco&DB that prvvidiq fiUi: infOUDatiOO may
rmllt In a finf,.IU!IpCIIIioa, or~OfW. Cll'jpmlzatloa'• sab.ttmce abuse earvia:t lcc:me(s).

/'10tPAQ.~
LICBNSB NUMBER(S)

1317 Winewood Bo~Rvard, Talllhassee, Florida 32399-0700
Mlselon: Prollel;tthe Vulnerat*. Pn:lril0t8 Strong and Economlcaly Self.Sul'llc.lent Families, and

Advance PensoneJ and Famiy Rec:ovary and ~Ieney

 p

STEPHEN M. HERZ

MS, LMHC, CAP,ICADC

13441 SW 1081ll Street ·Circle North Miami, Florida33186
H: 305-752-3755 I C: ~6-6331 I ~tephenherzlmhc@gm.ailcom
QUAUHCATIONSS~y

Dedicated and compassionate professional poised to merge outstanding relationship management experience
with advanced education to support quality patient care in a Mental Health Envirorune:nt. Relllted skills,

pradicum, f!1Ul experience include:
Human Development: Advanced training and programmatic experience in key mental
health topics, including adult, child, and adolescent p&ydtopatbology; sexuality; substance abuse; and
human growth. Extensive training in treating Jl\ental illness and addictio1;1.

.¢- Psydlology &

4- Counseling & Patient Care: Highly effective communication and active listening talents complemented
by recent trainJng in COUllSelJng. theories and practices. Keen understanding of individual. group,
coupJes, and famny therapy. Strong capacity 1x> plan and implement treatment I intervention strategies.
~

Administration &: Organization: Diligent and detail driVen with extensive experience ensuring
seamless compliance with organizational standards, bestpracticesJ' and client needs. Recent education
.spanning.research I evaluation, legal I eihical ismes, and case conceptualization. Dedicated to
increased effid.ency and reduced costs.

~

AchievementsI Strengths: Proven record of customer satisfaction across diverse organizational
environmenis including technfcal, non-profit, management, and retail roles. Excellent trainer, presenter,
and col1aborative team pl.Qyer. Outstanding technical skills and experience spamting network, desktop,
and productivity hardware and software.

EDUCATIONAl BACKGROUND
MS in Mental Health~ • NOVA SouniBASTBRN U.NlVERSITY, Miami, Florida

Bs in Politkal Sdence • OHio SrATE UNIVBRSrn', Columbus, Ohio
PRACilCUM & RnATED ~BRIENCE
ST. LlllCE'S ADDicriON TnnATMEl'IT PROGRAM, Muu4 FLolUDA
SruoBNT~1 8BPTHMBHR, 2009- AUGrSI', .2010

Provide day-to-day support to residential patienl5 of drug I alcohol duaJ diagn06is rehabilitation program
with accountability for therapeutic interventions, health and safety. Meet with assigned patienis in oneon-one and group sessions to help them resolve and accept addiction issues and leam to live substance
free.
MENTAL HEALTH PROFESSIONAL ExPBIUHNCB
:ROCOVFltY INsrrrurE OF SoUI'H FLORIDA
PROGRAM DlRECI'OR, MMCH 2014-PRE5BNT

0vERsims 'lHE CLINIC.AL OPERA'IlON OF AN ADDicriON TREATMENT PROGRAM THAT HAS AU. LBVELS OF CARB POR AN
ADULT DUAL DIAGNCES POPULATION. 'Ilm INCLUDES

DBTOX., REsiDENTIAL TlmATMEm', PHP, lOP AND OP.

Crmtinued...

 Lf.,b

STEPHEN M. HERZ • Page 2

ACCEPI'ANCE COUNSELING SERVICES

PRIMARY THERAPist OCTOBER 201.2- MARCH 2014
OVERsEEs AND FACll.lfATBS GROUP CO'ON5BLING AND PROVJ.li£61NDM'DUAL PSY<HOT.HERAPY IN AN INl'BNSlVB
OOTPATIBNTSBTJ'ING FORAN ADULT DUAL DIAGNOSED POPULAnON. l'ROGRAMCONS151SOFPHP, lOP AND OP
PROGRAMS. 5Ua::I5SFULLY CREATED AND RBCEV1ID UCENSURE FROM DO' FOR 'IHE PliP PROGRAM IN ]uNE OF .2013.
CURRENll.YSUl'ERVJSE 61l:lmAP.ISTS AND SI'Al'F.

ST. Ll.JKFS ADDICTION'nlEATMEN'r PROGRAM, MIAMI, FtolUDA
REsiDENTIAL COUNSELOR. AUGUST, 2010- OCfOB'ER 2012
Provide day-to-day support to residential patients of drug I alcohol dual diagnosis rehabilitation program

with accountability for therapeutic interventions, health and safe1y. Meet with assigned patients iil. one-on-one and group sessions to help them resolve and accept addiction :issues and leam to live substance
free.
~l.lTHMIAMJ HOSPITAL- ADDICTIONTREA.TMENTI'ROGKAM, South .Miami,. Florida
ResidentiRl Mtmitor, 'Jf.XY7- Provided day-to-day support to residential patients of drug I

aloohol

rehabilitation program with accountability for health and safety. Meet with patients in one-on-one and
group sessions to help them resolve and accept addiction issues and learn to live substance free.
G & G ~OumCTREATMENT~ N. Miami, Florida
Sobriety Coach, 2006 - 2007
A.ssi.sted residEmts of drug rehabilitation center with day to day activities. Conducted group and
individual coaching to support recovery and coping strah!gies for living with addiction.
PROFBSSIONAL Certifications

Trained :fn EMDR

Dueling Diagnoses: Understanding & Treating Addiction & Men1al Illness (2008}
Ceriitica.te in Addiction Studies (2007)
Introduction lx> Medication for Alcohol Dependence (2007)

Basic Life Support (BIS)
~zations
AMERICAN CoUNSEUNG .A$QQATION (ACA)
FLoRIDA COUNSEUNG AssoclATION
(FCA)
EMDR INTERNATIONAL AssociATION (HMDRIA)
_C OMMUNXTY SERVICE

COMMUNI'IY GRIEF CoUNSELOR 2010-PRESENT

SPEAKER ON EMDR AT HOUSTIC NURSES OF SOurn FLORIDA
OTHER PROFESSIONAL ExPiiRIJiNCE
SI'EVB'S MOUSE CALIS I PCs &. PROGRAMS, Miami, Florida

 c
STEPHEN M. HERZ · Page 3

General Mmuzger, 2000 - 2010
Led 1awtch and oversee daily operations for this network design I installation company serving
residential and small to mid-sized commercial clients. Utilize active listening to assess needs and provide
recommendations / expertise; troubleshoot technical issues. Carefully plan installation and
implementation projeds tn ensure on-time and on-target completion.
• Spearheaded $55I< server project for Humane Society of Greater Miami; provided ongoing
enhancement I support. including aeation of robust training program.
•

Generated exceptional customer satisfaction through diligent needs assessment and top-Bight
se:rrice for diverse projects.

