STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
HOME HEALTH CARE OF BAY )
COUNTY, FLORIDA, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 87-2151
) DEPARTMENT OF HEALTH AND ) REHABILITATIVE SERVICES, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, a formal hearing was held on September 11, 1987, in Panama City, Florida, and on September 21, 1987, in Tallahassee, Florida, before the Division of Administrative Hearings, by its designated Hearing Officer, Diane K. Kiesling.
APPEARANCES
For Petitioner: Bryon B. Mathews, Jr., Esquire
Vicki Gordon Kaufman, Esquire McDermott, Will and Emory
101 N. Monroe Street, Suite 1090 Tallahassee, Florida 32301
For Respondent: Theodore E. Mack, Esquire
Assistant General Counsel Department of Health and
Rehabilitative Services Regulation & Health Facilities Ft. Knox Executive Center
2727 Mahan Drive
Tallahassee, Florida 32308 ISSUES
The issue is whether Petitioner, Home Health of Bay County, Florida, Inc., (Home Health Care of Bay) is entitled to a certificate of Need to establish a Medicare-certified home health agency in Bay County, Florida.
Home Health Care of Bay presented the testimony of Mark Ehrman, M.D., Marta Hardy, and Deborah S. Kolb, Ph.D. Home Health Care of Bay's Exhibits 1, 2, 3, 3A, 3B, 3C, 4A, 4B, 5, 9-12, 18, and 20 were admitted in evidence. The Department of Health and Rehabilitative Services (DHRS) presented the testimony of Joyce Farr, David Carter, Laura Young, R.N., and Anne Parmer. Home Health Care of Bay recalled Dr. Ehrman and Dr. Kolb on rebuttal.
The parties filed proposed findings of fact and conclusions of law. All proposed findings of fact have been considered and a specific ruling has been made on each proposed finding of fact in the Appendix attached hereto and made a part of this Recommended Order.
FINDINGS OF FACT
This proceeding involves certificate of need (CON) application No. 4912 by Home Health Care of Bay to establish a Medicare-certified home health agency to serve Bay County Florida.
Home Health Care of Bay's CON application was timely filed on December 15, 1986. Home Health Care of Bay's application was deemed complete on March 2, 1987.
On April 30, 1987, DHRS preliminarily denied Home Health Care of Bay's CON application based on a determination that:
There was no need demonstrated by Home Health Care of Bay for an additional home health agency in Bay County.
Home Health Care of Bay is owned by Mark Ehrman, M.D. Dr. Ehrman is a board-certified internist, hematologist, and oncologist. Dr. Ehrman has been in private practice in Fort Walton Beach, Florida, since November, 1984. Prior to 1984, Dr. Ehrman was involved in the organization and delivery of medical services, the teaching of medicine, and the practice of medicine in Canada.
Home Health Care of Bay will serve all patients regardless of race, income, sex, ethnic background, religion, or physical handicap.
Home Health Care of Bay will provide 3 percent Medicaid and 3 percent indigent home health visits.
Dr. Ehrman, both in his office and in his durable medical equipment (DME) company, goes to great lengths to ensure that indigent persons receive medical services.
Dr. Ehrman, in his office practice, provides medical services to all persons regardless of their ability to pay. He is a participating physician in Medicare, Medicaid, and other insurance programs. Dr. Ehrman's participation in these programs and his determination not to screen patients financially has increase access to medically underserved patients. Dr. Ehrman's private practice includes approximately 5 percent Medicaid patients.
In the past, home health agencies have tended to focus on acute medical problems. The traditional model for home health care has been to shorten an acute hospital stay for a discrete problem. Even chronically ill patients still came to the hospital when they had an acute episode. There has been little focus on avoiding hospitalization.
There is now a shift in home health care which attempts to avoid hospitalization in appropriate cases. Dr. Ehrman, in treating patients at home, has become involved with sophisticated triage procedures, home pain management, and other procedures which maximize a patient's time outside the hospital. Such procedures allow patients to remain safely and comfortably in their homes.
Procedures which can be safely done in the home include the starting of I/V morphine drips or I/V antibiotics. These procedures have traditionally not been done in the home.
Nationally, and in Bay County, several factors are causing a shift to home health use. First, pressure is being applied in the form of reimbursement mechanisms to reduce the expense of institutional care. Patients are discharged from the hospital sooner and there is more pressure to use home health services.
Second, an increased incidence of chronic illnesses, such as AIDS, will increase the use of home health services. The incidence of AIDS and AIDS related diseases will continue to increase and has obvious implications for increased home health usage. Home health care will make "hospital-like" care more available and less expensive for AIDS patients.
Third, health consumers want to maintain the quality of their lives and remain at home as long as possible.
HOME HEALTH CARE OF BAY'S PROPOSAL
Home Health Care of Bay will provide medical personnel services in the disciplines of registered nursing, certified home health aides, occupational therapy, speech therapy, physical therapy, and medical/social work.
These services will be provided to Medicare, private insurance, and indigent patients.
Home Health Care of Bay will provide traditional home health services and many "high-tech" services which currently are not available at all or are not routinely done in Bay County. Such services include the transfusion of blood and blood products, professional pain management, the drawing of arterial blood gases, the care of Groshong and Hickman catheters, and the care of subcutaneous pumps and subcutaneous venous access devices.
Home Health Care of Bay's proposed services will be utilized by many different types of patients, including renal patients, chronic pulmonary patients, chronic heart disease patients, and cancer patients.
Home Health Care of Bay will provide health care services to AIDS patients.
Petitioner's Exhibit 5 contains a complete list of services which Home Health Care of Bay will provide.
Home Health Care of Bay's services will be available 24 hours a day, 7 days a week. This is an important commitment because home health care patients need services regardless of the time of day or day of the week.
Even more important than the discrete list of services that Home Health Care of Bay will provide is the integration of all these services into one agency. In that way, patients are not shuttled from place to place; their care can be organized and integrated for maximum benefit. This integration will be accomplished by formulation of a plan of therapy which will include evaluation by a social worker and a physician in order to deal with the patient's total needs.
