Intervenor. )
RECOMMENDED ORDER
Pursuant to notice the Division of Administrative Hearings, by its designated administrative law judge, David M. Maloney, held a formal hearing in the above-styled case on August 14-16 and August 22, 1996, in Tallahassee, Florida.
APPEARANCES
For Petitioner: Eric B. Tilton, Esquire
Gustafson, Tilton, Henning, and Metzger, P.A.
204 South Monroe, Suite 200 Tallahassee, Florida 32301
For Respondent: Lesley Mendelson, Esquire
Assistant General Counsel 2727 Mahan Drive
Fort Knox 3, Suite 3431
Tallahassee, Florida 32308-5403
For Intervenor: Seann M. Frazier
Panza, Maurer, Maynard and Neel, P.A.
3600 N. Federal Highway
Fort Lauderdale, Florida 33308
STATEMENT OF THE ISSUE
Whether CON 8241, Palm Beach Regional's application to convert its 200 bed acute care hospital to a 60 bed long-term care hospital should be granted or denied?
PRELIMINARY STATEMENT
On January 25, 1996, the Division of Administrative Hearings received a notice from the Clerk of the Agency for Health Care Administration, (the "agency" or "AHCA.") The notice advises the division of the agency’s receipt of a request for a formal administrative hearing from the Hospital Corporation of Lake Worth d/b/a Palm Beach Regional Hospital, ("Palm Beach Regional.") The notice further requests that a hearing officer (administrative law judge) be assigned to conduct all proceedings necessary under law and to submit a recommended order to the agency.
Attached to the notice is a Petition for Formal Administrative Hearing. In the petition, Palm Beach Regional contests the agency's preliminary decision to deny the hospital a certificate of need to convert 60 acute care hospital beds to 60 long-term care hospital beds, and to delicense another 128 acute care hospital beds. In essence, the petition claims that Palm Beach Regional had demonstrated in its application both need for the project and compliance with agency rules and statutes. Furthermore, the petition claims that the hospital has suffered a denial of administrative due process because it was treated differently by the agency from other applicants for long-term hospital CONs in other districts.
After the proceeding was initiated at the Division of Administrative Hearings, Central Park Lodges, Inc., d/b/a Integrated Health Services of Florida at West Palm Beach, ("Integrated,") petitioned to intervene. Palm Beach Regional opposed the petition to intervene. Following a hearing on the issue, the petition was granted subject to strict proof of standing at final hearing.
At the final hearing, Palm Beach Regional presented the testimony of eight witnesses: W. Raymond C. Ford, accepted as an expert in health planning and long-term care administration; Stacy Modlin, RN, accepted as an expert in admission review and discharge planning; Jeffrey Crudele, CPA, accepted as an expert in hospital finance; Elfie Stamm, AHCA Health Services and Facilities Consultant Supervisor and the agency's chief health planner in CON matters; Dr. Ronald T. Luke, Ph.D., accepted as an expert in health planning; Dr. Kathleen Griffin, Ph.D., accepted as an expert in health care planning with special emphasis on long-term care acute care and subacute care; Paul Arrington, accepted as an expert in health care finance; Valerie Phyliss Bouchelle, CPA, accepted as an expert in health care accounting and reimbursement; and, Elizabeth Dudek, Chief of the Certificate of Need and Budget Review Office at the agency.
Palm Beach Regional Exhibit Numbers 1-7, 9-13, 16-20, 26, 29
and 31 were admitted into evidence. Palm Beach Regional Exhibit Number 16 is the deposition of Dr. Wendell Williams taken August 2, 1996, and presented in lieu of live testimony. Dr. Williams is
accepted as a medical expert in long-term acute care. The agency presented the testimony of two witnesses called previously by Palm Beach Regional: Ms. Dudek and Ms. Stamm. AHCA Exhibit Numbers 9-
12 were admitted into evidence.
Integrated presented the testimony of three witnesses: Ms.
Katherine Rosenblatt, Administrator at Integrated; Ms. Linda Mier, Director of Respiratory Therapy at Integrated; and, Mr. Richard Baehr, accepted as an expert in health planning. Integrated Exhibit Numbers 22, 26-28, 31, 33 and 34 were admitted into evidence.
FINDINGS OF FACT
The applicant in this case is The Hospital Corporation of Lake Worth d/b/a Palm Beach Regional Hospital. A subsidiary of Columbia Hospital Corporation, ("Columbia,") Palm Beach Regional is a licensed general acute care hospital with 200 beds located in Palm Beach County, AHCA District 9. Palm Beach Regional's license is issued pursuant to Chapter 395, Florida Statutes, the chapter of the Florida Statutes entitled, "Hospital Licensing and Regulation."
The agency is "designated as the single state agency to issue ... or deny certificates of need ... in accordance with the district plans, the statewide health plan, and present and future federal and state statutes." Section 408.034(1), F. S.
