STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
INDIAN RIVER MEMORIAL HOSPITAL, )
)
Petitioner, )
)
vs. ) Case No. 89-1293
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, )
)
Respondent. )
) LAWNWOOD MEDICAL CENTER, INC., )
)
Petitioner, )
)
vs. ) Case No. 89-1294
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, )
)
Respondent. )
) INDIAN RIVER MEMORIAL HOSPITAL, )
)
Petitioner, )
)
vs. ) Case No. 89-1295
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, and ) HCA LAWNWOOD REGIONAL MEDICAL CENTER,)
)
Respondents. )
) ST. MARY'S HOSPITAL, INC., )
)
Petitioner, )
)
vs. ) Case No. 89-1297
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES and ) HCA LAWNWOOD REGIONAL MEDICAL CENTER,)
)
Respondents. )
) ST. MARY'S HOSPITAL, INC., )
)
Petitioner, )
)
vs. ) Case No. 89-1298
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, a final hearing in the above-styled matter was held on October 10 through 13 and 16, 17, and 19, 1989, in Tallahassee, Florida, before Joyous D. Parrish, a Hearing Officer with the Division of Administrative Hearings. The parties were represented at the hearing as follows:
APPEARANCES
For the Petitioner
Indian River Memorial Hospital: Kenneth F. Hoffman
Oertel, Hoffman, Fernandez & Cole, P.A.
2700 Blair Stone Road Post Office Box 6507
Tallahassee, Florida 32314-6507
For the Petitioner/Respondent
Lawnwood Medical Center, Inc.: John Radey
Jeffrey L. Frehn
Aurell, Radey, Hinkle & Thomas
101 North Monroe stieet
Suite 1000, Monroe Park Tower Post Office Box 11307 Tallahassee, Florida 32302
For the Petitioner
St. Mary's Hospital, Inc.: David Watkins
Patricia A. Renovitch Oertel, Hoffman, Fernandez
& Cole, P.A.
2700 Blair Stone Road Post Office Box 6507
Tallahassee, Florida 32314-6507
For the Respondent Department of Health and
Rehabilitative Services: Lesley Mendelson
Senior Attorney Department of Health and
Rehabilitative Services Ft. Knox Executive Center 2727 Mahan Drive, Suite 103
Tallahassee, Florida 32308
STATEMENT OF THE ISSUES
The central issues in these cases are:
As to case no. 89-1293--whether Indian River Memorial Hospital (Indian River) meets the statutory and rule criteria for a certificate of need (CON) to operate an inpatient cardiac catheterization laboratory, and therefore, whether the Department of Health and Rehabilitative Services (Department) should approve CON application number 5726. This application is opposed by Lawnwood Medical Center, Inc. (Lawnwood).
As to case no. 89-1294--whether Lawnwood meets the statutory and rule criteria for a CON to operate an open heart surgery program and an inpatient cardiac catheterization laboratory, and therefore, whether the Department should approve CON application number 5729. Indian River opposes the proposed approval of Lawnwood's inpatient cardiac catheterization laboratory in case no. 89-1295. St. Mary's Hospital, Inc. (St. Mary's) opposes the proposed approval of the inpatient cardiac catheterization laboratory in case no. 89-1297.
PRELIMINARY STATEMENT
Case no. 89-1293 began on February 22, 1989,, when Indian River filed a petition with the Department contesting the denial of its application for a CON to establish an inpatient cardiac catheterization laboratory at Vero Beach, Florida. Indian River's application (#5726) had been comparatively rewiewed with applications for cardiac cath inpatient programs requested by Bethesda Memorial Hospital (#5727) and Lawnwood (#5729) whose petition to intervene in this case was granted. This case was forwarded to the Division of Administrative Hearings for formal proceedings on March 10, 1989.
Case no. 89-1294 began on February 24, 1989, when Lawnwood filed its petition for formal hearing with the Department. Lawnwood sought to contest that portion of the Department's initial decision which denied its request to establish an open heart surgery program. Lawnwood alleged that, in addition to the CON for inpatient cardiac cath (which had been recommended for approval), it was entitled to establish an open heart surgery program. This case was forwarded to the Division of Administrative Hearings for formal proceedings on March 10, 1989.
Case no. 89-1295 began on February 22, 1989, when Indian River filed a petition challenging the proposed approval of Lawnwood's inpatient cardiac cath. As a co-batched applicant for the requested service, Indian River has standing to assert this challenge. This petition was among the group forwarded to the Division of Administrative Hearings on March 10 1989.
Case no. 89-1297 began on February 22, 1989, when St. Mary's filed a petition challenging the Department's preliminary decision to approve Lawnwood's inpatient cardiac catheterization laboratory. As an existing provider of the requested service, St. Mary's has standing to assert this challenge. This petition was also among the group forwarded on March 10, 1989.
It should be noted that at the outset of the formal hearing of these cases, two other cases which had been consolidated with the group were included in the hearing schedule. Martin Memorial Hospital Association, Inc. (Martin) was the petitioner in case no. 89-1296. That petition was filed with the Department on February 23, 1989, and challenged Lawnwood's inpatient cardiac cath laboratory. Prior to hearing, Martin moved to intervene in the case related to Indian
River's application for inpatient cardiac cath. Such motion was granted at the hearing. Subsequently, Martin withdrew from the proceedings and voluntarily dismissed its petition. Accordingly, no findings are included with regard to Martin's allegations and case no. 89-1296 has been closed and deleted from the style of these cases.
In case no. 89-1298, St. Mary's filed a petition for formal administrative hearing on February 22, 1989. That petition challenged the Department's preliminary denial of its CON application for an open heart surgery program (#5731). Two hospitals, AMI-Palm Beach Gardens Medical Center and JFK Medical Center, Inc., were permitted to intervene in that case. Although St. Mary's had not moved to intervene in the Lawnwood case, as a co-batched applicant for the requested service, this petitioner's application was entitled to be comparatively reviewed with the Lawnwood application. Accordingly, St. Mary's was permitted to participate in the proceedings related to Lawnwood's case.
Subsequent to the presentation of Lawnwood's case, St. Mary's withdrew its petition in case no. 89-1298 and abandoned its request for a certificate of need for an open heart surgery program. Therefore, no findings have been made regarding that matter.
