STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
HUMANA OF FLORIDA, INC. d/b/a ) HUMANA HOSPITAL PASCO, )
)
Petitioner, )
)
vs. ) CASE NO. 92-1497
)
AGENCY FOR HEALTH CARE ) ADMINISTRATION and ADVENTIST ) HEALTH SYSTEM/SUNBELT, INC. d/b/a ) EAST PASCO MEDICAL CENTER, )
)
Respondents. )
)
RECOMMENDED ORDER
Pursuant to Notice, this cause was heard by Linda M. Rigot, the assigned Hearing Officer of the Division of Administrative Hearings, on September 29-30, October 1-2, and 5, 1992, in Tallahassee, Florida.
APPEARANCES
For Petitioner: James C. Hauser, Esquire
Messer, Vickers, Caparello, Madsen, Lewis, Goldman & Metz
Post Office Box 1876 Tallahassee, Florida 32302
For Respondent: Edward Labrador, Esquire
Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308
For Respondent: Darrell White, Esquire
William Wiley, Esquire
McFarlain, Wiley, Cassedy & Jones
215 South Monroe Street Suite 600 Tallahassee, Florida 32301
STATEMENT OF THE ISSUE
The issue presented is whether the application of Respondent Adventist Health System/Sunbelt, Inc. d/b/a East Pasco Medical Center for a certificate of need to add 24 acute care beds to its existing facility should be approved.
PRELIMINARY STATEMENT
Respondent Adventist Health System/Sunbelt, Inc. d/b/a East Pasco Medical Center filed with the Department of Health and Rehabilitative Services an application for a certificate of need to add 24 acute care beds to its existing
facility, and the Department determined that the application should be approved. Petitioner timely filed a petition requesting a formal administrative hearing to challenge the Department's preliminary decision. This cause was thereafter referred to the Division of Administrative Hearings for the conduct of that formal proceeding. During the pendency of this proceeding the Department's certificate of need responsibilities were transferred to the Agency for Health Care Administration, and that agency was substituted as a party in this proceeding at the commencement of the final hearing.
Respondent Adventist Health System/Sunbelt, Inc. d/b/a East Pasco Medical Center presented the testimony of Bobby A. Dodd; A. David Jimenez; Susan I. DesHarnais, Ph.D.; Mary Elizabeth West, Ph.D.; Donald R. Edge; David H. Sikes, M.D.; Harvey G. Blackstone, M.D.; Rick Knapp; and W. Eugene Nelson.
Additionally, Respondent's Exhibits numbered 1-6, 8, 16, 17, 19-21, 24, 25, 27, and 28 were admitted in evidence.
Respondent Agency for Health Care Administration presented the testimony of Robert Garland, Jr., and Helen O'Loughlin. Additionally, the Agency's Exhibits numbered 1 and 2 were admitted in evidence.
Petitioner Humana of Florida, Inc. d/b/a Humana Hospital Pasco presented the testimony of William F. Jessee, M.D.; Lee J. Grossbard, M.D.; Ward M. Koutnik; Laurie Svec; Lisa L. Kelley; Robert C. Meade, Jr.; Robert Harrett; and Daniel J. Sullivan. Additionally, Petitioner's Exhibits numbered 1-4, 6-10, 13- 16, 18-21, 23-25, 27-39, 44-46, and 52 were admitted in evidence.
Joint Exhibits numbered 1 and 2 were also admitted in evidence.
All parties submitted post-hearing proposed findings of fact in the form of proposed recommended orders. A specific ruling on each proposed finding of fact can be found in the Appendix to this Recommended Order.
FINDINGS OF FACT
The Seventh Day Adventist Church owns Respondent Advent-ist Health System/Sunbelt, Inc. That corporation, which occupies a strong financial position, operates not-for-profit hospitals in several states, including Florida. One of the Florida hospitals is East Pasco Medical Center (East Pasco), located in Zephyrhills. Zephyrhills is in eastern Pasco County, which, for health planning purposes, is known as Subdistrict 2 of District 5.
East Pasco is an 85-bed acute care hospital which provides most of the common services found in a community hospital. In addition to providing general acute care and obstetrics (OB), it has an intensive care unit (ICU) and offers neurosurgery and kidney dialysis services. East Pasco also has completed but not yet opened an 11-bed skilled nursing unit (SNU) and a 10-bed observation unit. The 11 beds in the SNU and the 10 beds in the observation unit are in addition to the 85 acute care beds for which East Pasco is licensed.
For licensure purposes, acute care beds are not divided into types of service. East Pasco's current configuration for its 85 acute care beds is as follows: 68 medical-surgical beds, 8 ICU beds, and 9 OB beds.
East Pasco has an active emergency room which experiences up to 30,000 visits per year. East Pasco obtains approximately 55 percent of its in-patient admissions through its emergency room.
East Pasco is accredited by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).
Petitioner Humana of Florida, Inc. d/b/a Humana Hospital Pasco (Humana) is an existing 120-bed acute care hospital in Dade City. It is situated approximately 10 minutes away from East Pasco. Humana provides the same services that East Pasco provides, including medical-surgical, ICU/CCU, OB, kidney dialysis, and neurosurgery. Like East Pasco, Humana is accredited by the JCAHO. However, Humana's accreditation is "with commendation", the highest rating given by the JCAHO.
Like East Pasco, Humana has a large medical staff, primarily consisting of physicians who have their offices located in Zephyrhills or Dade City. The medical staff rosters of Humana and East Pasco are virtually identical. Dade City is also located in east Pasco County, and the primary service areas of Humana and East Pasco are virtually identical.
Like East Pasco, Humana serves the Medicaid and indigent patient populations. In its fiscal year 1991, Humana provided 6 percent of its patient days to Medicaid patients. In fiscal year 1992, that increased to 8.8 percent, the same as East Pasco. Humana's Medicaid patient days increased substantially with the introduction of OB services at Humana since Medicaid patients receive primarily OB services. East Pasco has been designated as a disproportionate share provider under the State's program to give economic incentives to hospitals serving a certain percentage of Medicaid patients. East Pasco also serves the indigent patient population pursuant to a contract between it and Pasco County.
In September, 1991, East Pasco filed its application for a certificate of need (CON) requesting approval for 24 additional medical-surgical beds (acute care beds) for the July, 1996, planning horizon. In January, 1992, the Agency notified East Pasco of its intent to approve the application and issue to East Pasco CON No. 6783. Humana filed this challenge to the Agency's intent to grant the application, and this proceeding ensued. All parties subsequently stipulated that Humana has standing to initiate and maintain this proceeding and that Humana was not obligated to present evidence of its standing.
East Pasco has proposed a new unit to house the 24 additional medical- surgical beds to be located on the third floor of a new three-story tower. That third floor would consist of 13,000 gross square feet (GSF), would cost
$4,087,810, and would consist of only private rooms with three nurse stations. East Pasco proposes no new services, only additional beds. Construction of the three-story tower has not yet commenced but is awaiting the outcome of this proceeding.
The first floor of the new tower will be a wellness center, a project which did not require CON review. The second floor will house a new ICU. East Pasco presented conflicting evidence as to the size of that new ICU. The Agency approved East Pasco's second floor ICU as a 12-bed ICU with a cost below the threshold cost which would have required CON review. In spite of the exemption from review obtained by East Pasco, it is specifically found that East Pasco intends to place a 16-bed ICU on the second floor of the yet-to-be-constructed tower. Thus, East Pasco would achieve its 16-bed ICU by relocating its existing 8-bed ICU and converting other beds to ICU beds. Thus, if the 24 new beds sought are approved they will produce 16 additional medical-surgical beds and 8 additional ICU beds.
Resolution of the number of beds proposed for the second floor of the new tower is required in this proceeding for two reasons. First, the cost of this project is impacted. If 8 of the new beds are to be used as ICU beds rather than as medical-surgical beds, they will be more expensive to construct and equip. Second, corporate approval of corporate projects is a prerequisite in Florida's CON process. East Pasco's Board of Directors met on August 14, 1991, to authorize the filing of this application. This application proposes 24 medical-surgical beds, the corporate resolution filed with the Agency authorized
24 acute care beds, but the minutes of the Board's meeting reflect that the Board itself approved 24 beds for ICU and PCU services. Although ICU, PCU, and medical-surgical beds are all acute care beds, they are constructed, equipped, and staffed differently.
For the reasons described below, there is no need in District 5 or in the east Pasco County Subdistrict for East Pasco's proposed 24 additional medical-surgical beds.
Rule 59C-1.038, Florida Administrative Code, includes the numeric need methodology for projecting acute care bed need. Under that Rule, applications for acute care beds will "not normally" be approved unless there is numeric need. For the September, 1991, application batching cycle, the Agency published a fixed need of zero acute care beds needed in District 5, Subdistrict 2, which is composed of only East Pasco and Humana hospitals. This fixed and published need of zero was not challenged.
Per paragraph (7)(d) of the Rule, additional acute care beds will "not normally" be approved unless the subdistrict occupancy is at or exceeds 75 percent. All parties agree that calendar year 1990 is the proper period to ascertain whether this standard is met. In 1990, the acute care bed occupancy rate in the Subdistrict was 55.33 percent. The parties agree that the Rule's occupancy standard is not met. Therefore, no additional beds should normally be approved.
There is ample unused capacity in District 5 and in the Subdistrict to meet acute care demand. Humana's occupancy is well below 50 percent. In years
and 2 for the proposed unit, East Pasco projects 1,042 and 1,760 patient days, respectively. Humana has sufficient unused capacity to accommodate that projected demand.
Utilization trends support the lack of need shown by the need methodology and the occupancy standard. Acute care utilization in the Subdistrict has decreased since 1986. In 1986, the two Subdistrict hospitals generated 42,830 patient days, a 57.2 percent occupancy. In 1991, notwithstanding population growth in the Subdistrict, the two Subdistrict hospitals generated 41,756 patient days, a 55.8 percent occupancy. Clearly, then, there is no increased demand for acute care services, but only a reshuffling of market share between the two hospitals.
Contrary to East Pasco's suggestion, first quarter utilization does not show need and has, in fact, been decreasing. For example, the first quarter (January-March) of 1986 generated 13,572 patient days in the Subdistrict, a 73.6 percent occupancy; in the first quarter of 1992, there were 12,482 patient days, a 66.9 percent occupancy, the lowest first quarter utilization in the last 6 years in the Subdistrict.
Additionally, the average length of stay (ALOS) in the Subdistrict continues to decline. In the first quarter of 1991, the ALOS was 5.4 days; in
the first quarter of 1992, the ALOS was 5.1 days. Accordingly, although East Pasco shows an increased number of admissions over the last several years, the continued decline in the ALOS has resulted in a decreasing number of patient days.
The population growth in the Subdistrict is not so substantial as to demonstrate need. Humana relied upon population projections produced by a national firm specializing in demographic analyses. Such a population data source is generally more reliable than a county's own projections, relied upon by East Pasco. The Subdistrict is growing but not at an extraordinary pace. In comparison, the West Pasco Subdistrict is growing faster.
There are no geographic access problems to receiving acute care services which would support a finding of need. There are many hospitals available and accessible to residents of the Subdistrict within 30 minutes travel time or less.
The entire Subdistrict is within a 30-minute travel time of Humana and of East Pasco. Most of the Subdistrict is also within 30 minutes travel time to other acute care hospitals, including University Community Hospital in Tampa, Lakeland Regional Medical Center in Lakeland, and South Florida Baptist Hospital in Plant City. The Zephyrhills area in particular is within 30 minutes travel time to those other facilities.
Humana is an available alternative to the proposed project. Humana is geographically accessible to the entire Subdistrict, provides all the services that East Pasco provides, and provides good quality of care. Humana's medical staff roster includes the same physicians that practice at East Pasco. Humana already serves the same geographic service area that East Pasco serves. Indeed, several East Pasco witnesses testified that patients are transferred to Humana when East Pasco is full, thereby acknowledging Humana as an alternative for Subdistrict residents.
Hospitals situated outside the Subdistrict are also available and appropriate alternatives to the proposed project. These hospitals have unused capacity to accommodate the projected demand from the Subdistrict. Notably, residents of the Subdistrict have historically greatly utilized hospitals located outside the Subdistrict. In 1990, 63.7 percent of the Subdistrict's residents went to a hospital other than Humana or East Pasco. Thus, physicians and residents regard hospitals situated outside the Subdistrict as appropriate and viable alternatives.