HBwLm1' PACKARD, Miami, rJorida
Tminer, 2001- .20(5

Am~ M41Ulger/I'edtniazl

Selected to conduct large--scale training initiatives for leading Computer Company; developed and
conducted informative presentations, demonstrations, and simulations for 150 retail employees covering
equipment usage and sales lechniques. Conducted 1roubleshooting and repair of hardware f software for

business customers.
•

Earned recognition for developing highly successful Point of Presentaticm standards and displays;
company implemenU!d standards nationwide.
COMPUSA, Miami, Florida
Technical Seroi.re Mtmager, 1999- 20!)0
Directed day-to-day service department operations for a leading computer retailer. Resolved escalated
repair / troubleshooting issues. Trained and mentored. reclmical tmm.

•

Boosted productivity to achieve #3 position district wide and exceed revenue averages by 9%

•

through implementation effeclive operating procedures.
Reduced repair tiJruoB by 40% by instituting on-hand parts inventoty.

8LOOMJNGI)ALB'S, Miami, Florida
Furniture Selling Mlllulger, 1998 -1999

Led sales teams in providing outstzmding customer service io diverse clientele. Utilized active listening
and dynamic communication talents to assess customer needs, recommend products, and close sales.

•

Triggered complete tamaround of underperforming store, leading tEam to achieYe revenues of
20%beyond company average.

...

..

 
3%


. "351$:

3


.h1.51Halli: 

II - 
Fu-

      
Antonio F. DeFilippo, M.D.
South F'1orida Pa;yclrimic Senices
2.225 North UnNerr;ity I>Im
Pembrolte Pines, Plorida 3S024
(954) 962-6200
.Fax: (9.5<0 962-549!5

PBRSONAL DATA
Date of Birth: M~23, 1965
MmtaJstat:us: Married

1IDUCA1l0N
1987-1991

Univenii;y of Sooth Florida CoJJep of ltfedlelne
Doctot of Medicine
Tampe, Florida

Ouiwrstty of Miami .

