STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
BEVERLY ENTERPRISES-FLORIDA, INC. ) d/b/a BEVERLY GULF COAST-FLORIDA, INC.,)
)
Petitioner, )
)
vs. ) CASE NO. 92-6656
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, UNICARE HEALTH )
FACILITIES, INC. & LIFE CARE )
CENTERS OF AMERICA, INC., )
)
Respondents. )
) HCR LIMITED PARTNERSHIP I d/b/a ) HEARTLAND OF BROOKSVILLE, )
)
Petitioner, )
)
vs. ) CASE NO. 92-6659
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, and BEVERLY )
ENTERPRISES-FLORIDA, INC., )
)
Respondents. )
) HCR LIMITED PARTNERSHIP I d/b/a ) HEARTLAND OF BROOKSVILLE, )
)
Petitioner, )
)
vs. ) CASE NO. 92-6660
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, and UNICARE )
HEALTH FACILITIES, INC. )
)
Respondents. )
) HCR LIMITED PARTNERSHIP I d/b/a ) HEARTLAND OF BROOKSVILLE, )
)
Petitioner, )
)
vs. ) CASE NO. 92-6661
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, and LIFE CARE )
CENTERS OF AMERICA, INC., )
)
Respondents. )
) LAKE PORT PROPERTIES, authorized ) to operate, LAKE PORT NURSING )
CENTER )
)
Petitioner, )
)
vs. ) CASE NO. 92-6662
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, LIFE CARE ) CENTERS OF AMERICA, INC., UNICARE ) HEALTH FACILITIES, INC., and ) BEVERLY ENTERPRISES-FLORIDA, INC., )
)
Respondents. )
) SOUTHERN MEDICAL ASSOCIATES, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 92-6669
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, LIFE CARE ) CENTERS OF AMERICA, INC., UNICARE ) HEALTH FACILITIES, INC., and ) BEVERLY ENTERPRISES-FLORIDA, INC., )
)
Respondents. )
)
RECOMMENDED ORDER
These consolidated cases were heard by Eleanor M. Hunter, the Hearing Officer designated by the Division of Administrative Hearings, from May 3 - 21, 1993, in Tallahassee, Florida.
APPEARANCES
For Petitioner: Douglas L. Mannheimer, Attorney Beverly Enterprises- Dennis LaRosa, Attorney Florida, Inc. d/b/a Broad & Cassel
Beverly Gulf Coast- 215 South Monroe Street Florida, Inc. Post Office Box 11300
Tallahassee, Florida 32302
For Petitioner: Alfred W. Clark, Attorney At Law HCR Limited Post Office Box 623
Partnership I, d/b/a Tallahassee, Florida 32308 Heartland of Brooksville
For Petitioner: James C. Hauser, Attorney
Lake Port Properties, Messer, Vickers, Caparello, Madsen Lake Port Nursing Lewis, Goldman & Metz, P.A. Center Lachlin Waldoch, Esquire
Post Office Box 1876 Tallahassee, Florida 32301
For Petitioner: Gary Anton, Attorney Southern Medical Stowell, Anton & Kraemer Associates, Inc. Post Office Box 11059
Tallahassee, Florida 32302
For Respondent: Edward Labrador, Attorney Agency For Health Richard Patterson, Attorney
Care Administration Agency for Health Care Administration
325 John Knox Road, Suite 301 Tallahassee, Florida 32303-4131
For Respondent: W. David Watkins, Attorney Unicare Health Robert Downey, Attorney
Facilities, Inc. Oretel, Hoffman, Fernandez, et al.
2700 Blair Stone Road, Suite C Post Office Box 6507 Tallahassee, Florida 32314-6507
For Respondent: R. Bruce McKibben, Jr., Attorney Life Care Centers Pennington & Haben, P.A.
of America, Inc. Post Office Box 10095
Tallahassee, Florida 32302 STATEMENT OF THE ISSUES
Which applicant(s) best meet the criteria for the issuance of certificates of need for nursing home beds in response to the publication of the need for 321 additional community nursing home beds in Agency For Health Care Administration District 3.
PRELIMINARY STATEMENT
On or about October 2, 1992, the Agency For Health Care Administration ("AHCA") published in the Florida Administrative Weekly, its intent to approve the following certificate of need ("CON") applications:
CON Number 6983P to Unicare to construct a
60 bed nursing home in Hernando County;
CON Number 6985 to Beverly Enterprises-Florida, Inc., ("Beverly"), to construct a 120 bed nursing home in Hernando County; and
CON Number 6986 to Life Care Centers of America, Inc. ("Life Care") to construct a 120-bed nursing home in Hernando County.
AHCA also published its intent to deny the following CON applications:
CON Number 6989 to Lake Port Properties ("Lake Port") to either convert 60 sheltered nursing beds to 60 community nursing home beds, or to convert the 60 beds and to add
60 beds for a total 120-bed community nursing home in Lake County;
CON Number 6991 to Unicare for the addition of 51 community nursing home beds to the 89 bed New Horizons Rehabilitation Center in Marion County;
CON Number 6992 to Ocala Health Care Associates, G.P. ("Ocala Health Care"), for the addition of 60 community nursing beds to TimberRidge Nursing and Rehabilitation Center in Marion County; and
CON Number 6993 to Southern Medical Associates, Inc. ("Southern Medical"), for the addition of 60 community nursing beds to Palatka Health Care Center in Putnam County.
HCR Limited Partnership I, d/b/a Heartland of Brooksville ("Heartland"), is an existing 120-bed nursing home in Brooksville, Hernando County, Florida.
Heartland's standing is at issue.
On April 26, 1993, Unicare filed a Motion For Summary Recommended Order to Dismiss Southern Medical's Petition based on the assertion that the Board Resolution attached to Southern Medical's letter of intent was not certified properly. Southern Medical filed a Memorandum in Opposition to Unicare's Motion on April 30, 1993. Unicare withdrew its Motion for Summary Recommended Order at the hearing on May 12, 1993, when the parties agreed to the approval of Certificate of Need ("CON") 6991 to Unicare and the denial of its CONs numbers 6983P and 6983.
On April 28, 1993, Beverly filed a Motion in Limine Against Lake Port, based on Beverly's claim that Lake Port was ineligible for 60 bed approval having failed to indicate in its initial application that it would accept a partial award of a CON for 120 beds. AHCA reviewed Lake Port's applications for both 60 and 120 beds, concluding after the review that both should be denied.
At a hearing on the motion, AHCA, Life Care, and Unicare supported Beverly's motion in limine, which was denied based on the fact that the non-rule policy of the agency has been applied inconsistently. At the conclusion of the hearing, Beverly withdrew it Motion in Limine.
On April 30, 1993, Southern Medical filed a Motion for Summary Recommended Order Dismissing the Petitions of Beverly, Unicare, and Life Care because they initially submitted substantially incomplete or "skeleton" applications. The Motion For Summary Recommended Order against Unicare was rendered moot by the partial settlement reached on May 12, 1993. At the conclusion of the hearing, Southern Medical withdrew its Motion for Summary Recommended Order Against Beverly, leaving only the motion against Life Care for consideration. AHCA argued that Southern Medical could not withdraw its Motion as directed to
Beverly without also dismissing its Motion as directed to Life Care. Subsection 408.037, Florida Statutes, gives a list of information which must be included in a CON application. AHCA checks for completeness within 15 days of the filing of the initial application. The applicant is notified in an omissions request of any additional information that AHCA requires, and has 21 days within which to file an omissions response. Rule 59C-1.008(1)(l), Florida Administrative Code. After the omissions response deadline has passed, AHCA is authorized to decline to review incomplete applications. See, Florida Administrative Code, Rule 59C- 1.010(2)(a)4.
AHCA's expert testified that the agency allows applicants to correct mistakes and submit any additional information, whether or not in response to an omissions request, before the omissions response deadline. Otherwise, an applicant would be penalized if AHCA failed to find every flaw in an initial application. Based on AHCA's interpretation and application of its rules, Southern Medical's motion to dismiss Life Care is denied and the issue of whether the motion must also be directed towards Beverly is not reached.
Southern Medical also filed a Motion To Compel and For Sanctions against Ocala Health Care for its failure to respond to discovery requests and for not complying with various requirements of the Prehearing Order. Because Ocala Health Care was represented by a non-lawyer, Southern Medical's alternative request to give the party an additional opportunity to comply was granted. On May 3, 1993, Ocala Health Care was ordered to respond to discovery requests by May 7, 1993, and to make its witnesses available for deposition at least 5 days prior to the presentation of its case-in-chief. On May 12, 1993, the day that Ocala Health Care was to have begun the presentation of its case-in-chief, Southern Medical moved to dismiss the petition of Ocala Health Care based on its failure to comply with the Motion to Compel as to the production of documents or responses to interrogatories, and the impossibility of compliance with the requirement to make witnesses available for deposition at least five days prior to the presentation of its case-in-chief. At the final hearing, there was no appearance or participation on behalf of Ocala Health Care after May 3, 1993.
Southern Medical's Motion To Dismiss Ocala Health Care was granted. By recommended order of May 14, 1993, the petition filed by Ocala Health Care was dismissed and its case returned to AHCA for final disposition.