Home Health Care of Bay's commitment to a total integration of patient services is evidenced by its plan to provide 4 percent of its visits in the medical/social work category. Such services are important in providing comprehensive care.
The provision of medical/social work services will help patients and their families identify both medical and non- medical needs. Once such needs are identified, the patients and families can be channeled to the appropriate services, agencies and resources.
Home Health Care of Bay will provide the physician with direct and timely communication about the patient. This will include daily delivery of complete medical records. Such a service is crucial in order to provide home care to patients with complicated problems.
Home Health Care of Bay has a budget line item for marketing of
$21,000 in the first year and $18,000 in the second year of operation. This money will be used to change the perception and pattern of home health use. Patients and doctors will be made aware of the availability of new home health services and the integration of those services with existing services.
Home Health Care of Bay's marketing effort will overcome the reluctance of some physicians to utilize home health services.
The demographics of the subdistrict of Bay County were analyzed and compared to the demographics of District II. The analysis shows that from 1986 to 1989, 3,076 persons 65 and over will be added to the population of Bay County. This represents a growth rate of 21.5 percent in Bay County compared to a district growth rate of 12.4 percent.
Of the elderly growth in District II of 7,355, approximately 40 percent of such growth is occurring in Bay County. Forty percent (40 percent) is a high percentage in a 14 county district and indicates that the elderly population in Bay County is growing at a very rapid rate.
Elderly persons are the most frequent users of home health services. Thus, rapid population growth is occurring in the segment of the population most in need of home health services.
STATUTORY CRITERIA 1/
Consistency With State Health Plan
Home Health Care of Bay`s proposal was reviewed for conformity with the State Health Plan and is consistent with that plan.
The 1985-1987 Florida State Health Plan states:
Home health agencies provide nursing, health aid, therapy and other kinds of services to patients in their homes. This allows individuals to remain at home rather than use more expensive institutional care to recover from acute illness or to manage chronic conditions.
The State Health Plan further states:
Home health services can be a cost effective form of long term care for the elderly and the infirm.
The provision of home health services proposed by Home Health Care of Bay will provide residents of Bay County with a lower cost alternative to institutionalized long term care as referenced in the above State Health Plan excerpts.
The State Health Plan also addresses the unwillingness of many providers to serve the medically needy:
Medicare is the largest payor for home health care to the elderly, though some private insurers and Medicaid both cover home health services. Policy makers are increasingly concerned about providers' willingness to serve Medicaid recipients and medically indigent Floridians.
Home Health Care of Bay has committed to provide at least 3 percent Medicaid and 3 percent indigent visits. Such a commitment will greatly increase access of medically underserved groups.
Approval of a provider who accepts a significant portion of Medicaid patients will encourage current providers to accept such patients in order to retain their Medicare and private referrals. Physicians and discharge planners are much more willing to refer to an agency that will care for all their patients.
The State Health Plan contains the following objective:
OBJECTIVE 1.5.: To assure that the number of home health agencies in each service area promote the greatest extent of competition consistent with reasonable economies of scale by 1987.
The methodology utilized by Home Health Care of Bay to project need maximizes competition consistent with economies of scale by allowing additional providers to enter the market while maintaining existing agencies at a size at which they can operate efficiently.
Consistency With Local Health Plan
Home Health Care of Bay's proposal was reviewed in relation to the 1986 District Two Health Plan and is consistent with that plan.
The local health plan contains a section on long-term care services, including home health services. This section contains a numerical methodology to determine need. That methodology indicates a need for an additional agency in Bay County.
The local health plan also contains priorities for home health services. Priority C states that:
Priority will be given to home health services applications who have a history of providing, or will commit to provide, services to Medicare, Medicaid and medically indigent patients.
Dr. Ehrman, the owner of Home Health Care of Bay, has a record in his practice of providing services to all payor groups. He has committed to continue to do so in his home health agency.
Priority D of the Local Health Plan states:
Priority will be given to home health services applicants who have a history of providing, or will commit to provide, a public marketing program for their services which includes pamphlets, public service announcement and various other community awareness activities.
Home Health Care of Bay has budgeted for and committed to an extensive marketing program.
A marketing priority is unusual in a local health plan and indicates an awareness of the need to educate the public about home health services.
Determination Of Need
DHRS currently has no rule governing the need for home health agencies.
A historical summary of the regulation of home health agencies in Florida is described in a memorandum prepared by Ms. Marta V. Hardy.
Ms. Hardy was the Deputy Assistant Secretary for Regulation and Health Facilities, DHRS, from September 1984 through June 1987. Ms. Hardy was responsible for all CON decisions and was the ultimate decision-maker in regard to the preliminary denial of Home Health Care of Bay's CON.
In the fall of 1984, DHRS attempted to promulgate a rule to replace the invalidated Rule of 300. This proposed rule was based on a use rate methodology, but was invalidated in a rule challenged proceeding in 1985.
After the invalidation of the proposed rule, DHRS implemented an interim policy which it used to review home health agencies. This interim policy is reflected in the "Bob Sharpe memo," dated May 15, 1986. The interim policy was applied to home health agency application beginning with the first batching cycle in 1986.
The interim policy utilized a variation of the previously invalidated rule and attempted to correct the problems which caused the proposed rule to be found invalid.
The interim policy is a use rate/population methodology which projects the number of Medicare enrollees using home health services in the future. This number is multiplied by the average number of visits per Medicare home health user. The total number of visits is divided by an agency size of 9,000 visits to yield the gross number of agencies needed. The total number of licensed and approved agencies is subtracted from the gross need number to yield the net number of agencies needs. The interim policy phased in the needed agencies over a three year period.
DHRS defended the interim policy in circuit court when the Florida Association of Home Health Agencies (FAHHA) sought to stop DHRS from using the policy. DHRS defended the interim policy in December, 1986, before the First District Court of Appeal.
Use of the interim policy resulted in the approval of 23 home health agencies.
DHRS abandoned its interim policy sometime in the fall of 1986. No notice was given to the public or to interested parties that a change in DHRS policy had occurred. DHRS published no document rescinding the Sharpe memo.