Integrated is a licensed 120-bed skilled nursing facility, also known as a long-term care facility, located in Palm Beach County, AHCA District 9. Its license is issued pursuant to Chapter
400, Florida Statutes, the statute entitled "Nursing Homes and Related Health Care Facilities."
The parent company of petitioner, Columbia has a stock market capitalization of between $15 and $20 billion and enjoys a profitability of over $1 billion per year. It owns approximately
340 hospitals, well over 100 ambulatory surgical centers, and an extensive number of home health agencies.
As to be expected of a Fortune 500 company, Columbia generates substantial annual revenues. In 1994, for example, the annual revenues generated by Columbia exceeded $17 billion.
Columbia also lays claim to being the largest hospital system in the state. It has five divisions with approximately 60 hospitals in its "Florida Group," the organizational title for its Florida operations. The net revenues of the Columbia Florida Group is approximately $4.5 billion.
One of five divisions of Columbia's Florida Group, the South Florida Division is a $1.2 billion operation. The division encompasses Dade, Broward and Palm Beach Counties and consists of
15 hospitals, six surgery centers, and one dozen home health agencies. The South Florida Division, of course, includes Palm Beach Regional.
Palm Beach Regional was purchased by Columbia shortly after Columbia had purchased JFK Hospital, a 300-bed tertiary hospital approximately three miles from Palm Beach Regional.
In August of 1995, as a business decision, Columbia consolidated the operations of the two facilities.
The consolidation resulted in a patient census drop at Palm Beach Regional. Shortly thereafter, with the permission of the agency, Palm Beach Regional ceased operations at its emergency room. The result of the consolidation and limitation of the services offered was that it cost only about $100,000 a month to keep Palm Beach Regional running with its small census. Even with the small census, and the relatively low monthly operational expense, the operational expense was more than $1 million per year.
In June of 1996, Palm Beach Regional and the agency entered a stipulation which authorized the hospital to suspend the acute care operations in contemplation of this proceeding. Palm Beach Regional's hospital-based skilled nursing unit has since been transferred. Palm Beach Regional is now closed and empty.
The reason Palm Beach Regional had been kept operating at all after the consolidation with JFK was to preserve the opportunity to convert the license as proposed in the application.
Certified for accuracy on September 18, 1995, under the signature of its authorized representative, Robert L. Newman, CEO of Columbia/HCA, South Florida Division, the application was submitted to the agency bearing a date of September 20, 1995.
The application describes what it seeks in the section titled "Project Summary" as follows:
Hospital Corporation of Lake Worth (Palm Beach Regional) proposes in this Certificate of Need Application to convert 60 acute care hospital
beds to 60 long-term acute care hospital beds and to delicense 128 existing acute care beds. (At a later date the existing 12 skilled nursing beds will be located to another Columbia/HCA hospital in District IX.)
Palm Beach Regional Exhibit No. 1, AHCA Form 1455A, Oct 92, AHCA 4600-0005 Aug 93.
The transfer of the 12 skilled nursing beds has already occurred and therefore is not at issue in this proceeding. Nor is the delicensure of the 128 beds really at the heart of the agency's denial and Integrated's opposition. In contrast, what is contested is the conversion of the 60 acute care hospital beds to 60 long- term acute care hospital beds. Such a conversion would make Palm Beach Regional a long-term acute care hospital.
Referring to a hospital as both "long-term" and "acute," is confusing. The two terms have divergent meanings both in terms of average length of stay and the traits of the illness suffered by the acute and the long-term patient. In the context of hospitals, "long-term" refers to a patient with an average length of stay of greater than 25 days. By comparison, the acute patient's stay is typically much less than 25 days, with the average length of stay being between 5 and 6 days. As is the patient in need of acute care, the typical long-term hospital patient is very ill. The difference in the type of illness suffered by the acute care patient as opposed to the long-term patient, however, lies in other characteristics. Unlike the acute care patient, the long-term
patient is not in the urgent, emergent or desperately critical state of patients in the acute care setting.
The two terms, "long-term" and "acute" have been used together with reference to the type of hospital to which Palm Beach Regional proposes to convert because of the history of the long- term care hospital’s development. Originally in Florida, long-term hospitals were licensed as acute care hospitals and were referred to, therefore, as "long-term acute," hence the combination of terms with disparate meanings. In the context of a study conducted by the Hospital Cost Containment Board, however, the agency examined the issue of whether long-term hospitals should be subject to CON review as long-term hospitals apart from other acute hospitals. As a result, long-term hospitals came to be reviewed in their own separate category under certificate of need review, subject to the same licensure requirements as a specialty acute care hospital. Because they had been licensed earlier as acute care hospitals, the term "acute" was carried over into the new category. At present, there is a recommendation to refer to long-term acute care hospitals simply as "long-term hospitals" to clear up any confusion caused by the terminology. This recommendation will be followed for the most part in the remainder of this order when reference is made to acute and long-term facilities and acute and long-term care.