Since East Pasco does not propose to offer any new service, and since there is accessible unused capacity at Humana and these other facilities, there are better alternatives to adding new beds at East Pasco. In addition, although approving more beds at East Pasco would improve availability of services at East Pasco, such is not a planning consideration or a review criterion.
East Pasco and Humana provide similar levels of Medicaid care. In calendar year 1991, Medicaid comprised 8.8 percent of all patient days at East Pasco, less than in 1990. From September, 1991, to August, 1992, 8.8 percent of all patient days at Humana were Medicaid days. The two hospitals also provide similar amounts of indigent care. Therefore, Humana is economically accessible to all residents of the Subdistrict. Facilities located outside the Subdistrict also are economically accessible.
Physician preferences are not significant in formulating conclusions of need on a District or Subdistrict basis. Physicians may well have their own reasons for doing things which may be contrary to sound health care planning principles. Further, physicians' personal preferences are not relevant to ascertaining how existing resources can be best and most efficiently used.
The acute care bed Rule provides that additional beds "may" be approved at a specific facility if its occupancy exceeds 75 percent even though no beds can be authorized pursuant to the mathematical calculations established by the Rule. While East Pasco achieved an occupancy rate of 78.78 percent in calendar year 1990, that statistic merely "opens the door" for an evaluation of whether there are compelling circumstances to justify the approval of beds at a specific facility despite the absence of need demonstrated by the acute bed methodology. There are no factors or circumstances which would justify the approval of 24 additional medical-surgical beds at East Pasco pursuant to the specific facility provision.
First, there are accessible and available alternatives for meeting projected demand. The majority of east Pasco County residents outmigrate even when beds are available at East Pasco. There is an excess capacity in the Subdistrict and in the District.
Second, East Pasco's application discusses seasonal overcrowding due, in large part, to using in-patient beds for "observation" patients. Observation patients are those with a hospital stay of less than 24 hours. East Pasco has recently completed a new 10-bed observation unit. In 1991, East Pasco averaged
observation patients per day; therefore, this new 10-bed unit will ease the strain on East Pasco's in-patient beds.
Third, East Pasco's application relies on the "overflow" of patients in the winter season to justify its proposed bed addition. The actual amount of "overflow" is reflected in East Pasco's transfer log, which shows that there were not that many patients transferred in 1991. In fact, there were several months in which there were zero transfers.
Fourth, the proposed beds are only intended to handle "seasonal" population demands. The proposed unit would not be open year-round. East Pasco was below 75 percent occupancy from May to October, 1991. East Pasco acknowledges that the proposed beds are only for part of the year and are intended to accommodate the demands of the seasonal population, who are not necessarily residents of the Subdistrict.
East Pasco's application in reality requests approval for adding 24 beds at a cost of over $4,000,000 to accommodate, by East Pasco's own projections, an average daily census of three patients the first year and five patients the second year in a unit that would be closed at least six months out of each year. That is an excessive expenditure to provide access to relatively few people, where access to nearby facilities exists. Although East Pasco has shown that on certain days it has exceeded its OB capacity, and although East Pasco maintains that its most common capacity problem is the lack of available ICU beds, East Pasco's application itself does not suggest that it intends to increase the number of OB or ICU beds. Further, although on certain days East Pasco has experienced over 100 percent occupancy and has placed patients in the hallways, that situation can be obviated by referring patients to other hospitals, and the situation will be alleviated when East Pasco soon opens its additional 10-bed observation unit and 11-bed SNU. East Pasco has, therefore, shown that it has an occupancy rate sufficient to entitle it to review despite
the lack of need under the acute care bed Rule, but it has shown no other reasons why its application should be approved.
The Florida State Health Plan includes various preferences for reviewing CON applications. On balance, the East Pasco application is not consistent with that Plan.
The first group of preferences relates to the addition of hospital beds. The first item in that group provides that no additional beds should generally be approved unless the subdistrict occupancy is at or exceeds 75 percent or unless the applicant-facility is at 80 percent. Since calendar year 1990 data was used to calculate the need formula and Subdistrict occupancy standard, it is appropriate to use that same data to determine East Pasco's occupancy for evaluating this preference, rather than using two different time periods as the Agency did. In 1990, the Subdistrict was below 75 percent, and East Pasco's occupancy was below 80 percent. Therefore, this preference is not met.
The second item under this group provides that "in the event that acute care bed need is shown", preference shall be given to an applicant who provides a disproportionate share of Medicaid and indigent services in the Subdistrict. This preference is not met since no "acute care bed need is shown".
The next group of preferences is entitled "transfer and conversion of acute care beds". Because East Pasco does not propose to transfer or convert acute care beds, East Pasco does not satisfy any of the preferences included under this grouping.
The next group of preferences is entitled "indigent care". The first item provides that preference shall be given to an applicant who provides a disproportionate share of Medicaid and charity care in relation to other hospitals in the District or Subdistrict. This preference is not met. Although East Pasco has historically provided more Medicaid and indigent care than Humana, there is no showing that East Pasco will provide disproportionately more Medicaid and indigent care for medical-surgical services specifically. Most of East Pasco's Medicaid participation is for OB and newborn services, not medical- surgical services. Both Humana and East Pasco provide less than 1 percent of their gross revenues for indigent care. Given that most of the Subdistrict population is elderly, indigent care is not a major issue. Also, it was stipulated that East Pasco does not know how much indigent care it provides for medical-surgical services only.
The second item under this group relates to whether CON approval would negatively affect the financial viability of a disproportionate share hospital. This preference is not relevant to East Pasco's application.
The third group of preferences is entitled "emergency services". The first item relates to the applicant's record of accepting indigent patients for emergency care. East Pasco presented no information on this in its application except for its proof that it has a contractual obligation to do so. The second item relates to whether the facility/applicant is a trauma center. East Pasco is not a designated trauma center. The third item relates to whether the applicant demonstrates a full range of emergency services. East Pasco did not address this in its application. The fourth item addresses whether the facility has ever been fined by HRS for violations of emergency services statutes. East Pasco did not address this item in its application. Therefore, East Pasco does not meet the preferences in this group.
The fourth group of preferences is entitled "teaching, research, and referral hospitals". The application does not address these particular preferences, and East Pasco does not hold itself out as a teaching, research or referral hospital. Therefore, East Pasco does not satisfy the items under this grouping.
The fifth group of preferences is entitled "specialized services". East Pasco does not propose to provide any specialized services and, therefore, items under this grouping are not satisfied.
The District 5 Local Health Plan includes recommendations for reviewing CON applications. On balance, the East Pasco application does not satisfy that plan.
The first preference relates to whether the applicant provides a disproportionate share of Medicaid and charity care. For the reasons indicated above regarding the State Health Plan, this preference is not met. Further, East Pasco's application does not suggest that the 24 medical-surgical beds sought will enhance its Medicaid or indigent participation.
The second recommendation provides that "if a numeric bed need exists as shown by the state bed methodology", preference is given to an applicant who has generated certain occupancy levels. Because no numeric bed need was shown per the Rule methodology, this recommendation is not met.
The third recommendation relates to the transfer of existing acute care beds. Because East Pasco does not propose a transfer of beds, its application is not consistent with this recommendation.
The fourth recommendation gives preference to applicants who document the cost-effectiveness and efficiency of their project. East Pasco does not satisfy this preference. East Pasco failed to show any cost efficiencies for its project. East Pasco proposes to spend over $4 million to serve, on the average, 3 to 5 patients per day in years 1 and 2. That is cost-inefficient. East Pasco did not prove that the charges or costs of providing medical-surgical services would be any less than what it currently charges.
East Pasco's application includes two pro formas: a hospital-wide pro forma and an incremental pro forma for the proposed 24-bed unit. The person who prepared those pro formas did not testify, and the person who did testify did not participate in preparing the pro formas. Further, the witness only testified to the reasonableness of the incremental pro forma; he did not testify, directly or indirectly, regarding the hospital-wide pro forma.
An incremental pro forma alone does not demonstrate long-term financial feasibility, even if the incremental pro forma were reasonable. An incremental pro forma alone does not reflect the project as a whole.
At East Pasco, there are several projects and activities on-going or planned that must be evaluated. In addition to the existing 85 beds, East Pasco has underway: (1) opening a 10-bed observation unit; (2) opening an 11-bed SNU;
(3) a planned wellness center on the first floor of the proposed 3-story tower; and (4) the planned relocation and enlargement of its ICU to the second floor of the proposed tower. Those projects add expenses, put strains on cash, and require debt. Without considering all the activity at the hospital, one cannot reasonably ascertain whether the proposed $4.1 Million third-floor project is
financially feasible. For example, a small project could show an incremental profit but the hospital as a whole could lose money.
East Pasco simply assumes that its 24-bed unit will be financially feasible in 1994 and 1995, years 1 and 2 of the project. The health care field is too dynamic and volatile for such assumptions. For example, East Pasco had an operating loss in 1990 but did well in 1991.
By not analyzing the hospital-wide pro forma and proving its reasonableness, East Pasco did not show the required financial feasibility. It only demonstrated the results of one component of an entire operation. East Pasco has left unanswered the question of whether the facility as a whole will be able to finance this project in conjunction with all its other requirements. Further, the application lacked sufficient and clear presentation of the assumptions underlying the hospital-wide pro forma. Restated, the hospital-wide pro forma is not self-explanatory.
The incremental pro forma, showing the proposed revenues and expenses for the 24-bed medical-surgical unit for years 1994 and 1995, is not reasonable. The projected revenues are overstated, and the projected expenses are understated. The assumptions underlying the financial projections are unreasonable. Further, the profit projections are unrealistic; in year two, East Pasco projects a profit of about $615,000 on an average daily census of less than 5 patients per day. On its face, that is unrealistic.
In 1991, East Pasco generated 24,517 patient days, which was virtually the same as its 1990 utilization. In 1993, East Pasco projects 26,220 days. In year 1 of this project (1994), East Pasco projects 27,262 days hospital-wide, including the 1,042 incremental days associated with this project. Thus, in just a 3-year period, East Pasco projects almost 3,000 additional patient days, and even more for year 2 (1995). It is not reasonable to assume such an increase in utilization since utilization during the first quarter of 1992 declined from first quarter 1991. Therefore, patient day projections are overstated, thereby causing overstated projected gross revenue.
East Pasco's projected daily charge is based on the hospital-wide average charge. It is not based on historical charges for medical-surgical services specifically. It is unreasonable to use charges for hospital services as a whole when the proposed project is for medical-surgical services only. Because the underlying assumption is invalid, projected revenues lack credibility.
In calculating deductions from gross revenues, East Pasco assumed the hospital-wide payor mix and did not specifically ascertain the payor mix (and, therefore, the deductions) for medical-surgical services specifically. Again, this is an unreasonable assumption. Deductions from gross revenue should have been analyzed for medical-surgical services specifically. Due to the invalid assumption, the deductions from revenue figures lack credibility.
East Pasco projects 5.8 FTEs for year 1 and 6.0 FTEs for year 2. East Pasco proposes to operate the 24-bed unit as an independent unit. These staffing levels are insufficient. East Pasco's proposed utilization equates to a 4.8 average daily census, which requires two nurses at all times. By East Pasco's admission, to staff a unit with two persons at all times throughout the year requires 9.2 paid nursing FTEs in addition to ward clerks and other support personnel. If the volume fluctuated and the census exceeded 7 or 8, more than two nurses would be needed. Thus, the 5.8 and the 6.0 FTE numbers are too low.
The proposed staffing does not allow one RN to be on the floor at all times. To maintain one RN on the floor at all times throughout the year requires 4.2 FTEs; East Pasco budgeted for one. East Pasco does not have excess RNs available from its existing staff to cover the proposed addition.
The supplies expense shown on the incremental pro forma was based on a hospital-wide average. The proposed project is for a specific service, and one cannot reasonably use a hospital-wide average instead. Accordingly, the calculation of expense for supplies is not reasonable.
The pro forma includes an expense item entitled "other". East Pasco offered no explanation for that expense. Also, the pro forma did not include a line-item for the HCCCB indigent care tax, which is 1.5 percent of net revenue.
East Pasco's proposed 24-bed medical-surgical unit will cover 13,000 GSF and will cost more than $4.1 million. All rooms will be private. The unit will have three nurse stations. According to East Pasco, the unit is to be a basic medical-surgical floor and is not intended to be a progressive care unit (PCU). This proposed design is not reasonable and is excessively large by at least 30 percent. This design is inefficient and, in reality, is not the design of a basic medical-surgical unit, but is instead the design of a PCU.