At the conclusion of the hearing, Lawnwood filed a motion for sanctions against St. Mary's which alleged that St. Mary's had misrepresented its intentions in order to participate in the proceedings related to Lawnwood's request for an open heart surgery program. Ruling on that motion is addressed in an order issued concurrent with this recommended order.
In order to limit the issues at hearing, Indian River filed a Motion for Order Determining Applicable Certificate of Need Rule for Additional Inpatient Heart Catheterization Facilities. The request arose out of confusion as to which version of Rule 10- 5.011, Florida Administrative Code, should be applied in the instant cases. This confusion stemmed from a final order entered in Florida Medical Center, et al. v. Department of Health and Rehabilitative Services, 11 FALR 3904 (June 29, 1989). In that case, Hearing Officer Ruff ruled that the proceedings had initiated a Section 120.54, Florida Statutes challenge.
Further, the final order found that the proposed amendments to the rule were adopted by the Department without adhering to the proper procedures thereby invalidating the amendments. Consequently, Indian River's motion sought to have the "old rule" applied in these cases. The Department's position has been that the proceedings initiated in the Florida Medical Center case constituted a Section 120.56, Florida Statutes, challenge, that the "new rule" had become effective, and that, consequently, the "new rule" must be applied in these cases. Moreover, the Department argued, since the final order had been properly appealed, such appeal, as a matter of law, stayed the effect of the ruling invalidating the amendments. In an abundance of caution, the parties were directed to submit evidence based upon both versions of the rule. In an effort to conserve future administrative resourses, findings are included as to both rule versions.
At the hearing, Indian River presented the testimony of ten witnesses: Michael J. O'Grady, Jr., CEO of Indian River Memorial Hospital; Myles Tonnacliff, assistant vice president for professional services; Wesley Tillis, vice president for finance; Jody Springer, a certified public accountant with Price Waterhouse; Michael D. Jernigan, health care planning consultant; Bruce Jackson, director of cardio-pulmonary services for Indian River Memorial Hospital; Dr. Charles Celano, medical director of Indian River's outpatient cardiac cath laboratory; Stephen P. Bunker, vice president of clinical services for Holmes Regional Medical Center; Sven Ransman, P.E. with Barr Dunlop &
Associates; and David A. Lyle, an EMS driver employed by Indian River Memorial Hospital. Indian River's exhibits numbered 1, 1A, 2, 3, 4, 5, 7, 8, 9, 10, 11,
12, 14, 16, 17, and 18 were admitted into evidence.
The following witnesses testified on behalf of Lawnwood: Stephen Burgin, director of cardiovascular services at Lawnwood; Ernest J. Peters, a consulting engineer with Peters and Associates; Rhoda Hammer, coordinator of the cardiac oath unit at Lawnwood; Jon Trezona, administrator for Lawnwood; Elizabeth Dudek, the Department's health services and facilities consultants supervisor; and Gene Nelson, health care consultant. Lawnwood's exhibits numbered 1 through 13, 14- 1, 14-2, 16, and 19 through 58 were admitted into evidence.
St. Mary's witnesses were: Jody Springer; Michael Schwartz, a health care consultant; and Patrick Nummy executive director of the heart institute at St. Joseph's Heart Institute. Elizabeth Dudek testified on behalf of the Department. The Department's exhibits numbered 1 through 4 were admitted into evidence.
The transcript of the proceedings was filed with the Division of Administrative Hearings on November 28, 1989. The Department requested an extension of the time within which to file a proposed recommended order which was unopposed by the parties in these cases. By order entered January 17, 1990, the parties were granted leave until January 29, 1990, to file their proposed recommended orders.
Rulings on the proposed findings of fact submitted by the parties are included in the attached appendix.
FINDINGS OF FACT
Based upon the testimony of the witnesses and the documentary evidence received at the hearing, the following findings of fact are made:
The Parties
Indian River is a private, not-for-profit hospital which is operated pursuant to a lease between itself and the Indian River Hospital District, a special tax district. Indian River is located in Vero Beach, Indian River County, Florida, and has 347 licensed beds of which 293 are medical-surgery beds, with 18 intensive care and critical care beds. Ad valorem tax monies support indigent care for Indian River County residents.
Lawnwood is a 335 bed acute care hospital located in Fort Pierce, St. Lucie County, Florida. Lawnwood is owned and operated by Lawnwood Medical Center, Inc., a wholly-owned subsidiary of Hospital Corporation of America (HCA). Lawnwood has an established outpatient catheterization laboratory located in a free-standing building on the hospital grounds.
St. Mary's is an acute care hospital located in West Palm Beach, Palm Beach County, Florida. St. Mary's has an established inpatient catheterization laboratory program.
The Department is the state agency responsible for administering those sections of Chapter 381, Florida Statutes, which govern the review process under which applications for CONs are either granted or denied.
Indian River, Lawnwood, and St. Mary's are located within the Department's District IX. The geographical boundaries for District IX encompass
Indian River, St. Lucie, Martin, Okeechobee, and Palm Beach Counties. With the exception of Martin Memorial Hospital (whose entitlement to inpatient cardiac cath is disputed by Lawnwood), all existing providers of inpatient catheterization services are located in Palm Beach County.
The Applications
On August 25, 1988, Indian River submitted a letter of intent to advise the Department of its plan to construct a cardiac catheterization laboratory within the hospital and to establish an inpatient cardiac cath program. The proposal set forth in that letter made reference to Indiarn River's patients who are generally routed to hospitals located in another district for cardiac cath services.
The application submitted by Indian River on August 26, 1988, estimated that the capital expenditure of the project, $1,779,750, would provide for the construction of a second floor addition to the hospital which would accomodate the new laboratory. The application alleged that, in the majority of cases, residents of Indian River County in need of cardiac catheterization are sent out of district for such services.
On October 13, 1988, the Department responded to Indian River's application by listing omissions from the proposal which the Department required in order to complete its review. This "omissions letter" specified that Indian River was to update its application utilizing the "new rule" for cardiac cath. The responses to the omissions were to be provided by November 14, 1988.
Indian River timely responded to the omissions letter on November 9, 1988. The Department deemed Indian River's application to establish an inpatient cardiac cath laboratory complete effective November 14, 1988.
On August 26, 1988, Lawnwood submitted a letter of intent to the Department to announce its intention to establish a cardiac cath and open heart surgery program. Lawnwood sought to be included in the application group for which the deadline was September 28, 1988. The timeline for this group required applications to be complete by November 14, 1988. Agency action on the applications submitted in the September, 1988 batch was scheduled for January 13, 1989.