At the final hearing, Life Care presented the testimony of John P. O'Brien (expert in accounting and finance with special emphasis on pro forma feasibility relating to nursing homes); James Wiegard; Bo Russ (expert in architectural design and nursing home design); David J. Gooch (expert in nursing home construction, including equipment cost estimation); Linda Exner (expert in nursing home administration); Timothy J. Beaulieu (expert in nursing home administration, including staffing, operations and programs), and Richard A. Stern (expert in nursing home acquisitions and financial feasibility). Life Care's exhibits 1-4, 6, 7, 10-13, and 15 were received in evidence. Life Care's rebuttal exhibit 1 was not received in evidence.
Beverly presented the testimony of James R. Pietrzak (expert in nursing home development); Schuyler Hollingworth, Jr. (expert in nursing home finance); Scott Bell (expert in nursing home administration and operations, including staffing and equipment costs); Scott Alexander (expert in nursing home administration, with emphasis on special programs); John Tolan (expert in third party reimbursement, with emphasis on Medicaid and Medicare); Stephanie Englebrecht Simon; Cheryl Kelsch (expert in rehabilitative therapies); Patricia Schmidt (expert in nursing); Alvin Taylor (expert in human resources), and Armand Balsano (expert in financial feasibility and health care planning).
Beverly's exhibits 1, 2, 4, 5, 7-19, 22, 23, and 27 were received into evidence. Ruling was reserved on all portions of the letter of March 26, 1993, except the first sentence, which was included in Beverly's exhibit 22 and on the entirety of Beverly's exhibit 24. The items in exhibits 22 and 24 are received in evidence having been distributed by the local health council and relied upon by some applicants. (See, e.g., Transcript p. 2289.) The weight given to the items is considered in light of the totality of the evidence, including Heartland's exhibit 8, in which AHCA criticized portions of the local health council's plan and directed the council to make certain changes in the plan.
Unicare presented the testimony of Robert J. Abramowski (expert in health care finance); Sharon Schott, R.N. (expert in nursing, nursing administration, and quality assurance), and Millie Koch (expert in nursing home administration and operations). Unicare's exhibits 2, 7A, 9, 16A, and 16B, were received in evidence. Following the testimony of Sharon Schott, Southern Medical, Lake Port and Heartland moved to compel Unicare to introduce into evidence all portions of a guidebook to the Unicare's "Lamplighter" Alzheimers' program, although Schott's testimony and the Unicare application addressed only certain portions of the guidebook. Pursuant to Section 90.108, Florida Statutes, Unicare was compelled to produce the entire guidebook for in camera inspection. The Motion to Compel introduction of the entire guidebook was withdrawn as a result of the partial settlement reached by the parties at hearing on May 12, 1993.
AHCA relied on the deposition testimony of Elizabeth Dudek and Alberta Granger and exhibits 1-3, which were received in evidence. On rebuttal, AHCA presented the testimony of Patricia Hall and rebuttal exhibit 1, concerning the licensure status of Lake Port. The rebuttal evidence is not considered because the evidence of licensure status was included in Lake Port's application, and could have been challenged in AHCA's case-in-chief.
Heartland presented the testimony of Milo Bishop (expert in health planning) and exhibits 1-10, which were received in evidence, except Exhibit 9, which was included in Beverly's Exhibit 22.
Lake Port presented the testimony of John A. Cowin, M.D. (expert in orthopedic medicine and rehabilitative care); Diane Techman, R.N. (expert in nursing and nursing administration); Carol Smith Clendinen, R.N. (expert in nursing); Robert J. Goldstein (expert in physical therapy and physical therapy services in nursing homes); Victor Gilbert, M.D. (expert in medicine); Bill Mobley (expert in nursing home administration); Neil Ezell (expert in health care finance and accounting); Rick Knapp (expert in health care accounting and finance, and financial feasibility), and Sharon Gordon-Girvin (expert in health care planning). Lake Port's exhibits 1 - 16 were received in evidence.
Southern Medical presented the testimony of Robert Davick, Steve Strawn, Anna Cornwell (expert in nursing home administration and operations); Carolyn Wallace, R.N. (expert in nursing administration and nursing home programs); Charles Wysocki (expert in accounting, financial feasibility and analysis, and Florida Medicaid and Medicare reimbursement), and Bruce Duncan (expert in health planning). Southern Medical's exhibits 1-10, 12, 14, 21, 29 and 43-49 were received in evidence, and ruling reserved on the admissibility of exhibit 15.
For the reasons given in Lee County Board of County Commissioners, etc. v. HRS,
11 FALR 6692, at 6707 (DOAH Case No. 89-0241 FO 12/1/89), AHCA's objection to the admissibility of Southern Medical's exhibit 15 is sustained, and its motion to strike all testimony regarding exhibit 15 is also granted.
FINDINGS OF FACT
The Agency for Health Care Administration ("AHCA") is responsible for the administration of the Certificate of Need ("CON") program in Florida, pursuant to Section 408.034, Florida Statutes (1992 supp.)
AHCA initially published a need for 313 community nursing home beds in the 16 county area encompassing District III on April 17, 1992, which was subsequently corrected and published as a revised total of 321 net bed need for District III.
On September 17, 1992, with a cover letter signed by Elizabeth Dudek, AHCA issued notice that it intended to issue:
CON No. 6983P to Unicare Health Facilities, Inc. ("Unicare"), for construction of a 60 bed community nursing home in Hernando County;
CON No. 6985 to Beverly Enterprises-Florida, Inc. ("Beverly"), for the construction of a 120-bed community nursing home in Hernando County; and
CON No. 6986 to Life Care Centers of America, Inc. ("Life Care"), for the construction of a 120-bed community nursing home in Hernando County;
and, intended to deny, among others:
CON 6983 to Unicare for the construction of a 120-bed community nursing home in Hernando County;
CON No. 6989 to Lake Port Properties ("Lake Port") for either the conversion of 60 sheltered nursing beds to 60 community nursing home beds or the conversion of the
60 beds and the construction of an additional
60 community nursing beds to be located in Lake County;
CON No. 6991 to Unicare for the addition of
51 community nursing home beds to New Horizon Rehabilitation Center, in Marion County;
CON No. 6992 to Ocala Health Care Associates, G.P., for the addition of 60 community nursing home beds to TimberRidge Nursing and Rehabilitation Center in Marion County; and
CON No. 6993 to Southern Medical Associates, Inc. (Southern Medical) for the addition of
60 community nursing beds to Palatka Health Care Center in Putnam County.
Prior to the hearing, the parties stipulated that all participants have standing, except Heartland. Additional stipulations, accepted during the hearing, in the absence of a representative for Ocala Health Care Associates, are as follows: subsection 408.035 (1)(m) is not in dispute; proposed project costs and design are reasonable; the applicants' Schedules 1, notes and assumptions, the schematics, and the narrative responses to all of objective 4 in each application are in evidence, not in dispute, and are reasonable. The parties also stipulated to the approval of CON 6991 for Unicare to add 51 beds to its New Horizon Rehabilitation Center in Marion County, and the denial of CONS 6983 and 6983P to Unicare.
LIFE CARE
Life Care Centers of America, Inc. ("Life Care"), a privately-held corporation established in 1976, by its sole shareholder, Forrest L. Preston, owns, operates or manages 131 nursing homes and 14 retirement centers in 26 states. In Florida, Life Care manages four facilities with superior licenses, located in Altamonte Springs, Punta Gorda, and two in Palm Beach County, Lakeside and Darcy Hall. Life Care also owns, as well as operates, the facility in Altamonte Springs. Life Care owns and operates 28 nursing homes through leases, 6 or 7 of which are capital leases. Under the terms of the capital leases, Life Care is responsible for capital expenditures and projects. Life Care is not responsible for capital expenditures and projects at approximately
91 of its 131 facilities.
Life Care proposes to construct and operate a 120-bed nursing home in the southwest section of Hernando County, near Spring Hill, and to finance the total project cost of approximately $5 1/2 million from bank loans. Life Care has not identified a specific site for its facility.
Life Care has proposed to accept a CON condition to provide 75 percent of its patient days to Medicaid beneficiaries, to establish a separate 20-bed wing for Alzheimers and related dementia ("ARD") residents, and to provide intravenous therapy, inpatient and outpatient rehabilitative therapy, wound care and adult day care. Life Care's proposed Medicaid condition exceeds the 1991 district average of 73.78 percent, and is consistent with its experience in Altamonte Springs of up to 73 percent Medicaid without a CON condition, and over
80 percent Medicaid in West Palm Beach. The Medicaid percentages indicate that Life Care will offer mainly traditional nursing home services.
BEVERLY
Beverly Enterprises, Inc., the ultimate corporate parent of the applicant, owns 830 nursing homes, with a total of 89,000 beds in 35 states. Beverly Enterprises-Florida, Inc., the applicant in this proceeding, is a wholly-owned subsidiary of Beverly California Corporation, a wholly owned subsidiary of Beverly Enterprises, Inc. Beverly Enterprises-Florida ("Beverly") owns 41 of the total 68 nursing homes owned in Florida by Beverly-related companies. Of the 40 nursing homes owned by Beverly at the time the application was filed, 31 had superior licenses. Three facilities had moratoria within the preceding 36 months, one a facility built in 1929, another with a two-week moratorium which is now licensed superior, and a third which is still conditional while physical plant improvements are underway. See, Finding of Facts 28, infra.
Beverly proposes to construct a 120-bed nursing home in Spring Hill, Hernando County, for $5,213,077, with its CON conditioned on the provision of 74
percent of annual patient days to Medicaid residents and a $10,000 grant for gerontology research at Hernando-Pasco Community College. Beverly proposes four beds for a ventilator-dependent unit, two beds for respite care, 20 beds on a separate wing for ARD residents, and to establish an adult care program.