Hospital-based long-term care is a distinction established in federal Medicare regulations that describes a
hospital with patients having an average length of stay of greater than 25 days. The distinction allows an exclusion from the Medicare prospective payment system so that reimbursement is received by the long-term hospital on the basis of cost.
The distinction is of great import financially because of the distinction between "cost-based" Medicaid and Medicare reimbursement systems and another payment system used by Medicaid and Medicare: the prospective payment system.
Before the prospective payment system was instituted, hospitals generally were well utilized, in fact, “filled to the brim.” The high utilization was due to the "cost-based" reimbursement system which contained a financial incentive for the hospital to keep patients in the hospital. Under the cost-based system, the more a hospital spent, the more reimbursement it would receive from Medicare and Medicaid. The prospective payment system was instituted to save taxpayers the high cost of the cost-based reimbursement system.
Under the prospective payment system, the hospital receives a flat fee for Medicare and Medicaid patients depending on the diagnostic category, or diagnostic-related group, ("DRG,") into which falls the illness treated. The flat fee is figured on the basis of average length of stay for that diagnostic category. Under this system, unlike the cost-reimbursed system, the hospital receives the same reimbursement for Medicare and Medicaid patients who stay for less than the average length of stay assigned to the patient's DRG as for those who stay longer. With regard to a
patient who stays in the hospital longer than the average length of stay for the patient's DRG, the hospital, in many cases, not only profits less the longer the patient stays but begins to lose money at some point in the stay. If the average length of stay for an appendicitis patient is four days, for example, then the hospital profits more in the case of an appendicitis patient who stays only two days because it has incurred only two days of costs instead of the expected four days of costs. In the case of another appendicitis patient, who stays longer than the average length of stay, the hospital makes less money and reaches the point eventually in some cases where the hospital actually loses money for treating the patient if the patient stays long enough.
Medicare provides additional payments for both "day-outliers" and "cost-outliers," but not enough to prevent financial pressure on hospitals to discharge acute patients as soon as possible.
The prospective payment system has succeeded in forcing hospitals to operate more efficiently; the average utilization of hospitals has declined dramatically. Today, about half of the hospital beds in Florida on any given day go unused.
The system does not have the same effect on long-term hospitals; they are exempt from the prospective payment system. Instead, long-term care hospitals are reimbursed under a cost-based system. A long-term hospital well located geographically is particularly attractive to a large hospital system, such as Columbia. Not only will it likely be a financial success in its own right but it will assist Columbia’s sister acute care hospitals
in relieving them of patients too sick to be discharged to a subacute setting yet finished with the acute episode which required the acute care hospital’s service in the first place.
The first long-term care hospital was instituted in Florida in the 1980's. Fairly soon thereafter there were three long-term care hospitals in Florida, but then there was a lull in the attempt to establish long-term care hospitals.
With the advent of the prospective payment system, however, there eventually came the closing of a number of small hospitals in Florida because of their inability to continue to operate in sound financial condition. At the same time, four or five applications for the conversion of small hospitals to long- term care hospitals were filed with the agency.
In the early part of the present decade the agency conducted a study of long-term hospital care. The study took place within a larger study by the Hospital Cost Containment Board. Ultimately, it was recommended that long-term care hospitals be regulated separately from acute care hospitals and that they be subject to separate certificate of need review.
The recommendation was made for a number of reasons. First, long-term hospitals were viewed by the agency as very different from acute care hospitals because of the patients' average lengths of stay. Second, long-term care hospitals were found to be expensive for the type of care given in them which was of great concern to the state since cost control is an objective of
the certificate of need program. Third, long-term hospitals were found to experience high mortality rates.
As the result of the study and recommendation, the agency made the creation or conversion of hospitals into long-term hospitals subject to certificate of need review.
In the study, the agency also found that there are no clear admission criteria for long-term hospitals. To date, neither the Health Care Finance Administration (“HCFA”), nor the Joint Commission on Accreditation of Hospital Organizations ("JCAHO,") or any of its sub-organizations have developed any criteria to define a long-term care hospital. It is not clear, therefore, exactly what type of patients are suitable for care in a long-term hospital.
The parties are in agreement that sub-acute care is a level of care that is below acute care. Palm Beach Regional claims, however, that the care provided by long-term care hospitals is not subacute but rather falls into a category of care between acute and sub-acute. An understanding of this claim requires some discussion.
Unlike other classes of hospitals which are exempt from the prospective payment system, like cancer, children's or psychiatric hospitals, patients in long-term care hospitals do not have a specific type of illness nor are they limited to serving a specific age group.
Generally, however, they are patients who have had an acute episode, whose program of care has been identified and who need a longer term of care to recover or to be rehabilitated because of an acute illness or surgical procedure. And, although they are not limited to a specific age group, the experience of long-term care hospitals is that a major part of their patient population is elderly, virtually all of whom are covered by Medicare. In these respects, long-term care hospital patients are not much different from patients in other "subacute" settings: comprehensive rehabilitation hospitals, acute care hospital skilled nursing units, skilled nursing facilities in free-standing nursing homes, and, even, in some cases, home health care, assisted living and outpatient services for the elderly.