Lawnwood's application was received and reviewed by the Department. The omissions letter which outlined approximately six questions requiring further elaboration was issued on October 13, 1988. Lawnwood's omissions response was timely provided on November 14, 1988. The Department deemed Lawnwood's application for an inpatient cardiac cath laboratory and an open heart program complete effective November 14, 1988.
Inpatient cardiac catheterization is not currently available in Indian River and St. Lucie Counties. As a result, potential patients residing in these counties are geographically isolated from the existing District IX providers of the same services.
State Agency Action Report
On January 20, 1989, the Department issued its State Agency Action Report (SAAR) which recommended the approval of an inpatient cardiac cath program for Lawnwood. The portion of Lawnwood's application which sought a CON for an open heart program was denied. The SAAR evaluated the applicants based
upon the following criteria: Section 381.705, Florida Statutes; Rule 10-5.011, Florida Administrative Code; and the 1988 District IX Health Plan (DHP).
The Health Plans
Pertinent to these proceedings are the following portions of the DHP:
B. In planning for the specialized services of cardiac catheterization laboratories and open heart surgical services, District IX, in its entirety, shall be the subdistrict.
* * *
Priority shall be given to area facilities for specialized services which can show a commitment to, or an historical record of, service to Medicaid/Indigent, Handicapped and Underserved population groups.
* * *
Priority shall be given to Certificate of Need applicants who propose to have both inpatient cardiac catheterization services and open heart surgical services in the same facility. However, should it become evident,
at any time, that there is a need for one service and not for both services, then an applicant would not be expected to have to apply for both.
The State Health Plan (SHP) sets a goal of ensuring the appropriate availability of cardiac catheterization and open heart surgery services at a reasonable cost. In pursuit of that goal two objectives are specified:
Objective 4.1.: To maintain an average of 600 cardiac catheterization procedures per laboratory in each district through 1990.
* * *
Objective 4.2.: To maintain an average of 350 open heart surgery procedures per program in each district through 1990.
The "Old Rule"
Need determination for cardiac catheterization capacity under the version of Rule 10-5.011, Florida Administrative Code, which was effective on April, 1988, provided for a calculation whereby the number of catheterization procedures for the projected year equaled the actual use rate (number of procedures per hundred thousand population) in the service area for the 12 month period beginning 14 months prior to the letter of intent deadline (the batching group) multiplied by the projected population in the service area for the projected year. The projected year was the year in which the proposed cardiac cath laboratory would initiate service (not more than two years into the future).
The "old rule" further provided that no additional cardiac cath laboratories would be established in a service area unless the average number of caths performed per year by the existing and approved laboratories were greated
than 600. This volume level contemplated inpatient and outpatient procedures. Consequently, applications for proposed cardiac cath laboratories may not be approved if they would reduce the average volume of procedures performed below 600.
The Department did not publish a fixed need pool for this batch of applicants under the "old rule." The Department's goal under the "old rule" provided that it will not normally approve applications for new cardiac catheterization laboratories unless additional need is indicated based upon the calculations explained above.
The number of cardiac cath procedures performed in District IX during the relevant time period was 4765. The population during the use rate period was 1,151,929. The historic use rate is therefore 413.65 per 100,000 population. The projected population for the planning horizon is 1,259,178.
The projected use for the period is 5208.6. That number divided by 600 yields a total need for the planning period of 8.68 cath laboratories for this District. Applying the Department's historical practice of rounding the number to the nearest whole number establishes a need for 9 cardiac cath laboratories. By subtracting the existing cath laboratories (Boca Raton, JFK, St. Mary's, Palm Beach Gardens, and Delray) results in a need for an additional 4 cardiac cath laboratories. Pursuant to the "old rule," both applicants in this case have established numeric need for their proposed program.
The "New Rule"
The need formula expressed in the "new rule" is as follows: NN=PCCPV - ACCPV - APP
Where:
NN is the annual net program volume need
in the service planning area projected 2 years into the future for the respective planning horizon. Net need projections are calculated twice a year. The planning horizon for applications submitted between January 1 and June 30, shall be July of the year subsequent to the following calendar year. The planning horizon for applications submitted between July 1 and December 31, shall be January of the year 2 years subsequent to the following calendar year.
PCCPV is the projected adult cardiac catheterization program volume which equals the actual adult cardiac catheterization program volume rate (ACCPV) per thousand adult population 15 years and over for the most recent 12 month period available to the department 3 weeks prior to publication of the fixed need pool, multiplied by the projected adult population 15 years of age and over 2 years into the future for the respective planning horizon. The population projections shall be based on the most recent population projections available from the Executive Office of the Governor which are available to the department 3 weeks prior to the fixed need
pool publication.
ACCPV equals the actual adult cardiac catheterization program volume for the most recent 12-month period for which data are available to the department 3 weeks prior to the publication of the fixed need pool.
APP is the projected program volume for approved programs. The projected program volume for each approved program shall be 300 admissions.
The Department did not publish a fixed need pool for this batch under the "new rule." The projected program volume contemplates 300 admissions which relate to inpatient procedures.
In addition to the formula set forth above, the "new rule" provides that the actual outmigration from one service planning area to another shall be considered in the review of a CON application.
In this case, the actual number of cardiac cath procedures for District IX is understated. The actual number utilized by the Department in the evaluation of these applicants failed to consider the outmigration of patients residing in Indian River County who travelled out of the district for services. The actual number of Indian River patients who travelled out of the District for cardiac catheterization during the period was understated by at least 500.
Prior to the evaluation of these applicants, neither the Department nor the applicants had data to calculate the outmigration for cardiac cath services from District IX. That it was occurring was obvious--there were no inpatient facilities in the northern counties. Further, the established referral patterns suggest that patients in the northern counties preferred the outside facilities which were geographically closer than existing programs within District IX. However, no study quantifying the number of residents receiving services elsewhere had been performed.
Regardless of the net need calculated under the "new rule" formula above, the rule further provides that no additional cardiac catheterization programs shall normally be granted unless ACCPV, divided by the number of operational programs for the service planning area, is at or exceeds a program volume of 300 patient admissions.