Bache1or of Science- Biology

Con! Gebles, Flmic1a

WQU:EXPERIENCE
..-lOU~ :.s~ MJ--~~i1f~,.....
~~~ ~...7~ MIIdiciilf~Q:ca~Jh•

fll. hiiCCdillc!t

~~ 1""h'!C ~,~~~&ld,•l"flclliiet .

Nov 2008-2011

Medical Director, Right Place Rdulbilitdon Cooter

Oct 2008-2009

Medical Director, John's Place Rehabilitation Center

Oct 2008-2009

Medical Director, Recovery Place Rehabilitatiot1 Center

~.~J!III!I,~•t.::?~. :D4e•i~•' ~,. ~t\ll.....,.._llatatrli~ilru
J6iMI ~ ..i..~~Mn!tical.DtiMii:lll'. ~~.
Dec 2007-2009

Medical Director, BCC Partial Hospitalization Program

Jan 200S- 2009

Adjunct Professor. Florida 1ntemat:ioDal Univeaity

JU2005-2007

Medkal Director, Miami Behavionl Health Specttum Programs

Jrm 2001-2003

Member at Large, Medical Exec:otive Committee, Ftorida Medical Center

Mar~l-2002

Medical Director. Sunrise Reponal )fedic:al Center

Jcm 2001-2003

Medical Director, fllorida Medical Center, Partial H~ Program

 J\Ul ~o- 2004

Medkal ~.Plantation Cenenl. Hospital, Matemal .Addidion Program

Mar 2()0D- 2002

Medical Din!d:or, CreOO Q)mmunif;y Mental Health Center

ADr 2000- Present

Medical Director. $QsaJI,_ll. ~~· .!.

Sep 1999-2000

Medical Director, New Dimeusicms Community Mental Health Center

--~~~~XZG:-1!:~~~~~.:~:--~· -·..,.;;.;~··-·:...-

.

~~-*'if11l~~OI!Mia411it)~-~biiter

i}lf_~~~~ ::.~-~~}Di.......~~-~~~BM&~-;

J~~ ~~~- ~}~~.1f:~~~~~-~Bd 1Pilft)jijijg~Jt;
Mediad Direct:or, Riventood Scltooland DayTrt.t1ment Center

Atisodate Psycbiatxist. Broward CountySebooJs
Jan 1996- 1997

Vice Chairman, Hotlywood P.a:vilion Hospital Medical Board

~~JO.IIi .~-::.:::rz;r=:;,.._~...._-~-~
Jull99l-1995

Resident, Jacbon KemoriaJ Hospital, Department ofPsydri.atry

Jul19!)4-1995

Senior Reaident,Ja.cbon Memorial Hospital~ Center

1) Trained Speaker

lillyBli :Pharmaceutk;als

2) Natio:oal. .Accredited Speaker

Pfizer Phann&a!Uticals

3) National Aocredited Speaker

Forest Labs Phannaceotieals

4) TJained Speaker

Bristol M,as Squibb Pharmaceuticals

5) Natiooal Accredited Speaker

~ Smith Kline Pharmaceo.ticals

6) TrabledSpeaker

Searle Pharmaceuticals

7) National Accredited SpeaJrer

Cephal011 PlwmaceaticaJs

8) TraiDed Speaker

Astra 7.Ameca Pbarmaoeuticals

9) Trafned Spealcer

.Abbott Pharmaceuticals

to) Trained Speaker

Sepacor Plwmac:eutkaJ8

11) Nationsl Accredited Speaker

Janssen Pharmaceuticals

omcxs
1.

2225 N Ulliversil;y Drive, Pembroke Pines, Florida 33024

2.

1995 E.Oaldand Patk Blvd. Suite 350 , Fort Lauder:dale, Ftoricla 333~

Board, C!;rti1icatiow
1997

Diplomat American Board of Psychiatry and Neurology

2005

Dip'knnat American Board ofPsychosomatic Medicine

2

 2007

Rcoertifi.Dd American Board ofPsy~ llbd Neurology

2009

DJplomat Academy ofSubstance Abuse ~edicine

Medical School
B:dtnaships in Ane.stbmiolor;y and Cal'dlothoraclc Sllrgelytn Cukunl
Ru:hanse with Italy

President of Note Service

1985-1987

Alpha EpsJ1on Delta Premedical Honor Society

1983-1987

Hemy KJns SlaDfOrd Scholarship

1983-1987

Florida SCholar~ Scbolanhfp

Medica} &:hDCl
1990

Yearbool:: Staff

1989-1990

Volunteer at Pa.scq ~ Flr:meutary School

1987-1990

Jutramural Sports and Med-Oiympjcs

1987-1988

AIDS Educaticm

1983-1987
1987-1988

1983-1987
PROF'ESSJONAL ORGAHIZAllQNS
1983-1990

.Ameriean Medkal As5oclation

1983-1994

Florida Meclli:alhsoeiation

1983-1990

BiDsborough County Medic:al.AAociatiou

1983-1990

American Med:it.al StudentAModation

3

 ..

1991-1993

Dade Coun1;Y Mectical Association
American P.sychiatrieAsaoc:iatioD
ASAM

1994

'Mle Bfl.'eet d. Nalmafeneon Diet ofAbstinentAicohotic6
Meutor: B. Mason, Ph.D.

1990

AlcOOol aDd Drog Abwle in Medical Studenta
Mentor: M. Sheehan, M.D.

11)86

Friendship and Bonding in Pr~ooJ adldnm
Meutor. T. Fields, l'b.D.
Uui"'lelllity of Miami. Maih:nan Center

1.ANGUAGE8

4

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15


Lee, Kelly
From:
Sent:

Barbara Rustowicz <BarbaraR@recoveryinstitute.com>
Thursday, February OS, 2015 4:45 PM
Lopez, Maritza
Lee, Kelly; John Lichtenberg
Recovery lnstittute of South Florida and Christian Recovery Solutions bCF Responses to
Survey in September, 2014
RISF and CRS Letter to DCF from Executive Director.pdf; RISF Corrective Action Plan
from September, 2014 Survey.pdf; CRS Corrective Action Plan from September, 2014
Survey.pdf

To:

Cc:
Subject:
Attachments:

Dear Ms. Lopez,
Thank you for your correspondence on December 17, 2014 of the completed survey for Recovery Institute of South
Florida (RISF) and Christian Recovery Solutions (CRS.) We are sending you the required corrective action plan according
to your site visit.
The attachments contain:
1. A Letter from the Executive Director for RISF and CRS.
2. Recovery Institute of South Florida's corrective action plan.
3. Christian Recovery Solutions corrective action plan.
We will be mailing all of the information to Department of Children and Families located 201 W. Broward Boulevard Suite 511 as well as this email. Thank you for your attention to this matter.
$~~)

6c:wb-o.-r-a.- A.

R~

e~A~

Recovery lnstitute of South Florida

I080 SE 3rd Avenue
Fort Lauderdale, FL 33316
Phone: 954-960-7091

Fax: 954-533-4053

1

 Phone: (954}~7091
Fax: (954) 588-4058
(877) 25-SOB:ER

February 5, 2015
Ms. Maritza Lopez
Substance Abuse Services Coordinator
Florida Department of Children & Families (DCF)
Circuit 17 (Broward County)
Substance Abuse Mental Health (SAMH) Program Office
20l W. Broward Boulevard- Suite 511
Ft. Lauderdale, Florida 33301
Re:

Recovery Institute of South Florida- License# 1706AD352501, License# 1706AD352502

Christian Recovery Solutions- License# 1706AD702801
Dear Ms. Lopez:

In accordance with your office's correspondence dated Decem~r 17, 2014 we are providing the
reqUired c.orrective action plan. We have addressed each of the specific issues of concern raised in
the site visit summary.

If there are any questions or further clarification of our corrective action plan please do not hesitate to
contact me at (g54) 960-7091. Thank you for your assistance and attention to this matter.

John Lichtenberg
Executive Director
Enclosures (2)
Jllbr

 ~- .....

Chrlltian R~very Sohltions
Department of Children and FamD.les
IJeensurelnspecdG•
Survey Respoues from September, 2.014

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u

l

l.

4.
5.

'·
7•

••
wbl.ch will be a

'Ihc
Bulinesa me.

Dimc1or is currenlly in.lhe procea ofupdatillg the handbook.