If there is a difference between the long-term hospital
patient and patients in other subacute settings, it is that the long-term hospital patient has more at-risk types of physical problems, is more likely to be medically unstable or is, in fact, medically unstable. But this difference is not strictly observed because of the financial pressure on hospitals to discharge patients from the acute setting into a subacute setting. Medically unstable patients, therefore, are found in subacute settings such as skilled nursing facilities whether hospital-based or in free- standing nursing homes.
In contrast to what has become commonplace practice, Dr. Kathleen Griffin, an expert in health care planning with a specialty in long-term acute care and subacute care, testified that
it would not be appropriate for a medically unstable patient to be transferred to a skilled nursing bed. In her opinion it would be best for a medically unstable patient about to be discharged from acute care to be admitted instead to a long-term care hospital.
Despite the reality that there are no admission criteria for long-term care hospitals, Dr. Griffin maintains that if a hospital discharge planner believes through information gathered from the medical and nursing staffs that the patient "is highly acute and at risk, and there is a long-term care acute hospital available, then that would be the placement of choice." (Tr. 523.)
If a long-term care hospital is not available, however, the alternative is to keep the at-risk, medically unstable patient in the acute care hospital rather than discharge the patient into a nursing facility.
Dr. Griffin's opinion is shared by the physician practicing in long-term hospitals. Representative of such a physician is Dr. Wendell Williams, presently the Medical Director of a long-term care hospital, Specialty Hospital of Jacksonville. Dr. Williams sees a distinction between long-term acute care and subacute care. Long-term hospital care is acute care without the need for "highly technical diagnostic capabilities," and "high surgical capabilities," but still care in the "medically complex case that requires frequent physician direction [and] high skill level of caregivers." (Petitioner's Ex. No. 16, pg. 13.) In Dr. Williams view, long-term hospital care occupies a level of care between acute and subacute care.
The views of Dr. Griffin and Dr. Williams find support in analyses of nursing hours per patient. In a typical nursing home, the number of hours per patient is about 4.5 hours per day, while in a long-term care hospital, the number is around 6.5 hours per patient day. At Specialty Hospital of Jacksonville, the nursing hours per patient day for non-ventilator patients is 6.75 hours, and for ventilator patients is 10 hours.
In contrast, Integrated, a nursing home, provided nursing hours per patient day in its "med-surg unit" at 4.34 hours in March of 1996, 4.60 hours in April and 4.52 hours in May although at times Integrated's nursing hours per patient day have reached as high as 6 hours.
The opinions of Dr. Griffin and Dr. Williams have not yet been generally accepted. Following the agency's study in the earlier part of the 1990's, the federal government, under the auspices of HCFA, launched a major study that addresses what AHCA viewed as the "whole gamut of what is marketed as subacute care," (Tr. 272). The study included long-term care hospitals, as well as those settings which the parties all agree are clearly in the category of "subacute": hospital-based skilled nursing facilities, free-standing nursing homes, comprehensive rehab hospitals and home health care.
The report was issued in November of 1995. It confirmed that there was a great deal of overlap among the settings studied including between the long-term care hospital and other settings unquestionably subacute. Moreover, it confirmed that many of the
services are "primarily driven by reimbursement," (Tr. 275), and not by which provides the best or most cost-effective health care for the very ill, elderly patient no longer in need of acute care. In other words, the financial pressure on hospitals to discharge patients from the acute care setting was what accounted for the tremendous growth of subacute services and the move toward more long-term care hospitals rather than what is actually best for the patient or the health care system.
The study concluded that there is insufficient data to determine the cost effectiveness of subacute care as defined in the study. As for overlap in the various settings, the extent of overlap was not precisely determined. But just as long-term care hospitals provide ventilator treatment, skilled nursing units specialize in ventilator patients. Nursing home subacute units specialize in wound care, infectious disease programs and IV antibiotic therapy programs, as well, just as would Palm Beach Regional if approved.
The HCFA study also confirmed that the cost of care and mortality rates at long-term care hospitals are high, $2,000 per day and 40 percent, respectively. The average cost per discharge at a long-term care facility was between $150,000 and $250,000.
Despite the long-term hospital's recognition by the federal government, the presence in Florida for more than eight years, and separate CON regulation for the last several years, it remain unsettled which patients should be treated and cared for in long-term hospitals. While for some, such as Dr. Griffin and Dr.
Williams, the question is one which discharge planners, after consultation with nursing and medical staff, ably make, it is not generally accepted that it is clear which patients should be cared for in long-term care hospitals. It is not generally accepted as evidenced by the wont of admission criteria for long-term hospitals. Furthermore, it is not clear whether long-term hospitals represent the best means or the most cost-effective way of treating patients ready for discharge from an acute care setting.