Utilizing the most conservative ACCPV (4133) divided by the number of operational programs (5) would yield an average program volume well in excess of
300. In that instance, the average volume per program would be 827. That assessment assumes a translation of "admissions" to equal "procedures." In contrast, utilizing the 600 figure set forth in the SHP, yields a program need for 7 facilities. That figure confirms that two additional cardiac catheterization programs would be appropriate and adequately supported by District use. In reaching this conclusion, the cardiac catheterization program located at Martin Memorial Hospital has not been included in the number of existing programs. The program at Martin was reportedly approved in the settlement of a prior batch CON case. As such, it may not reduce the number of facilities calculated in this case under the pertinent rule. Based upon the "new rule," both of these applicants have established numeric need for their proposed program. The number of projected procedures (4565) divided by 600 further establishes a need for 7 programs.
Open Heart Need
Pursuant to the Rule 10-5.011, Florida Administrative Code, the need for open heart surgery programs is determined by computing the projected number of open heart surgical procedures in the service area for a projected year. That number equals the actual use rate (number of procedures per hundred thousand population) in the service area for the 12 month period beginning 14 months prior to the letter of intent multiplied by the projected population in the service area for the year in which the proposed open heart surgery program would initiate service (not more than two years into the future).
Based upon the open heart need formula there is no numeric need for additional open heart surgery programs in District IX. Further, the approval of an additional open heart program would reduce the average volume of existing open heart surgery facilities to below 350 open heart procedures annually. The Department will not normally approve applications for new open heart surgery programs in any district unless there is a finding of numeric need coupled with a finding that the additional program will not reduce the volume of existing providers below 350.
Not Normal Circumstances Reviewed
There are three open heart programs currently operating in District IX (Palm Beach Gardens, Delray, and JFK). All of these programs are located within Palm Beach County which is south of Lawnwood's service area. The closest of these programs (Palm Beach Gardens) is approximately 44.3 miles from Lawnwood. Another open heart program which is located outside of District IX, Holmes Regional Medical Center (located in Brevard County to the north), is approximately 49.8 miles from Lawnwood.
Not normal circumstances warranting the approval of an open heart program require a showing of financial, programmatic or geographical conditions which establish that residents of the given service area are unable to access the service. In this case, District IX must be examined and considered as a whole. It is inappropriate to "subdistrict" for purposes of reviewing not normal circumstances. While a number of the residents of the northern counties do avail themselves of services outside of District IX, the basis for that outmigration may be the physicians' established referral patterns, patient preference, or the provider's reputation in the medical community for quality care. Open heart services are available and accessible to all residents of District IX. Consequently, no persuasive not normal circumstances have been established.
Ouality of Care
Indian River and Lawnwood are properly accredited and have established records of providing quality care in their existing programs and departments. Lawnwood's outpatient cardiac catheterization laboratory has operated without question to its quality of care.
Since neither applicant currently provides open heart services, it is anticipated that both will operate their inpatient cardiac cath laboratories in accordance with a transfer agreement for emergency patients. Such agreement could provide for the relocation of patients to a hospital authorized to provide open heart surgery. By rule, the receiving hospital must be located within 30 minutes travel time by emergency vehicle to the inpatient cath facility. In this case, Indian River intends to transfer emergency patients to Holmes
Regional Medical Center, a hospital currently authorized to provide open heart surgery services. That hospital is within 30 minutes emergency travel time of Indian River.
Lawnwood also proposes to transfer emergency patients to Holmes Regional Medical Center. In order to meet the 30 minute travel time criteria, transfer in this instance must be by helicopter. Lawnwood intends to meet this requirement by agreement with Holmes. Holmes has four pilots, two mechanics, one full-time helicopter, and one backup helicopter to provide this service. By helicopter, the travel time from Lawnwood to Holmes is within 30 minutes.
Availability and Access
With the addition of the programs at Indian River and Lawnwood, residents in the northern counties of District IX will have an increased access to inpatient cardiac cath. This geographic accessibility will lessen the outmigration for these services by providing more convenient, locally situated programs. It is anticipated that local programs will reduce patient anxiety incidental to the travel associated with attaining the services. Further, when considered in connection with the outpatient programs (existing at Lawnwood and planned for Indian River), a significant volume of cath procedures will be performed without requiring travel to adjacent counties/hospitals. Increased volume will improve the efficiency and skill of personnel administering the procedures. Since the service areas for Indian River and Lawnwood have not, historically, conflicted, it is anticipated that patients of each facility will access their respective hospital for the service required.
Personnel Availability and Costs
The staffing, training and costs of providing same proposed by Indian River and Lawnwood are reasonable and adequate to fully support inpatient cardiac cath laboratories. Both hospitals have established procedures to monitor and to provide for quality assurance in connection with the services to be performed. Additionally, both have ongoing educational training to enhance their programs. Both hospitals have a cardiologist or other appropriately credentialed physician on staff to anchor the cardiac cath team.
Financial Feasibility
There are sufficient procedures anticipated to be performed by these hospitals to assure a level of utilization which will provide for the financial feasibility of the inpatient cardiac cath programs.
Indian River currently refers approximately 500 cardiac cath procedures to facilities outside District IX. Lawnwood has commenced an aggressive outpatient progrom. With the availability of extending that program (in Lawnwood's case) and recapturing its referrals (in Indian River's case), both of these hospitals should have no financial difficulty in establishing their inpatient programs.
Effect on Competition and Costs
There should be no appreciable impact on costs or competition in the health care community within District IX if these applications for cardiac cath are approved. While there will be a decline in the service utilization of other facilities outside the district when referrals cease, there is no data from which it must be concluded that such decrease will adversely affect the health
care community as a whole. Further, the increased service availability within District IX should not affect competition or costs since historically these facilities do not compete for patients. Similarly, since the potential patients do not currently utilize existing and approved programs (for the most part) within District IX, the approval of these applications for inpatient cardiac cath will not adversely affect the ability of existing providers to attract and retain the personnel or patients for their programs.
In the case of Lawnwood's proposal for open heart, such program would, however, detract from the existing providers. Since, on average, the existing providers are not operating at appropriate levels, the creation of an additional provider would significantly affect the existing programs' abilities to attract patients. Theoretically, the existing providers should have the first opportunity to secure outmigrating patients. This would assure that their programs develop and retain a volume to assure quality of care.
Indigent Care
As stated previously, Indian River is a tax-supported hospital which pledges tax revenues to provide health care for the indigent. It is anticipated that such practice will continue and that those residents of Indian River County who are unable to afford inpatient cardiac cath services will obtain indigent care according to Indian River's historical record.