Beverly commits to group patients with ARD or other losses in cognitive functioning together in a 20-bed area, to offer subacute rehabilitative care in a 24 bed Medicare skilled nursing unit, and to provide intravenous therapy.
Beverly also intends to establish a dedicated four-bed ventilator unit staffed with at least one registered nurse with a minimum of two years experience in critical care continuously on duty, a separately staffed adult day care program, and respite care. Beverly's would be the first ventilator beds other than in hospitals and the first licensed adult day care program in Hernando County.
One of Beverly's existing Florida nursing homes is Eastbrooke which is also located in Hernando County, approximately 10 miles from the proposed Spring Hill site. Beverly expects its experienced personnel from Eastbrooke to train and assist in establishing Spring Hill. Beverly has identified a site for the Spring Hill facility which is across the street from an acute care hospital. Spring Hill is in southern Hernando County, near Pasco County.
UNICARE
By stipulation of the parties, the Unicare Health Facilities, Inc. ("Unicare") proposal to add 51 beds to New Horizon Rehabilitation Center in Marion County was recommended for approval on May 12, 1993. Unicare withdrew its requests for the approval of CONs 6983P and 6983 in Hernando County. As a result, the parties agreed that the number of beds needed was reduced from 321 beds to 270 beds.
LAKE PORT
Lake Port is a 60-bed licensed skilled nursing center, with a superior rating, located at the Lake Port Properties Continuing Care Retirement Community, in Leesburg, Lake County. Lake Port Properties is a partnership, for which Johnson Simmons Company serves as the managing general partner. The Lake Port community includes independent living residences, a 66-bed adult congregate living facility, and the 60 sheltered nursing beds. Among the services provided are post-operative care and orthopedic rehabilitative therapy for patients who have had knee or hip replacement surgery or shoulder injuries, neurological therapies for stroke injuries, pain management, subacute, open wound and respite care, and hospice services. Lake Port currently has 11 Medicare certified beds, and has had from 8 to 22 Medicare certified beds at a time. Lake Port has a contract with Hospice of Lake-Sumter County to provide interdisciplinary services to approximately five hospice residents a year. Rehabilitation services are also provided by contract at Lake Port. Lake Port has a relatively high volume of residents who are discharged home following intensive therapy within an average of three weeks. As an indicator of the intensity of therapeutic services, Lake Port has provided 26 percent Medicare, while the Lake/Sumter planning area average was 7.2 percent. Life Care projected a Medicare rate of 6.7 percent, Beverly projected 10 percent Medicare, and the Hernando County average is 9.3 percent.
In this proceeding, Lake Port proposes either to convert the existing
60 skilled nursing beds to 60 community nursing beds at no cost, or the 60 bed conversion and the approval to construct an additional 60 community nursing home beds, for a total 120-bed community facility at a cost of $1.4 million. Lake Port proposes to have either CON, if approved, conditioned on the provision of
29.2 percent and 33.81 percent Medicaid, in years one and two, and respite, subacute, and intense rehabilitative care. Historically, the payer mix has included 25-30 percent Medicare and 30-35 percent Medicaid. All of the proposed services are provided currently at Lake Port.
The effect of the change in licensure categories is to eliminate the requirement that the facility serve exclusively the retirement community residents after five years in operation, or after August 1995. Lake Port would still be obligated to provide nursing home care to Lake Port community residents at discounted costs, pursuant to the terms of their continuing care contracts. Occupancy levels at Lake Port exceed 95 percent, with 7 to 8 percent of patient days attributable to retirement community, and the remainder to patients in a service area which includes West Lake and Sumter Counties.
Lake Port asserts that its financial viability depends on its ability to continue to serve all residents of its service area.
SOUTHERN MEDICAL
Southern Medical Associates, Inc. ("Southern Medical") is a Florida corporation which owns two nursing homes, one with 60 beds in Okaloosa County and one with 120 beds in Palatka, in Putnam County. Palatka Health Care Center opened with 60 beds in May 1989, added 60 beds in November 1990. Both nursing homes have superior licenses and are managed and staffed by National HealthCorp, L.P., which was founded in 1971, and manages 86 nursing homes, twenty-nine of those in Florida. The management fee is 6 percent of net revenues.
In its application for CON number 6993, Southern Medical proposes to add 60 beds to the existing 120-bed nursing home, known as Palatka Health Care Center. Occupancy levels at the Palatka Center ranged between 96 and 99 percent in 1992-1993. Total project costs of $2.1 million will be financed by or through National HealthCorp. Southern Medical proposes that its CON be conditioned on the establishment of a 20-bed distinct Alzheimer's wing and the provision of 74 percent of total patient days to Medicaid patients.
Southern Medical provides rehabilitation services in a 14-bed Medicare certified unit, antibiotic intravenous therapy, hospice and respite care. It exceeds the 73 percent Medicaid condition of its CON.
SUBSECTION 408.035(1)(a) - NEED IN RELATION TO STATE AND LOCAL HEALTH PLANS
The Florida State Health Plan includes 12 preferences to consider in reviewing nursing home CON applications, most of which overlap statutory review criteria in Section 408.035, Florida Statutes.
Preference 1 encourages more nursing homes beds in subdistricts with
90 percent or higher occupancy in existing beds. District 3 is not subdistricted, but its nursing home bed occupancy rate was 91 percent in 1991. Therefore, all applicants for nursing homes in District 3 meet the preference.
District 3 has been divided into planning areas by the local health council. The applications filed in this proceeding coincide with the planning areas for Hernando, Putnam, and Lake/Sumter Counties. In 1991, occupancy rates averaged 92 percent for Hernando, 96 percent for Putnam, and 93 percent for Lake/Sumter planning areas. Each applicant meets preference 1 using planning areas as substitutes for subdistricts.
Preference 2 favors applicants whose Medicaid commitments equal or exceed the subdistrict-wide average. In the absence of subdistricts, the district wide average is used, which is 73.78 percent. Beverly's 74 percent commitment, Life Care's 75 percent commitment, and Southern Medical's 74 percent commitment, entitle them to be favored under preference 2. In addition, Beverly cites its 76.9 percent Medicaid patient days in 1991 at Eastbrooke, but it has failed to achieve its Medicaid commitment at one Florida nursing home in Cape Coral. Lake Port committed to provide a minimum of 33.81 percent Medicaid patient days and argued that it meets the exception to the preference for providing multi-level care. As described in the 1989 Florida State Health Plan, multi-level health systems offer a continuum of care which may range from acute care and ambulatory surgery centers to home health and education, including traditional nursing care. Special emphasis is placed on short-term intensive rehabilitation programs. Although Lake Port's proposal includes some of the features of a multi-level system, such as post-operative rehabilitative therapy and respite care, the Medicaid exception is inappropriate for Lake Port, because the same services are also proposed by Beverly and Southern Medical. See, also, Section 408.035(1)(n), Florida Statutes.
Preference 3 relates to providing specialized services, including acquired immune deficiency syndrome ("AIDS") services to residents, ARD residents, and the mentally ill. This preference is met by Beverly, Life Care, and SMA, particularly for ARD patients for which all three applicants proposed to establish separate 20-bed units. The preference is also met by Lake Port, particularly with its emphasis on specialized, intense rehabilitative services. See, also Subsection 408.205(1)(f), Florida Statutes.
Preference 4 supports applicants proposing to provide a "continuum of services to community residents," including respite and adult day care. Beverly and Life Care propose to offer both respite and adult day care. Lake Port and Southern Medical propose to provide respite and hospice care.
Preference 5, for the construction of facilities which provide maximum comfort and quality of care, was stipulated as being met by all the parties.
The applicants also stipulated that project costs and construction plans are reasonable. See, also, Subsection 408.035(1)(m),(2)(a) and (2)(c), Florida Statutes.
Preference 6 is met by all of the applicants:
. . . proposing to provide innovative therapeutic programs which have been proven effective in enhancing the residents' physical and mental functional level and which emphasize restorative care.
Life Care, Beverly and Southern Medical propose to offer specialized services to ARD residents. Lake Port and Southern Medical emphasize physical rehabilitation. All of the applicants meet the requirements for preference 6.
Preference 7 is for applicants whose charges do not exceed the highest Medicaid per diem rate in the subdistrict, which, for District 3, is $74.05, or
$93.49 inflated at 6 percent to 1996. Life Care Care's proposed Medicaid charges are $93.69 for year 1, and $94.46 for year 2. Beverly projected that the average Medicaid per diem rate in the subdistrict will be $93.49 in 1996, its charge will be $95.00, but it will expect Medicaid reimbursement to be
$93.30 for that year. Lake Port projected proposed charges to Medicaid patients
as $90 to $93.92 in year one and $93 to $97.37 in year two, for the full 120 beds or the partial 60 beds, respectively. Southern Medical's Medicaid charges will be $90.22 in year one and $94.28 in year two.
Preference 8 applies to applicants with a history of providing superior resident care programs, as indicated by licensure ratings. Of Beverly's 40 Florida facilities, 31 held superior licenses at the time the application was filed. Of the nine Beverly nursing homes with conditional ratings, six are now superior. Renovations or, in the case of one facility built in 1929, construction of a replacement building, are underway at the three others. Life Care, Southern Medical and Lake Port have histories of consistently superior license ratings. See, also, Subsection 408.035(1)(c), Florida Statutes.