The Palm Beach Regional proposal to convert to a long- term care hospital is modeled after another Columbia long-term care hospital, Specialty Hospital of Jacksonville, the hospital of which Dr. Williams is the medical director. Opened in 1992, Specialty offers four major program areas: ventilator and other respiratory complications, infectious diseases, wound management and complex medical and rehabilitative services.
The typical ventilator patient is quite ill; often with other attendant system breakdown such as cardiac or renal failure. The goal is to free the patient from ventilator dependence. If the patient is judged to be a lifetime custodial ventilator patient, the patient would not be appropriate for Specialty.
A variety of infections are treated in the infectious disease program. Often the primary antibiotic treatment has failed and there may be other conditions attendant.
The typical wound care patient admitted to Specialty has
severe wounds that may derive from circulatory problems. Often admission is from a hospital or nursing home. The patient may be diabetic, paraplegic or quadriplegic. The patient may have experienced a surgical intervention which has not healed. Or the patient may have a distressed digestive system which inhibits the body's ability to absorb the proper nutrients to support the healing process.
The typical complex medical and rehab patient includes the spinal cord injured patient and the multiple system failure patient.
The patients at Specialty are under the management of an attending physician but typically four or five different specialties are involved in each patient's care.
Specialty Hospital has experienced approximately five percent Medicaid and one percent charity care.
A representative patient at Specialty Hospital has an average length of stay of 23 days. The representative patient in the infectious diseases program would experience an average length of 18, 20 days in the pulmonary program, 29 days in the ventilator program, 36 days in the wound program, 18 days in the physical medicine and rehabilitation program and 26 days in the medicine program. These lengths of stay resemble acute or Medicare certified skilled nursing bed lengths of stay more than the historical 90 day lengths of stay experienced in Florida at long- term care hospitals.
A representative patient at Specialty Hospital will
experience an average daily charge of $1,122 and an average charge per case of $25,810, the highest averages incurred by the ventilator program at $1,848 per day and $52,781 per case.
From a medical standpoint, all of the patients treated at Specialty Hospital could be treated in an acute care hospital.
There is one difference between Specialty's patient profile and the one expected at Palm Beach Regional. The approach proposed by the applicant will include patients with greater levels of instability. Whereas Specialty has taken the approach that patients at the intensive care level should be in a general acute care hospital, Palm Beach Regional expects to treat patients in need of services from an intensive care unit. Palm Beach Regional, therefore, has planned for an intensive care unit at the facility should its CON application be approved.
Sixty of Integrated 120 beds are dedicated to meet the needs of patients requiring subacute care. Although they may differ slightly in intensity of application because of slightly lower acuity levels of the patients, the programs offered in this sixty-bed skilled nursing unit encompass the four programs proposed for Palm Beach Regional's long-term care hospital: ventilator and respiratory complications; infectious disease; wound management; and complex medical and rehabilitation service program.
Integrated uses its own method to measure the acuity of its patients. Within this method, two of the levels require active treatment of co-morbidities, multiple diseases which complicate the
primary diagnoses. By whatever means acuity is measured, it is reasonable to expect that the average level of acuity would be somewhat higher among patients treated at a Palm Beach Regional long-term care facility. (Although without criteria to measure acuity for admission or to know for sure what patients are actually being treated at long-term hospitals, this is not certain.) Nonetheless, considering both diagnosis and treatment, Integrated's patients at Integrated's two highest levels of acuity, even if not at quite as high an acuity level on average, would be similar to the patients Palm Beach Regional might serve if its application were granted. Patients at a Palm Beach Regional's long-term care facility who would exceed the highest level of acuity of those patients at Integrated are patients appropriate for treatment in an acute care hospital.
Ventilator patients are treated in skilled nursing facilities both in hospitals and in free-standing nursing homes like Integrated. Some skilled nursing units even specialize in ventilator care. There is clearly overlap between ventilator services in skilled nursing facilities and long-term care hospitals. The precise extent of the overlap is not clear. While the overlap may not be 100%, it is certainly significant.
Twenty of Integrated's 60 subacute beds are capable of assisting ventilator patients. Within this 20 bed unit, Integrated provides oxygen, air, and wall suctioning just like in a hospital setting. Additionally, Integrated can provide respiratory services
outside of its specific unit by using portable suction machines and oxygen concentrators. The ventilator patients treated at Integrated are similar to the ventilator patient treated in intensive care units in hospitals. Some of Integrated ventilator patients are in need of acute care. All are hemodynamically stable but some are medically unstable. Nonetheless, there are patients who would be too unstable to allow them to be suitable for admission into Integrated's respiratory unit. Patients who would need to remain in acute care in the hospital would be patients who, for example, were bleeding or having trouble with a post-surgical trach placement.
The medical director at Integrated is a pulmonologist. Integrated has a 24-hour respiratory staff. The ventilator program at Integrated meets the description in the application of the proposed ventilator program at Palm Beach Regional. Comparison of the respiratory services offered at Integrated to the services proposed to be offered in Palm Beach Regional's ventilator program reveals significant overlap between the two.