u.

were retraJned, intc:mal wrt ravi8w clev$ped by ellni.W dtrc:ct.or to ensum
Treatment plan traiDing Wlllll offered twice daring the put two montlu.

P... laf6

.,..,....
<(;,;I:J

 -Christian Recovery Solution!II
Department of Children and Famllies
Llcenwr:e Inspecdon
Survey Respoases from_September, 2014

u.
13.

Barbara
Beatriz

is backed liP

2.

Clientlpertioipant reoord8 shall be kept secure from UNIUtborized
accen and maintained in accordance with 42 Codo ofPedenll
Regulations. Part2 and IS. 397.50(7), P.S..... ~BMRpolley
to adtlreu oftllcltments tU lWII
u •lecJrrmk recorrJ US#!, cJtm tl(o /ongrnly in .r~. protection
Leo

ProJtllll Diremr updated and J!oatcd tha
Council. ad the District'& Substaaoc Abuse and Meatal Health Program Office. Phone numbm will also
bo provided 10 clients at intake aod in·the patient orientation handbook.

5.

1'rocedurel.

James
Batbara

Pap.2of8

 Christian ·aeeovery Solutions
Department of ChUd.ren and FamJHes
Ltcensnreln~~on

Survey Responses from September, 2014

PlltliU8Ilt to o:ll.l"-'U.UU't

be made to ensure that hotlaebepiiag and maintc:IWl.ce services arc
capable ofkeep!Dg tho bWlding and equipment clean aDd in gpod
repair....Movlngfoi'WIU'dcdling/rml fl~ tbortn~gh ~gull:rr
cleaning lo d«rtNUs dwt QCCUINIUzdtm, insecllpesl Ct119tJ'OI
1ervlcsneeded to dt!crease
IMide T'Uide11r:es, nguku

Houaekeepirlg will ensure all buildiogs and equipment aro clean and in good rqKI.ir.
Supervi$01" will ensuro all da:lly maintenance l!ld houscla::epilli func:tiolla are met.

Iamea
Barbara

mt"

are

7.

Jobn

James
Barbara
There are tranap.ortatiotllogs that are beio.g maintall1ed, lbat eaeb cllent aigns when they.ve le!Mng
unit and they mnat sign upon mum. This log lndicatt. the destination, departure time, staff membez and

muao on duty.

c:lwt review developed.by clinical director to CDIUUI oo.mplimco.
Tieatlncnt plan b:aiDlng offered on two occuloos during 1he past 2 months.

Pt.ae8ol6

Edward
Barbun

Beatriz

 Christian Recovery Soludons
Department of Chtldren and Faunllles

Lleena.ure Inspection
Survey Responses from September, 2014

• RULB: PIUSIIallt to 650.30.004 (17) (a), F.A.C.. The type md
liequeocy ofservices to be provided, and. .. JJOI aH obj~ ltawr

'·

• RULB: Pursuant to 650.30.0()4 (17) (c). F.A.C., Progn:ss notes
silall be enured inlo tho eliCilt recoal oocm:nenting a client's
pro&JCSS or lack ofprogras toward meeting t:re&tnlellt plan goats
and objectives.••• Jll)t all -notes Tlfjkct cllenl's progrlW or lack of

were retranted. cli.oical clirector is worldng with medical records to modify the cumnt
popWato go.la aod objedivee Into tho DAP notea. In 1he interim, coun8CI.on 'Wi.U bo rnollitmW by d.inl.cal
director to eDSUrl!l progress nota contain and reftect progmsa in Jllecting goels and objccti.WII.

progrt&r In »t«t<1lg IX pkm

emd

wm

to ensure compliw:e.

Clinical 11hector trained coun sehn to provide a rtlllliD8l')'

oo.aaecure

K1pu

Clie:otlparticipant mxn-dl shan be la:pt aec11re &om lln8Utborized
acce&l and maintained in accordance with 42 Code oCFecleral
Regulations. Part 2 and 11. 397.50(7), F.S. ... Updale EMRpolfey
to addnlu a~tl tU -rl Q8 electronic record Ute, cUat Info
l011gmty in~. protection/rrmtfo,er mp~. llachn,

clicut's Involvement in trca1mcnt.

I every lli&ht

Leo

Barbara
Bcatriz

l'see4~8

 Christiau R~very SoluUons
Department of Cblldren and Families
LkeDJure Inspeetlon
Survey Responses from September, 2.014

Intake AslltSIIlDGnt furm was
·

actio111 takm.
2.

every avenue

3.

provide

4.

s.

'·
monitmed In eiiSUie
Director win update

detallti necessary to

Dontrell
Barbara

caro.
Barbara
Nikki

-nrc~

retrained, iDtcmal cbart revU!w developed by cliJUcal ditcc:IDr to ensure

Beetriz

Cmmselois wa-e traim:d to include ch~nge hlle"'el of care in the treatme:nt plm'a goals and objcetive&..
~t plm u.iniftg Will ofremt twice durin,dlc.pelt two l1lOiltiJ&.

Counsel.orJ wm retrain~, in~ chart review developed by. olin:i.cal.·din:lctcr to eD~Ute compliance.
'l"n:aim.eaJ plan training WBI offered twice during the put two mooths.
(17) (c).
lball be e.nta"cd .into the cllw teCOrd documenting a cHent's
progxesa or lack of~ toward meeting treatment plan goals
and cbjecttvea .... Not all no• refl«t clitmt'8progrw or lacl of

were retrained, el.IDical dircelm is worll:ini with medical reoordt to modify lhe cment fbnn.t to
populate goaJa and objective& Into the D.AP D.Ote&. Treatment plu 1rainlng Will offered twice during the
put two mcmthl. Counselors will be mooitozed to eoaure complimce.

PIP6of8

Bemiz

 Christian Recovery Sol,.tiom
Department or Children and :Families
Lkensure Inspection
Survey Respomes from September, 2014

2.

Pursuant to «J>l}..;sQ.UU'I
CUcat/particlpant records shall be kept &ecurc fi'om unauthorlzed
ll.CCe$1 and maiirtaiued In ac:cordance with 42 Cede of Fcdc:ra1
Regulations, Part 2111Jd sa. 397.50(7), F.S._•.Updat• EMRpolicy
to odrirws attoclunttwl m ~11 Q6 ~le.ctroiJ/c ri!OOTa""' client 111/o
longevity ln1vrv, prutectionfrom former emplo~ .&at:Jzn,

KipuEMB.

ona~CCUIC

everyn~bt.

Leo

Beatriz

PQBo6of6

 /~-~­

.. ,. ... .·.

..;~
I[·.,

Recovery l:astitute of South Florida
Department of C.Wdren and Famllles
Llcennre lnspeedon
·survey Responses from September, 2014

/{

- ..

~-'<;)

<.Q.

6' .,_

'

New

formwa&

()

intake staff was

action.s t:akal.
toensurec~

is placed in

or
review tool was created byclinical director-to eosurc compliance. F\u1ber
Beattlz

7.

IGCft&un:

Beeniz

IIJe

Statrm:ei.vecl tDtiDiJig IUld lnstrudions on reimall:'!qulremmtl to enaure MH neeclt ~
'Ibis training iru:ludccl documentation requiremr:nts.

prq~Cdy.

10.

Program

Pqelall8

 Reeovery Institute of S011th Florida
Department o.f Clrlldre• and Families
IJcensureinspe~Uon

Survey Responses from September, 2014

14.
15.

lO.

11.

Barbara
Beatrlz

Pqe2af18

 Reeovery Institute of Sowth Florida
Department of Cbiklre• and FamiHes
Lteensure Inspection
Survey RespoDJes from September, 2014

l.

3•

...

11. I • RULE: Pwsuant to CI'I>-.SV.W4(. • . •.
plan reviews shall be al.aned and dated by the penon providing the
servle4.•.Not compltterJ.
12. I • RULE: Purswmt to 6ID-30.004(17)
plan reviews shall be signed and dated

Beatriz

completed.
13.

current forma to
populase soals IDd o})Jcctivel·iDJo the DAP notes. Tteatmmt plan 118.1D!Dg was otrei:ed twice duriDg lhe