Preference 9 favors applicants proposing staffing levels exceeding minimum standards. Due to the ventilator, intravenous and rehabilitative services proposed, Beverly will staff in excess of that required by the state, with at least one registered nurse with a minimum of two years experience on all shifts and a full-time physical therapist. It intends to rely on its current Hernando County facility, Eastbrooke's relationship with Hernando-Pasco Community College, for recruitment and training of staff, although Beverly has not opened a new nursing home in Florida since 1987. Life Care similarly intends to rely on a CON approved facility in adjacent Citrus County. Southern Medical employs St. Augustine Vocational College students who are certified nurse assistants training to become licensed practical nurses, and licensed practical nurses training to become registered nurses are employed at Palatka, which also has internships for health sciences students from the University of North Florida. Its occupational, speech and physical therapists are full-time employees. Lake Port's staffing ratios will also exceed the minimums, in order to provide intensive rehabilitative therapies. See, also Subsection 408.035(1)(h), Florida Statutes.
Each applicant meets preference 10 based on their proposed or current use of a variety of professional disciplines. See, Finding of Fact 29.
Preference 11 seeks to ensure resident rights and privacy as well as implementing plans for quality assurance and discharge planning. All of the applicants were shown to follow well established residents' rights and privacy policies, and to have effective quality assurance programs. Pre-admission screening programs include discharge planning. Beverly has the most highly standardized corporate structure of incentives to maintain quality.
Preference 12 relates to applicants proposing lower administrative costs and higher resident care costs compared to the average nursing home in the District. Average costs in District III are expected to be $54.79 for resident care and $13.97 for administrative overhead by 1996. Life Care expects resident care costs of $51.97 a day and administrative costs of $17.43 a day. Beverly projects its resident care to cost $61.89, with administrative costs of $8.86. Southern Medical proposes administrative costs of $19.88 per patient day and patient care costs of $46.23 per patient day. Lake Port's administrative costs are expected to be $27.80 for 60 beds or $22.12 for 120 beds, with patient care costs of $43.04 for 60 beds or $45.08 for 120 beds. Beverly, best meets the preference and expects enhanced economics and efficiency from combining some overhead for the operation of two nursing homes in Hernando County. Life Care, however, notes that its proposal enhances competition in view of the existence
of one Beverly facility in Hernando County. See, Subsection 408.035(1)(e),(1)(h) and (1)(l), Florida Statutes, which also relate to costs, resources, and competition.
District III includes 16 west central Florida counties, from Hamilton, Columbia, Union Bradford and Putnam in the North to Hernando, Sumter and Lake in the south. The allocation factors in the plan for District III are prepared by the North Central Florida Health Planning Council, the local health council for the district. The district has not been subdivided by agency rule.
Using its planning areas, the local health council has given priority rankings for applicants in certain areas of the district. Dixie, Lafayette and Union Counties, which have no nursing homes, are favored by the local plan. If, as in this case, there are no applicants from these counties, Hernando should be favored, followed by Putnam County. No priority was given to Lake County. The council also quantified bed need by planning area for the January 1995 planning horizon, with additional beds needed, ranging from 120 to 180 in Hernando, and up to 60 in Putnam.
The parties agree generally that the council may establish planning areas in the discharge of its duties, but they disagree whether the establishment of upper limits, or caps in numeric need by planning area is authorized by law. Section 408.034, Florida Statutes, requires a uniform need methodology, which the agency has established by enacting the nursing home rule, Rule 59C-1.036(1)(c), Florida Administrative Code. Once the agency determines numeric need for a district and the district driving time standard, the local plan cannot alter these determinations.
The local plan also includes certain fundamental principles for the allocation of new beds: (1) to promote geographic access, (2) to consider the locations of at-risk population need factors, and (3) to increase supply based on demand. In order of importance, the local plan lists three allocation factors (1) for counties without nursing homes, (2) for new nursing homes 20 miles or 25 minutes drive from existing or approved beds, and (3) for locations without approved beds and with existing nursing homes averaging occupancy levels at least 95 percent for the most recent six month or 90 percent for the most recent 12 months.
With respect to the specific allocation factors, Life Care, Beverly, Southern Medical and Lake Port are in areas with over 90 percent average occupancy within a 20 mile radius. Life Care, Beverly and Southern Medical are proposing to establish facilities in areas of greater need than that in the area of Lake Port. Hernando and Putnam Counties also have lower ratios of nursing home beds to population than Lake County.
The local health council's determination of the greatest need in Hernando County, was confirmed by expert testimony, based on analyzing licensed and approved beds, occupancy rates, distribution of population ages 65 and older, and 75 and older, and most importantly, projected growth of population 65 and older, and of 75 and older. The bed to population ratio for Hernando was, in 1992, 15.5 percent for 65 and older, and 44.9 percent for the population 75 and older, both of which are below the ratios for any other planning areas in the District. The projected increase in population 75 and older for the state is 12 percent, in contrast to the projected increase of 38 percent for Hernando County.
Expert testimony for Beverly supported the addition of up to 300 beds in Hernando County to bring Hernando County's bed distribution in line with that of the entire district. The only approved provider in the county, Hernando Health Care, has surrendered its CON to add 18 nursing home beds in Hernando County. On the contrary, Heartland's expert calculated numeric need of only 119 additional beds in Hernando County.
AHCA, however, gave no consideration to the effect on occupancy, fill- up rates, or financial feasibility of it preliminarily approving all new beds in Hernando County. The experience was compared, by Southern Medical's expert, to that in Clay County, in which 555 beds were 95 percent occupied, prior to the opening of two 120-bed facilities, one in December 1989, and the other in April 1990. At the end of the first year of operation, the facility that opened first was 48.5 percent occupied, the second was 21.7 percent occupied, and district occupancy was 77.7 percent. At the end of the second year, the rates were 81 percent, 55.6 percent, and 85.6 percent. However, by 1992, the nursing homes in that subdistrict averaged 93 percent occupancy.
Opponents to the AHCA proposal to locate all new facilities in Hernando County, contend that the bed-to- population ratio or "parity" approach used to support the approval of 240 beds in that county does not take into account demographic variables among the counties in the district.
While the bed-to-population ratio is not reliable in and of itself, alternative analyses for the determination of the location of greatest need within the district support the same conclusions. Those analyses relied upon current nursing homes occupancy levels, poverty, and population migration trends and available alternatives to distinguish among the various proposed locations.
Based on occupancy levels, the District III counties of greatest need for additional beds are Putnam, Lake and Sumter, and Hernando, in that order. Putnam County residents are being placed in facilities outside the county due to the lack of available nursing home beds. In terms of poverty level and mortality levels, the figures for Putnam and Marion Counties indicated their populations were less healthy than those in Hernando and Lake. Hernando had
6.05 percent of its over 65 population, which is 85 and older, as compared to
9.34 percent in Lake, 8 percent in Putnam, and 8.28 percent as the district average. Hernando and Putnam Counties also had lower percentages of people 75 and older than did Lake and Marion Counties.
ALTERNATIVES AND EXISTING NURSING HOMES IN DISTRICT 3
Subsections 408.035(1)(b) and (d) require consideration of other like and existing facilities in the district, as well as health care services which are alternatives to nursing homes. Currently, there are 4 nursing homes in Hernando County, and 12 in Lake County. In Putnam County, there are 3 nursing homes and 15 additional "swing beds," which may be used for acute care or long term care, approved for Putnam Community Hospital. Those beds are not available to serve Medicaid patients and are not included on the inventory of community nursing home beds.
In the 511 existing nursing home beds in Hernando, there is an average daily census of 45 beds occupied by residents originating from other counties, while 23 Hernando residents constituted the average daily census leaving the County. Hernando cannot expect to retain in-migrating patients with the development of nursing homes in those residents' counties of origin, particularly, Citrus and Pasco. Given the decrease in nursing home patient days
form 1991 to 1992, there is also no reason to expect any significant increase in use rate for the population in Hernando. The most compelling support for need in Hernando County is that the rate of growth of its over 75 population, which is more than three times that of the State. Putnam County has the lowest migration and a greater demand for nursing home services for the population age
85 and older. Putnam County nursing homes exceed 95 percent occupancy. Lake County area nursing homes were 93 percent occupied for the same period of time, and with the relinquishment of an approved CON for 60 beds by Leesburg Regional Hospital, that occupancy rate rises to approximately 95 percent. The award to Leesburg Regional established a need for 60 beds in Lake County, but there is also an approved CON for a 120-bed facility in Mount Dora. According to Lake Port's expert witnesses, the Mount Dora nursing home will not alleviate the need for beds in western Lake County. That facility, owned by the Adventist health group, is expected to be a referral facility from the nearby Adventist Hospital in Orlando and Sanford. Based on the alternative considerations of occupancy levels, poverty and morality rates, the need for additional beds in Putnam County is greater than the need in Lake County. Projected population increases and the limited alternatives also support the conclusion that a greater need exists in Hernando than in Lake County.
Heartland of Brooksville ("Heartland"), is an existing 120-bed community nursing home in Brooksville, which is licensed superior. Heartland contends that the virtually simultaneous establishment of both Beverly and Life Care will adversely impact Heartland, and make it difficult for the new nursing homes to meet their projected utilizations. The trend of twice as many people migrating to, as there are leaving Hernando County for nursing home services, will be reversed as more nursing homes are established in surrounding counties. See, Finding of Fact 45.
Heartland reasonably expects gradually to lose up to 30 percent of its residents who came from the Spring Hill area, where Beverly and Life Care intend to build new nursing homes. Heartland also reasonably expects to lose Medicare patients among the group from Spring Hill. Medicare residents average 9.3 percent of the total mix in the county, but account for 15 percent of the patient mix at Heartland. Heartland will be adversely affected for at least the first two years if both Life Care and Beverly are approved. See, Finding of Fact 40, supra.