There are three main reasons why the design is excessive. First, it is not necessary or reasonable to have all private rooms. A regular medical- surgical unit should have about an equal split of semi-private rooms. Notably, East Pasco's new 11-bed SNU has 5 private and 3 semi-private rooms for patients who will require hospitalization for up to 90 days. Second, these private rooms are almost twice the minimum size required by state licensure regulations. Third, three nurse stations are unnecessary; only one nurse station is needed for a basic 24-bed medial-surgical unit. East Pasco currently has 68 medical- surgical beds on 2 units, and each such unit has only 1 nurse station.
The existing 68 medical-surgical beds at East Pasco average about 360 GSF per bed. The proposed 24 beds will average 542 GSF per bed. All private rooms and 3 nurse stations are, clearly, the design for a PCU. A PCU is a step- down unit from an ICU, which has high staff-to-patient ratios thereby requiring more nurse stations.
East Pasco's projected construction cost for the 24-bed medical- surgical unit is $142.91 per GSF. This is unreasonably understated.
It is uncontroverted that an SNU is less costly to construct than a medical-surgical unit. According to its projections, East Pasco's 11-bed SNU cost $171 per GSF in 1992. Clearly, that SNU cost is substantially greater than East Pasco's projected construction cost at issue. This inconsistency was never explained by competent evidence.
In evaluating East Pasco's estimates, the Agency's architect relied upon 1991 Means construction cost data. He averaged the Means' medium figure ($123 per GSF) with the high figure ($172 per GSF) to derive a 1991 estimate of
$147.50 per GSF. To that, one must add a 10 percent contingency factor, inflation, and an architectural fee. That totals $187.69 per GSF. The $187.69 projected figure is consistent with the 1992 SNU cost figure of $171. Thus, for construction costs alone, East Pasco underestimated by $44.77 per square foot, which is about $582,000.
East Pasco proposed to construct a three-story tower; the third floor will house the proposed 24 medical-surgical beds. The second floor will house a 16-bed ICU, comprised of relocating the existing 8 ICU beds and converting 8 other acute care beds. East Pasco's application project costs only cover the third floor; East Pasco maintains the second floor is exempt from CON review and thus its cost is not relevant. As described below, East Pasco unreasonably failed to include costs of the second floor in its application.
A hospital project costing $1,000,000 or more (other than an out- patient project) requires CON review. In its letter for exemption East Pasco states that the second floor would contain 12 ICU beds and cost $975,000 (calculated by multiplying 6,500 GSF by $150/foot). That letter is erroneous for several reasons: (1) the $150/foot is in 1992 dollars and does not include inflation; (2) the $150/foot does not include a 10 percent construction contingency fee, which is necessary and reasonable; (3) the $150/foot does not include an 8.4 percent architectural/engineering fee, which is necessary and reasonable; and (4) the $150/foot does not include any debt or financing fee. Including these necessary amounts alone shows that the second floor, in truth, exceeds the $1,000,000 threshold. Also, the cost for equipping an ICU bed is
$45,000 per bed; for 16 beds, that is $720,000 for equipment.
Surely the size and cost of a 16-bed ICU is different from and greater than a 12-bed ICU. East Pasco stated in its exemption request letter that the second floor would have 12 beds even though East Pasco intends 16 beds. East Pasco and the Agency correctly argue that the exemption given to East Pasco by the Agency for its second-floor ICU project is not part of the instant application and cannot be considered in this proceeding. However, the accuracy and reasonableness of the costs projected by East Pasco attendant to the 24 additional beds it seeks are an integral part of this proceeding, as is the scope of the project being reviewed and challenged.
The second and third floor projects are, in truth, one project. It is East Pasco's intention to add 16 medical-surgical beds and 8 ICU beds to its facility. To establish the 16-bed ICU unit, East Pasco needs additional acute care beds; East Pasco does not have 8 available beds among its existing bed complement to convert to ICU purposes. The OB beds often run at 100 percent occupancy and, during the peak season, the medical-surgical beds run high occupancy. Thus, East Pasco cannot fully implement the second floor without approval of the proposed 24 new beds.
There will be no community benefits in terms of charges if this application is approved. "Net revenues" must be the basis for comparing charges between facilities. Net revenues refers to what third party payors (such as Medicare, Medicaid, HMO/PPOs and most insurors) actually pay for hospital services as opposed to what hospitals charge. Few patients ever pay gross charges, particularly in the elderly East Pasco Subdistrict.
In 1991, Humana's average net revenue per day was lower than East Pasco's. Humana's actual net revenue per admission in its fiscal year 1992 was
$4,180. East Pasco's projected 1992 net revenue per admission is $5,301. Thus, for 1992, third party payors paid, on behalf of their patients, less per admission at Humana than at East Pasco. In its application, East Pasco projects an 8 percent per year increase in charges. An annual increase of 8 percent is not promoting charge-efficiency.
East Pasco's application did not demonstrate cost-efficiencies resulting from approval, but rather, cost-inefficiencies. First, Humana would
lose patient volume should East Pasco be approved. Humana currently receives transfers and direct admissions when East Pasco is full. Loss of patient volume would increase operating costs per patient day at Humana.
Second, there is no need for additional beds in the Subdistrict.
There is already excess capacity in the Subdistrict. Exacerbating excess capacity promotes cost-inefficiency. East Pasco admits the unit will not even be open six months out of the year because there is no need for it then.
Third, East Pasco projects very low census in years 1 and 2, about 3 patients per day in year 1 and less than 5 patients per day in year 2. Spending over $4,000,000 to accommodate such low utilization is inefficient and unreasonable.
Approval of East Pasco's application would not promote positive competition. There is competition now in the Subdistrict between Humana and East Pasco. East Pasco already captures a larger market share of the Subdistrict than Humana. Approving this application would only tip the scales more in favor of East Pasco and would adversely impact Humana's already poor financial condition.
The quality of care delivered at Humana is very good. The JCAHO rates all acute care hospitals, and its rating is widely recognized in the hospital industry. The JCAHO evaluates many factors and components of a hospital.
Humana is accredited "with commendation", the highest rating given. Only 5-6 percent of all acute care hospital in the country receive that highest ranking. Humana maintains a good utilization management program. Humana implements an excellent quality improvement plan, including soliciting and reviewing patient satisfaction comments.
Mortality statistics cannot, by themselves, meaningfully measure the quality of care delivered at a hospital. Although the Health Care Finance Administration (HCFA) produces such a report for Medicare patients, the report itself represents that it is not intended to measure quality of care, and the American Hospital Association does not view HCFA mortality statistics as a measure of quality of care. There are many factors which influence mortality statistics at a hospital and, even more importantly, mortality is only one clinical outcome resulting from a hospital admission.
When East Pasco is full, there is no medical problem or complication resulting from transferring patients to Humana or from directly admitting patients at Humana. There is no diminution of care or loss of continuity of care in transferring to or directly admitting to Humana.
Emergency medical services are available in the Subdistrict, and, therefore, transfer is not a problem. Also, driving to Humana or to a hospital outside the Subdistrict is neither a problem nor an unusual circumstance. The large seasonal population drive to Florida in the winter, and, therefore, it is a mobile patient population. Most of its residents seeking hospital services receive them outside the Subdistrict. Subdistrict residents currently leave the Subdistrict to receive a variety of hospital services, including: in-patient cardiac cath, open heart surgery, Level II NICU, psychiatric services, substance abuse services, and comprehensive rehabilitation services. Thus, there is no merit to the suggestion that transferring patients from East Pasco to Humana or elsewhere is problematic.
There would not be community benefits regarding Medicaid/indigent care by approving this application. As indicated, for all hospital services, Humana and East Pasco provide similar amounts of Medicaid and indigent care, although indigent care at both facilities is relatively insignificant. Therefore, access to Medicaid and indigent care does not provide a basis for approving East Pasco's application. Also, East Pasco's payor mix in its application was based on hospital-wide averages. East Pasco has not shown the amount of Medicaid or indigent care which would be specifically provided to, or which is needed for, medical-surgical patients.
Finally, East Pasco's Policy and Procedure Manual includes several provisions requiring deposits upon in-patient admission absent verification of third party payor coverage. Such provisions are inconsistent with the proposition that East Pasco accepts all patients regardless of ability to pay.
In Florida, an application for a CON must include a certified copy of an authorizing resolution of the applicant's Board of Directors. East Pasco included its corporate resolution in its CON application, that resolution being adopted at an August 14, 1991, meeting.
That resolution clearly states, among other things, authorization to file an application for up to 24 additional acute care beds. The minutes of that meeting clearly reflect the Board's approval for 24 beds for ICU and PCU. The application itself requests approval of 24 medical-surgical beds. PCU, ICU, and medical-surgical beds are all types of acute care beds. Accordingly, East Pasco did file a proper corporate resolution consistent with the minutes and consistent with the application. The minutes and the application, however, are inconsistent.
Although the corporation resolution is technically correct and fulfills the requirements for a CON application, the inconsistency among the corporate resolution, the minutes, and the application raised questions about the actual intent of East Pasco. The intent became more questionable during the final hearing when East Pasco's witnesses contradicted each other as to the number of beds to be placed in the to-be-constructed ICU on the second floor of the to-be-constructed 3-story tower. It is clear that the Agency only approved the construction of a 12-bed ICU on the second floor. It is also clear that East Pasco in fact intends to construct a 16-bed ICU on that second floor. It is also clear that East Pasco intends to construct a "medical-surgical" unit on the third floor in accordance with a design for a PCU.
While the corporate resolution technically complies with the requirements for a CON application, the questionable nature of its accuracy, when considered in conjunction with the conflicting evidence of the scope of this project, raises concern as to East Pasco's projections regarding revenue, expenses, staffing, and the actual services to be made available in the Subdistrict. The lack of clarity as to East Pasco's proposal is a compelling reason to deny East Pasco's application.
East Pasco's occupancy rate is quite high. It is higher even during the "peak season," i.e., November through April. The projections contained in East Pasco's application are based upon the historic high occupancy rate experienced at East Pasco. Those projections, however, do not take into account, nor did the Agency consider in reviewing East Pasco's application, the fact that East Pasco now has more than the 85 beds which formed the basis for its historic occupancy rate and its projections related to this project. Construction has been completed on the 10-bed observation unit and the 11-bed
SNU. East Pasco already has an expanded capacity in place which should alleviate some of its occupancy problems. For example, East Pasco has experienced an increased number of out-patient observation days. With its new observation unit, the beds previously used for observation days are now available for in-patients which, in turn, will likely alleviate East Pasco's most common capacity problem-the lack of available ICU beds. Similarly, the SNU beds will also be available for in-patients.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties hereto and the subject matter hereof. Section 120.57(1), Florida Statutes.
CON proceedings are de novo in nature and are designed to formulate agency final action; they are not proceedings to review the agency's preliminary action or to accord it a presumption of correctness. Beverly Enterprises- Florida, Inc. v. Department of Health and Rehabilitative Services, 573 So.2d 19 (Fla. 1st DCA 1990). The statutory review criteria which govern this proceeding were found in Sections 381.705(1) and 381.707, Florida Statutes, but have been, during the pendency of this proceeding, renumbered without substantive change to Sections 408.035 and 408.037, respectively. Since the renumbered Sections are not reproduced in the 1992 Supplement to the Florida Statutes and are, therefore, not yet codified, the review criteria will be analyzed in accordance with their previous numbering. Similarly, the Agency's rule criteria governing this proceeding were found in Rule 10-5.038, Florida Administrative Code, but have now been transferred to Rule 59C-1.038 without substantive change. Since Rule 10-5.038 is no longer codified in the Florida Administrative Code, that Rule will be referred to under its new number.
Prior to the final hearing, the parties entered into a Joint Prehearing Stipulation in which the parties specifically agreed that Humana has standing to initiate and to maintain this proceeding. The parties further stipulated that Humana was not required to present any proof regarding its standing in this proceeding. Accordingly, the evidence offered by East Pasco and by the Agency to suggest that granting East Pasco's application would have no impact, or a negligible impact, on Humana is irrelevant and contrary to the parties' Stipulation.