Integrated primarily uses a Bear 3 Ventilator. Other equipment used by Integrated includes pulse oximeters and pneumatic blood pressure cuffs to provide hemodynamic monitoring. The respiratory unit is able to obtain an assessment of the patient's arterial blood gases within two hours through an arrangement with a courier service and nearby JFK Hospital. On average the blood work results are received within an hour of the blood being drawn from the patient.
An interdisciplinary team of therapists, including respiratory therapists, physical therapists, occupational therapists and speech therapists, work together on the plan of care and recovery of the ventilator patient including weaning the patient from the ventilator. Of those ventilator patients determined to be weanable, 75% are actually weaned from the machines. Ninety-two percent of the tracheotomy patients achieve decannulation.
The average length of stay in the respiratory unit for Integrated's ventilator patients is 37 days, an average length of stay that meets that which defines the long-term care hospital patient, that is, in excess of 25 days.
Just as long-term care hospitals, nursing homes offer infectious disease programs employing IV anti-biotic therapies.
Integrated provides its patients with multiple antibiotic therapies. Among the IV anti-biotic therapies used at Integrated are cepo, fortaz and vancomycin.
Integrated treats patients with pulmonary edema, pleural affusion, pulmonary embolus and pulmonary infarcts and patients with bi-lobar and multi-lobar pneumonia. Patients are treated with intravenous cortico steroids, intravenous bronchodilators, intraveous diuretics and intramuscular antimedics.
Nursing homes offer wound management programs. There is significant overlap between patients treated for wounds at nursing homes and at long-term care hospitals. Limitations in care of the wound patient are similar as well. Just as a patient in need of surgical intervention for wound care, for example, would be discharged to an acute care hospital from a nursing home so would that patient be discharged to an acute care hospital from Specialty Hospital of Jacksonville, the model hospital for Palm Beach Regional's long-term care facility.
Integrated offers wound and skin management treatment of the type described by Palm Beach Regional's proposal. Many of Integrated's patients recieve wound care upon admission. For instance, respiratory patients who have tracheotomies receive care for their wounds throughout the day.
Integrated treats all levels of decubitous ulcers, including the most severe, Stage III and IV ulcers, as required by law in order to qualify for Medicare Certification.
Integrated offers radiology and other imaging services on campus: mobile chest x-rays, normal x-rays, and video flouroscopy as well as an in-house staff of rehabilitation professionals: physical and registered occupational therapists and registered speech therapists.
The rehabilitation programs proposed by Palm Beach Regional and those programs of other long-term care hospitals
overlap significantly with those programs already offered at Integrated.
The difference between the complex medical and rehabilitative care offered at Integrated and that proposed for Palm Beach Regional lies in the expected acuity of the patients. One would reasonably expect the patients to be slightly higher in acuity at Palm Beach Regional if approved than as are presently at Integrated. Nonetheless, the patients at Integrated are similar to those Palm Beach Regional would care for, in that Integrated treats patients with co-morbidities, including combinations of congestive heart failure, post-open heart surgery, arteriosclerotic heart disease and renal failure.
On an average month, Integrated offered 7.28 hours per day of nursing and respiratory, physical and occupational therapy care per day to the patients within its subacute unit.
Forty percent of Integrated's subacute nursing hours are provided by registered nurses, 20% by licensed practical nurses, and the remaining 40% by certified nurse aides.
A sample of Integrated's admissions noted numerous patients admitted with cardiopulmonary vent and ventilator needs. Integrated also maintains a large number of orthopedic patients in need of complex rehabilitation. Integrated treats patients with congestive heart failures, patients recovering from recent open- heart surgery, patients requiring specialized wound care, patients
with post-operative cranial head injuries, and patients requiring tube feedings, IVS, ventilator and tracheostomy care.
Integrated offers the equipment that is listed in the application as equipment to be purchased by Palm Beach Regional if approved.
Integrated accepts patients who are medically unstable. These include patients admitted to Integrated's cardiopulmonary unit, patients with recent tracheostomies, patients on ventilators, patients with hemodialysis and peritoneal dialysis who have co- morbidities.
Palm Beach Regional's application lists diagnoses of patients to be treated through long-term care which it claims are not appropriate for skilled nursing facilities. The application alludes to various types of comprehensive therapies, care and resources available for these patients. Yet, despite the application's claim that care of these patients is not appropriate for the skilled nursing facility, present at Integrated for the benefit of patients with the same diagnoses are very nearly all, if not all, of these therapies, care and resources. These include:
IV antibiotic therapy, IV drips, plasma pheresis, management of severe decubitus ulcers, tracheotomy care with hourly suction, treatment with chest tubes and PCA pumps, cardiac monitoring, dialysis and an on-site pharmacy.
Moreover, Integrated's roster of consulting physicians credentialed at the facility included the range of specialists listed in Palm Beach Regional's application. Integrated's roster
of physician ranges from family practitioners to practitioners specializing in internal medicine, dermatology, neurology, and infectious disease control, to orthopedic specialists, physiatrists and psychiatrists, nearly the "full gamut" of specialties in medicine.