Only after applications were filed in the second batching cycle of 1986, were applicants informed that DHRS had changed its interim policy.
Applicants in the December, 1986, batching cycle, including Home Health Care of Bay, were asked for an unlimited extension of time within which DHRS could render a decision.
Applicants who refused to agree to an extension were evaluated on the basis of the "statutory need criteria." Applicants who did not agree to an extension were denied.
In only one instance was a CON granted after abandonment of the interim policy. This occurred in Franklin County, where no home health agency existed at the time of that approval.
DHRS' new "policy" was not developed by DHRS health planners.
The "policy" put the burden of proof on the applicant to demonstrate an unmet need. Such a demonstration would be difficult to make.
The Office of Community Medical Facilities, the office within DHRS responsible for preliminary CON review, reviewed Home Health Care of Bay's application using the "policy" based on "the thirteen statutory criteria." Such a review required Home Health Care of Bay to prove need by demonstrating an unmet need.
However, as evidenced by the Office of Community Medical Facilities' review of Home Health Care of Bay's application, a policy requiring an applicant to meet a negative burden of proof is unreasonable. It imposes a standard which is virtually impossible for an applicant to meet.
Ms. Joyce Farr was the DHRS employee responsible for the review of Home Health Care of Bay's application and for the development of the related State Agency Action Report (SAAR). The SAAR was the only work product Ms. Farr prepared in regard to Home Health Care of Bay's application.
Ms. Farr has never been qualified as an expert witness in the home health area. Ms. Farr has no formal education in health planning and is unfamiliar with Medicare reimbursement. Ms. Farr does not consider herself to be an expert in financial feasibility projections, staffing, or quality of care.
Ms. Farr is not in a policy-making position at DHRS.
Ms. Farr was given no instructions by her superiors as to how to review Home Health Care of Bay's application.
DHRS presented the testimony of Ms. Farr to attempt to explain how Home Health Care of Bay's application was reviewed. Ms. Farr was tendered and accepted, not as an expert health planner, but as an expert in "CON review."
Ms. Farr articulated the standard she used to determine need: [I]f an applicant or residents of a county
or community resources of a county or just
about any organization basically says that there is an unmet need, meaning that there is no home health services available or there is an accessibility problem where certain groups are not being served -- certain services are not being offered -- I become aware of it by their simply documenting, "I cannot get home health services," like CAPS [Capitol Area Community Aging Agency] that said, "They aren't serving these people. We need somebody in here to serve these people."
That would show that there was an unmet need.
Unless an applicant, or community resource, could demonstrate an accessibility problem, no need existed according to Ms. Farr.
Ms. Farr did not review the Medicare cost reports of current providers to determine the services they provided prior to recommending denial of Home Health Care of Bay's application.
Ms. Farr reviewed utilization data of current providers for only one year.
Ms. Farr did no analysis of the types of visits provided by existing providers. Ms. Farr looked only at the total number of visits. The only information Ms. Farr utilized in regard to the type of visits being provided was information given to her by existing providers.
In determining that no need existed for medical/social work services, Ms. Farr relied on the list of social service agencies included in the local health plan, but did no analysis as to what services such agencies offered.
Ms. Farr determined that no Medicaid access problem existed in Bay County based on information current providers gave her. She did not verify these representations with the Medicaid office.
Ms. Farr did no charge comparison in her review.
At the time of her review, Ms. Farr did not know when a new competitor last entered the market in Bay County.
Ms. Farr did not address Objective 1.5 of the State Health Plan in her review. She was unaware of Objective 1.5 until it was pointed out to her in deposition.
Ms. Farr utilized no planning horizon in determining need, though she admitted that one of the purposes of CON review is to plan for future health needs.
Ms. Farr's review of Home Health Care of Bay's application was deficient for several reasons. First, Ms. Farr's review did not look at a projection of future need. It did not analyze demographics or utilize a planning horizon. It contains no elements of a needs analysis. A mere review of what currently exists misses the point of health planning.
Second, in making a determination of no need, Ms. Farr relied solely on comments of existing providers who told her that there was no need for a competing agency.
Dr. Deborah Kolb, vice-president of Jennings, Ryan, Federa & Co., participated in the preparation of Home Health Care of Bay's CON application.
In preparing the needs assessment portion of the application, Dr. Kolb reviewed the State Health Plan, the Local Health Plan, utilization data, home health CON decisions, and services offered by current providers.
The need methodology which appears in Home Health Care of Bay's application is contained in Dr. Kolb's expert report.
The methodology appearing in her report and the application was the interim policy in use by DHRS at the time the application was filed. This was the methodology in the Bob Sharpe memo.
Home Health Care of Bay will provide home health services to the residents of Bay County.
Bay County is in DHRS Service District II. According to the 1986 District II Health Plan, District II is composed of 14 separate subdistricts. Each subdistrict is composed of one county.
Bay County is a reasonable service area for Home Health Care of Bay.
Dr. Kolb utilized a two-year planning horizon to project the need for home health agencies. This is a reasonable planning horizon.
Table 3 of Dr. Kolb's report analyzes need on a district-wide basis. Two time frames, July, 1988, and January, 1989, are shown because Home Health Care of Bay's application was filed in December, 1986. Two years from that date would be December 1988. The official population projections from the Governor's Office focus on July and January of each year. Use of the two project dates straddles the December, 1988, planning horizon.
The population numbers of District II for 65 and over are 62,546 for January, 1988, and 63,558 for January, 1989.
The 1984 Medicare use rate, which is an estimate of the number of Medicare home health visits per elderly person in Florida for 1984, is multiplied by the projected elderly population to arrive at a projected number of visits.
The number of projected visits in Table 3 of 118,565 in July, 1988, and 120,483 in January, 1989, is a result of multiplying the use rate by the projected population.
To determine the number of agencies needed, the projected number of visits is divided by optimal agency size. This calculation yields a gross agency need of 13 agencies in the district in July, 1988, and January, 1989.
The number of licensed and approved agencies, 12, is subtracted from gross need, 13, to yield net need of one (1) agency in July, 1988, and January, 1989.