As the applicant, East Pasco has the burden of proving that its CON application satisfies, on balance, the relevant statutory and rule criteria. Boca Raton Artificial Kidney Center v. Department of Health and Rehabilitative Services, 475 So.2d 260 (Fla. 1st DCA 1985). No single criterion is necessarily determinative. The appropriate weight to be given to each criterion varies, depending upon the facts in each case. North Ridge General Hospital, Inc. v. NME Hospital, Inc., 478 So.2d 1138 (Fla. 1st DCA 1985).
Rule 59C-1.038, Florida Administrative Code, is the acute care bed need rule. That Rule contains the methodology for computing the numerical need for additional acute care hospital beds in any agency service district and further provides for the allocation of district need by subdistricts. After the mathematical computation, the subdistrict bed allocation adjustment is made which provides that no beds will be approved for a subdistrict unless the average occupancy rate for all existing acute care hospital beds in that subdistrict is at or exceeds 75 percent. It is uncontroverted that when the required adjustment for occupancy rate is made for the East Pasco Subdistrict, the numeric need for additional acute care beds is zero. That numeric need was
published by the Agency and was not challenged. Accordingly, the numeric need in the Subdistrict for the planning horizon is zero.
The Rule contains an exception for an existing hospital which permits a specific facility to obtain additional acute care beds by virtue of showing an occupancy rate for that facility which exceeds 75 percent. Subsection (7)(e) of the Rule is the provision under which East Pasco offers its application, arguing that although the Agency will not normally approve beds unless the numeric need rule is met, beds may be approved for a specific facility based upon circumstances concerning that facility.
To prove that its circumstances are "not normal" East Pasco relies on its historic high rate of occupancy, which is exacerbated by the influx of persons into that area of Florida during the winter months. East Pasco did prove that there are times when it is "full", that its OB capacity has exceeded
100 percent, that it has experienced an increased demand for observation beds, and that its most common capacity problem is the lack of available ICU beds during the peak season. Taking all these allegations as true, East Pasco has failed to prove that those circumstances are "not normal" for hospitals in the State of Florida during the winter season. Further, at the time that East Pasco filed its application, it was also obtaining approval for a 10-bed observation unit and an 11-bed SNU. In its application and at the final hearing in this cause, East Pasco failed to address, and the Agency never considered, how those additional 21 beds in those two units which have now been constructed and are about to open will ease the occupancy problems which East Pasco has faced. It is obvious that the 21 additional beds will have an impact on East Pasco since they represent a 25 percent increase in the number of beds previously available to East Pasco. It is obvious that acute care beds currently being used for observation beds will again be available to be used as acute care beds. Similarly, the SNU offers an additional level of service in addition to more beds for patients at East Pasco. It seems clear that East Pasco has already relieved itself of some of the capacity problems with which it has been suffering.
Although East Pasco correctly suggests that increasing its beds will allow it to serve more patients, that truism is not the basis for any rule or statutory criteria or generally accepted health planning policy. The applicable criteria consider whether there are sufficient beds within a geographic area to serve the needs of the population of that area, not whether a certain hospital can serve more patients. Although the Agency has discretion to approve additional beds at a particular facility despite the absence of numeric need, sufficient circumstances must be present to justify exercising that discretion, particularly when empty beds exist ten minutes away and over 63 percent of the residents go outside the Subdistrict to receive hospital services.
Turning to the statutory review criteria, East Pasco has failed to prove that it meets sufficient statutory criteria so as to justify approving beds based upon "not normal" circumstances. Section 381.705(1)(a), Florida Statutes, addresses the need for the additional beds in relation to the State Health Plan and the applicable local plan. East Pasco fails to meet this criterion. Although the institution-specific provision in the numeric need rule turns on an occupancy rate of 75 percent, the State Health Plan requires an occupancy rate of greater than 80 percent. For the 1990 calendar year, the same year used by the Agency to compute the Subdistrict occupancy rate, East Pasco's occupancy rate did not exceed 80 percent. Next, although East Pasco is a Medicaid disproportionate share provider, that status only receives preference under the State Health Plan if there is a numeric need. Although East Pasco's
provision of Medicaid services once exceeded that of Humana, Humana's Medicaid participation has been increasing since it started its OB service, but East Pasco's has remained the same. At this time, East Pasco and Humana are providing similar levels of Medicaid service although East Pasco receives an additional economic incentive because of its designation as a disproportionate share provider. Since East Pasco's Medicaid participation is primarily OB services, and East Pasco is not proposing to increase its OB services with this project, increased Medicaid participation is not likely.
As to the provision of indigent care, East Pasco has been providing substantially less than 1 percent of its gross revenue in indigent care. Since East Pasco does not know how many indigent patients receive medical-surgical services at East Pasco, there is no representation by East Pasco that the number of indigent patients served would increase by the approval of the additional beds sought by East Pasco. Although East Pasco does have a contractual responsibility to Pasco County to accept indigent patients, there is no showing that the percentage of services rendered to indigents is meaningful and, therefore, indicative of a need to approve additional beds for indigent care.
As to the remaining preferences in the State Health Plan, East Pasco does not suggest that it is a trauma center, that it provides a range of emergency services, that it provides specialized services, or that it is a teaching or research facility.
As to the local health plan, East Pasco has failed to show that its application complies with the preferences in that plan for the same reason that if fails to comply with the State Health Plan. In addition, East Pasco has failed to prove that there is cost effectiveness or efficiency attendant to this project. Essentially, this project will cost over $4,000,000 to add beds for an average of 3 to 5 patients a day. The cost of constructing the project is quite high. On the other hand, there is no indication that the costs or charges to patients will be reduced, and East Pasco's 1992 budget submitted to the State of Florida shows a substantial increase in patient charges. Further, the application itself does not address specific cost efficiencies attendant to the project. Accordingly, East Pasco has failed to show the need for its project in relation to the applicable district plan.
Section 381.705(1)(b), Florida Statutes, addresses the availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of other providers in the service district. Humana experienced an occupancy rate of 38.7 percent during calendar year 1990 and 39.4 percent during calendar year 1991. Humana's occupancy rate for the first quarter of 1992--the peak season--was 45.5 percent. Thus, acute care beds are available only ten minutes away from East Pasco. Further, with the advent of OB services, Humana has increased substantially its Medicaid participation and is accessible to Medicaid patients. Since East Pasco has been designated a Medicaid disproportionate share provider, it derives greater revenue for services rendered to Medicaid patients than Humana. Although it does not appear that Humana has provided more than minuscule indigent care, East Pasco's services to indigent patients has also been negligible and is not a meaningful issue in this proceeding.
As to quality of care, East Pasco suggested in its application quality of care problems at Humana based upon one year's mortality data relating to Medicare patients published by HCFA. That publication itself states that the information is not to be interpreted as a direct measure of quality of care. Yet, East Pasco attempted to do so by commissioning a study after this proceeding was initiated to gather data for a number of years regarding non-
Medicare patients to then conclude that the mortality rates as to them proved that Humana does not offer good quality of care. The results of that study were excluded from evidence in this proceding since that study did not relate to information contained in East Pasco's application, it was created specifically for and during this litigation, and constitutes an amendment to the application. On the other hand, Humana has been accredited with commendation, the highest rating available from a nationally recognized accrediting body, and is thus rated higher than East Pasco itself.
As to the extent of utilization of the beds in the Subdistrict, although the number of admissions has increased, the number of patient days has not increased and is in fact lower than the number of patient days in the Subdistrict in 1986. Further, there is not significant population growth in the Subdistrict to support a conclusion of increased utilization necessitating East Pasco's project. East Pasco has failed to demonstrate that it meets the criterion contained in Section 381.705(1)(b).
Section 381.705(1)(c), Florida Statutes, is not an issue in this proceeding since the parties have stipulated that East Pasco historically has and will continue to provide quality of care.
Section 381.705(1)(d), Florida Statutes, addresses the availability of alternatives to the project being proposed. There are adequate and appropriate alternatives to East Pasco's proposal, specifically Humana Hospital, an available, accessible, and appropriate provider of quality services. Accordingly, East Pasco does not meet this criterion.
Section 381.705(1)(e), Florida Statutes, addresses economies that may be derived from operation of joint or shared health care resources. East Pasco's application does not address and, therefore, does not meet this criterion.
Section 381.705(1)(f), Florida Statutes, addresses the need in the service district for special equipment and services not reasonably or economically accessible in adjoining areas. This application does not propose to offer any special equipment or services but rather purports to simply be an application for medical-surgical beds. Such acute care beds are reasonably and economically accessible in adjoining areas and in the same Subdistrict. Accordingly, East Pasco does not satisfy this criterion.
Section 381.705(1)(g), Florida Statutes, addresses whether an application promotes the need for research and educational facilities. This criterion is not addressed by East Pasco's application, and East Pasco does not purport to be a research or educational facility. Accordingly, this criterion is not met.
Section 381.705(1)(h), Florida Statutes, addresses the operation of the project. The parties stipulated that East Pasco has available the financial resources to accomplish the project proposed in its application. There was also testimony that East Pasco participates in a program for training student nurses. Further, the proposed project would be accessible to all residents of District 5, as East Pasco's beds are currently available to all residents. As to whether the proposed project is the best use of East Pasco's resources, such does not logically appear to be the case. The expenditure of over $4,000,000 to increase the average daily census by three to five patients when East Pasco is about to bring on-line 21 additional beds in its SNU and observation unit does not appear, on its face, to be a reasonable expenditure of East Pasco's resources.
Accordingly, all of the factors in this criterion are not met, and some of those which are are currently met without the project.
Section 381.705(1)(i), Florida Statutes, addresses immediate and
long-term financial feasibility of the proposal. East Pasco has failed to prove the long-term financial feasibility of its proposal. The proposed 24-bed unit is part of a 3-story tower, which is part of a hospital facility. East Pasco only evaluated the incremental revenues and expenses of the 24-bed unit and considered no other aspect of the 3-story tower or the hospital facility.
Additionally, East Pasco's incremental pro forma is unreasonable for the following reasons: utilization projections are overstated; the assumptions underlying gross revenues and deductions are unreasonable; expenses are understated, particularly staffing expenses; and other operating expenses are based on unreasonable assumptions. Although East Pasco included a hospital-wide pro forma in its application, East Pasco offered no evidence at the final hearing regarding that pro forma. Since an incremental pro forma is, by itself, not sufficient to prove financial feasibility, and since the incremental pro forma is unreasonable, East Pasco has failed to prove that it meets this criterion.
Section 381.705(1)(j), Florida Statutes, addresses the needs of health maintenance organizations (HMOs). This criterion was not addressed and is not met.
Section 381.705(1)(k), Florida Statutes, addresses the needs and circumstances of entities which may provide a substantial portion of their services to individuals not residing in the service district. No evidence was offered on this criterion, and it is not met.
Section 381.705(1)(l), Florida Statutes, addresses the impact of the project on the cost of health care services, including competition, cost- effectiveness, and the promotion of quality assurance. East Pasco has failed to meet this criterion. The project does not purport to promote charge effectiveness or cost-effectiveness. East Pasco, like Humana, continues to increase its charges on a regular basis. There will be, however, substantial cost inefficiencies resulting from application approval, i.e., the addition of acute care beds in a Subdistrict with excess capacity. Competition currently exists in the Subdistrict, and the addition of new beds at East Pasco could only increase East Pasco's "market share" and decrease Humana's. Quality of care in the Subdistrict is adequate. Further, transferring patients to Humana when East Pasco is full or refusing to admit additional patients when East Pasco is full does not present a problem in the delivery of medical services to such patients. Finally, there are no quantifiable community benefits resulting from application approval.
Section 381.705(1)(m), Florida Statutes, addresses the costs and methods of proposed construction, including the availability of less costly alternatives. East Pasco has failed to meet this criterion. The proposed medical-surgical unit is excessively large by at least 30 percent and, therefore, costs too much. All private rooms and three nurse stations for 24 medical-surgical beds is unnecessary and wasteful. Designing a medical-surgical unit as a PCU is unreasonable and not the least costly alternative. Excessive project costs are contrary to CON objectives. Morton F. Plant Hospital Association, Inc. v. Department of Health and Rehabilitative Services, 491 So.2d
586 (Fla. 1st DCA 1986).