peat two ttlOiltbs. Counsetora will be monitnred to.a~~Ur& compli.alc:e.

Plp&otl.S

 Recovery Institute of Soutll Florida
Department Cblldren and F'amDies
I.Jcensure Inspection
Survey Responses from September, 1014

or

Leo

and inC8ko ltaff'WBil

l.

3.

oveey avenue IMiilable to vet

4.
5.

Pilp4ot1S

 Recovery Institute of South Florida
Department of Chlldren and FamDies

IJcensure Inspection
·survey Responses from September, 2014

Wayne

to c:osurc MEl

neeu are eddrc&sed

Beatrlz

are

lralniDg on timclinca of services and

monitored to en.sure compliance.

Beatriz

Bcatrlz

Prognm

will be mDrutored to

17.

Beatriz

Pa.. 6ofltJ

 Reeovery Inetltute ot South Florida
Department of Childreu and Familles
IJcensurelospeetion
Suvey Relpoues from September, 2.014

2..

Jaxnes

5.

BcuStkeopilag wiU eoaurc all buildings and equipment are clean md in good repair,
Supcrviacr will e:osme all daily maiDtenance and housekuping ~na are met.

6.

Safety

eoaore tbat all chemia ~n properly

con1aioer.

P~ge8 ot 13

James

James

 Recovery IDstltute of South Florida
Department of.Cblldren and F'amfHes
IJeensurelnlp~n

Survey Respon1es from September, 2014

l.

Berbe.m
3.

...

regarding
Ph)'Sicll form will indicale that MD 5ignature ia required and not initialed.

&

part oftbo medical records teYif:W procea, ataffwill mab sure that MD aigt111tUrc:s are
required. Alto that all ab rcwlta an: uploaded into the BMR..

&tamped

5.

6.

r:very avenue

to vet

abale.

10.

needs are addressed

J>ase7ol18

to

Nikki

WaYJie

 Recovery Institute of South Florida
Department of Chlldren and Famutes
IJcen~urelnspe~Uon

Survey Responses from SeptembeJ', 2014

u.
14.

16.
17,

Leo

l.

phone numbers of lhc Abuse Hotl!no, Florida Advocacy

3.

aacl Mental Health Proaram Office. Pbooc number~ will ako I Beettb.

Plan

5.

eJJilll'e all builctinga aud oqul))ment arc clcM1 and in aood repair.
etiSUJ:e an ,dally mmntcunce md housekeeping fimctions are met.

Pap8 all3

James

 Reeovery Institute of South Florida
Department of Children and Families
Litensure Inspection
Survey Respo.nses from September, 1014

part ofthe nuraing assessment process, sta1f will Is malcing IIUl'8 that MD sisnatures are in place where
teq'llircd. All n:sults will be rr!Yir:wed/siguadltime stamped prior to being scanned into the BMR.

Protocol will be ru In place for mediul stabilization. Ifdemx i& not needed fur cliem, tb.oy wDl
on 3-day mediul ob5c:rvation stlllul and then oleared to tranafer to Jeut restrictive ncceaary setting.
any

Tho

~ility

Businesa iDe.

control Policies 8Dd 'PJocod1ua will be llodded to Patient Orieolation
Director Is cmreutly in the proceu of updating the handbook.

6.

7.

I

Progmm

I • RULE: Pursuant to 6SD-30.004 (17) (a) 5., F.A.C., A meclli:al
Pmtocal will bo put in place for medical smblll28ti.on. IfdetoX lanotnecdcd for cllent, the,ywill be placed
plan for .-abilizationmd dctoxlftcati.on .... For LK nor evtdmtt-F01' on 3 day medical ol>servatioo status and theo cleared to transfer to least mtrictive neeeswy setting.
AP-PI'el!entlngproblem nata: cJienlcmtrplairuofjob
ho!YinTMnt, aPIXfety, hx oftloJnutlc violence, no alco1wl: MD
thaJ

8.

haehfl3

 Recovery lnltitute of South Florida
Department of Cblldren and FamiJies
Licensure Inspection
Survey Responses from September., 1014

current lbmu to
popl.atc goe1a aDd objectives into the DAP..nOteL Tn:atmcllt plon tmiDiq wai offered twice dm.ing the
past two moothl. CouniClon will be 1JlllllitoRd1o cmure complimce.

will be.monitored ao 1111 oqoing
requirocl documcntati.on.and signalm'el.

Bcatriz

to cn•we

13.

documontation is ob1ainod. every effort to ~

mental healtb treMme'Ot

needs are

Pap10o!18

and

Linden

 Recovery Institute of South Florida
Department of CbHdren and Families
IJ~eusurelnrpecdon

Survey ResponteS from September, 2014

l.

oounseHn&SOIIsions ahall be of sufficient duration to enable staff
IG make reasoaablo decisions reprdiog the client's need for other
services...AlJJsougiJ cll#mt wru PfOYirkd with 111/)port/1/'e
OOillJSeling, clUm contlnwd to deny IJSJR3 wftA SA wllJch 18
Bpported by MD~ order 8flllirtg cltt:nt dJa PJOt mat cr11m1:1for

I RULB: Punulll!.t to 650..30.006(2)(a)2., F.A.C ., Services aho1l be
directed toward asl\lring that the oli.ont's moat immelllate needs are
llddreascd IUld encoumging tho client to remain onjqed In
treatment llJ'Id to follow up on rdt:rrala after dl!ldlarge .... Nut
evident«>- clfm/3 Gdr4ttt«< to detoJt prog1'G1ft appeared to haw
a stro11g MH IJJ&tOI'y tmd twt a.r ,.ucJJ or 1'10 hfstory wUh 8.4 lNt
___ , .l MY,IMIJ.' nnt mldrv!R.f#'d.
1
3.

I

Staffreceived traillillg ancl i:natr:uctioas on ref.'crral ~iR:mtnts to I:II8UI'C MH ncedl are
properly. Thla 'lnli.criu& i~~eluded documentation requirements.

Pursuant to 6S0.30.004 (1) (a). F.A.C.• For those
650..30,004{6), PAC., c:acb.
physician wolkiog with a provider shall embHsh written protocols
tbr the prcM&lon ofmedical&ervices pun\lallt to Chaptera458 and
459, F.S.. and ftlr managing medication according to medical and
ph11Jlt18C)' Btaodanis, pumwrt to Chapter 465, F.S .... Protccol
tai&U ht:YWieYer, no provlsiUfl frnmd whlcb state& U'N can override
MD 'a dn:181o11 to .admit client to de1a% wAm MD ltas alrttady
tk/omjnetl cl/ent did nor Meet crlterill.

~identified in u.

2.

3.

1 • RULE: Pursuant to 6SD-3i).004 (12) (a), F.A.C.,
Client/participant records shall be kept secure from unauthorized
aceess and maintained ID accordmco with 42 Code of Federal
~Part 2 BDd a 397.S0(7), P.S .... lJpJau EMR.polk:y

I

KlPU BMR. Pill TeOOrds are kept on a aeoun'; cuuaDIIJc

data ia enmypted, dateba'IC i• bacllcd \II)

evo.ry night.

Progmn Dliec'lor upduted and poe&cd the pbOM DUmbm of tho Abule Hotline,.

Co\mcil, and the Distrl~a SubstaDco Abuao end Mcartal Health l'roiram Oftice. Phone numbers will also
be provided to clients alintake and in the patient crlen1at!on haodbook.

PapllcA13

 Reeovery lnsdtute of South Florida
Department of Children and Families
Licensure Inspection
Survey Responses from September, 2.014

be IJIBdo to ensure1h111 adcquaw space and equipmellt an: available

for all of the se.Mco componema oftbe 18cillty, snd tbc 'WllioUII
f\mctiODS within the faciJityM,. AithoJigJa cJfen/'S CCVI beplact!Jd In a
nearby bdroom, lhe observation ofcliMtJ placed in a smaU
couc" in llr• middle ofan open mom/hall way ~rmnce 1eems
5.

on 1:1 obaCI'VIdion ror .my