Dr. Kolb utilized 9,000 for the optimal agency size figure. This is consistent with the interim policy and with data which suggests that is where economies of scale occur. An optimal agency size of 9,000 appears in the Local Health Plan methodology.
Table 4 of Dr. Kolb's report presents the same analysis as Table 3, described above, on a subdistrict basis to determine where the one agency found to be needed in District II should be located.
Use of the same methodology results in a gross agency need of three. The two existing agencies are subtracted from the gross need of three to yield a net need for one agency in July, 1988, and January, 1989, in Bay County.
The methodology described above is a reasonable one for determining need. The methodology utilizes a common health planning approach. It is the same methodology used by DHRS as an interim policy. It is the same type of methodology used by DHRS in planning for other types of health services.
Beyond the numerical analysis discussed above, other factors indicate the need for an additional home health agency in Bay County.
Bay County has a very low home health use rate and a very high nursing home use rate.
The Bay County home health use rate is 1.5 visits per person 65 years and older. The Bay County use rate is significantly lower than the state use rate of 1.89. This disparity indicates a gap between real need and historical utilization.
At the same time, Bay County has a nursing home use rate of 41 beds per thousand elderly compared to a state rate of 23 beds per thousand.
Additionally, the occupied nursing home beds per thousand elderly is much greater in Bay County than in the state. In the state there are 21.3 occupied beds per thousand elderly. The utilization of Bay County's nursing home beds is approximately 75 percent greater than utilization in the state as a whole.
These statistics suggest an inappropriate allocation of resources between home health care services and more expensive institutional nursing home services.
Nursing home utilization would decrease with more sophisticated home health care. Many people are inappropriately institutionalized in nursing homes and could be cared for at home.
From a medical perspective, Dr. Ehrman was of the opinion that an additional home health agency was needed.
Availability, Quality Of Care, Efficiency, Appropriateness, Accessibility, Extent Of Utilization, And Adequacy Of Like And Existing Services
There are currently two Medicare-certified home health care agencies serving Bay County.
One way to evaluate agency performance is to analyze the mix of services and the number and types of visits being provided. Current providers have concentrated heavily on providing nursing and aide visits. Of approximately 18,000 visits provided each year, approximately 16,000 visits comprised the nursing and aide categories. Neither provider did any specifically medical/social work visits in 1985 or 1986.
Additionally, the total number of visits delivered to the residents of Bay County has remained constant in 1985 and 1986. Bay County's constant use rate illustrates the need for more education in regard to home health services.
While current providers do certain high tech procedures if directed to by a doctor, current providers are not committed to consistently doing high tech procedures. High tech services are not the most profitable. Their margins are often low and it is more economically beneficial for current providers to provide aide services. Transfusions, initiation of I/V antibiotics, continuous infusion of morphine, pain nursing, and catheter care are all services which existing agencies have rarely done or do with great difficulty. Without doing such procedures as a regular basis, competency is difficult to maintain.
Bay Home Health Care Agency d/b/a Home Health of Panama City (Home Health of Panama City) is a free-standing home health agency and has been in business for 11 1/2 years. Home Health of Panama City does no Medicaid visits. Bay Medical Center Home Health receives referrals from Home Health of Panama City because Home Health of Panama City does not take Medicaid or indigent patients. Home Health of Panama City does no medical/social work visits.
Home Health of Panama City has no money budgeted for marketing.
Bay Medical Center Home Health is a hospital based home health agency. It functions as a department of Bay Medical Center, an acute care hospital located in Panama City, Florida.
In the past two years, Bay Medical Center Home Health has provided no medical/social work visits though some of those services were provided by nurses during nursing visits or by other departments of Bay Medical Center.
Bay Medical Center Home Health does not currently provide care of certain high tech devices such as the Denver pleuroperitoneal pump or the subclavian pump. Its staff would have to be trained to provide such care.
Bay Medical Center Home Health has never given blood transfusions or cared for a Denver shunt.
Bay Medical Center Home Health has a very low number of average visits per patient (6.8) when compared to the state average of 30 visits per patient.
Bay Medical Center Home Health does a low percentage of Medicaid visits. In 1986, Bay Medical Center Home Health was reimbursed for 120 Medicaid visits out of a total of 3,280 Medicaid-reimbursed visits provided in District II.
A comparison of reimbursed Medicaid visits provided by Bay Medical Center Home Health to District II as a whole demonstrates a Medicaid access problem. In 1986, Bay County had 25 percent of the district's population and 16 1/2 percent of the district's Medicaid eligible. Yet only 3.7 percent of the district's Medicaid-reimbursed home health visits were provided in Bay County. If services were Medicaid accessible, the number of Medicaid visits would be closer to the Medicaid percent of the population.
Bay Medical Center Home Health Care's Medicaid visits represented only 1 percent of their total visits for 1986.
When Home Health of Panama City's zero (0) Medicaid visits is considered, out of all home health visits provided in Bay County only 0.7 percent were Medicaid visits.
Approximately 25 percent of Dr. Ehrman's patients from the Panama City area are Medicaid or indigent. This evidences a need for more Medicaid services.
Bay Medical Center Home Health has no line item for marketing and advertising.
Ability of the Applicant To Provide Quality of Care
Dr. Ehrman is a highly trained and experienced physician. While in Canada, Dr. Ehrman established a hematology and oncology health care delivery system in Montreal. This system is still in existence and working well.
Dr. Ehrman has been instrumental in improving the delivery of health care in his practice area. He has established tumor boards at local hospitals and provided many new procedures and devices in the home.
Dr. Ehrman has raised the level of awareness on the part of other practitioners in his area as to a team approach to the delivery of services. This has increased the type of home services now available.
Dr. Ehrman has responded to the needs of his patients for a multi- disciplinary approach to oncology by associating a clinical psychologist. This person deals with the psychological needs of the cancer patients seen by Dr. Ehrman.
Dr. Ehrman has been instrumental in beginning many new and innovative practices in his office. For instance, he administers chemotherapy to Medicare patients in his office. He accomplished this by arranging with local pharmacists to mix and supply chemotherapy drugs. Dr. Ehrman will work with these same pharmacists in Home Health Care of Bay.