Additionally, East Pasco's projected construction costs are understated by approximately $500,000 as to the third floor of the 3-story tower alone. Since the design of the third floor is the design of a PCU and since the minutes of the meeting of the Board of Directors authorizing this project authorizes PCU and ICU beds, it is unknown as to the amount by which the construction costs have been understated in addition to the known $500,000. Since the second floor of the tower which was represented to the Agency to be a 12-bed ICU will, in reality, be a 16-bed ICU, and since it is clear that some of the beds East Pasco seeks in this application will constitute 8 of the ICU beds needed to implement its 16-bed ICU, some of the construction costs attendant to the second floor should have been included in the projected construction costs for the third floor. Accordingly, East Pasco's true costs have not been proven in this proceeding; what has been proven, however, is that the cost of this project is excessive and inconsistent with this criterion.
Section 381.705(1)(n), Florida Statutes, addresses the applicant's provision of Medicaid and indigent care. East Pasco is a Medicaid disproportionate share provider and has contracted with Pasco County to provide care for indigents. Accordingly, East Pasco does meet this criterion. However, East Pasco's compliance with this criterion is not a sufficient basis to justify approving this application. Humana's level of Medicaid participation has increased substantially with the initiation of OB services at that hospital. East Pasco's participation has not so increased and no specific participation for Medicaids patients has been proposed for the 24 additional beds sought herein. Similarly, East Pasco's provision of indigent care is not substantial. Humana is a viable alternative for Medicaid and indigent patients, and East Pasco has not suggested that its Medicaid and indigent care will increase as a result of the addition of these beds.
Section 381.707(4), Florida Statutes, requires an applicant to include a certified resolution by the applicant's Board of Directors containing certain provisions. East Pasco did so. The minutes of that Board meeting reveal that the Board approved a 24-bed ICU and PCU project. The corporate resolution approves 24 acute care beds. The application is for 24 medical- surgical beds. Technically, the application was authorized by the certified resolution. However, the application is not consistent with the minutes of that meeting. East Pasco offered testimony of the person making the presentation to the Board that the minutes were wrong. Yet, that person also testified that the minutes are reviewed for correctness by up to 6-7 people, and no subsequent minutes have been located reflecting that the Board itself determined that its earlier minutes were inaccurate. Although East Pasco argues that parole evidence is admissible, East Pasco's argument is not persuasive.
The minutes are consistent with the design for the third floor--the design of a PCU. In other words, the Board's approval of 24 beds for ICU and PCU purposes, as reflected in the minutes, perfectly matches the design that East Pasco has proposed. East Pasco's application for medical-surgical beds only is inconsistent with the Board's approval, and, therefore, the purpose for requiring the certified resolution--assurance that the applicant's Board of Directors has approved the specific project being proposed--has been defeated. Florida law is clear that Section 381.707 must be strictly complied with by CON applicants and that failure to strictly comply mandates rejection of the application. Humhosco, Inc. v. Department of Health and Rehabilitative Services, 561 So.2d 388 (Fla. 1st DCA 1990).
Section 381.707(2)(c), Florida Statutes, requires a CON application to contain "[a] detailed financial projection, including a statement of the
projected revenue and expenses for the period of construction and for the first
2 years of operation after completion of the proposed project." East Pasco offered evidence only as to the incremental pro forma for the 24-bed unit and no evidence regarding the period of construction. Accordingly, East Pasco has failed to meet this mandatory requirement.
Based upon the foregoing Findings of Fact and Conclusions of Law, it is,
RECOMMENDED that a Final Order be entered denying East Pasco's application for Certificate of Need No. 6783.
DONE and ENTERED this 9th day of February, 1993, at Tallahassee, Florida.
LINDA M. RIGOT
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 9th day of February, 1993.
APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 92-1497
Petitioner's proposed findings of fact numbered 1-32, 34-82, and 84-96 have been adopted either verbatim or in substance in this Recommended Order.
Petitioner's proposed finding of fact numbered 83 has been rejected as being unnecessary for determination of the issues herein.
Petitioner's proposed findings of fact numbered 33 and 97 have been rejected as not constituting findings of fact but rather as constituting recitation of the testimony, argument of counsel, or conclusions of law.
The Agency's proposed findings of fact numbered 2-6, 8, 13, 14, 27, 28, 31-33, 37, 40, 41, 43, 44, 47, 49, 51, and 90 have been adopted either verbatim or in substance in this Recommended Order.
The Agency's proposed findings of fact numbered 20, 21, 34, 45, 52, 54, 56-58, 68, 71, 73, 82, and 89 have been rejected as being unnecessary for determination of the issues herein.
The Agency's proposed finding of fact numbered 1 has been rejected as not constituting a finding of fact but rather as constituting recitation of the testimony, argument of counsel, or a conclusion of law.
The Agency's proposed findings of fact numbered 7, 9, 19, 26, 48, 59, 61, 62, and 64 have been rejected as being irrelevant to the issues under consideration herein.
The Agency's proposed finding of fact numbered 46 has been rejected as being subordinate to the issues involved in this proceeding.
The Agency's proposed findings of fact numbered 10-12, 15-18, 22-25, 29, 30, 35, 36, 38, 39, 42, 50, 53, 55, 60, 63, 65-67, 69, 70, 72, 74-81, 83-88, and 91-93 have been rejected as not being supported by the weight of the credible, competent evidence in this cause.
East Pasco's proposed findings of fact numbered 1-3, 5-7, 10, 13, 16- 18, 20, 22-24, 37, 38, 40, 45, 46, 48, 62, 63, 66-69, 73, 78, 79, 81, 82, 85, 89, 118, 119, 131, 135, 140, 174, 178-180, and 192 have been adopted either verbatim or in substance in this Recommended Order.
East Pasco's proposed findings of fact numbered 15, 25, 26, 55, 56, 70, 83, 90, 92, 94, 95, 100, 121, 127-129, 145, 146, 163, 164, 171-173, 176, 177, 184-189, 191, and 194 have been rejected as being unnecessary for determination of the issues herein.
East Pasco's proposed findings of fact numbered 19, 87, and 88 have been rejected as not constituting findings of fact but rather as constituting recitation of the testimony, argument of counsel, or conclusions of law.
East Pasco's proposed findings of fact numbered 4, 8, 9, 11, 12, 14, 21, 30, 31, 33-36, 39, 41, 51, 61, 86, 96-98, 102, 103, 105, and 154 have been rejected as being irrelevant to the issues under consideration herein.
East Pasco's proposed finding of fact numbered 84 has been rejected as being subordinate to the issues involved in this proceeding.
East Pasco's proposed findings of fact numbered 27-29, 32, 42-44, 47, 49, 50, 52-54, 57-60, 64, 65, 71, 72, 74-77, 80, 91, 93, 99, 101, 104, 106-117, 120, 122-126, 130, 132-134, 136-139, 141-144, 147-153, 155-162, 165-170, 175, 181-183, 190, and 193 have been rejected as not being supported by the weight of the credible, competent evidence in this cause.
COPIES FURNISHED:
Edward G. Labrador, Esquire Agency for Health Care
Administration
2727 Mahan Drive, Suite 103
Tallahassee, Florida 32308
James C. Hauser, Esquire Messer, Vickers, Caparello,
Madsen, Lewis, Goldman & Metz Post Office Box 1876 Tallahassee, Florida 32302-1876
Darrell White, Esquire William Wiley, Esquire
McFarlain, Wiley, Cassedy & Jones
215 South Monroe Street Suite 600
Tallahassee, Florida 32301
Sam Power, Agency Clerk
Agency for Health Care Administration The Atrium, Suite 301
325 John Knox Road Tallahassee, Florida 32303
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
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AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
HUMANA OF FLORIDA, INC., d/b/a HUMANA HOSPITAL PASCO,
Petitioner,
CASE NO: 92-1497
vs. CON NO: 6783
RENDITION NO: AHCA-93-66-FOF-CON
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION and ADVENTIST HEALTH SYSTEM/SUNBELT, INC., d/b/a EAST PASCO MEDICAL CENTER,
Respondents.
/
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 Agency for
Health Care Administration (AHCA). The Recommended Order entered February 9, 1993, by Hearing Officer Linda M. Rigot is incorporated by reference.
RULINGS ON EXCEPTIONS
East Pasco excepts to the finding that Humana provides the same services as provided by East Pasco. The challenged finding is supported by competent, substantial evidence; therefore, the exception is denied.
East Pasco excepts to the finding that the medical staff rosters are virtually identical. The challenged finding is supported by competent, substantial evidence; therefore, the exception is denied.
East Pasco excepts to the finding that Humana serves indigent patients. Neither hospital provided significant levels of service to indigent patients. The exception is denied.
East Pasco challenged the finding that commencement of construction of the planned three story tower is awaiting the outcome of this proceeding. The finding is irrelevant; thus, it is unnecessary to rule on the exception.
5-7. East Pasco excepts to findings in paragraph 11 and 12 regarding a project which was exempt from CON review. Elsewhere, (paragraph 69) the Hearing Officer recognized that the exempted project should not be considered in this proceeding. Accordingly, the challenged findings are given no weight herein.
East Pasco excepts to the last four sentences of paragraph 12. Here the Hearing Officer points out a conflict in the evidence between the corporate resolution authorizing the proposed 23 acute care beds and the minutes of the board meeting. East Pasco points to other evidence in the record and suggests that the minutes are inaccurate. The Hearing Officer did not find the corporate resolution to be invalid; she simply noted the inconsistency with the minutes. The challenged sentences are not findings, but are merely comments on the evidence. No ruling on the exception is required. Houle vs. Department of Environmental Regulation, 10 FALR 3671, 3674 (DER 1988).
East Pasco excepts to the Hearing Officer's ultimate conclusion in paragraph 13 that there is no need for the 24 beds it proposes to add. I disagree with East Pasco that lack of need in District 5 is irrelevant. See the Ruling On Exceptions 16 and 17. As to the subdistrict, the availability of Humana's beds is factually correct and must, of course, be considered in weighing the merits of East Pasco's proposal to add beds. See Goss vs. St. Johns School Board, 601 So2d 1232, 1235 (Fla. 5th DCA 1992). The ultimate conclusion of no need is rejected.
East Pasco objects to the findings in paragraph 16 that there is excess capacity in both the district and subdistrict. The factual accuracy of these findings is not challenged and they have been weighed in making the decision on East Pasco's application.
11-14. East Pasco objects to paragraphs 17, 18, and 19, but not their factual accuracy. The findings have been considered.
15. East Pasco excepts to the finding in paragraph 20 that a county's projection of its own population growth is generally less reliable than a projection made by a national firm specializing in demographic analyses. The
challenged finding is supported by competent, substantial evidence; therefore, the exception is denied.
16-17. East Pasco objects to the consideration of hospitals within 30 minutes travel time but outside the subdistrict. The boundaries of a health planning area are not an "iron curtains." Such facilities are not a factor in the numeric need formula, but are appropriate to consider in making the ultimate decision on need. See Charter vs. Department of Health and Rehabilitative Services, 495 So2d 759, 763 (Fla. 1st DCA 1986).
East Pasco excepts to the Hearing Officer's finding that Humana's underutilized beds are an alternative to East Pasco's proposal. See the Ruling on Exception 9 and the discussion the conclusions of law expressed in this Order.
This exception to paragraph 24 is discussed in the response to exceptions 16 and 17.
The only new issue raised in exception 20 is whether improved availability of services at East Pasco may be appropriately considered in reviewing the application. Consideration is appropriate where as here, the applicant seeks approval under "not normal" circumstances.
East Pasco challenged the finding that both hospitals provide similar levels of medicaid and indigent care. The finding is based on the most recent data, not historical provision of such services. The finding is correct as far as it goes and is accepted.
East Pasco excepts to the conclusion that physician preferences are not relevant in evaluating a health facility proposal. I disagree with the Hearing Officer. Physician preferences are clearly relevant. The weight given will vary depending on the circumstances. It is also noted that physician preferences may or may not be consistent with sound health planning, but this does not mean they are irrelevant.
East Pasco excepts to the conclusion meeting the 75 percent occupancy threshold of subsection (7)(e) 1/ of the need rule merely opens the door to agency discretion. East Pasco maintains that need should be presumed if a facility meets the threshold. I concur with the Hearing Officer. There is no presumption of need. The applicant must establish additional circumstances justifying approval despite lack of numeric need.
Paragraph 29 and the exception to its reiterates matters previously ruled on. See response to exceptions 9, 16 and 17.