FINANCIAL FEASIBILITY
Heartland, Southern Medical and Lake Port assert that Beverly will be successful in Hernando County, but that Life Care will not. Beverly is already established in the county, will provide services not currently available in nursing homes, and will open its facility seven months before Life Care. Life Care projected a net loss of $589,042 in year one, and a net gain of $254,991 in year two of operation. Life Care's projections fail to consider the company's
6.5 percent management fee, income taxes, and Medicaid reimbursement rate ceilings. By contrast to the other proposals and to the Hernando County average of 9.3 percent, Life Care is relying on a payor mix of only 6.7 percent Medicare, the group for which competition will be most intense. That mix parallels its Florida experience, which has historically allowed it to achieve a profit margin of 16 to 22 percent of net revenues in the third year of operation.
Life Care's experience and audited financial statements support its contention that it can borrow essentially 100 percent of the funds necessary to support the project and complete the proposed project, a debt arrangement it has
successfully used in the past, without defaulting on loans. Life Care's resources are also potentially subject to a $12 to $18 million judgment, due to litigation which is on appeal. Life Care has a contingency fund of $8 million to satisfy the judgment and has sufficient equity in its properties to pay the balance through refinancing. The deficiencies in Life Care's pro forma and its potential liabilities are off-set by the size and strength of the company, and its Hernando County project is financially feasible in the short and long terms.
Beverly projects opening at Spring Hill 15 1/2 months after issuance of a CON, reaching 90 percent utilization within 15 months of opening. Beverly reasonably expects an after tax profit of $239,489 in the second year of operation.
Beverly estimates project costs of $5.2 million, financed by the parent corporation, Beverly-California. Beverly-California has from $35 to 45 million available to contribute a 40 percent ($2 million) equity investment, and a $35 million loan commitment from which it will draw the balance to finance the project.
Southern Medical has a letter of interest for financing of the total project costs of $2.1 million at 12 percent rate of interest by National HealthCorp. During the construction period, Southern Medical estimates that the existing 120 beds will remain 94 percent full, and that the new beds once open will fill at a rate of 10 percent a month, which is consistent with the experience of the management company, National HealthCorp. Southern Medical's actual experience in Palatka was, in fact, better. The first 60 beds were filled after 5 months while the additional 60 beds were filled in 7 to 8 months. Projected revenues of $290,000 during construction, $323,000 after year one, and
$488,000 after year two are reasonable.
Southern Medical's balance sheet shows short term debt of approximately $1.4 million attributable to the construction of the Okaloosa nursing home. Although Southern Medical secured a $3 million loan commitment for the Okaloosa facility, it has drawn from that account $473,000. That debt will be refinanced and recategorized as long term debt. Southern Medical's project is financially feasible in the short and long term, based on its actual experience in the existing 120-bed facility.
Lake Port has the financial resources to construct 60 additional beds for $1.4 million. Lake Port's proposed conversion of the licensure category for its existing 60 beds is at no cost, except for approximately $37,000 in filing and consultants fees.
In its third year of operation, Lake Port has achieved 97 percent occupancy. At present, delays of up to a week may be experienced in transfering patients from acute care hospitals to nursing homes in the Leesburg area. From October to May, due to the influx of northerners, beds are generally not available in the Leesburg area of western Lake and Sumter Counties. Lake Port's projections of occupancy and its financial ability to complete either 60-bed conversion and/or 60-bed addition make either proposal financially feasible in the short or long term.
CONCLUSIONS OF LAW
The Division of Administrative hearings has jurisdiction over the subject matter and parties to this comparative review of CON applications. Subsections 408.039(5) and 120.57(1), Florida Statutes.
Each applicant bears the burden of proving its entitlement to a certificate of need, based on a balanced consideration of the criteria. Collier Medical Center, Inc. v. Department of Health and Rehabilitative Services, 462 So.2d 83 (Fla. 1st DCA 1985).
A numeric need exists for 270 additional community nursing home beds in AHCA District 3, following the stipulated approval of 51 beds to Unicare.
There is no dispute concerning the need for additional nursing home beds in Hernando and Putnam Counties, but over the magnitude of the need in Hernando and the feasibility of establishing two 120-bed nursing homes in Hernando County, especially the financial feasibility of the second nursing home to open.
Life Care and Beverly established the need for both of their projects in Hernando County. On balance, both applicants meet the applicable statutory and rule criteria. Beverly established its stronger financial position and that it would introduce services not otherwise available in nursing homes in the area, while Life Care established a superior history of providing quality of care, as determined by licensure ratings. On balance, a comparison of the two demonstrated that Beverly's proposal is preferable.
Life Care, although expected to open 7 months after Beverly, also established that its proposal is financially feasible in the short and long term, as required by Subsection 408.035(1)(i), Florida Statutes.
Heartland demonstrated its standing and that it will be most adversely affected by intense competition for Medicare patients, primarily with Beverly.
Southern Medical's proposal meets all of the statutory and rule criteria for approval. The evidence on demographics of the area demonstrates a greater need for additional community nursing home beds in Putnam than in Hernando County.
Lake Port's proposal does not meet preferences for Medicaid providers by proposing to serve 33.8 percent Medicaid in contrast to the district average of 74 percent. Lake Port also demonstrated that the need for additional community nursing home beds in Lake is less compelling then the need in Hernando and Putnam Counties. Lake Port's proposed licensure conversion of its existing
60 beds is desirable to allow it to continue to serve community residents, but primarily is based on institution-specific factors.
The approvals of the applications of both Beverly and Life Care meet the need for 240 of the 270 beds needed, using AHCA's numeric need calculations.
Rule 59C-1.008(2)(d)3 allows the fixed need number to be exceeded as follows:
3. If a qualified applicant exists but the proposed project exceeds the beds or services identified in the fixed need pool, the agency may award beds or services in excess of the pool when warranted by special circumstances as defined in the applicable section of Rule 59C-1, F.A.C., for the particular type of
bed or service.
Referring to the nursing home rule, there is the following provision:
(1). . . . The agency will not normally approve applications for new or additional community nursing home beds in any agency service subdistrict if approval of an application would cause the number of community nursing home beds in that agency service subdistrict to exceed the numeric need for community nursing home beds . . .
The nursing home rule also provides criteria for the determination of whether a nursing home application should be approved due to special circumstances.
(g) Geographically Underserved Areas. In a competitive certificate of need review within the nursing home subdistrict as defined in paragraph (2)(c) of this rule, the agency shall award a certificate of need if the applicant meets all applicable criteria for a geographically underserved area as specified in subsection 408.032(18), Florida Statutes (F.S.), and if the applicant meets applicable statutory certificate of need review criteria specified in section 408.035, F.S., including bed need according to the bed need formula contained in this rule, unless the agency can show circumstances which justify the denial of a certificate of need. . . .
Turning to the statutory criteria, one definition is: (18)"Nursing home geographically underserved
area" means:
(c) An area with a radius of at least 20 miles in which all existing nursing homes have maintained at least a 95 percent occupancy rate for the most recent 6 months or a 90 percent occupancy rate for the most recent 12 months.
Section 408.032(18)(c), Florida Statutes.
With 96 percent occupancy in Putnam County, and no approved beds within a 20 mile radius, the approval of Southern Medical's 60-bed addition complies with the statutory and rule criteria, even though it results in adding
30 beds more than the numeric need methodology suggests. That approval is also justified by the absence of any overlap between Hernando and Putnam service areas, the urgent conditions indicative of need in Putnam County, and the inability to meet that need without leaving the district 90 beds below the calculated numeric need.
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED
That AHCA issue CON 6985 to Beverly Enterprises-Florida, Inc. to construct a 120-bed nursing home in Hernando County, conditioned on the provision of 74 percent of total annual patient days to Medicaid residents, and the operation of a 4-bed ventilator-dependent unit, 2 beds for respite care, an adult day care program, and a 20-bed separate unit for residents with Alzheimer's and related dementia.
That AHCA issue CON 6986 to Life Care Centers of America, Inc. to construct a 120-bed nursing home in Hernando County, conditioned on the provision of a minimum of 75 percent of total annual patient days to Medicaid residents, the operation of a 20-bed dedicated wing for residents with Alzheimer's and related dementia, and the operation of an adult day care.
That AHCA issue CON 6993 to Southern Medical Associates, Inc. for the addition of 60 community nursing home beds at Palatka Health Care Center in Putnam County, conditioned on the provision of 74 percent of total annual patient days to Medicaid residents, and the establishment of a 20-bed district Alzheimer's wing.
That AHCA deny CON 6989P and CON 6989 to Lake Port Properties.
DONE AND ENTERED this 20th day of July, 1994, in Tallahassee, Leon County, Florida.
ELEANOR M. HUNTER
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 21st day of July, 1994.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 92-6656
To comply with the requirements of Section 120.59(2), Fla. Stat. (1991), the following rulings are made on the parties' proposed findings of fact:
Petitioner, Beverly Enterprises-Florida, Inc., d/b/a Beverly Gulf Coast-Florida, Inc.'s Proposed Findings of Fact.
1. Accepted in Preliminary Statement and Finding of Fact 3.
2-9. Accepted in or subordinate to Findings of Fact 8-10, 24 and 25.
10. Accepted in Preliminary Statement.
11-15. Accepted in relevant part in Finding of Fact 33.