Dr. Ehrman is involved in a durable medical equipment company. Many new devices and treatments were first used in the area by Dr. Ehrman's company. Dr. Ehrman has been a leader in the community in keeping up with new home health care developments.
Home Health Care of Bay will have adequate staff on a full-time basis and add staff as utilization increases.
Dr. Ehrman currently contracts with two nurses who are well trained and have over 1,000 hours of in-service training.
Home Health Care of Bay is committed to keeping up with state-of-the- art home health care services and will add new services as they are developed.
Availability and Adequacy of Alternatives
There are no realistic alternatives to the establishment of a new home health agency.
The alternative of nursing home care is not satisfactory. Most persons would prefer home care to nursing home care when at all possible.
The alternative to home care which is currently being used is to shuttle the patient from the emergency room to the hospital to the doctor's office. Eventually the patient drops out of the system or settles for a lower level of services.
Availability of Resources, Including Health Manpower, Management Personnel and Funds for Capital and Operating Expenditures . . . Extent to Which the Proposed Services Will Be Accessible to All Residents
The staffing requirements for Home Health Care of Bay are shown on Table 11 of the application. That staffing plan is reasonable.
Home Health Care of Bay will have a full-time administrator at a salary of $27,000. A capable administrator can be recruited at that salary.
Home Health Care of Bay will employ a full-time nurse supervisor at a salary of $21,000. A nurse supervisor can be hired at that salary.
Home Health Care of Bay will employ a full-time clerical person at an annual salary of $16,000. A clerical person can be hired at that salary.
The above salaries and Home Health Care of Bay's ability to recruit such persons is reasonable based on Dr. Ehrman's experience employing similar personnel in his office.
Home Health Care of Bay will hire contract staff to provide skilled nursing services, physical therapy services, speech therapy services, occupational therapy services, medical/social work services, and home health aide services.
Such persons can be contracted with to provide the type of services Home Health Care of Bay proposes based on discussions with such persons.
Dr. Ehrman currently contracts with two nurses in Ft. Walton Beach to provide nursing services similar to those proposed by Home Health Care of Bay. Such services are provided mainly to non-Medicare patients and the arrangement has worked very well.
Funds for Capital and Operating Expenditures
Project costs are depicted on Table 25 of the application. The costs are reasonable.
Home Health Care of Bay can be started for $22,600.
Immediate and Long-Term Financial Feasibility of the Proposal
At hearing, DHRS admitted the short-term financial feasibility of Home Health Care of Bay's proposal.
The statement of projected income and expense in Figure 7 of the application and on page 14 of Dr. Kolb's report was prepared under Dr. Kolb's supervision.
The majority of assumptions on which the pro forma is based have been stipulated to by DHRS as reasonable assumptions on which to base a financial projection. The only assumptions not admitted by DHRS relate to utilization and payor mix. DHRS, however, introduced no evidence that refuted the reasonableness of these assumptions.
The utilization projection used to calculate gross revenue in the pro forma was 3,800 visits in 1988 and 8,500 visits in 1989. The utilization projections are reasonable based on the agency's demographic base and Dr. Ehrman's commitment to education and marketing.
The projection of costs and charges depicted on page 45 of the application is reasonable based on Dr. Ehrman's current office experience.
The number of visits is multiplied by the charge per visit type to calculate gross revenue. This calculation yields a gross revenue of approximately $200,000 in year 1 and $462,000 in year 2.
The payor mix for Home Health Care of Bay is found on Table 7 of the application. Home Health Care of Bay predicts 3 percent Medicaid visits, 80 percent Medicare visits, 14 percent private pay and insurance visits, and 3 percent indigent visits. The pay mix projections are reasonable based on the mix of patients Dr. Ehrman currently sees. Ms. Farr admitted that the projections were reasonable.
The difference between Medicare and Medicaid reimbursement and full charges results in the contractual allowances figure. Bad debt and charity deductions were calculated based on 3 percent indigent and 3 percent Medicaid visits.
Deductions from gross revenue, which are funds not received because of contractual allowances, bad debts, or charity, are subtracted to yield net revenue. Deductions from revenue are approximately $38,000 in year 1 and
$135,000 in year 2.
Net revenue is approximately $162,000 in year 1 and $327,000 in year
2.
The second portion of the pro forma lists expenses. This list
contains all the expenses expected for a new home health agency. All the expenses listed are reasonable.
The pro forma shows a loss of $28,505 in the first year and a profit of $13,207 in the second year. Home Health Care of Bay has the equity to sustain a loss in the first year.
In the second year of operation, based on the above assumptions, expenses are $314,000 and net revenue is $327,000 for a net income of $13,000.
These projections indicate that the project is financially feasible in the long term.
Table 26 on page 41 of the application presents the project timetable anticipated when the application was filed. Any delay in this timetable due to this litigation will not materially change the projections or commitments contained in the application.
Impact of the Proposal on Costs of Providing Health Services, Including Effects of Competition
and Improvements in Financing and Delivery of Health Services Which Foster Competition and Services To Promote Quality Assurance and Cost Effectiveness
The introduction of a new home health agency into the Bay County market will stimulate competition. Such competition will stimulate growth in competitors and increase the overall level of services.
Approval of a new competitor where there has been no new competition for nine to ten years will put pressure on providers to provide a wider range of services as well as higher quality services.
Ms. Young, administrator of Bay Medical Center Home Health, admitted that if Home Health Care of Bay's CON is approved, her agency might begin educating physicians in regard to available services, rather than waiting for physicians to request a service.
As the current providers testified, as agency visits go up or down, the number of staff required can be adjusted without incurring unreasonable costs. Current providers have control over their costs and staffing.
Home Health Care of Bay's charges are competitive. In some areas, such as skilled nursing and home health aide, Home Health Care of Bay's charges are lower than current providers' charges. Price competition allows competition for private pay patients.
Impact
The addition of Home Health Care of Bay to the home health market will not significantly affect current providers. Studies have indicated that new entrants into the home health market do not significantly affect existing providers.