There will be adverse impact on Integrated if Palm Beach Regional's proposal is approved. The impact occurs as the result of a combination of significant overlap of services offered by Integrated and proposed for Palm Beach Regional and the likely loss of admissions to Integrated's subacute unit generated by patients discharged from JFK Hospital.
JFK Hospital and Palm Beach Regional are each approximately 2 miles from Integrated. Approximately 85% of Integrated's subacute admissions come from JFK. A good estimate of how many patients JFK refers to Integrated's subacute unit on an annual basis is 460. It is reasonable to assume that many of these patients would be referred to Palm Beach Regional by its sister Columbia Hospital, JFK, if the application were approved.
If only two-thirds of these patients were lost to Palm Beach Regional, using a conservative figure for contribution margin of
$100 per patient day, the loss to Integrated would be about $1 million in contribution margin per year.
Furthermore, if the application is approved, Integrated will also have to either raise salaries to keep qualified staff for ancillary staff or risk losing them because Palm Beach Regional
proposes to offer ancillary staff salaries higher than those paid by Integrated.
The criteria to be used in evaluating the application are found in statutes, and in rules of the agency which implement these statutes.
Neither the District 9 Treasure Coast Health Plan nor the State Health Plan contain any mention of long-term acute care beds. Both plans were written before there were any CON requirements for this type of bed.
There is no agency rule regarding need determination for long-term acute care beds. Neither is long-term hospital care defined by agency rule as a referral service, one dependent upon other hospitals to refer patients.
The service area for a referral hospital is larger than just one district. Patients are referred from districts 9 and 11 to the long-term care hospitals in District 10. This is certainly not surprising for patients in district 9 since there is no long- term hospital in the district and referrals are the common way for long-term hospitals to gain patients. Patients are referred from Districts 3, 5, 6 and 8 to the long-term care facility in Tampa. With the exception of the long-term care hospital in District 11
where the largest proportion of patients came from within the District 11, all of the long-term hospitals in the state, "had referrals from all over the place." (Tr. 288.) Palm Beach Regional itself proposes to serve patients from Districts 7 and 10.
The reality is that long-term care hospitals are primarily referral hospitals. Nonetheless, since there is no agency rule defining long-term care hospitals as referral hospitals and since there is no agency rule defining the service area of a long-term care hospital, District 9 may be the appropriate service area for the health planning purposes of Palm Beach Regional's application. In order for the district to be the appropriate service area, however, the application must demonstrate that there is a need for a certain number of beds based on the data collected from District 9.
Since there is no need methodology applicable to long- term care acute beds, Palm Beach Regional developed three different methodologies for the agency's consideration. The agency found the "components," (Tr. 910,) of the methodologies to be reasonable. Indeed, the agency never offered any other need methodology which it claimed was superior to those offered by the agency. Instead the agency criticizes the methodologies for failing to take into consideration the availability of like and existing services and alternative to the proposed services.
Patients who will be served in the proposed facility are currently being served in either the short-term acute hospitals or skilled nursing facilities in nursing homes such as Integrated,
both of which are less costly alternatives to this proposal.
Palm Beach Regional anticipates referrals from other Columbia Hospitals in the districts; however, six of the eight Columbia Hospitals have skilled nursing units which propose to treat the same patients and conditions the applicant proposes to treat. Furthermore, at the time of hearing, five Columbia hospitals in the districts had 56 approved skilled nursing beds not then operational. Included among the 56 were the 12 skilled nursing unit beds transferred from Palm Beach Regional.
Palm Beach Regional's presents arguments in favor of improved quality of care to the patient in need of care following stabilization of an acute episode. There is, however, no data to support a conclusion that outcomes are better in long-term care hospitals.
As for the applicant’s ability and record to provide quality of care, there is little doubt. The testimony of Dr. Ron Luke as to the high quality of care to be provided by Palm Beach Regional was not challenged.
The patients proposed to be served by the applicant are currently being served in hospitals, subacute units at nursing homes or hospitals, or in rehabilitation facilities. Some may even be in home health with high technology equipment. Transferring these patients to a long-term care facility has significant financial implications costly to the health care system.
The 60 beds proposed in the application will, in all likelihood, be adequately utilized. In the case of long-term care
hospitals, demand follows the supply because of the strong financial incentive to fill the beds.
There is nothing to indicate, however, that acute care beds are not an alternative to long-term hospital beds. There are plenty of empty beds in acute care hospitals to be filled by patients who would be treated by the applicant. That these patients proposed to be treated by Palm Beach Regional might receive treatment, if the application is denied, in hospital-based skilled beds or, perhaps inappropriately at times, in nursing home skilled nursing units is not due to lack of alternatives. Rather, it is the product of financial pressure on the acute care hospitals to discharge patients from the acute setting.