Lawnwood's historical record for providing indigent care (as supported by its outpatient cardiac cath data) is less than exemplary. It is anticipated that as a conditon upon the issuance of the CON, Lawnwood will be required to provide a minimum of 2 percent of the total annual visits to Medicaid patients and a minimum of 3 percent of total annual visits o medically indigent/charity care patients. Those amounts are an appropriate commitment to assist the medically needy within Lawnwood's service area.
Miscellaneous Criteria
The applicants did not propose the operation of joint, cooperative, or shared health care resources.
The applicants did not predicate need for their requested service on the need for research and educational facilities.
The special needs and circumstances of health maintainance organizations was not at issue.
The parties stipulated as to the reasonableness of the costs and methods for construction of the proposed facilities. Both hospitals intend to construct new laboratories. The costs associated with Indian River's proposed construction are less than those proposed by Lawnwood.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of these proceedings.
An applicant for a CON bears the burden of establishing, by competent substantial evidence, its entitlement to a CON to operate the requested program. Rainbow Community Hospital v. Department of Health and Rehabilitative Services, 453 So.2d 1200 (Fla. 1st DCA 1984).
Such applicant must meet the criteria set forth in Section 381.705, Florida Statutes, together with the applicable rules of the Florida Administrative Code. A balanced consideration of all pertinent criteria must be made with regard given to the facts of each case. North Ridge General Hospital
v. NME Hospitals, 478 So.2d 1138 (Fla. 1st DCA 1985).
Based upon the record in this case, the applicants have established numeric need for the requested inpatient cardiac catheterization laboratories. The remaining criteria have also been met. These applicants have demonstrated consistency with the State and District Health Plans regarding cardiac cath laboratories. Approval of these applications will increase accessibility and availability of services in the District without detracting from the existing programs. The inconvenience of travel to outside programs will be greatly reduced. These applicants have a history of providing quality care to their respective patients. It is anticipated that that care will extend to their inpatient cardiac cath programs. Based upon the volume of procedures intended to be performed, both applicants have established the financial feasibility of the inpatient cardiac cath service. With the addition of a commitment to indigent care included as a condition of the CON, both applicants will significantly contribute to the provision of health care services to Medicaid and the medically indigent.
Lawnwood has not established not normal circumstances justifying the issuance of a CON for an open heart surgery program. District IX must be reviewed as a whole with consideration given to the existing providers of this service and the average volumes their programs experience. Accordingly, on balance, Lawnwood has failed to meet the statutory and rule criteria for issuance of a CON for open heart services. The approval of the Lawnwood request would significantly reduce the average volume of existing providers. Further, open heart services are reasonably available to all residents of District IX. Such residents are not precluded from obtaining open heart services due to geographic, financial, or programmatic circumstances.
Based upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Department of Health and Rehabilitative Services enter a final oider approving the certificate of need applications filed by Indian River Memorial Hospital and Lawnwood Regional Medical Center to establish inpatient cardiac catheterization laboratories. It is further recommended that Lawnwood's application to establish an open heart surgery program be denied.
DONE AND ENTERED this 28th day of March, 1990, in Tallahassee, Leon County, Florida.
Joyous D. Parrish Hearing Officer
Division of Administrative Hearings 1230 Apalachee Parkway
Tallahassee, Florida 32301
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 28th day of March, 1990.
Appendix to Case Nos. 89-1293 et seq.
RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY INDIAN RIVER:
Paragraphs 1 through 16 are accepted.
With regard to paragraph 17, it is accepted that Indian River physicians have established referral patterns outside of District IX for inpatient and outpatient cath procedures. To the extent that Indian River's application and response to the omissions letter made reference to this phenomenon, it is accepted that such activities were properly placed at issue in these proceedings. As to the calculations expressed in paragraph 17, no formal study was performed by any party to accurately quantify the number of procedures performed outside District IX on residents of Indian River and St. Lucie Counties. It is accepted that Dr. Celano and his partner performed outpatient procedures cn approximately 200 patients. It is further accepted that another
300 procedures were performed on Indian River residents at Holmes or Florida Hospital. Consequently, the utilization rate has been significantly understated. The total volume of which is unknown except as addressed herein, paragraph 17 is rejected as speculation or unsupported by the record in this cause.
The first three sentences of paragraph 18 are accepted. The last sentence is rejected as speculation.
With regard to paragraph 19, it is accepted that referrals to other hospitals can cause patient anxiety due to waits or transfer difficulties. Otherwise rejected as comment, argument, recitation of testimony or unnecessary.
Paragraphs 20 and 21 are accepted.
Paragraph 22 is rejected as irrelevant.
Paragraph 23 is accepted.
Paragraph 24 is rejected as speculation unsupported by the weight of the evidence or irrelevant.
Paragraph 25 is accepted.
Paragraph 26 is accepted.
Paragraph 27 is accepted.
Paragraph 28 is accepted.
To the extent that the "new rule" requires consideration of inmigration and outmigration, paragraph 29 is accepted. That data became available subsequent to the finding that these applications were complete is irrelevant. Since no data quantifying outmigration/inmigration was available, the rule read as a whole must dictate whether the applicants have established numeric need. The applicants and the Department knew of the outmigration, consequently, reading
the rule as a whole establishes that the existing providers are performing an ample number of procedures to guarantee their continued success and that an additional two programs are warranted.
See response to paragraph 29 above regarding paragraph 30.
Paragraph 31 is rejected as argument--see response to paragraph 29 and findings reached in paragraphs related to "new rule."
Paragraph 32 is rejected as argument, comment or unnecessary.
Paragraphs 33 through 41 are accepted.
With regard to paragraphs 42 through 80, except as noted by findings of fact related to the applicants and the assessment of their proposals, such paragraphs are unnecessary (need for two programs has been established), argument, irrelevant (as to allegations regarding Lawnwood's open heart proposal), or contrary to the weight of competent evidence.
RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY LAWNWOOD:
Paragraphs 1 through 7 are accepted.
With regard to paragraph 8, it is accepted that currently Indian River does not have an outpatient cardiac cath program; however, regardless of the outcome of this proceeding, Indian River will establish an outpatient facility.
Paragraphs 9 and 10 are accepted.
Paragraph 11 is accepted but is unnecessary since it does not provide a fact related to the conclusions reached in this order.