The elderly population of Bay County is growing rapidly. When the 1984 home health use rate is applied to elderly population growth between 1986 and 1989, approximately 5,800 new visits are attributable to population growth alone.
Home Health Care of Bay projects it will deliver 3,800 visits in its first year of operation and 8,500 visits in its second year. Thus, a large percentage of those visits are attributable to population growth alone.
Home Health Care of Bay's marketing and education programs will raise the local use rate and generate more visits.
Dr. Kolb analyzed the financial impact of Home Health Care of Bay's project on current providers. Her analysis considers a worst case scenario and assumes that current providers' visit levels will be affected by the introduction of a new provider. The analysis then calculates the financial impact on current provider.
In order to do this, Table 11 calculates the average cost per visit from existing agencies' 1985 Medicare cost reports.
Home Health Care of Panama City's average cost per visit is $37.18. Bay Medical Center Home Health's average cost per visit is $41.76.
The Medicare program pays agencies the lower of Medicare cost caps or actual costs. The current providers in Bay County are well below the Medicare cost caps and so will be paid their actual costs.
Table 11 calculates the difference between actual agency costs and Medicare cost caps. Home Health of Panama City was 18 percent below its cost caps. Bay Medical Center Home Health was 24 percent below its cost caps.
Thus, Home Health Care of Bay could provide the number of visits it projects and even if all those visits came from existing providers, the current providers could still operate at a level of cost that would be Medicare reimbursable.
The approval of Home Health Care of Bay's application will not have a significant adverse impact on existing providers.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the parties to and the subject matter of these proceedings. Section 120.57(1), Florida Statutes.
Home Health of Bay, as the applicant, has the initial burden of proving by competent, substantial evidence that it is entitled to a CON under the applicable criteria. Florida Department of Transportation v. J.W.C. Co., Inc., 396 So.2d 778 (Fla. 1st DCA 1981). Once Home Health of Bay makes a prima facie showing of entitlement, the burden of going forward shifts to DHRS.
The applicable statutory criteria are contained in Section 381.494(6)(c), Florida Statutes (1985). The parties stipulated and it was found that the criteria in Section 381.494(6)(c) 5, 6, 7, 10, 11 and 13 are uncontested or inapplicable. The criteria in Section 381.494(6)(c)1, 2, 3, 4, 8, 9, and 12 are the criteria still at issue in this proceeding. Those criteria still at issue are:
The need for the health care facilities and services and hospices being proposed in relation to the applicable district plan and state health plan . . . .
The availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing health care services and hospices in the service district of the applicant.
The ability of the applicant to provide quality of care.
The availability and adequacy of other health care facilities and services and hospices in the service district which
may serve as alternatives . . . .
The availability of resources, including health manpower, management personnel, and funds for capital and operating expenditures, for project accomplishment and operation;
the availability of alternative uses of such resources for the provision of other health services; and the extent to which the proposed services will be accessible to all residents of the service district.
The immediate and long-term financial feasibility of the proposal.
12. The probable impact of the proposed project on the costs of providing health services proposed by the applicant, upon consideration of factors including, but not limited to, the effects of competition on the supply of health services being proposed and the improvements or innovations in the financing and delivery of health services which foster competition and service to promote quality assurance and cost- effectiveness.
Of these criteria still at issue only the determination of need and the availability of existing services merit extensive discussion. All the other criteria simply involve factual determinations which were made supra in the Findings of Fact. Accordingly, it is concluded that criteria 3, 4, 8, 9, and 12 have been satisfied by Home Health of Bay and Home Health of Bay's entry into
the area will promote competition and improvement of home health services in Bay County, Florida.
DHRS has no rule to determine need for home health agencies. Instead, DHRS asserts that its incipient policy is to apply the statutory criteria.
McDonald v. Department of Banking and Finance, 346 So.2d 569 (Fla. 1st DCA 1977), permits an agency to refine its incipient policy through the adjudication of individual cases. However, when an agency attempts to utilize policy not contained in adopted rules, the agency:
[M]ay be required by any disappointed applicant to defend its policy in a Section
120.57 proceeding where the Division will be required to present evidence and argument and to "expose and elucidate its reasons for discretionary action." McDonald, supra, 346 So.2d at 584.
State, Department of Administration, Division of Personnel v. Harvey, 356 So.2d 323, 326 (Fla. 1st DCA 1978). Thus, where an agency attempts to rely on non- rule policy, it must defend and explicate such policy in a Section 120.57 hearing.
The manner in which an agency must prove up incipient policy in the CON context was articulated in Florida Medical Center v. Department of Health and Rehabilitative Service, 463 So.2d 381 (Fla. 1st DCA 1985) There the court noted that DHRS had failed to appropriately establish its non-rule policy. The court stated at page 382:
To the extent an agency may intend in its final order to rely upon or refer to policy not recorded in rules for discoverable precedents, that policy must be established by expert testimony, documentary opinion, or other evidence appropriate to the nature of the issues involved and the agency must expose and elucidate its reasons for its discretionary action. Florida Cities Water Co. v. Public Service Commission, 384 So.2d 1280 (Fla. 1980); Anheuser-Busch, Inc. v.
Department of Business Regulation 393 So.2d 1177 (Fla. 1st DCA 1981); McDonald v.
Department of Banking and Finance, 346 So.2d
569 (Fla. 1st DCA 1977).
E.M. Watkins & Co. v. Board of Regents, 414 So.2d 583, 588 (Fla. 1st DCA 1982). See also Amos v. Department of Health and Rehabilitative Services, 444 So.2d 43, 47 (Fla. 1st DCA 1984).
In this case, DHRS' incipient policy for review of home health agency CONs was represented by the Office of Community Medical facilities to be a review of Home Health Care of Bay's application in relation to the thirteen statutory criteria.