East Pasco excepts to paragraph 30. East Pasco objects to the Hearing Officer's inference that the new observation beds will "ease the strain" on East Pasco's acute care beds. The inference is reasonable; therefore, the exception is denied. See the Ruling on Exception 29.
East Pasco excepts to paragraph 31 wherein the Hearing Officer found that "there were not that many patients transferred in 1991" and there were several months with "zero transfers." The Hearing Officer relied on Humana's Exhibit 33 which is a daily transfer report. The finding of several months with zero transfers is rejected as it is not supported by competent, substantial evidence.
East Pasco excepts to paragraph 32 regarding whether the proposed beds would be opened only during the season of peak demand. Clearly, the proposal is East Pasco's response to very high utilization in the late fall, winter, and early spring seasons. Whether the proposed beds or other beds would be closed during the off season is irrelevant. A hospital's decision to temporarily take beds out of service during a seasonal period of low demand does not appear unreasonable.
East Pasco excepts to paragraph 33 wherein the Hearing Officer concludes that cost of East Pasco's proposed beds is excessive in consideration of the number of patients to be served and the availability of beds at other hospitals. As discussed elsewhere, excess capacity at Humana is an important consideration, but it is not dispositive.
East Pasco excepts to the finding in paragraph 33 that the days of over 100 percent occupancy will be alleviated to some extent by the opening of the 10 bed observation unit and 11 bed skilled nursing unit. The inference regarding the observation beds is reasonable as there will be less need to place observation patients in acute care beds. But see paragraph 87 where the Hearing Officer noted the increasing number of observation patient days at East Pasco. I find no evidence that East Pasco has kept nursing patients in acute care beds; thus, the exception is denied in part and granted in part.
East Pasco excepts to the conclusion in paragraph 33 that it failed to show any reasons justifying approval of its application except for satisfying the 75 percent occupancy threshold under subsection (7)(e) of the need rule. This conclusion is rejected for the reasons discussed in the conclusions of law of this Final Order.
31-39. East Pasco excepts to the conclusion that its proposal is not consistent with the State Health Plan. The Plan recommends approval of beds at an existing facility only if occupancy for the most recent 12 months is at or exceeds 80 percent. 2/ For this time period the occupancy was 80.99 percent.
Thus the finding that East Pasco did not meet the Plan's occupancy recommendation is rejected as unsupported by competent, substantial evidence.
The Plan gives preference to proposals transferring or converting acute care beds. No preference is appropriate here.
The Plan gives preference to an applicant who provides a disproportionate share of Medicaid and charity care. Based on the parties stipulation that East Pasco is a disproportionate share provider this preference should be given to East Pasco. The Hearing Officer's contrary recommendation is rejected.
The Plan recommends against approval where a disproportionate share provider would be threatened financially. There is no evidence that such a provider will be threatened financially. Humana is not a disproportionate share provider and as previously noted East Pasco is.
Regarding emergency services, East Pasco showed that it receives fifty-five percent (55%) of its inpatient admissions through its emergency department, which is close to twice the national average. See finding of fact 4 and paragraph 10 of the appendix to the Recommend Order and page 29 of the transcript of the final hearing. It is entitled to preference here. The Hearing Officer's contrary recommendation is rejected.
East Pasco is not entitled to preference as a teaching or referral hospital, nor for specialized services.
In conclusion East Pasco meets some of the preferences of the state plan and does not meet others. The Hearing Officer goes too far in finding East Pasco's proposal inconsistent with the plan. See the Ruling On Exception 89.
40-44. Likewise, the Hearing Officer's conclusion that East Pasco's proposal is inconsistent with the District 5 Local Health Plan goes too far. East Pasco's proposal meets some preferences and does not meet others. See the Ruling On Exception 89. East Pasco is entitled to preference as a disproportionate share provider of Medicaid. The second preference is tied to numeric need in the planning area. No preference is appropriate. The third preference is applicable only if the applicant proposes to transfer acute care beds. This preference is not given. The fourth preference favors an applicant who documents the cost efficiency of its proposal. This is a close call as I concur with the Hearing Officer's criticisms regarding the size of the rooms and that only private rooms are proposed, but on balance I conclude that East Pasco is entitled to this preference. See the Ruling On Exception 58.
45-49. These exceptions deal with the issue of financial feasibility. First, East Pasco excepts to the finding in paragraph 48 that there was no testimony regarding the hospital-wide pro forma. East Pasco's witness on this issue focused on the document (the incremental pro forma) addressing the financial feasibility of the proposed 24 bed addition, but did touch on the hospital-wide pro forma. See Transcript pages 1162 - 1163. The witness testified that his evaluation of the incremental pro forma was not affected by his evaluation of the hospital-wide pro forma. The challenged finding is rejected as it is not supported by competent, substantial evidence.
Next, East Pasco excepts to the conclusion in paragraph 49 that as a matter of law a showing of financial feasibility of the specific proposal to add beds is not enough to satisfy the statutory requirement that the agency review the financial feasibility of the proposal. Section 381.705(1)(i), Florida Statutes requires the agency to review "the immediate and long-term financial feasibility of the proposal" (emphasis added). Paragraph 49 is rejected as contrary to logic and the plain language of the statute. The correct way to review financial feasibility a CON proposal by an existing facility is on an incremental basis. The financial feasibility of the proposal is the issue.
Next, East Pasco excepts to paragraph 50 where the Hearing Officer continues with findings on financial feasibility which improperly expand the scope of review as discussed in the previous paragraph. Paragraph 50 is rejected for the same reason. Additionally, in paragraph 107, the Hearing Officer noted the parties stipulation that East Pasco has the financial resources to carry out its proposal.
East Pasco excepts to the finding in paragraph 51 that it simply assumed the financial feasibility of its proposal. This finding is not supported by competent, substantial evidence and is rejected. East Pasco presented extensive testimony by a highly qualified professional on the feasibility of its proposal. See Transcript pages 490-569 and 1150-1164. The rest of paragraph 51 is accepted.
East Pasco excepts to paragraph 52 where the Hearing Officer again faults East Pasco for focusing on the financial feasibility of the proposal. Paragraph
is rejected for the reasons previously given.
50-57. In paragraphs 53 through 60 the Hearing Officer found that East Pasco's pro form a or financial projection for the proposed 24 bed addition was unreasonable in several respects. East Pasco maintains that these findings should be rejected or given little weight because the Hearing Officer's analysis of the pro forma is flawed.
I concur with East Pasco that the Hearing Officer's analysis of the pro forma is flawed in several respects. First, the Hearing Officer's conclusion that projected daily charge for services is unreasonable because it is based on an historical average instead of historical charges for medical/surgical services is rejected. The record contains testimony that there would be no significant variance between a revenue and expense profile based on a hospital wide average and a medical/surgical specific profile (T565). The estimated difference was only three tenths of one percent (T1156). Furthermore, the witness; a health care consultant with 20 years experience; testified that a specific medical/surgical breakout of expenses and revenues was not typically done (T1152). No statute or rule of the agency requires such an approach.
Paragraphs 55, 56 and 59 of the Recommended Order are based on the flawed analysis and are rejected.
In paragraph 57 the Hearing Officer found that East Pasco's projected staffing levels were insufficient. This conclusion rests on testimony that if the addition of 24 beds is treated as an independent unit instead of an addition to an existing facility, the projected staffing is insufficient (T1096, 1097).
East Pasco's staffing projections are based on partial use of existing staff to help with the new beds (T339, 359, 361). This failure to distinguish between an incremental staffing projection of an existing facility and a staffing projection for a new free standing facility is a fatal flaw in paragraphs 57 and 58: therefore, the findings are rejected.
The exceptions to paragraphs 54 and 60 are denied. Paragraph 53 is a summary based on the specific findings in paragraphs 54 through 60. Paragraph
is inherently flawed in light of the rejection of paragraphs 55 through 59. Additionally, paragraph 53 is inconsistent with the finding that East Pasco experiences very high occupancy during its peak season with utilization sometimes exceeding 100 percent and the finding a high percentage of subdistrict residents, 63.7 percent in 1990, needing acute care services go outside the subdistrict to obtain services. Paragraph 53 is rejected.
58-60. East Pasco excepts to paragraphs 61, 62 and 63 wherein the Hearing Officer concludes that the proposed new rooms are excessively large and therefore an inefficient use of resources. The proposed square footage greatly exceeds minimums required by agency; therefore, the findings are supported by competent, substantial evidence and the exceptions are denied.
61-63. East Pasco excepts to paragraphs 64-66 wherein the Hearing Officer concluded that the proposed construction costs were materially underestimated. The summary conclusion in paragraph 64 is flawed because it is based on incorrect findings in paragraphs 65 and 66. In paragraph 65 the Hearing Officer correctly points out that a nursing bed is less costly than an acute care beds. She compares the projected cost of the new beds of $142.91 per square foot with a previous projection of $171.00 for nursing beds. The Hearing Officer refused to admit evidence that the actual cost of the nursing beds was only $110.00 per square foot. The Hearing Officer ruled that only the relevant construction contract could be used to prove the cost of the nursing beds. The ruling disregarded the broad rule of admissibility for administrative proceedings set
forth in Section 120.58(1)(a), Florida Statutes and also was an incorrect application of the best evidence rule. Because the Hearing Officer based her comparison on a paper projection rather than evidence of actual costs, paragraph
65 is rejected.
Paragraph 66 is based on the testimony of a witness who was not accepted as an expert in construction costs (T1103). Therefore, paragraph 66 is rejected as not being supported by competent, substantial evidence. The summary conclusion in paragraph 64 is rejected.
64-67. In paragraphs 68 through 70 the Hearing Officer makes findings that East Pasco does not intend to keep its commitments regarding another project that was previously held to be exempt from CON review. Elsewhere, the Hearing Officer recognized that the exempted project should not be considered in this proceeding. See paragraph 69 of the Recommended Order. If East Pasco fails to keep its commitments there are appropriate administrative and judicial remedies. It is inappropriate to permit this proceeding to be used as a vehicle to collaterally attack the exemption decision: therefore, paragraphs 68 through 70 are rejected.
3/ East Pasco excepts to paragraph 72 of the Recommended Order on the grounds that it compares "apples and oranges." The finding appears to compare actual revenues at Humana to projected revenues at East Pasco. No weight is given to this comparison. I find no competent, substantial evidence in the record to support the finding that the projected eight percent (8%) inflation is unreasonable for hospital charges; therefore, the finding regarding projected increases is rejected.
East Pasco excepts to paragraph 73 because the Hearing Officer made findings regarding the anticipated effect of the new beds on Humana without considering East Pasco's evidence on this issue. See paragraph 90 of the Recommended Order where the Hearing Officer cited the parties' stipulation on standing as the reason for refusing to admit this evidence. Clearly, evidence inadmissible for one purpose may be admissible for another purpose. To make a finding regarding anticipated effect on the basis of only Humana's evidence did not comport with the essential requirements of law. Paragraph 73 is rejected.
East Pasco excepts to paragraph 74 wherein the Hearing Officer cites the excess capacity in the subdistrict. The parties stipulated to a lack of numeric need under the rule formula, but the issue in this case is whether there are not normal circumstances justifying approval despite lack of numeric need. The findings in paragraph 74 are factually correct. The exception is denied.
East Pasco excepts to the conclusion in paragraph 75 that the expenditure of funds required to construct the beds is unreasonable. Under normal circumstances this would be a correct conclusion, but the gist of this case is "not normal" circumstances where East Pasco finds itself more than 100 percent full at times during the peak season. This is in contrast to residents and physicians declining to use Humana, and the high percentage of residents who go outside the subdistrict for hospital services. Paragraph 75 goes to the ultimate conclusion in this case and is rejected.
East Pasco excepts to the Hearing Officer's finding in paragraph 76 that approval of the proposed bed addition would not promote competition. East Pasco maintains that it "should not be held hostage by the stagnation at
Humana." I concur. To deny the application would in effect coerce residents to use Humana or go outside the subdistrict when East Pasco's beds are full.
Paragraph 76 is rejected.
73-74. East Pasco excepts to findings of high quality at Humana in paragraph 77 and 78. Again, the Hearing Officer has made a finding on the basis of Humana's evidence while refusing to admit contrary evidence tendered by East Pasco. The Hearing Officer ruled East Pasco's evidence inadmissible on the grounds it would constitute an amendment of East Pasco's application. See paragraph 91. The tendered evidence was supplemental and relevant to the application as it addressed issues raised in the application. The evidence should have been admitted. Holmes Regional Healthcare vs. Department of Health and Rehabilitative Services, 10 FALR 7040 (HRS 1988). Because the findings fail to comport with the essential requirements of law, paragraphs 77 and 78 are rejected.