Except as accepted in the findings of fact related to the "old rule," paragraphs 12 through 15 are rejected as contrary to the weight of the evidence. In theory, Lawnwood's proposed findings correctly state how the "old rule" should be applied. The actual numbers differ slightly with the findings reached in the recommended order.
Except as accepted in the findings of fact related to the "new rule," paragraphs 16 through 20 are rejected as contrary to the weight of the evidence. In theory, Lawnwood's proposed findings correctly state how the "new rule" should be applied. The actual numbers and conclusions differ slightly with the findings reached in the recommended order.
Paragraph 21 is accepted.
Except as accepted in the findings of fact related to open heart need, paragraphs 22 and 23 are rejected as unsupported by the weight of the evidence, argument, or irrelevant.
Paragraph 24 is accepted.
Paragraphs 25 through 28 are accepted.
Paragraph 29 is rejected as contrary to the weight of competent evidence, irrelevant (an out of district provider would not have standing to oppose the request), or argument.
Paragraph 30 is accepted to the extent that it states Martin's inpatient cath program located in Martin County has improved accessibility; however, that program did not exist when these applications were filed and evaluated by the Department otherwise rejected as irrelevant.
Paragraph 31 is rejected as contrary to the weight of the evidence or irrelevant.
Paragraph 32 is rejected as contrary to the weight of the evidence related to open heart. Open heart facilities are available and accessible for District IX residents. Transfers to open heart facilities under emergency circumstances after cardiac cath procedures would be the exception and not the rule.
Paragraphs 33 and 34 are rejected as irrelevant to the issue of open heart. While outmigration is to be considered in determining need for cardiac cath under the "new rule," such outmigration does not establish inaccessibility for open heart services.
Paragraphs 35 through 41 are rejected as contrary to the weight of the evidence, contrary to the appropriate rule application, or irrelevant.
Paragraphs 42 (deleting open heart) through 44 are accepted.
With regard to paragraph 45, the program located at Martin has not been considered in the evaluation of these applicants since approval for that program occurred after this batch closed.
Paragraph 46 is accepted.
Paragraph 47 is rejected as irrelevant.
Paragraph 48 is rejected as irrelevant.
Paragraph 49 is rejected as irrelevant.
Paragraphs 50 and 51 are rejected as argument or contrary to the weight of the evidence.
Paragraph 52 is accepted.
Paragraph 53 is accepted.
Paragraph 54 is rejected as irrelevant.
Paragraph 55 is accepted.
Paragraph 56 is rejected as contrary to the weight of the evidence.
Paragraphs 57 through 61 are rejected as contrary to the weight of the evidence.
Paragraph 62 is accepted.
Paragraphs 63 through 80 are accepted.
Paragraph 81 is rejected as contrary to the weight of the evidence.
Paragraphs 82 through 85 (related only to cardiac oath) are accepted. Related to the allegations foil open heart, such paragraphs are rejected as contrary to the weight of the evidence or irrelevant.
Paragraphs 86 through 90 are accepted.
Paragraphs 90 through 96 are accepted only as to representations of facility and staffing it is agreed Lawnwood will have. Otherwise, assumption that volume of surgical cases will exist is rejected as contrary to the weight of the evidence.
Paragraphs 97 through 105 are accepted.
With regard to paragraph 106, it is accepted that the term emergency vehicle includes helicopter; otherwise, rejected as a conclusion of law.
Paragraph 107 is rejected as argument.
Paragraph 108 is rejected as argument or contrary to the weight of the evidence.
RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY THE DEPARTMENT:
Paragraphs 1 through 3 are accepted.
The conclusion reached in paragraph 4 is rejected as contrary to the weight of the evidence.
Paragraph 5 is accepted.
The conclusion reached in paragraph 6 is rejected as contrary to the weight of the evidence.
Paragraph 7 is accepted.
Paragraph 8 is accepted.
Paragraph 9 is rejected as to the conclusion reached regarding the cardiac cath program as contrary to the weight of the evidence. With regard to the conclusion reached regarding the open heart program, the paragraph is accepted.
Paragraphs 10 through 13 are accepted.
Paragraph 14 is rejected as irrelevant.
Paragraphs 15 through 16 are accepted.
Paragraph 17 is rejected as argument.
Paragraph 18 is rejected as argument, contrary to the weight of the evidence, or irrelevant.
Paragraph 19 is accepted.
Paragraph 20 is rejected as irrelevant.
Paragraph 21 is rejected as irrelevant.
Paragraph 22 is accepted.
Paragraph 23 is rejected as contrary to the weight of the evidence, irrelevant or multiple facts.
Paragraphs 24 through 25 are accepted.
Paragraph 26 is rejected as comment, argument, or irrelevant.
Paragraphs 27 and 28 are accepted.
Paragraph 29 is rejected as argument.
Paragraph 30 is rejected as repetitive or argument.
The second sentence of paragraph 31 is accepted; otherwise, the paragraph is rejected as irrelevant.
Paragraph 32 is accepted.
Paragraph 33 is accepted.
Paragraph 34 is rejected as contrary to the weight of the evidence.
Paragraph 35 is accepted.
Paragraph 36 is accepted.
Paragraph 37 is accepted.
Paragraph 38 is rejected as contrary to the weight of the evidence.
Paragraph 39 is accepted.
With the substitution of the word "maintenance," paragraph 40 is accepted.
Paragraph 41 is accepted.
Paragraphs 42 through 47, with the exception of the conclusion that only one cath program is needed (that conclusion is contrary to the weight of the evidence), are accepted.
Paragraph 48 is rejected as irrelevant.
Paragraph 49 is accepted.
RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY ST. MARY'S:
Paragraph 1 is accepted.
The first two sentences of paragraph 2 are accepted. The balance of the paragraph is rejected as unsupported by the record.
The first two sentences of paragraph 3 are rejected as contrary to the weight of the evidence. The last sentence is accepted.
The first sentence of paragraph 4 is accepted. The balance of the paragraph is rejected as argument. It is accepted that Lawnwood does not have a significant history in connection with the outpatient cath facility.
Paragraph 5 is rejected as argument.
Paragraph 6 is rejected as irrelevant.
Paragraphs 7 through 18 are rejected as argument, irrelevant, contrary to the weight of the evidence or recitation of testimony.
The first sentence of paragraph 19 is accepted. The balance of the paragraph is rejected as argument, contrary to the weight of the evidence, or irrelevant.
Paragraph 20 is rejected as irrelevant.