16-19. Accepted in part in Findings of Fact 9, 20-21, 37-39. 20-23. Accepted in Findings of Fact 19-32.
24-30. Accepted in Findings of Fact 9, 23, 24, 29 or 30.
31. Accepted in Findings of Fact 19-32.
32-38. Accepted in Findings of Fact 9, 23, 24, 29 or 30. 39-42. Accepted in or subordinate to Finding of Fact 28.
43-48. Accepted in or subordinate to Findings of Fact 29-31.
49. Accepted in or subordinate to Findings of Fact 29-30.
50-56. Accepted in or subordinate to Findings of Fact 50-51.
57-62. Accepted in or subordinate to Findings of Fact 29 or 30.
63-64 Accepted in or subordinate to Findings of Fact 32, 39 and 46-47.
Accepted in Finding of Fact 25.
Accepted in Finding of Fact 22.
67-68. Accepted in Findings of Fact 9-10.
69. Subordinate to Finding of Fact 6.
70-71. Accepted in or subordinate to Findings of Fact 6, 7 and 10.
72-75. Accepted in or subordinate to Findings of Fact 5-7, 8-10 and 48-51.
76. Accepted in Finding of Fact 32.
77-79. Accepted in or subordinate to Findings of Fact 48-49.
Petitioner, Southern Medical's, Proposed Findings of Fact 1-2. Accepted in Finding of Fact 16.
Accepted in Finding of Fact 34.
Accepted in Findings of Fact 16 and 17. 5-14. Subordinate to preliminary statement.
15. Accepted in Finding of Fact 2.
16-17. Accepted in Finding of Fact 20. 18-19. Accepted in Finding of Fact 17. 20-22. Rejected in conclusions of law 4.
23. Accepted in Finding of Fact 36.
24-41. Accepted in or subordinate to Findings of Fact 21 and 33-45.
Accepted in Finding of Fact 19.
Accepted in Findings of Fact 20-21.
Accepted in Finding of Fact 22.
Accepted in Finding of Fact 23.
Accepted in Finding of Fact 24.
Accepted in Finding of Fact 25.
Accepted in Finding of Fact 26.
Accepted in Finding of Fact 27.
Accepted in Finding of Fact 28.
Accepted in Finding of Fact 29.
Accepted in Finding of Fact 30.
Accepted in Finding of Fact 31.
Accepted in part in Finding of Fact 32.
Accepted in part in Findings of Fact 19-32.
56-57. Accepted in part in Findings of Fact 43-45.
58-60. Accepted in or subordinate to Finding of Fact 28. 61-62. Accepted in Findings of Fact 18, 22 and 28.
Subordinate to Finding of Fact 28.
Accepted in Finding of Fact 28.
65-69. Accepted in or Subordinate to Finding of Fact 34 and 43-45. 70-72. Accepted in Findings of Fact 17-18 and 22-23.
73-74. Accepted in Findings of Fact 29-30.
75. Accepted in Finding of Fact 24.
76-77. Accepted in Finding of Fact 29.
78-96. Accepted in Findings of Fact 52-53.
Accepted in Finding of Fact 25.
Accepted in Finding of Fact 22.
Rejected in Findings of Fact 34-39 and 45.
100-101. Rejected in Findings of Fact 41-42 and 45.
102. Accepted in relevant part in Findings of Fact 43-45.
103-109. Rejected in relevant part and accepted in relevant part in Findings of Fact 41-45.
110-112. Rejected in Finding of Fact 45.
Accepted in Findings of Fact 48 and 49.
Rejected in Finding of Fact 45.
Accepted in conclusions of law 60.
116-120. Accepted in relevant part in Findings of Fact 48 and 49.
121. Rejected in Finding of Fact 5.
122-123. Rejected in Findings of Fact 39 and 40. 124-125. Issue not addressed at hearing.
Accepted in relevant part in Finding of Fact 48.
Rejected in Finding of Fact 29.
Petitioner, HCR Limited Partnership I d/b/a Heartland of Brooksville's Proposed Findings of Fact
Accepted in part in Findings of Fact 8-10.
Accepted in part in Findings of Fact 5-7.
Accepted in part in Findings of Fact 12-14.
Accepted in part in Findings of Fact 16-18.
Accepted in Preliminary Statement and Findings of Fact 2 and 11.
Accepted in Finding of Fact 40.
Accepted in Finding of Fact 33.
Accepted in Finding of Fact 34.
9-16. Accepted in Findings of Fact 34-38.
17. Accepted in Findings of Fact 21 and 43.
19-22. Accepted in Findings of Fact 21, 42 and 43.
23-33. Accepted in Findings of Fact 38, 42 and 43.
Rejected in Finding of Fact 45.
Accepted in Finding of Fact 39.
36-41. Accepted in or Subordinate to Findings of Fact 45 and 47. 42-44. Rejected in Finding of Fact 5.
45. Accepted in Findings of Fact 45, 48 and 49.
Petitioner, Lake Port Properties's Proposed Findings of Fact
Accepted in Finding of Fact 2.
Accepted in Finding of Fact 3.
Accepted in Findings of Fact 3 and 40.
Accepted in preliminary statement.
Accepted in Findings of Fact 4 and last sentence rejected in preliminary statement.
Accepted in Preliminary Statement.
7-28. Accepted in Findings of Fact 12-15.
29. Rejected in Finding of Fact 45.
30-34. Accepted in Findings of Fact 39-43 and 46.
35. Rejected in Finding of Fact 46.
36-38. Accepted in Findings of Fact 12-15.
39-42. Facts accepted, conclusions rejected in Findings of Fact 44-46. 43-47. Accepted in Findings of Fact 33-39.
48. Rejected in Finding of Fact 39.
49-54. Conclusion in first sentence rejected in Finding of Fact 39. Facts accepted in Findings of Facts 39-45.
55-60. Not solely relied upon but not disregarded. Facts generally accepted in Findings of Fact 39-45.
61-74. Accepted in part and rejected in part in Findings of Fact 19-32. 75-82. Accepted in part in Findings of Fact 33-38.
83-93. Accepted in or subordinate to Findings of Fact 28-29. 94-100. Accepted in Findings of Fact 54-55.
101-103. Accepted in Findings of Fact 15 and 54.
104. Accepted in Finding of Fact 31.
105-106. Accepted in Finding of Fact 22.
107-111. Rejected first sentence in Findings of Fact 39 and 40. Remainder of 107-111 accepted in Findings of Fact 8-10 and 19-38.
112-113. Conclusion rejected in Findings of Fact 45, 48, and 49.
114-117. Accepted in Findings of Fact 45, 48 and 49.
Rejected in Findings of Fact 45, 48 and 49.
Accepted in Finding of Fact 6.
120-121. Subordinate to Finding of Fact 7.
122-125. Accepted in Findings of Fact 7 and 48. 126-130. Rejected in Finding of Fact 5.
Respondent, Life Care Centers of America, Inc.'s, Proposed Findings of Fact.
1-9. Accepted in Findings of Fact 33-43. 10-12. Accepted in Findings of Fact 12-15.
13. Rejected in Finding of Fact 12.
14(a-d)-20. Accepted in Findings of Fact 33-40. 21(a-d). Accepted in Findings of Fact 19-32.
22. Accepted in Finding of Fact 34.
23-28. Accepted in Findings of Fact 44-47.
Accepted in Finding of Fact 7.
Accepted in Finding of Fact 39.
Accepted in part or subordinate to Findings of Fact 43-45.
Subordinate to Finding of Fact 45.
Subordinate to Finding of Fact 17.
34-40. Accepted in relevant part or subordinate to Findings of Fact 5-7. 41(a-c). Accepted in Findings of Fact 8-10 and 29.
42. Rejected in relevant part in Finding of Fact 12. 43-45. Subordinate to Finding of Fact 17.
Subordinate to Finding of Fact 17.
Subordinate to Finding of Fact 17.
Rejected in Findings of Fact 44.
47-48. Subordinate to Finding of Fact 45. 49-50. Accepted in Findings of Fact 5-7. 51-54. Subordinate to Finding of Fact 29. 55-62. Accepted in Findings of Fact 48-49. 63-64. Accepted in Finding of Fact 29.
65-69. Accepted in Findings of Fact 48-49.
Subordinate to Findings of Fact 54-55.
Subordinate to Finding of Fact 52.
Subordinate to Finding of Fact 29. 73-74. Accepted.
75. Accepted in Finding of Fact 4.
76-77. Accepted in Findings of Fact 40-43. 78-79. Accepted in Finding of Fact 29.
Subordinate to Finding of Fact 52.
Accepted in Finding of Fact 25.
82-85. Accepted in or subordinate to Finding of Fact 22.
Subordinate to Finding of Fact 47.
Accepted in conclusions of law.
Accepted in preliminary statement.
Issue not reached.
Subordinate to preliminary statement.
Conclusion rejected in Finding of Fact 16.
Respondent, AHCA's Proposed Findings of Fact
Accepted in or subordinate to preliminary statement and Findings of Fact 1-3.
Accepted in preliminary statement.
Accepted in Findings of Fact 2 and 21 and conclusions of law 66.
Accepted in Finding of Fact 2 and 21.
Accepted in Finding of Fact 2 and 4.
Accepted in preliminary statement and Finding of Fact 3.
Accepted in Findings of Fact 12-15.
Accepted in Findings of Fact 16-18.8.
Accepted in Findings of Fact 8-10.
Accepted in Findings of Fact 5-7.
Subordinate to preliminary statement and Finding of Fact 3.