Nursing IIUrtion), if requested by client.

I • RULB: Pur&uaat to 650-30.004 (34) (9). F.AC., Th.e writnm
shall inco«porate evact1ation procedures. .. , Update policy to
Include all ~p.e.' ofdllarters and tlse r-uval and 1torage ofall

Plan & Bmctgency Preparednca Management Pbm in Policies &: I Nikki

enrore all bnildingJ and equipmemt arc ckall and in good repeir.
Supervisor will encure all daily maintenance and houaekeqling furu:tioos ate met

6.

7.

I

I • RULE: Pll1'8U8nl to 6SD-30.004 (34) (J), F.AC. , Pnmders

will ensure that

ensure that hazardous matl:riala are properly ideatified, b:ldled,
stored. used, 8lld dispensed.... Lmmdry room looks grrtGt; Jt.#
tkbrislloose JUnu howe11er, arbfti'wterlng and proper l1mTige ()j
cbemletJI.J and la11ndry lktergtml whtk client$ Q7'e wruhi~ Js

8.

I • RULB: Plli8U8llt to OJlrjU.UUO -

- - -

.

services ~hall be provided u an initial pbase of dotoxification....
Practi« ofp!acr:mtDU Ill derox 'fiQI no prior hlnory and no
SJ~PPiemettt<Jry ilr[ormmkmjrom otlJer c&icalwureu. Luwut
re$/rictivB !let#ng of~nt ~prior 1o ruol'llng to
maybe plami on 1:1 o'*lrVa1lon till' Ut!ty (atatrsrts Wltbin 5
on couch (outside ofNurlii!B station). ifrequetl!ld by client.

9.

tor the politton.

Page 12of18

Nikki

 Reeovery Institute of South Florida
Department of Cbildrea and Familles
Licensure Inspection
Survey Responses from September, 2014

or certificates as

HRfiles

by I HR

job deScrlptlon.

criminal and juvenile m:ords

Departmeot ofLaw

are

cunent (DOt apiriDg llll1i1 ·1212015) and in tile.
6.

Federal crimlnali'CCOI'da cllCCb through the Federal Buteau of~n (FBI) are curreri1 (not
expiring until8fl01 S) 1111d in file.

'ltdi:teDces bave been cootllcted; lettr:ra

PaJB

La ona

10bc

HR. file.

HR. Director

 Page 1 of2
FW: Beatriz's CAP
.JJ Jon Mackler
..- to:
Kelly Lee
11/17/2014 03:29PM
Hide Details
From: Jon Mackler <JonM@recoveryinstitute.com>
To: Kelly Lee/DlO/DCF@DCF

1 Attachment

~

Beatriz Dantzler CAP.pdf

Hi Kelly
I apologize for the delay. The Clinical Director is Beatriz Dantzler, MA, LCDC, CAP. Please advise if you require
anything else? Jon

From: Nancy Zlfer
Sent: Monday, November 17, 2014 3:13PM

To: Jon Mackler
Subject: Beatriz's CAP

Attached is Beatriz's CAP.

file://C:\Temp\notes03 7E 1B\,..,web9508.htm

11118/2014

 Page 2 of2

.NatlaJ Zlf,e!t
Human Resources Director
Recovery Institute of South Florida
1080 SE Third Ave
Fort Lauderdale, FL 33316

file://C:\Temp\notes037E1B\~web9508.htm

11/18/2014

 c' '

(
FLORIDA CERTIFICATION BOARD
August 20, 2014

A Privale, Not-For-Profi1
CQtPOration

Beatri.z Danzler
1350 W Bay Harbor Drive 10 E
Bay Harbor Islands, FL 33154
Re: Your credential Has Been Awarded

Boord of Directors
Deborah Doin
Chairman

Orlando, FL
Timothy Nugent
Past Chalnnao
Ft. Myer.s, FL
Kay Doughty

Secretary
Ta~~~pa,

FL

ThomasOJk
Treanrer
'[al/aha.u{J.8, FL

Dear Ms. Danzler:
Congratulations! The florida Certification Board is pleased to award your
Certified Addiction Professional certification. You are now entitled to use the
initials CAP with your professional credentials.
Please find the enclosed official certificate and verification card. Your CAP
credential Is valid from the date of Issuance through June 30, 2015 and must be
renewed annually. Your certificate will only be printed once. Upon annual
renewal. you will receive a new verification·card.
Please vi~ it our website at wmv.ftwtlf!cationboard.O!'B for important information
regarding the renewal process and approved continuing education providers.
If we can be of further assistance, please contact our office at 850.222.6314

Ray Berry
Hollywood, FL
Frank:Fnmcisco
Maidmrd,FL
LawunPagd
Femandlna Be:ach, FL

Sincerely,

Gabe Holmes
Certification Specialist

hvfng Williams
Pensacola, FL

Neal A. McGany
Presldeat & CEO

1715 S. Gadsden Street • Tallahassee. Florida 32301 Phone: 850-222-6314 Fax: 850-222-62~7 Website: www.flcertificationboard.org

 (

Beatriz Dantzler
1350 W Bay Harbor Drive 10 E
BAY HARBOR ISLANDS FL 33154
United states

08104/2014

Dear Beatriz Dantzler:
Thank you for taking the Florida Addiction Exam. Below you will find your preliminary resuHs:
Score: 79

Results: Pass
Congratulations!! Your credential effective date is the same date you passed the Florida Addiction
Exam. The FCB will be mailing your wall certificate and wallet certification card within four to six weeks.
For questions or information, please contact your Certification Specialist at 850-222-6314.
Again, ~ngratulatlons on this exciting professional accomplishment!
Florida Certification Board

httt>s:/lwww.smttest.com/smtrei>ortlibiPreview.aspx

8/19/2014

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Qualified Professional
Kelly Lee to: jonm

11/06/2014 12:56 PM

Jon,
I received a notice from Stephen Herz indicating that he is no longer associated with RISF or Christian
Recovery Solutions. An updated clinical director and their license is necessary for the files.
Thanks.
Kelly Lee
Licensing Specialist
Florida Department of Children & Families
Broward County - Circuit 17
201 W. Broward Boulevard, Suite 511
Ft Lauderdale, FL 33301
OFFICE- 954.453.3467
NUMBER HAS CHANGED -PLEASE MAKE A NOTE OF IT!

DCF Mission
* Protect the Vulnerable
* Promote Strong and Economically Self-Sufficient Families
*Advance Personal and Family Recovery and Resiliency

 Page 1 of 1
Clinical License
J Stephen Herz
' to:
Kelly Lee
11/04/2014 02:25PM
Hide Details
From: Stephen Herz <sherz@rmisfl.org>
To: Kelly Lee/DIO/DCF@DCF

I wish to inform you that I no longer have any affiliation with the "Recovery Institute or South
Florida" or "Christian Recovery Solutions" and would like my name and license removed as their
Clinical Director of record.
Thank you
Stephen M. Herz MS, LMHC, CAP
Clinical Director
R~wakening Wellness Center
3600 Red Road, 5th Floor
Miramar, Fl 33025
Office: (954) 544-3000 Ext. 1028
Fax: (305) 230-3869
The document(s) included in this electronic transmission could contain confidential health
infonnation that is legally privileged. This infonnation is intended only for the use of the
individual or entity named above. The authorized recipient of this information is prohibited from
disclosing this information to any other party unless required to do so by law, and is required to
destroy the information after its stated need has been fulfilled.
If you are not the intended recipient, you are hereby notified that any disclosure, copying,
distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If
you have received this information in error, please notify the sender and arrange for the return or
destruction of these documents."

file://C:\Temp\notes037E1B\-web3687.htm

11/4/2014

 Rick Scott
Governor

State of Florida

Department of Children and Families

Mike Carroll
Interim Secretary

MYfLFAMIU ES.COM

em4eJ" J

011 ,_, (!; /'ecc~ I
.J

/ I

Dennis Miles

"'Sh ~ ·CD" D~rector
Rf!gional Managing

September 29,2014
Jon Mackler, CEO
Recovery Institute of South Florida, Inc.
1080 S.E. 3rd Avenue
Ft. Lauderdale, Florida 33316
Dear Dr. Jon Mackler
This letter is official notification that your facility has completed a licensure site visit by
this Department on 09/19/2014 and will be issued a license for Residential
Detoxification and Residential Level21ocated at 5540 Davie Road, Davie, Florida
33314 and Day or Night Treatment with Community Housin~, Intensive Outpatient
Treatment, and Outpatient Treatment located at 1080 SE 3 Avenue, Fort Lauderdale,
Florida 33316. The actual licenses and monitoring report are being processed and will
be mailed to your office when completed.
Contact me at 954.453.3467 should you have questions regarding this matter.

cc: Licensure File

Substance Abuse and Mental Health Program Office
Southeast Region and Circuit 17
201 W. Broward Boulevard, Suite 511 , Fort Lauderdale, Florida 33301

Mission: Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and
Advance Personal and Family Rec<1Very and Resiliency

 State of Florida

Department of Children and Families

0811812014
Jon Madder, CEO
Recovery ln8tltuta of South Florida. Inc.
1080 S.E. 3rd Avenue. Floor# 1
A. Lauderdale, Florida 33316
Dear Jon Mackler.
The C17 Substance Abuse ttnd Mental Healh Program Office ~ yow application
tor licensure spaclftc to substance abuse treatment and/or seMce& at 1080 SE 3td Ave,
Ft. Lauderdale, Florida, 33316. The applca1fon was Incomplete as follows:
- q.
a ~t~,.

f

Provide the fire inspeclian 5540 Davia and IJrthe Community Housing Address;__-;
Cunant General Uabillty Binder with the Ccnmunly HouDig addr&es addec{;? - f\D {.'{, (..f..e ;..
~
• C&mlnt P!OfessJonal Liability Binder,
;- e
··~~~·K • Provide lk:enae and bbforthe Qualifled PratessJonal and Medk:al Director;
'·

4

.S • Provide documentation of 1tnanctal labftlty;
'4-b. Provtda thP. Affldavit of Good Maiil Character for Terry LMnl;

14..b • Pro'Jide the Organizational Chat_With the posftlon n corresponding names:
t 1· b • HiV/AIDS Education: Jnclude oompleUon confirma~n d baalc HfV/AIDS
f()
educdo" requirement as required In eectlon 381.0036. F.S.;
/.

I/

4

:

.::::~=~~~InspeCtion br 6540 Davfe Addtedi(_.,.. l)o

Pli'SU8ntto s. 850-30.003(9) (a) 1•• F.A.C., folowfng rec.eipt ofwrltlen notification that
the appllcatlools Incomplete, the applicari shall h8Y8 10 working day& to aubml the
requ~ fnl'ormation to~ cireult o1l1ce.. If the apPlicant naedsedditional ti.ine to submit
the required Information it may request such additional time Within 6 daya of the
deadline for submitting the information. The mqueat shEll be approved or denied by the
clroutt office wlthih 5 days of receipt. Any n:mewal applka1t that fails to meet these
deadlines shal be asseSSed ah additional fee equaJ to tha late fee provlc:.fed for In s.
397.407(2), F.S., $100 per licensed oomponem.
·

contact me at 954.453.3467 should ~u haw questions rvgarding this matter.

cc: l...icen8ln Ale
Substance Abuse and Mentllf Heellh Program OITice
Soulheut Region and Crcuit 17
201 W. Broward Boulevard, Sule 611, Fort Laudanfale, Aot1da 33301

Minion: hoiiCIIM

V.JI1D'Qbl~ Pr~ SIMftg lllfll ~ &/f-Silffldmt F-.6/q.

Advance Penonol a1WI F111111ly ~ 1111dIWiJJIJtq

attd

 Page 1 of 1
Requested additional documentation
~ SteveHerz
.,. to:
Kelly Lee
09/09/2014 12:34 PM
Hide Details
From: Steve Herz <SteveH@recoveryinstitute.com>
To: Kelly Lee/DIO/DCF@DCF

I Attachment
IJil.

}.

DCF Requested Documents. pdf
Attached, please find the documents you requested in addition to what we already sent In for our licenses. If
you need anything else, please don't hesitate to let me know.
Sincerely,

Stephen M. Herz L1YIHC, CAP
Program Director
The Recovery Institute of South Florida
1080 SE 3rd Ave, Fort Lauderdale, FL 33316
954-960-7091 #602
Steveh@recoveryinstitute.com

file://C:\Temp\notes037E1B\~web7756.htm

9/9/2014

 Rick Scott
Governor

State of Florida

Department of Children and Families

Mike Carroll
Interim Secretary

MYFLfAMILIES.COM

~. L I : j ~ tZ> · ~

08/18/2014

Dennis Miles
Regional Managing

vt.A ~cciV't:nl
1'1 s£~.
· J
~/rector

Jon Mackler, CEO
Recovery Institute of South Florida, Inc.
1080 S.E. 3rd Avenue, Floor# 1
Ft. Lauderdale, Florida 33316
Dear Jon Mackler:
The C17 Substance Abuse and Mental Health Program Office received your application
for licensure specific to substance abuse treatment and/or services at 1080 SE 3rd Ave,
Ft. Lauderdale, Florida, 33316. The application was incomplete as follows:
•
•
•
•
•
•
•
•
•
•

Provide the fire inspection 5540 Davie and for the Community Housing Address;
Current General Liability Binder with the Community Housing address added;
Current Professional Liability Binder;
Provide License and bio for the Qualified Professional and Medical Director;
Provide documentation of financial liability;
Provide the Affidavit of Good Moral Character for Terry Livorsi;
Provide the Organizational Chart with the position and corresponding names ;
HIV/AIDS Education: Include completion confirmation of basic HIV/AIDS
education requirement as required in section 381.0035, F.S.;
Provide the Pharmacy License;
Provide the Facility/Group Home Inspection for 5540 Davie Address;

Pursuant to s. 650-30.003(9) (a) 1., F.A.C., following receipt of written notification that
the application is incomplete, the applicant shall have 10 working days to submit the
required information to the circuit office. If the applicant needs additional time to submit
the required information it may request such additional time within 5 days of the
deadline for submitting the information. The request shall be approved or denied by the
circuit office within 5 days of receipt. Any renewal applicant that fails to meet these
deadlines shall be assessed an additional fee equal to the late fee provided for in s.
397.407(2), F.S., $100 per licensed component.