Paragraph 21 is accepted but is irrelevant.
Paragraph 22 is rejected as irrelevant.
Paragraph 23 is rejected as recitation of testimony.
Paragraph 24 is rejected as irrelevant.
Paragraph 25 is rejected as irrelevant.
The first sentence of paragraph 26 is accepted. The balance is rejected as argument or conclusion of law.
Paragraphs 27 and 28 are rejected as argument.
Paragraph 29 is accepted.
The first sentence of paragraph 30 is accepted. The balance of the paragraph is rejected as argument.
Paragraph 31 is rejected as contrary to the weight of the evidence.
Paragraph 32 is rejected as argument.
Paragraph 33 is rejected as argument.
Paragraph 34 is accepted.
Paragraph 35 is rejected as argument.
Paragraph 36 is rejected as argument.
Paragraph 37 is accepted.
Paragraphs 38 and 39 are accepted.
Paragraph 40 is rejected as irrelevant.
COPIES FURNISHED:
Kenneth F. Hoffman
Oertel, Hoffman, Fernandez & Cole, P.A.
2700 Blair Stone Road Post Office Box 6507
Tallahassee, Florida 32314-6507
John Radey Jeffrey L. Frehn
Aurell, Radey, Hinkle & Thomas
101 North Monroe Street
Suite 1000, Monroe Park Tower Post Office Box 11307 Tallahassee, Florida 32302
David Watkins Patricia A. Renovitch
Oertel, Hoffman, Fernandez & Cole, P.A.
2700 Blair Stone Road Post Office Box 6507
Tallahassee, Florida 32314-6507
Lesley Mendelson Senior Attorney
Department of Health and Rehabilitative Services Ft. Knox Executive Center
2727 Mahan Drive, Suite 103
Tallahassee, Florida 32308
Sam Power Agency Clerk
Department of Health and Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
John Miller General Counsel
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
INDIAN RIVER MEMORIAL HOSPITAL,
Petitioner,
CASE NO.: 89-1293
vs. CON NO.: 5726
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES,
Respondent.
/ LAWNWOOD MEDICAL CENTER, INC.,
Petitioner,
CASE NO.: 89-1294
vs. CON NO.: 5729
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES,
Respondent.
/ INDIAN RIVER MEMORIAL HOSPITAL,
Petitioner,
CASE NO.: 89-1295
vs. CON NO.: 5726
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES and HCA LAWNWOOD REGIONAL MEDICAL CENTER,
Respondents.
/
MARTIN MEMORIAL HOSPITAL ASSOCIATION, INC.
Petitioner,
CASE NO.: 89-1296
vs. CON NO.: 5729
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES and LAWNWOOD MEDICAL CENTER, INC.
Respondents.
/ ST. MARY'S HOSPITAL, INC.
Petitioner,
CASE NO.: 89-1297
vs. CON NO.: 5729
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES and HCA LAWNWOOD REGIONAL MEDICAL CENTER,
Respondents.
/ ST. MARY'S HOSPITAL, INC.
Petitioner,
CASE NO.: 89-1298
vs. CON NO.: 5731
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 THE DEPARTMENT
Counsel challenges the Hearing Officer's calculation of numeric need under the "old" rule. The "new" rule is applicable to the applications at issue; therefore, there is no need to address the exception. See Nu-Med Pembroke Pines, Inc. vs. Department of Health and Rehabilitative Services, Case Number 89-1255 (HRS 2/27/90).
Counsel excepts to finding of fact 23. The rule calls for the number of admissions, not the number of procedures. The number of admissions in the district for the relevant period was 4,122 (HRS #3). This number was not disputed. The new rule calls for "the actual adult cardiac catheterization program volume for the most recent twelve month period for which data are available to the department." The term "cardiac catheterization annual program volume" is defined as the total number of inpatient and outpatients to the cardiac cath program. Therefore, for the purposes of calculating the need under the rule, it is the volume performed in the cardiac cath programs, not the number of procedures performed on residents of the district, which is to be
counted. The Hearing Officer states "the actual number utilized by the department in the evaluation of the applications failed to consider the outmigration of patients residing in Indian River County who traveled out of the district for services." While the department did not take this into consideration in counting program volume, this was not a "failure" on the part of the department because the rule does not require consideration of outmigration. Finding of fact 23 is rejected as an incorrect conclusion of law.
Counsel excepts to finding of fact 26. Under the "new rule", it is only if there is need for a cardiac cath program under paragraph 8(a) through
(d) that the provisions of subparagraph (e) come into play. In other words, subparagraph (e) serves to disqualify need for a program which exists pursuant to 8(a) through (d), and not to create need where none is indicated pursuant to 8(a) through (d). Because there is need for one program pursuant to paragraphs 8(a) through (d), paragraph (e) can only be used to determine whether that one program can be disqualified, not used to determine need for two.
In the appendix at page 30 of the Recommended Order, the Hearing Officer accepted paragraph 19 of the department's proposed order; however, that paragraph was not stated in the Recommended Order. Paragraph 19 proposed by HRS is hereby adopted and reads as follows:
The base year population (January 1988) aged 15+ in District IX, was 950,495. The most recent District admissions available to HRS three weeks prior to the date the fixed need pool should have been published was 4,122. The period of time during which these admissions occurred was April 1987 through March 1988. The District population aged 15+ for the planning horizon of January 1991 is 1,052,733 and the projected admissions for the planning horizon which result is 4,656. The difference between the number of admissions in the base year and the number of admissions projected for the planning horizon is 443 which could justify the addition of one, but not more than one, additional program. (HRS #3) (T-1129). In concluding there is a need for one additional program, HRS did not take into consideration the approved program at Martin Memorial. (T-1129).
There is numeric need for one additional cath program. Finding of fact 26 is rejected as an incorrect conclusion of law.
Counsel excepts to the implication of paragraph 33 that Lawnwood satisfies the rule requirement that the applicant be within 30 minutes emergency travel time from a hospital providing open heart surgery. The facts stated in paragraph 33 are supported by competent, substantial evidence and are accepted;
however, is it uncontradicted that Lawnwood does not have a helicopter, thus the
23 minute travel time by helicopter between Lawnwood and Holmes must be doubled as Lawnwood must rely on Holmes's helicopter. Lawnwood does not satisfy the travel time requirement. The exception is granted.