75-76. East Pasco excepts to paragraphs 79 and 80 regarding risks of transferring patients from East Pasco to Humana or other hospitals. The Hearing Officer's conclusion that in general there is no medical problem with transferring patients is accepted, but is qualified by the previous discussion regarding the quality of care issue.
East Pasco excepts to the Hearing Officer's conclusion in paragraph 81 that approval would not enhance access to Medicaid and indigent patients. Although East Pasco's historical track record is superior in this regard, recent data shows Humana much improved. The finding is accepted.
East Pasco excepts to the conclusion in paragraph 82 that East Pasco's policy manual requirement that persons seeking admission to the hospital must make a deposit if they lack insurance necessarily implies that an indigent person will be denied admission. I conclude that the finding is not supported by competent, substantial evidence; therefore, the finding is rejected.
79-80. Paragraphs 83 and 84 state the statutory requirement that a CON application must include a certified copy of an authorizing resolution by the applicant's board of directors. The Hearing Officer notes that East Pasco's application includes the required resolution. The findings are accepted.
81-82. In paragraphs 85 and 86 the issue of whether East Pasco intends to honor its commitments regarding the exempt project is again raised by the Hearing Officer. To the extend that the Hearing officer allowed a collateral attack on the exempt project the findings are rejected for reasons previously discussed.
The challenged portions of paragraph 87 (all but the first three sentences) simply restate challenged findings in paragraph 33. The exception is denied in part and granted in part for the reasons stated in the Ruling On Exception 29.
East Pasco excepts to paragraph 90. See the Ruling On Exception 69.
East Pasco excepts to paragraph 94. See the ruling on exception 30 and the conclusions of law stated in this Final Order.
The exception to paragraph 95 is denied. See the Ruling On Exception
23.
The conclusion in paragraph 96 that East Pasco failed to establish "not normal" circumstances is rejected. See the conclusions of law expressed in this Final Order. The findings of fact reiterated in paragraph 96 are discussed elsewhere.
The exception to paragraph 97 is denied. See the Ruling On Exceptions 21 and 104.
East Pasco excepts to paragraph 98 which reiterates the Hearing Officer's findings regarding the preferences stated in the state and local health plans. As discussed in the rulings on exceptions 31 through 44, East Pasco's proposed bed addition is consistent with some preferences and inconsistent with others. The fact that 100 percent consistency is lacking is not a "per se" reason for denial. Instead, the agency is required to consider and give appropriate weight to all applicable criteria. This has been done.
Paragraph 99 addresses the criteria of availability of other providers in the service district. In paragraph 99 the Hearing Officer reiterates her findings regarding the availability of excess capacity at Humana. See the Ruling On Exceptions 10, 18, 69, 70, and the conclusions of law stated in this Final Order.
The Hearing Officer's conclusion in paragraph 100 that East Pasco's tendered evidence of quality of care problems constituted an amendment of East Pasco's application is rejected. See the ruling on exceptions 73 and 74 where the factual finding of high quality at Humana is rejected.
East Pasco excepts to paragraph 101 wherein the Hearing Officer reiterates her conclusion that the extent of utilization of beds in the subdistrict weighs against approval. As discussed elsewhere this is an important consideration. The ultimate issue is whether the "not normal" circumstances shown by East Pasco outweigh the availability of beds at Humana. See Rulings On Exceptions 10, 71, 72, 73, 74, and the conclusions of law expressed in this Final Order.
In paragraph 103 the Hearing Officer concludes that the criteria of "availability of alternatives" weighs against approval. The conclusions regarding paragraph 101 are equally applicable here.
Paragraph 104 addresses the criteria of economies resulting from shared resources. The exception to paragraph 104 is denied.
Paragraph 105 addresses the criteria of need for special equipment and services not available in adjoining areas. This criteria is not applicable as East Pasco seeks only to add acute care beds. The Hearing Officer again reiterates her findings regarding the availability of beds at other facilities. See Ruling On Exceptions 92 and 93.
Paragraph 106 addresses the criteria of need for research and teaching facilities. This criteria is not applicable. The exception is denied.
In paragraph 107 the Hearing Officer reiterates her findings that the cost of the new beds is not the best use of resources by East Pasco in consideration of the number of patients which can be served and the new observation and nursing beds. I disagree. See Ruling On Exceptions 28, 29, and 71.
In paragraph 108, the Hearing Officer again considers the issue of financial feasibility. Based on the discussion of exceptions 45 through 57, the Hearing officer's conclusion that East Pasco failed to show long term financial feasibility is rejected.
Paragraph 109 addresses the needs of health maintenance organizations. This criteria is not applicable and the exception is denied.
Paragraph 110 addresses the needs of facilities providing a substantial portion of their services to nonresidents of the service district. This criteria is not applicable and the exception is denied.
Paragraph III addresses the criteria of impact on costs, competition, and quality. Based on the availability of Humana's beds the Hearing Officer weighs this criteria against East Pasco's proposal. I disagree in consideration of the "not normal" circumstances shown by East Pasco.
In paragraph 112 the Hearing Officer addresses the criteria of "less costly" alternatives. Again, in consideration of the "not normal" circumstances, I disagree with the conclusion that this criteria should be weighed against East Pasco's proposal.
In paragraph 113 the Hearing Officer reiterates her finding that East Pasco understated construction costs and that East Pasco does not intend to keep its commitments regarding the exempt project. The Hearing Officer's conclusions are rejected. See the Ruling On Exceptions 61 through 67.
In paragraph 114 the Hearing Officer addresses the criteria of Medicaid and indigent care. See the Ruling On Exception 21. I concur with the Hearing Officer's conclusion that East Pasco meets this criteria, but that East Pasco is entitled to little weight regarding this criteria. The exception is denied.
In paragraph 105 the Hearing Officer concludes that the resolution of East Pasco's board of directors authorizing the CON application is so defective it fails to satisfy the statutory requirement. This conclusion is rejected.
See Ruling On Exceptions 64 through 67 and 79 through 82.
East Pasco and AHCA challenge the conclusion in paragraph 117 that East Pasco's projections of revenue and expenses were defective because the time during which construction will take place was not addressed. The hospital-wide pro forma includes information concerning the period of construction. See page
64 of East Pasco Exhibit 2. Additionally, it is noted that the parties stipulated that East Pasco has the financial resources to accomplish the project. See paragraph 107 of the Recommended Order. The exception is granted.
FINDINGS OF FACT
The agency hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order except where modified or rejected in the Rulings On the Exceptions.
CONCLUSIONS OF LAW
The agency 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 and the conclusions of law expressed here.
Respondent, East Pasco Medical Center (East Pasco) seeks approval of CON 6783 to add 24 acute care beds to its highly utilized hospital facility.
Petitioner, Humana Hospital Pasco (Humana) only ten minutes away from East Pasco maintains that use of its underutilized facility is a better alternative.
The decision is not easy because the rule under which East Pasco seeks approval to some degree conflicts with a major goal of CON regulation which is to control costs by discouraging unneeded investment in health care facilities. 4/ Morton F. Plant Hospital vs. Department of Health and Rehabilitative Services, 591 So2d 586 (Fla. 1st DCA 1986). On the other hand, East Pasco, has made a compelling case for approval despite a lack of numeric need under the rule formula. 5/, 6/
The applicable need formula for hospital, acute care beds is found at Section 59C-1.038, F.A.C. All parties stipulated to the lack of numeric need in the appropriate subdistrict; thus, the rule mandates denial unless there are "not normal" circumstances. Subsection (7)(e) of the rule addresses the issue of "not normal" circumstances. A threshold requirement under (7)(e) is that the applicant-hospital must have an average annual occupancy exceeding seventy-five percent (75%).
East Pasco's occupancy of 78.7 percent allowed it to seek approval under (7)(e). I respectfully disagree with the Hearing Officer's conclusion that there were no facts and circumstances beyond meeting the occupancy threshold which would justify approval. East Pasco demonstrated and the Hearing Officer found that during the late fall, winter, and early spring seasons East Pasco is bursting at the seams with occupancy sometimes exceeding 100 percent. During the peak season, Humana, only ten minutes away, with substantially the same physicians on staff, and offering the same services has not reached 50 percent occupancy. See paragraph 99 of the Recommended Order. Humana and East Pasco are the only hospitals located in the subdistrict. Logically, Humana's unused beds are an alternative to East Pasco's proposal, but physicians and consumers have not been willing to use this alternative.
Because Humana seeks an order denying East Pasco's application it was incumbent (not as a matter of law, but as a matter of persuasion) on Humana to adequately address in the record why physicians and consumers are bypassing Humana in favor of East Pasco and hospitals located outside the subdistrict, and what can be done to remedy this situation. This was not done. Humana vigorously opposed the admission of evidence tendered by East Pasco on whether there is a quality of care problem at Humana. The Hearing Officer erroneously sustained Humana's objection to this evidence (T235-260, 292).
Another important consideration is the fact that a high percentage of subdistrict residents requiring hospitalization in 1990, 63.7 percent went to hospitals outside the subdistrict. 7/ See paragraph 24 of the findings of fact. Accessibility to acute care services within the subdistrict will be enhanced by East Pasco's bed addition.
Finally, East Pasco receives fifty-five (55%) of its inpatient admissions through its emergency department, which is close to twice the national average. See Finding of Fact 4, paragraph 10 of the appendix to the Recommended Order and page 29 of the transcript.
Having reviewed the entire record and considered the positions of the parties as stated in the exceptions and response thereto, I conclude that East Pasco has proved "not normal" circumstances justifying approval of its application.
Based upon the foregoing, it is
ADJUDGED, that the application of Adventist Health System/Sunbelt, Inc. d/b/a East Pasco Medical Center for CON 6783 to add 24 acute care beds be APPROVED.
DONE and ORDERED this 3rd day of June, 1993, in Tallahassee, Florida.
Douglas M. Cook, Director Agency for Health Care Administration
ENDNOTES
1/ Section 59C-1.038(7)(e) gives the agency discretion to approve new beds despite lack of numeric need where there are "not normal" circumstances.
2/ The most recent 12 months at the time of review was July 1990 through June 1991. See East Pasco Exhibit 5. The need rule required the use of calendar year 1990 data yielding an occupancy figure of 78.78 percent.
3/ It is noted that the exception originally numbered 68 was deleted. See counsel for East Pasco's letter of March 23, 1993, and attached corrections of clerical errors.
4/ Access and quality of care are also important goals.
5/ In certificate of need law, a great deal of importance is attached to a calculation of need or lack thereof under a rule formula. A lack of numeric need under the rule formula establishes a rebuttable presumption of no need. Humhosco vs. Department of Health and Rehabilitative Services, 476 So2d 258, 261 (Fla. 1st DCA 1985).
6/ When there is no numeric need under the rule formula, a CON application may nevertheless be approved if there are "not normal" circumstances justifying approval. The decision on whether to approve on the basis of "not normal" circumstances is a conclusion of law and thus a matter of agency discretion so long as the decision is based on competent, substantial evidence. Humana vs.
Department of Health and Rehabilitative Services, 492 So2d 388, 392 (Fla. 4th DCA 1986); Federal Property Management vs. Department of Health and Rehabilitative Services, 382 So2d 475, 477 (Fla. 1st DCA 1985).
7/ It is recognized that neither East Pasco nor Humana provide tertiary or other highly specialized services; thus, residents needing such services were required to use other hospitals.
COPIES FURNISHED:
James C. Hauser, Esquire MESSER, VICKERS, CAPARELLO,
MADSEN, LEWIS, GOLDMAN & METZ
Post Office Box 1876 Tallahassee, Florida 32301
Edward Labrador, Esquire Senior Attorney
325 John Knox Road, Suite 301 Tallahassee, Florida 32303-4131
FALR
Post Office Box 385 Gainesville, Florida 32602
Darrell White, Esquire William Wiley, Esquire
McFARLAIN, WILEY, CASSEDY & JONES
215 South Monroe Street, Suite 600 Tallahassee, Florida 32301
Linda M. Rigot, Hearing Officer The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
Elizabeth Dudek (AHCA/CON) Alberta Granger (AHCA/CON) Elfie Stamm (AHCA/CON)
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named people by U.S. Mail this 3rd day of June, 1993.