The only standard by which the assessment of need was to be made was whether the applicant affirmatively demonstrates that there is an unmet need, that there is no home health service available, or there is an accessibility problem where certain services are not being offered. This is the standard articulated by Ms. Farr, DHRS' witness. Ms. Farr was not competent to expose and elucidate DHRS' reasons for its incipient policy. She was simply the person at DHRS who tried to carry out the incipient policy. Accordingly, it is concluded that DHRS failed to carry its burden of establishing and supporting the non-rule standard for determination of need which it applied in this case.
Further, at the same time that DHRS has been applying this nebulous standard for need assessment in its Office of Community Medical Facilities, it has been rejecting the same standard in Final Orders in other cases. Specifically, in Nurse World, Inc. v. Department of Health and Rehabilitative Services, 9 FALR 4258 (Final Order July 23, 1987), the Recommended Order stated and the Final Order adopted the following at page 4273:
Since HRS had no need methodology or policy in place at date of hearing, it took the position that an applicant must
demonstrate need by finding people who are not getting the service. Ms. Gordon-Girvin Petitioner's expert who had been employed at HRS in health planning for 11 years, opined that there is no adequate quantifiable technique available as a health planning methodology that will allow a health planner to make use of a negative demonstration of need. She suggested use of responses to a newspaper advertisement and then demolished that method of proof as "impractical".
Another difficulty with this type of negative demonstration approach is that existing agencies can deal with increased need demands by simply continuing to add staff. Gordon- Girvin knew of no applicant that had acquired a CON by proving lack of access.
Additionally, a similar agency position (the Rule of 300) has been struck down by the courts. This negative burden of proof concept has been given short shrift by the courts and is rejected here as well. See Department of Health and Rehabilitative Services v. Johnson and Johnson Home Health Care, Inc., 447 So.2d
361 (Fla. 1st DCA 1984).
Thus, in Nurse World, the Secretary of DHRS explicitly rejected the policy which the Office of Community Medical Facilities attempted to prove in this case. In this case, DHRS put on no witness in a policy-making position who could attempt to explain this blatant inconsistency.
DHRS' position in this case can only be characterized as arbitrary and capricious. Further, DHRS' preliminary decision had no reasonable basis in law or fact at the time it was made. In the context of administrative proceedings, arbitrary and capricious are defined as follows:
A capricious action is one which is taken without thought or reason or irrationally. A arbitrary decision is one not supported by facts or logic, or despotic.
Agrico Chemical Co. v. Department of Environmental Regulation, 365 So.2d 759, 763 (Fla. 1st DCA 1979). DHRS' review of Home Health Care of Bay's application, with its attendant negative standard for determining need, falls squarely within the Agrico definition. The policy DHRS utilized to assess the need for Home Health Care of Bay's proposal is rejected as unreasonable, arbitrary and capricious, and inconsistent with current DHRS policy as embodied in Nurse World. Therefore, a reasonable methodology to assess need must be determined.
When no state-wide rule, policy or approach is in effect, a methodology proven by expert testimony to be reasonable may be utilized. Nurse World, 9 FALR at 4276. The use rate population based need methodology presented by Home Health Care of Bay to determine need is reasonable.
This methodology was proven to be a reasonable methodology by an independent health planning expert. It uses commonly applied health planning principles and data. The same methodology was utilized, and viewed as reasonable by DHRS in the batching cycle just prior to Home Health Care of Bay's application. See also Englewood Home Health Care, Inc. v. Department of Health and Rehabilitative Services, 9 FALR 4221, 4240 (Final Order July 23, 1987).
Section 381.494(6)(c)1 directs that need for a project be reviewed in relation to the applicable state and local health plans. Home Health Care of Bay's project will promote the goals of the state health plan by maximizing competition while insuring reasonable economies of scale. The project will also be cost effective and offer an alternative to institutional long term care.
DHRS has recognized that:
All of the available date indicates that there is a range of "economies of scale" in costs per visit for new start-up home health agencies, breaking somewhere between 6,000 and 9,000 or 10,000 visits. Once this breaking point is reached, the relatively small level of fixed costs in home health level off, and the data do not show any further significant points of economies of scale.
Englewood Home Health, 9 FALR at 4236. Home Health Care of Bay utilizes 9,000 visits as part of the basis of its needs assessment.
Home Health Care of Bay's project is consistent with the local health plan because it will increase access of economically underserved groups to home health services. The proposal will also raise public awareness about the use of home health services.
The availability, adequacy and appropriateness of existing home health services in inadequate. The two existing providers do not offer many of the high tech nursing services proposed by Home Health Care of Bay. Current providers concentrate on nursing and aide services, while failing to provide other services, such as medical/social work.
Additionally, access of economically underserved patients is restricted in Bay County. One provider does no Medicaid visits and the other provider does only a very small percentage.
The provision of services to Medicaid and indigent patients is an important consideration in CON review. St. John's Home Health Agency v. Department of Health and Rehabilitative Services, 509 So.2d 367 (Fla. 1st DCA 1987); Englewood Home Health Care, Inc. v. Department of Health and Rehabilitative Services, 9 FALR at 4223; Visiting Nurse Association v. Department of Health and Rehabilitative Services, 9 FALR 4203, 4212-13 (Final Order July 23, 1987).
Here, Home Health of Bay's Commitment to provide 6 percent of its patient visits to the traditionally underserved will serve to increase availability and accessibility both through provision of those services by Home Health of Bay and through increased competition by existing providers.
The statistical evidence also supports a conclusion that existing services are not accessible. Even though Home Health of Bay did not specifically identify a person or persons who sought services which were unavailable, the statistical data regarding existing services and utilization compared with demographics clearly indicates that there is a need for the services which Home Health of Bay proposes.
Based on "a balanced consideration of all the statutory criteria," Balsam v. Department of Health and Rehabilitative Services, 486 So.2d 1341, 1349 (Fla. 1st DCA 1986), it is concluded that there is a need for another Medicare- certified home health agency to serve Bay County. Home Health of Bay has established its entitlement to be that agency.
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health and Rehabilitative Services enter
a Final Order granting CON No. 4912 to Home Health Care of Bay County, Florida, Inc., to establish a Medicare-certified home health agency in Bay County, Florida.
DONE AND ENTERED this 17th day of December, 1987, in Tallahassee, Florida.