Accepted in relevant part in Findings of Fact 5-7 and 19-33.
Relevant as to availability due to occupancy ratio in Findings of Fact 37-45.
Accepted in Finding of Fact 28.
Accepted in Findings of Fact 48-49.
Accepted, except first sentence in Findings of Fact 8-10 and 19-32.
Accepted in Findings of Fact 19-20 and 44.
Accepted in Findings of Fact 8-10 and 19-32.
Accepted in Findings of Fact 50-51.
Accepted in Findings of Fact 33-39.
Conclusions rejected in Findings of Fact 19-32.
Accepted facts in 19-20 and 44.
Accepted in Findings of Fact 8-10.
Accepted in Findings of Fact 52-53.
Accepted in Findings of Fact 12-15 and 19-32.
Rejected in Findings of Fact 19 and 20.
Accepted in Finding of Fact 28.
Accepted in Findings of Fact 54 and 55.
COPIES FURNISHED:
Douglas L. Manheimer, Attorney Dennis LaRosa, Attorney
Broad & Cassel
215 South Monroe Street Post Office Box 11300 Tallahassee, Florida 32302
Alfred W. Clark, Attorney at Law Post Office Box 623
Tallahassee, Florida 32308
James C. Hauser, Attorney Lachlin Waldoch, Attorney
Messer, Vickers, Caparello, Madsen Lewis, Goldman & Metz, P.a.
Post Office Box 1876 Tallahassee, Florida 32301
Gary Anton, Attorney Stowell, Anton & Kraemer Post Office Box 11059 Tallahassee, Florida 32302
Edward Labrador, Attorney Richard Patterson, Attorney
Agency for Health Care Administration
325 John Knox Road, Suite 301 Tallahassee, Florida 32303-4131
W. David Watkins, Attorney Robert Downey, Attorney
Oretel, Hoffman, Fernandez, et al.
2700 Blair Stone Road, Suite C Post Office Box 6507 Tallahassee, Florida 32314-6507
R. Bruce McKibben, Jr., Attorney Pennington & Haben, P.A.
Post Office Box 10095 Tallahassee, Florida 32302
R. S. Power, Agency Clerk
Agency for Health Care Administration Atrium Building, Suite 301
325 John Knox Road Tallahassee, Florida 32303
Harold D. Lewis, Attorney
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 ten 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
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 July 20, 1994, by Hearing Officer Eleanor M. Hunter is incorporated by reference.
RULING ON EXCEPTIONS FILED BY AHCA
Counsel notes that in paragraph 13 the Hearing Officer refers to the existing beds at Lake Port incorrectly as 60 "skilled nursing beds". These beds are in fact "sheltered" beds. The requested correction is made.
Counsel excepts to the Hearing Officer's conclusion that beds may be approved in excess of the numeric need pursuant to Rule 59C-1.036(2)(g), which provides in pertinent part as follows:
Geographically underserved areas. In a competitive certificate of need review within the nursing home subdistrict as defined in paragraph (2)(c) of this rule, the agency shall award a certificate of need if the applicant meets all applicable criteria for
geographically underserved area as specified in subsection 408.032(18), Florida Statutes, and if the applicant
meets applicable statutory certificate of need review criteria specified in Section 408.035, Florida Statutes, including bed need according to the bed need formula contained in this rule, unless the agency can show circumstances which justify the denial of a certificate of need. . . (emphasis added)
The plain language of the rule requires compliance with the review criteria of "bed need according to the bed need formula". The Hearing Officer's conclusion is rejected.
RULING ON EXCEPTIONS FILED BY HEARTLAND
The first exception addresses the Hearing Officer's conclusion that beds in excess of the fixed need pool may be approved pursuant to Rule 59C-1.036(2)(g). See the ruling on AHCA's exceptions.
Heartland excepts to the finding in paragraph 37 that average occupancy in Hernando County exceeded 90 percent. The finding is ambiguous in that the finding does not state whether the occupancy refers to the most recent six months or 12 months time period. The ambiguity is noted.
Heartland excepts to the finding that Life Care established a need for its project in Hernando County. The finding is supported by competent, substantial evidence so the exception is denied.
Heartland excepts to the finding that Life Care established the financial feasibility of its proposal. Clearly, long term financial feasibility must address the proposed facility. While the Hearing Officer found that Life Care's pro forma was deficient in certain respects, she did not find it to be fatally flawed. The financial condition of the applicant is circumstantially relevant to the financial feasibility of a proposal. The finding is supported by competent substantial evidence so the exception is denied.
RULING ON EXCEPTIONS FILED BY LAKE PORT
Lake Port excepts to the Hearing Officer's rejection of its proposed findings to the effect that Life Care's application failed to comply with the statutory requirement of disclosure of the applicant's capital projects. The Hearing Officer concluded in paragraph 5 that Life Care is not responsible for
capital projects at 91 of its 131 facilities. The agency has no authority to reweigh the evidence so the exception is denied.
Lake Port's exception to the' Hearing Officer's finding that Life Care's proposal is financially feasible is denied. See the ruling on Heartland's exceptions. Lake Port's exception to the Hearing Officer's recommendation to approve beds in excess of the numeric need projected under the need rule is granted. See the ruling on AHCA's exceptions.
RULING ON EXCEPTIONS FILED BY SOUTHERN MEDICAL
Southern Medical excepts to the Hearing Officer's recommendation to approve
240 beds for Hernando County. This issue is addressed elsewhere in this Final Order. Southern Medical excepts to the recommendation that Southern's proposal should be approved pursuant to Rule 59C-1.036(2)(g). This issue has been addressed. Southern Medical's exception to the Hearing Officer's finding that Life Care's proposal is financially feasible has been addressed. Finally, Southern Medical excepts to the Hearing Officer's rejection of its Exhibit 15. I concur with the Hearing Officer's ruling. The exhibit amended the application. The exception is denied.
FINDINGS OF FACT
The agency hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order except where inconsistent with the Ruling on 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 Ruling on Exceptions.
In certificate of need law, a great deal of importance is attached to a calculation of need under the rule formula. A lack of numeric need under the rule formula establishes a rebuttable presumption of no need. Balsam vs.
Department of Health and Rehabilitative Services, 486 So2d 1341, 1349 (Fla. 1st DCA 1986) Humana vs. Department of Health and Rehabilitative Services, 492 So2d 388, 392 (Fla. 1st DCA 1985). In the absence of numeric need, an applicant for nursing home beds must in the application address and establish special circumstances under Rule 59C- 1.036 (2)(h). An application addressing numeric need can not be amended at an administrative hearing to address "special circumstances" need.
I conclude that there is no record basis in this comparative review proceeding for the award of beds in excess of the numeric need. Thus, the Hearing Officer's recommendations must be accepted in part and rejected in part. The Hearing Officer found both Hernando and Putnam Counties to be areas of high need. She characterized the need in Putnam County as urgent in paragraph 70.
Thus beds, should be approved in both counties. Up to 270 beds may be approved.
The Hearing Officer's recommendation of approval for both 120 beds proposals for Hernando County must be rejected so that sufficient beds are available to allow approval of Southern Medical's proposal to add 60 beds to its existing 120 bed facility in Putnam County.
Regarding the two proposals for Hernando County, the Hearing Officer concluded that Beverly's proposal is superior. See paragraph 60. I concur for the reasons stated by the Hearing Officer. The only other application which could be approved without exceeding 270 beds is Lake Port's proposal to convert
60 "sheltered" beds 1/ beds to community nursing home beds. Geographically, District 3 is a very large 16 county area extending from the Florida-Georgia border to Central Florida. The district health council has assigned priority rankings to counties based on need with Dixie, Lafayette, and Union Counties ranked highest, followed by Hernando and Putnam Counties. Lake County was not given a priority ranking. The Hearing Officer recommended denial of Lake Port's application based on her conclusions that Hernando and Putnam Counties were the areas of priority need in the district, Lake Port's proposal fails to meet Medicaid preferences, and Lake Port's proposal is supported primarily by institution specific factors. Additionally, the requested conversion of all its nursing beds (60 of 60) would leave no beds reserved for the residents of Lake Port. 2/ Based on a balanced weighing of the applicable criteria, I conclude that Lake Port's proposal should be denied.
The approvals made in this order use 180 of the 270 beds needed. It is noted that no applications were received for Dixie, Lafayette, and Union Counties which presently have no nursing homes. Nursing home proposals there would receive priority consideration if the need continues in later review cycles.
Based upon the foregoing, the application of Beverly Enterprises-Florida, Incorporated, for CON 6985 is approved subject to the conditions recommended by the Hearing Officer on page 35. The application of Southern Medical Associates, Incorporated, for CON 6993 is approved subject to the conditions recommended by the Hearing Officer. The applications of Lake Port Properties for CON 6989 and 6989P are denied. The application of Life Care Centers of America, Incorporated, for CON 6986 is denied. Case Number 92-6660 is closed based on the agreement of the parties referred to in the first paragraph of page 5 of the Recommended Order.
DONE and ORDERED this 17th day of October, 1994, in Tallahassee, Florida.