R. S. Power, Agency Clerk State of Florida, Agency for Health Care Administration
325 John Knox Road
The Atrium Building, Suite 301 Tallahassee, Florida 32303
(904)922-3808
NOTICE OF RIGHT TO JUDICIAL REVIEW
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, 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 NTH 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 |
|---|---|
| Jan. 11, 1994 | AGENCY APPEAL, ONCE THE RETENTION SCHEDULE of -KEEP ONE YEAR AFTER CLOSURE- IS MET, CASE FILE IS RETURNED TO AGENCY GENERAL COUNSEL. -ac |
| Jun. 07, 1993 | Final Order filed. |
| Feb. 16, 1993 | Memo to S. Powers from L. Sokol (RE: enclosing page 18 of recommended order) sent out. |
| Feb. 12, 1993 | Letter to LMR from Darrell White (re: request for Recommended Order) filed. |
| Feb. 09, 1993 | Recommended Order sent out. CASE CLOSED. Hearing held 9/29-30/92, 10/1-2,5/92. |
| Jan. 13, 1993 | Humana's Notice of Withdrawal of Motion to Strike filed. |
| Jan. 13, 1993 | East Pasco Medical Center's Notice of Withdrawal of Motion for Attorney's Fees filed. |
| Jan. 11, 1993 | East Pasco`s Response to Humana`s Motion to Strike Portions of the Proposed Recommended Orders of East Pasco and AHCA, Motion to Strike, and Motion for Attorney`s Fees filed. |
| Jan. 07, 1993 | Order sent out. (Humana's Motion to Reopen Record GRANTED; R. Meade Affidavit is Admitted as Evidence as Humana's Exh. #46) |
| Jan. 07, 1993 | Humana`s Motion to Strike Portions of the Proposed Recommended Orders of East Pasco and AHCA filed. |
| Jan. 06, 1993 | Notice of Withdrawal of East Pasco`s Opposition to Humana`s Motion to Reopen Record and East Pasco`s Alternative Motion to Reopen Record for Additional Purposes filed. |
| Jan. 05, 1993 | (Petitioner) Notice of Statutory Provisions filed. |
| Jan. 04, 1993 | East Pasco Medical Center`s Reply to Supplement to Humana`s Motion to Reopen Record, and, Alternative Motion to Reopen Record for Additional Purposes w/Exhibit-A filed. |
| Dec. 31, 1992 | (Petitioner) Supplement to Humana`s Motion to Reopen Record filed. |
| Dec. 30, 1992 | (Petitioner) Notice of Motion Hearing (set for 1/6/93; 9:00am) filed. |
| Dec. 21, 1992 | AHCA'S Proposed Recommended Order filed. |
| Dec. 21, 1992 | East Pasco Medical Center's Proposed Recommended Order filed. |
| Dec. 21, 1992 | Proposed Findings of Fact, Conclusions of Law, and Recommended Order of Humana Hospital Pasco filed. |
| Dec. 17, 1992 | Humana's Reply to EPMC Response to Humana Motion to Reopen Record filed. |
| Dec. 15, 1992 | East Pasco Medical Center's Response in Opposition to Motion to Reopen Record filed. |
| Dec. 11, 1992 | Order sent out. (unopposed motion for extension of time is granted) |
| Dec. 08, 1992 | Humana`s Motion to Reopen Record w/Affidavit of Robert Meade filed. |
| Dec. 07, 1992 | (Respondent) Unopposed Motion for Extension of Time filed. |
| Nov. 06, 1992 | Letter to LMR from James C. Hauser (re: filing PRO) filed. |
| Oct. 28, 1992 | Transcript (Vols 1-8) filed. |
| Oct. 05, 1992 | CASE STATUS: Hearing Held. |
| Sep. 28, 1992 | Subpoena Duces Tecum w/Affidavit filed. (From James C. Hauser) |
| Sep. 04, 1992 | Amended Notice of Hearing sent out. (hearing set for 9/29/92 - 10/2/92 & 10/5/92; 9:00am; Tallahassee) |
| Sep. 04, 1992 | CC Letter to James C. Hauser from Darrell White (re: Bob Dodd's Ability to Testify) filed. |
| Aug. 27, 1992 | East Pasco's Response in Opposition to Human's Motion to Reschedule Final Hearing filed. |
| Aug. 27, 1992 | Humana's Request for Oral Argument filed. |
| Aug. 26, 1992 | Humana's Motion to Reschedule Final Hearing filed. |
| Jul. 06, 1992 | Order Continuing and Rescheduling Formal Hearing sent out. (hearing rescheduled for September 29, 1992 - October 2, 1992; 9:00; Tallahassee) |
| Jul. 02, 1992 | Humana's Motion for Continuance filed. |
| Jun. 29, 1992 | HRS Final Witness & Exhibit List filed. |
| Jun. 29, 1992 | Joint Prehearing Stipulation filed. |
| Jun. 24, 1992 | East Pasco's Notice of Taking Discovery Deposition Duces Tecum filed. |
| Jun. 24, 1992 | East Pasco's Notice of Taking Deposition Duces Tecum filed. |
| Jun. 17, 1992 | Order Establishing Discovery Guidelines sent out. |
| Jun. 17, 1992 | Order sent out. |
| Jun. 16, 1992 | Humana's Notice of Taking Discovery Depositions Duces Tecum filed. |
| Jun. 15, 1992 | HRS Preliminary Witness List filed. |
| Jun. 15, 1992 | Humana's Preliminary Witness List filed. |
| Jun. 15, 1992 | East Pasco Medical Center's Preliminary Witness List; Agreed to Response to Order to Show Cause w/Exhibits A&B filed. |
| Jun. 15, 1992 | (unsigned) Order Establishing Discovery Guidelines; (unsigned) Order & cover ltr filed. |
| Jun. 12, 1992 | East Pasco's Response to Humana's Second Motion to Compel Discovery filed. |
| Jun. 12, 1992 | Humana's Notice of Service of Answers to Second Set of Interrogatories filed. |
| Jun. 10, 1992 | Humana's Notice of Taking Discovery Depositions Duces Tecum filed. |
| Jun. 09, 1992 | Order to Show Cause sent out. (parties to show cause why this case should not be closed, must file reply by 6-15-92) |
| Jun. 08, 1992 | Humana's Second Motion to Compel Discovery filed. |
| Jun. 04, 1992 | (Respondent) Notice of Service of Answers to Humana`s Second Set of Interrogatories; East Pasco Medical Center`s Response to Humana`s Second Request for Production of Documents filed. |
| Jun. 03, 1992 | Humana's Notice of Taking Deposition Duces Tecum filed. |
| Jun. 03, 1992 | Humana's Notice of Taking Deposition Duces Tecum filed. |
| May 28, 1992 | Humana's Notice of Taking Deposition Duces Tecum filed. |
| May 26, 1992 | CC Letter to Darrell White from James C. Hauser (re: response to ltr of May 19 which included PRO on East Pasco Motion to Compel Discovery)filed. |
| May 21, 1992 | (unsigned) Proposed Recommended Order w/cover ltr filed. |
| May 20, 1992 | Ltr. to J. Hauser from D. White; Proposed Order re: Production filed. |
| May 14, 1992 | East Pasco's Response to Humana's Request for Site Visit filed. |
| May 14, 1992 | CC Letter to DSM from James C. Hauser (re: May 8 motion hearing) filed. |
| May 08, 1992 | Ltr. to DSM from J. Hauser (2) enclosing Final Order (2) in case no. 90-1526; Affidavit of Robert C. Meade filed. |
| May 08, 1992 | CASE STATUS: Hearing Partially Held, continued to 5-18-92; 8:30am; Tallahassee) |
| May 08, 1992 | East Pasco`s Response to Humana`s Motion to Establish Deadline for Exchange of Con Application Updates; East Pasco`s Response to Humana`s Motion to Compel Discovery filed. |
| May 08, 1992 | Affidavit of Robert C. Meade filed. |
| May 07, 1992 | Humana's Supplemental Answers to East Pasco's First Set of Interrogatories filed. |
| May 06, 1992 | Emergency Motion for Expedited Ruling on East Pasco`s Motion to Quashor Modify Subpoenas Duces Tecum w/Exhibits A-C; Notice of Availability for Motion Hearing filed. |
| May 06, 1992 | Humana's Response to East Pasco Motion to Compel filed. |
| May 06, 1992 | Humana's Second Request for Motion Hearing w/Exhibits A&B filed. |
| May 05, 1992 | Objections to Subpoenas Duces Tecum w/Exhibit-A filed. (From Gerald B. Sternstein) |
| May 05, 1992 | Humana's Second Request for Production of Documents to East Pasco Medical Center; Humana's Motion to Permit Additional Interrogatories w/Exhibit-A filed. |
| May 05, 1992 | ((Petitioner) Request for Motion Hearing filed. |
| May 04, 1992 | Humana`s Request for Site Visit; Humana`s Motion for Protective Order; Humana`s Motion to Establish Deadline for Exchange of Con Application Updates filed. |
| May 01, 1992 | East Pasco Medical Center's Motion to Permit Additional Interrogatories; Exhibit A-B filed. |
| May 01, 1992 | Humana's Notice of Taking Depositions Duces Tecum filed. |
| May 01, 1992 | Humana's Motion to Compel Discovery on East Pasco filed. |
| May 01, 1992 | East Pasco Medical Center's Motion to Permit Additional Interrogatories filed. |
| May 01, 1992 | (Adventist Health System/Sunbelt) Notice of Service of Interrogatories filed. |
| Apr. 30, 1992 | (E Pasco Medical Center) Notice of Hearing (motion hearing set for 5/7/92; 10:30am); East Pasco's Second Motion to Compel filed. |
| Apr. 29, 1992 | (Respondent) East Pasco`s Motion to Compel w/Exhibits A-D filed. |
| Apr. 20, 1992 | East Pasco's Second Request for Production of Documents to Humana Hospital Pasco filed. |
| Apr. 16, 1992 | Amended Notice of Hearing sent out. (hearing set for July 6-10, 1992;9:00am; Tallahassee) |
| Apr. 16, 1992 | Amended Notice of Transfer sent out. (proceedings were transferred to the undersigned on 3-30-92) |
| Apr. 16, 1992 | Second Amended Prehearing Order sent out. (parties shall file their prehearing stipulation no later than June 26, 1992) |
| Apr. 15, 1992 | Humana's Notice of Change of Address filed. |
| Apr. 14, 1992 | Humana's Notice of Change of Address filed. |
| Apr. 08, 1992 | Letter to DSM from Darrell White (re: Prehearing Order dated April 1,1992) filed. |
| Apr. 03, 1992 | (Petitioner) Notice of Service of Interrogatory Answers filed. |
| Apr. 01, 1992 | Notice of Transfer sent out. (proceeding transferred to the undersigned on 03/30/92) |
| Apr. 01, 1992 | Amended Prehearing Order*(Prehearing Stips due no later than 06/06/92) sent out. |
| Apr. 01, 1992 | Notice of Hearing sent out. (hearing set for 07/6-10/92:9:00AM:Tallahassee) |
| Mar. 31, 1992 | Notice of Withdrawal of Motion to Disqualify filed. |
| Mar. 30, 1992 | (Humana) Stipulation filed. |
| Mar. 26, 1992 | Humana's Written Objections to East Pasco's Written Discovery Requests filed. |
| Mar. 24, 1992 | (Petitioner) Response to Prehearing Order filed. |
| Mar. 23, 1992 | (E Pasco Medical Center) Notice of Service of Answers to Petitioner`s First Set of Interrogatories filed. |
| Mar. 23, 1992 | East Pasco Medical Center's Response to Humana's First Request for Production of Documents filed. |
| Mar. 23, 1992 | Letter to EMH from James C. Hauser (re: Motion to Disqualify) filed. |
| Mar. 18, 1992 | (Respondent) Motion to Disqualify w/Exhibit-A; Notice of Appearance filed. |
| Mar. 11, 1992 | Prehearing Order sent out. |
| Mar. 09, 1992 | Notification card sent out. |
| Mar. 04, 1992 | Notice; Humana's Petition for Formal Administrative Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Jun. 03, 1993 | Agency Final Order | |
| Feb. 09, 1993 | Recommended Order | Certificate Of Need for acute care beds denied where no numeric need shown and no facility specific special circumstances proven to justify increasing excess capacity. |