DIANE K. KIESLING
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904)488-9675
Filed with the Clerk of the Division of Administrative Hearings this 17th day of December, 1987.
APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 87-2151
The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case.
Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Home Health Care of Bay County,
Florida, Inc.
Each of the following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1-3(1-3); 5(4); 7-10(5-8); 12-16(48- 52); 18(53); 19 & 20 (54); 21(55); 24-27(56-59); 28- 31(59-62); 37-52(9-24); 54-57(25-28); 58-77(28-47); 78-89(63-74); 91-102 (75- 86); 104-114(87-97); 116-129(97-110); 130(110); 131(111); 133-135(112); 136- 139(113); 140 & 141(114); 142-153(115-126); 154-163(126-135); 165-175(136-146); 179-182(147-150); 183(150); 184 & 185(151); 186(152); 187 & 188(153); 189- 191(154); 192 & 193(155); 194 & 195(156); 196(157); 197(158); 200-203(159-162); 207(163); 209(164); 210(165); 212-218(166-172); and 219-225(172-178).
2. Proposed findings of fact 17, 32-36, 53, 90, 103, 115, 132, 164, 176-
178, 198, 199, 204-206 and 211 are subordinate to the facts actually found in this Recommended Order.
Proposed findings of fact 22, 23 and 208 are rejected as being unsupported by the competent, substantial evidence.
Proposed findings of fact 4 and 11 are rejected as being unnecessary and/or irrelevant.
Specific Rulings on Proposed Findings of Fact Submitted by Respondent, Department of Health and
Rehabilitative Services
Each of the following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1(1 & 2); 2(3); 6(Footnote 1); 7(148) and 13(4).
Proposed findings of fact 3-5, 8-12, 14-40, 43-45 and 47-53 are subordinate to the facts actually found in this Recommended Order.
Proposed finding of fact 42 is rejected as being unsupported by the competent, substantial evidence.
Proposed findings of fact 4 and 46 are rejected as being unnecessary and/or irrelevant.
COPIES FURNISHED:
Byron B. Mathews, Jr., Esquire Vicki Gordon Kaufman, Esquire McDermott, Will and Emory
101 N. Monroe Street Tallahassee, Florida 32301
Theodore E. Mack, Esquire Assistant General Counsel Department of Health and
Rehabilitative Services Regulation & Health Facilities Ft. Knox Executive Center
2727 Mahan Drive
Tallahassee, Florida 32308
Gregory L. Coler, Secretary Department of Health and
Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
Sam Power, Clerk Department of Health
and Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
=================================================================
AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
HOME HEALTH CARE OF BAY COUNTY, FLORIDA, INC.,
Petitioner,
CASE NO.: 87-2151
vs. CON NO.: 4912
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES,
Respondent.
/
FINAL ORDER
This cause came on before me for the purpose of issuing a final agency order. The Hearing Officer assigned by the Division of Administrative Hearings (DOAH) in the above- styled case submitted a Recommended Order to the Department of Health and Rehabilitative Services (HRS). A copy of that Recommended Order is attached hereto.
RULING ON EXCEPTIONS FILED BY HRS
HRS excepts to the Hearing Officer's conclusion of law that the department's reliance on the statutory criteria to evaluate need is "nebulous" and the further conclusion that the failure to establish a need methodology is arbitrary and capricious. This exception is granted as the department is not required by law to promulgate a need methodology.
HRS excepts to the Hearing Officer's reference to a requirement that an applicant prove an "unmet need". This exception is granted as a decision on an application for a CON to provide home health services must be made on the basis of a balanced weighing of all applicable statutory criteria.
HRS excepts to the Hearing Officer's reliance on Final Orders entered in other cases. This exception is denied.
HRS excepts to the Hearing Officer's reliance on a need methodology abandoned by the department. The exception is granted to the extent that the Hearing Officer would reinstate the abandoned methodology and establish it again as non rule policy of the department. The exception is denied to the extent that the methodology is merely evidence presented by the applicant relevant to the statutory criteria of need. An applicant is entitled to present evidence to show that the application satisfies the statutory criteria. This exception is granted in part and denied in part. The Hearing Officer's findings and analysis regarding the abandoned methodology are found on pages 11, 12, and 36 of the Recommended Order.
FINDINGS OF FACT
The Department hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order.
CONCLUSIONS OF LAW
The Department hereby adopts and incorporates by reference the conclusions of law set forth in the Recommended Order except where inconsistent with the rulings on the exceptions.
Based upon a balanced weighing of all applicable statutory criteria, it is ADJUDGED, that the application for CON 4912 by Home Health Care of Bay
County, Florida, Inc. be approved. The CON is subject to the requirement that service to Medicaid patients and other indigent patients shall be provided as follows: Medicaid 3 percent of total visits, other indigents - 3 percent of total visits.
DONE and ORDERED this 15th day of February, 1988, in Tallahassee, Florida.
Gregory L. Coler Secretary
Department of Health and Rehabilitative Services
by Assistant Secretary for Programs
COPIES FURNISHED:
Diane K. Kiesling Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32301
Bryon B. Mathews, Jr., Esquire Vicki Gordan Kaufman, Esquire McDERMOTT, WILL & EMERY
Monroe-Park Tower, Suite 1090
101 North Monroe Street Tallahassee, Florida 32301
Theodore E. Mack, Esquire Assistant General Counsel Department of Health and
Rehabilitative Services 2727 Mahan Drive
Tallahassee, Florida 32399
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing was sent to the above-named people by U.S. Mail this 17th day of February, 1988.
R. S. Power, Agency Clerk Assistant General Counsel Department of Health and
Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407
Tallahassee, Florida 32399-0700 904/488-2381
NOTICE OF RIGHT TO JUDICIAL REVIEW
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF HRS, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
| Issue Date | Proceedings |
|---|---|
| Dec. 17, 1987 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Feb. 15, 1988 | Agency Final Order | |
| Dec. 17, 1987 | Recommended Order | Incipient policy. HRS standard requiring applicant to affirmatively show unmet need, unavailability of services or inaccessibility is arbitrary |