Counsel excepts to the second and third sentences of finding of fact
The challenged findings are supported by competent, substantial evidence; therefore, the exceptions are denied. Heifetz vs. Department of Business Regulation, 475 So2d 1277 at 1281 (Fla. 1st DCA 1985).
RULING ON EXCEPTIONS FILED BY ST. MARY'S HOSPITAL
St. Mary's takes exception to the Hearing Officer's finding of fact 5, which states that the entitlement of Martin Memorial Hospital to inpatient cardiac cath is "disputed by Lawnwood Medical Center, Inc." The entitlement of Martin Memorial to inpatient cardiac cath is not at issue in this case; therefore, no ruling is required.
The second exception reiterates the department's first exception.
The third exception reiterates the department's second exception.
The fourth exception reiterates the department's fourth exception.
St. Mary excepts to finding of fact 34. The Hearing Officer's recommendation for 2 cardiac cath programs is based on her finding of numeric need for 2 programs. There is no suggestion in finding of fact 34 that the approval of one program would not increase accessibility, lessen outmigration, lessen patient anxiety, and improve efficiency.
St. Mary excepts to finding of fact 38. The finding is supported by competent, substantial evidence; therefore, the exception is denied.
St. Mary excepts to the second sentence of finding of fact 41. No ruling is required in view of the disposition reached in this Order.
8. In exceptions 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22,
28, 29, 30, and 31; St. Mary excepts to the Hearing Officer's rulings on proposed findings of fact. Some of the proposed findings were rejected as irrelevant based on the Hearing Officer's recommendation that both Lawnwood and Indian River be approved. Having concluded that only one proposal should be approved some of the rejected findings are now relevant, and could justify a remand to the Division of Administrative Hearings for further fact finding. I conclude that the present record is sufficient to choose one of the competing proposals. There is judicial precedent for making the decision without remand. Humana vs. Department of Health and Rehabilitative Services, 492 So2d 388 (Fla. 4th DCA 1986), see also H. B. A. Corp. vs. Department of Health and Rehabilitative Services, 482 So2d 461 (Fla. 1st DCA 1986).
9. Exceptions 23, 24, 25, 26, and 27 reiterate the department's exception number 4.
RULING ON EXCEPTIONS FILED BY LAWNWOOD
Lawnwood excepts to finding of fact 39. The finding is supported by competent, substantial evidence; therefore, the exception is denied.
Lawnwood excepts to the Hearing Officer's finding regarding outmigration in finding of fact 30. Under the rule a proposal may be approved where special circumstances outweigh the lack of numeric need under the rule formula. The Hearing Officer did not hold that outmigration can never constitute a special circumstance, she only held that in this case "no persuasive not normal circumstances have been established." The exception is denied.
Lawnwood excepts to the Hearing Officer's finding that its record of providing indigent care is less than exemplary. The finding is supported by competent, substantial evidence; therefore, the exception is denied.
Lawnwood asserts that the Hearing Officer did not "properly balance" the evaluation criteria in recommending denial of the open heart proposal. It is clear that the Hearing Officer considered all criteria, but properly concluded that in the absence of numeric need or sufficient special circumstances, the application should be denied.
FINDINGS OF FACT
The Department hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order except where inconsistent with the rulings on the exceptions.
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. I conclude that only one of the competing proposals should be approved. There is a need for one additional program under the rule formula (numeric need). There are no special circumstances justifying approval of both applications despite lack of numeric need.
I conclude that Indian River's proposal is superior for the following reasons:
Indian River's history of provision of care to the indigent in contrast to Lawnwood's less than exemplary record. (See Recommended Order findings of fact 40 and 41).
Indian River's ability to satisfy the emergency travel time requirement (See Recommended Order findings of fact 32 and the ruling on the department's fourth exception).
Indian River's proposal is less costly (See Recommended Order finding of fact 45).
Considering the approval of a cardiac cath program at Martin Memorial Hospital in Stuart, Martin County; Indian River's geographic location in Vero Beach, Indian River County, is preferable to Lawnwood; which is located in Ft. Pierce, St. Lucie County. Official notice is taken that Martin and St. Lucie are adjoining counties.
Based on a balanced weighing of all applicable rule and statutory criteria, it is
ADJUDGED, that the application for CON 5726 of Indian River Memorial Hospital to establish an inpatient cardiac catheterization program be APPROVED. It is further adjudged that the application of Lawnwood Medical Center, Inc. for CON 5729 as to both cardiac catheterization and open heart surgery be DENIED. Case Number 89-1926 is closed on the basis of- a voluntary dismissal by
Martin Memorial Hospital Association, Inc. Case Number 89-1298 is closed on the basis of a voluntary dismissal by St. Mary's Hospital.
DONE and ORDERED this 11th day of May, 1990, in Tallahassee, Florida.
Gregory L. Coler Secretary
Department of Health and Rehabilitative Services
by Deputy Secretary for Programs
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
Copies furnished to:
Kenneth F. Hoffman, Esquire OERTEL, HOFFMAN, FERNANDEZ, &
COLE, P.A.
P. O. Box 6507 Tallahassee, FL 32314-6507
John Radey, Esquire Jeffrey L. Frehn, Esquire
AURELL, RADEY, HINKLE, & THOMAS
Suite 1000, 101 North Monroe Street Post Office Drawer 11307 Tallahassee, FL 32302
W. David Watkins, Esquire Patricia A. Renovitch, Esquire OERTEL, HOFFMAN, FERNANDEZ, &
COLE, P.A.
P. O. Box 6507 Tallahassee, FL 32314-6507
Lesley Mendelson, Esquire Assistant General Counsel Department of Health and
Rehabilitative Services 2727 Mahan Drive
Fort Knox Executive Center Tallahassee, FL 32308
Joyous D. Parrish Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, FL 32399-1550
Byron Mathews Jr., Esquire
201 South Biscayne Boulevard 22nd Floor, Miami Center Miami, FL 33131
FALR
Post Office Box 385 Gainesville, FL 32602
Wayne McDaniel (PDDR) Susan Lincicome (PDRH)
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing was sent to the above-named people by U.S. Mail this 17 day of May, 1990.
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
| Issue Date | Proceedings |
|---|---|
| Mar. 28, 1990 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| May 11, 1990 | Agency Final Order | |
| Mar. 28, 1990 | Recommended Order | Two applicants demonstrated that a statutory and rule criteria are met. District must be reviewed as a whole and one applicant failed to meet criteria. |