ntact me at 954.453.3467 should you have questions regarding this matter.

cc: Licensure File
Substance Abuse and Mental Health Program Office
Southeast Region and Circuit 17
201 W. Broward Boulevard, Suite 511, Fort Lauderdale, Florida 33301
Mission: Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and
Advance Personal and Family Recovery and Resiliency

 '

11.8.(1 )(b) Renewal Applicants
Complete application C&F-SA Form 4024 as follows:
1.

~b._

Accreditation Information

~

If tc&edited by a Department recognized accrediting agency, include a copy of the most current accreditation
papers and accreditation survey report. Also, include the effective and expiration dates of accreditation.
Effec:tiw Date of Accreditation: _ _ _ _ _ _ _ _ _ __
Expiration Date of Accreditation:_ _ _ _ _ _ _ _ _ __

2. LAgency Information
Provide name and address of the applying service provider and its director, owner, corporate officers, board
members, and shareholders.
Note - this only applies if there has been a change since either the initial application, or most recent renewal.

3. /
Fire and Safety
Provide documentation of compliance with local fire and safe
Expiration Date: - - - - - - - -

License Number: _ _ _ __ _ __
Note: If a private organization is used, the inspector must be licensed by the State of Florida Fire College.
(Please add expiration date on each application. Agencies with multiple sites please use addendum listing
addresses and ~nd iniJXpiraJoJ dates).

4.1 Healthlr~=,,.;,;nf2Yood)l~p'!jti~ns
Provide

5.

docume~f compliance with health codes.

_L

Zoning Compliance
Provide_qpgumentation..of compliance wclh~eo~ ic~lly appropriate zoning ordinances.

6.

r~~oral c~~ter 1'0( {vn

Provide the notarized s tement of good moral character. located at the following address.
://www.dcf.state.fl.usf r: rams/back roundscreenin /docs/Affidavit%20of%20Good%20Morai%20Charact
10.
er%2

_L

7.
Business Tax Receipt
Provide the Business Tax Receipt as required in your county or municipality (Formerly referenced as
Occupational License).
Note: If your organization is exempt from paying a business tax receipt, include documentation from the
jurisdiction providing the exemption.

/,i/Ar

8.
Medication Maintenance Programs Only
If ~adone and medication maintenance treatment program, pr·:>Vide documents demonstrating approval
by the Drug Enforcement Administration (DEA), Substance Abuse and Mental Health Services Administration
(SAMHSA) and, State Board of Pharmacy (Board).

 Treatment Resource Affidav
Provide the treatment resource affidavit as proof of fingerprinting and Level 2 b ackground screening for:
Owners,
• Chief Executive Officers (~ ,
Chief Finane· - fficers{CFOs), and
• Staff and volu nteers who have direct contact with clients under the :;~ge vf ~ 8 and adult-s who are
developmentally disabled.
The form is located at the f ollowing address:
http://www. dcf.state.fl.us/programs/samh/SubstanceA buseldocsltreatmentresource. pdf.
See (http://www.dcf.state.fl.us/programslbackgroundscreeningl) to find the DCF Regional Background
Screening Coordinator nearest to you. ·
Background Screen ing OCA/Identifier Number: - --

- -- --

10. /
Local Law Enforcement Check
Provide the results of the local law enforcement check for:
• Owners,
• CEO,
• CFO, and
• Staff who have direct contact w ith clients.
The licensee must re-screen applicable staff every five years, in the person's County of residence.
11 . /
Client Service Fee Schedule
Include policy regarding a client's/participant's financial responsibility outlining what the client/participant is
obligated to pay.
Inmate Programs operated within Department of Corrections (DOC) facilities, or contracted to the Department
of Management of Services (OMS), are exempt from this requirement.

Note - this only applies if there has been a change since either the initial application, or most recent renewal.

_i__

12.
Application Item #29:
Include in block 29 (not as an attachment) a comprehensive and concise outline of the services to be provided.
Each application should contain the program description for that component only. Space is limited to 1,000
characters.
Addictions Receiving Facilities, Detox and Residential programs should include licensed bed capacity in their
program description.

Note - tpis only applies if there has been a change since either the initial application, or most recent renewal.

V

13.
Provider CEO Information
Provide documentation of the competency and ability of the applicant and its CEO to carry out the
requirements of ch. 65D-30, F.A .C. This includes, but is not limited to:
• Curriculum vitae, or resume;
• Credentials; and
• Board of Directors' minutes approving the appointment of CEO.
10

 Providers accredited by a Dep
1ent-recognized accrediting organizatic ~ 'ind Inmate Programs operated
directly by DOC or OMS are exempt from this requirement.
Note - this only applies if there has been a change since either the initial application, or most recent renewal.

14. _ _ Financial Viability
Provide documentation of financial viability.
Providers accredited by a Department-recognized accrediting organization and Inmate Programs operated
directly by DOC or OMS are exempt from this requirement.

V

15.
Current Insurance Coverage
Provide documentation demonstrating professional and property liability insurance coverage.

Add expiration date on each application. Agencies with multiple sites please use addendum listing addresses
and corresponding expiration dates.
Providers accredited by a Department-recognized accrediting organization and Inmate Programs operated
directly by DOC or OMS are exempt from this requirement.

L

16.
HIV/AIDS Education
Include documentation of compliance with s. 381 .0035, F.S.
Note - this only applies ff there has been a change since either the initial application, or most recent renewal.

17. _ _ Application Fee
Include the license fee (Please paper c lip to the first page of the application packet).
18. _ _ Application Checklist
Include a copy of this completed checklist.

19. _ _ Application for Licensing
C&F-SA Form 4024, in the latest revis'ion.
Note: Completed application must be provided to the Department at feast 60 days prior to expiration of current
license. Late applications will incur a $100.00 late fee per licensable service component.

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