Douglas M. Cook, Director Agency for Health Care
Administration
ENDNOTES
1/ A sheltered nursing home is a nursing home bed within continuing care facility and designated for use of residents of the continuing care facility as needed. Sheltered beds may be used by persons who are not residents of the continuing care community for up to five years from the date of licensure. Rule 59C-1.037(1)
2/ Official notice is taken of the agency's intent to approve the conversion of
50 of the 60 beds in a subsequent batching cycle. The notice of intent was given in a letter of September 16, 1993, from Elizabeth Dudek to Bill Mobley. Health Quest vs. Department of Health and Rehabilitative Services, 477 So2d 576,
577 (Fla. 1st DCA 1985)
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 WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
COPIES FURNISHED:
Douglas L. Mannheimer, Esquire BROAD & CASSEL
Post Office Box 11300 Tallahassee, Florida 32302
James C. Hauser, Esquire PARKER, SKELDING, LABASKY, CORRY, EASTMAN & HAUSER, P. A.
318 North Monroe Street Tallahassee, Florida 32301
Richard Patterson, Esquire Health Care Administration
325 John Knox Road
Atrium Building, Suite 301 Tallahassee, Florida 32303-4131
Gary Anton, Esquire STOWELL, ANTON & KRAEMER
Post Office Box 11059 Tallahassee, Florida 32302
W. David Watkins, Esquire OERTEL, HOFFMAN, FERNANDEZ & COLE, P. A.
Post Office Box 6507 Tallahassee, Florida 32314-6507
Bruce McKibben, Jr., Esquire PENNINGTON & HABEN, P. A.
Post Office Box 10095 Tallahassee, Florida 32302
Eleanor M. Hunter Hearing Officer
The DeSoto Building 1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
Alfred W. Clark, Esquire Post Office Box 623 Tallahassee, Florida 32302
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 addresses by United States Mail this 18th day of October, 1994.
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
=================================================================
DISTRICT COURT OPINION
=================================================================
IN THE DISTRICT COURT OF APPEAL FIRST DISTRICT, STATE OF FLORIDA
LIFE CARE CENTERS OF AMERICA, NOT FINAL UNTIL TIME EXPIRES TO INC., FILE MOTION FOR REHEARING AND
DISPOSITION THEREOF IF FILED
Appellant,
CASE NO. 94-3583
v. DOAH CASE NO: 92-6656
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION; BEVERLY ENTERPRISES-FLORIDA, INC.; SOUTHERN MEDICAL ASSOCIATES, INC.; and HCR LIMITED PARTNERSHIP I d/b/a HEARTLAND OF BROOKSVILLE,
Appellees.
/ Opinion filed July 5, 1995.
An appeal from Order of the Division of Administrative Hearing.
R. Bruce McKibben, Jr. and Charles W. Murphy of Pennington & Haben, P.A., Tallahassee, for Appellant.
Richard A. Patterson of Agency for Health Care Administration, Tallahassee, for Appellee Agency for Health Care Administration; Jay Adams of Douglas L. Mannheimer, P.A., and Broad and Cassel, Tallahassee, for Appellee Beverly Enterprises-Florida, Inc.; Gary J. Anton and Lisa East of Stowell, Anton & Kraemer, Tallahassee, for Appellee Southern Medical Associates, Inc.; Alfred W. Clark, Tallahassee, for Appellee HCR Limited Partnership I.
PER CURIAM.
AFFIRMED.
ZEHMER, C.J., ALLEN and KAHN, JJ., CONCUR.
MANDATE
From
DISTRICT COURT OF APPEAL OF FLORIDA FIRST DISTRICT
To the Honorable Douglas M. Cook, Director Agency for Health Care Administration
WHEREAS, in that certain cause filed in this Court styled:
BEVERLY ENTERPRISES-FLORIDA, INC. d/b/a BEVERLY GULF COAST-FLORIDA, INC.; HCR LIMITED PARTNERSHIP I d/b/a HEARTLAND OF BROOKSVILLE, ET AL.
vs. Case No. 94-3583
Your Case No. 92-6656
AGENCY FOR HEALTH CARE 92-6659
ADMINISTRATION, UNICARE HEALTH 92-6660
FACILITIES, INC.: LIFE CARE CENTERS 92-6661
OF AMERICA, INC., AND BEVERLY 92-6662
ENTERPRISES FLORIDA, INC. 92-6669
The attached opinion was rendered on July 5, 1995
YOU ARE HEREBY COMMANDED that further proceedings be had in accordance with said opinion, the rules of this Court and the laws of the State of Florida.
WITNESS the Honorable E. Earle Zehmer
Chief Judge of the District Court of Appeal of Florida, First District and the Seal of said court at Tallahassee, the Capitol, on this 21st day of July, 1995
JON S. WHEELER
Clerk, District Court of Appeal of Florida, First District
| Issue Date | Proceedings |
|---|---|
| Jul. 25, 1995 | Opinion and Mandate filed. |
| Nov. 02, 1994 | AGENCY APPEAL, ONCE THE RETENTION SCHEDULE OF -KEEP ONE YEAR AFTER CLOSURE- IS MET, CASE FILE IS RETURNED TO AGENCY GENERAL COUNSEL. -ac |
| Oct. 20, 1994 | Final Order filed. |
| Aug. 25, 1994 | Life Care Centers of America, Inc. Response to Exceptions to Recommended Order filed. |
| Jul. 21, 1994 | Recommended Order sent out. CASE CLOSED. Hearing held May 3-21, 1994. |
| May 25, 1994 | Notice of Name and Address Change (from R. B. McKibben) filed. |
| Jan. 04, 1994 | Letter to EMH from Douglas L. Mannheimer (re: error in PRO) filed. |
| Sep. 16, 1993 | Letter to EMH from R. Bruce McKibben, Jr. (re: error in Proposed Recommended Order) filed. |
| Sep. 09, 1993 | Notice of Service of Proposed Recommended Order filed. (From Alfred Clark) |
| Sep. 09, 1993 | Respondent`s Proposed Recommended Order; Proposed Findings of Fact, Conclusions of Law and Recommended Order of Lake Port; Proposed Findings Fact, Conclusions of Law, and Recommended Order of Beverly Enterprises-Florida, Inc. filed. |
| Sep. 09, 1993 | Proposed Recommended Order filed. (From Alfred Clark) |
| Sep. 09, 1993 | Southern Medical Associates, Inc.`s Proposed Recommended Order filed. |
| Sep. 09, 1993 | Respondent AHCA`S Proposed Recommended Order filed. |
| Aug. 16, 1993 | Transcript (20 Vols) filed. |
| May 14, 1993 | Recommended Order of Dismissal sent out. (Case no. 92-6664 is closed, matter is referred to referring agency for final deposition) |
| May 14, 1993 | Recommended Order of Approval of Con 6991 and Denial of Con 6983 and Con 6983P sent out. (Case nos. 92-6670 and 92-6671 are closed) |
| May 04, 1993 | Lake Port`s Written Response in Opposition to Motion for Summary Recommended Order of Dismissal Filed by SMA filed. |
| May 04, 1993 | Lake Port`s Written Response in Opposition to Motion in Limine Filed by Beverly filed. |
| May 03, 1993 | Unicare`s Response to Southern Medical`s Motion for Summary Recommended Order filed. |
| May 03, 1993 | (AHCA) Notice of Appearance Co-Counsel filed. |
| Apr. 30, 1993 | Southern Medical Associates, Inc.`s Motion to Compel or for Sanctions w/Exhibit-A filed. |
| Apr. 30, 1993 | Southern Medical Associates, Inc.`s Motion for Summary Recommended Order Dismissing Certain Petitions and Denying Certain Certificates of Need and Request for Oral Argument; Southern Medical Associates, Inc.`s Memorandum in Opposition to Unicare`s Motio |
| Apr. 30, 1993 | Notice of Hearing filed. (From W. David Watkins) |
| Apr. 29, 1993 | Order Granting Motion to Strike and Motion In Limine and Denying Motion for Sanctions sent out. (motion to strike and motion in limine is granted; Unicare`s motion for sanctions is denied) |
| Apr. 29, 1993 | (Unicare Health Facilities, Inc.) Motion to Substitute Witness filed. |
| Apr. 28, 1993 | Motion of Beverly Enterprises-Florida, Inc. for an Order in Limine Against Lake Port Properties w/Exhibits A-D filed. |
| Apr. 26, 1993 | Unicare`s Motion for Summary Recommended Order Dismissing Southern Medical`s Petition and Request for Oral Argument filed. |
| Apr. 26, 1993 | (Respondent) Notice of Production of Unicare Health Facilities, Inc.`s First Requests to Beverly Enterprises-Florida, Inc.; Beverly`s Objection to Unicare`s First Request for Production; Notice of Serving Answers to Interrogatories filed. |
| Apr. 23, 1993 | Lake Port`s Written Objections and Response to Unicare`s Discovery Requests filed. |
| Apr. 23, 1993 | Life Care Centers of America, Inc.`s Response to Southern Medical Associates` First Request for Production of Documents filed. |
| Apr. 22, 1993 | (Respondent) Motion for Continuance; Notice of Appearance of Counsel for Department of Environmental Regulation filed. |
| Nov. 10, 1992 | Prehearing Order and Order of Consolidation sent out. (Consolidated cases are: 92-6655, 92-6656, 92-6657, 92-6658, 92-6659, 92-6660, 92-6661, 92-6662, 92-6663, 92-6664, 92-6665, 92-6666, 92-6667, 92-6668, 92-6669, 92-6670, 92-6671) |
| Nov. 09, 1992 | Notification card sent out. |
| Nov. 05, 1992 | Notice of Related Petitions; Notice; Petition for Formal Administrative Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Jul. 05, 1995 | Opinion | |
| Oct. 18, 1994 | Agency Final Order | |
| Jul. 21, 1994 | Recommended Order | Approval of beds in excess of numeric need for geographically underserved nursing home area in comparative review process. |