Effective utilization of at least 85 percent of cost- based services such as long-term services is an important consideration because fixed costs can be spread over more patient days, thereby decreasing the costs per patient day. The average utilization rate in Florida for long-term care beds is 66 percent. The most recent occupancy rate for Specialty Hospital is only 41 percent.
The record of long-term care hospitals would indicate that the utilization projections by Palm Beach Regional are unreasonable. But, there was nothing established that indicated the three methodologies used by Dr. Luke were unreasonable in any way. Given that Palm Beach Regional will be able to draw patients from its sister Columbia acute care hospitals, all of whom will be anxious to provide patients to this long-term hospital, and given
that long-term hospital care is a kind of care for which demand follows the supply, it is likely that utilization at Palm Beach Regional, if approved, will be strong.
Despite the record of other long-term care hospitals, Palm Beach Regional’s utilization projections are reasonable.
There are no plans to provide research or education at this facility.
The State Agency Action Report shows that the agency believes that there will be adequate levels of staffing available. The adequacy of the staffing levels was confirmed by the administrator of Specialty Hospital of Jacksonville.
Palm Beach Regional will be able to adequately staff the hospital at the salary levels proposed in the application.
Long-term acute care hospitals treat the very old. Since almost all of these people have Medicare coverage, economic access is not a problem for the individuals the applicant proposes to serve. The applicant has a 1% indigent commitment and a 5% projected Medicaid utilization.
Geographic access is also served well by this facility. The facility is located where the population base of the elderly population is in District 9.
The immediate financial feasibility of Palm Beach Regional is evident from its ability to open and operate for the
first two years with a positive cash flow with a financing letter in the amount of $407,000 from Columbia.
Palm Beach Regional, in its pro formas and the analysis underlying its pro formas concluded that it would be under the prospective payment system for six months before it could transer to a facility exempt from the prospective payment system. This conclusion is reasonable. Palm Beach Regional has two months to get the necessary certification changed prior to the end of its fiscal year. Palm Beach Regional will be able to institute the necessary six month evaluation, within CON constraints, when it chooses. Furthermore, Palm Beach Regional could change the end of its fiscal year so that the six-month time period could be accommodated.
Finally, short-term financial feasibility was demonstrated by the pro forma which properly shows reimbursement levels for patients who were treated in the first six months, and who were discharged after the first six months. Under Medicare regulations, the hospital would be reimbursed on a cost basis for these patients.
Palm Beach Regional projected an occupancy level of 85% in the first year of operation and 87% in the second year of operation. Neither Specialty Hospital of Jacksonville, the model for Palm Beach Regional, nor the other long-term care hospitals in Florida have occupancy levels that high. Comparison, however, is not valid. The long-term care hospitals that converted from acute care facilities converted their entire complement of beds which
resulted in overbedding. In contrast, Palm Beach Regional seeks to convert only 60 of its 200 beds. The situation of Specialty is very different. It is a converted 105 bed facility which was in bankruptcy when it first started, limiting its ability to attract patients. Within its district, Specialty competes with Vencor of North Florida, a 60 bed facility. Not only does Palm Beach Regional not have any in-district competition, but it will benefit greatly from being a member of the Columbia system.
Palm Beach Regional's application demonstrates financial feasibility, both immediate and long-term.
Whether the facility provides an additional level in the continuum of care available to HMO patients is uncertain. It is not generally accepted that the level of care Palm Beach Regional argues it will provide, that is, a level between acute care and subacute care, even exists let alone whether such a level of care is necessary, cost-effective or the best means of treating patients.
There are no facilities in the district which provide a substantial portion of its service to individuals residing outside the district.
Total property costs for Palm Beach Regional amount to
$3.572 million per year, or approximately $250,000 per month. This includes depreciation, interest, insurance and all other property costs.
Because Palm Beach Regional would enjoy cost- reimbursement from Medicare instead of being paid on the basis of the prospective payment system, Medicare would pay as much as $190 per patient day for simple property costs and not for patient care, if Palm Beach Regional's utilization projections prove true. Were Palm Beach Regional's utilization projections to turn out to be incorrect and Palm Beach Regional's occupancies were more in the range of other long-term care facilities, (50% the first year and 60% the second), the cost would be "into the $3-400 a day cost range for the cost of [the] ... property allocated per patient day, which would be picked up in their entirety or close to their entirety [by Medicare.]" (Tr. 782.)
Either way, the high property costs of Palm Beach Regional would result, should the application be approved, in shifting a huge financial burden to Medicare. The result would be to "wind up costing the Federal government, the Medicare program, multiples of what it now cost[s] ... to treat those same patients in acute care hospitals." (Tr. 792).
Palm Beach Regional projected a 5% Medicaid utilization but its commitment is to indigent care only and that being a mere
1%. The commitment to indigent care (as opposed to the projection for Medicaid care) is meager.
Furthermore, Palm Beach Regional has little established pattern accepting patients in these payor classes. Given the savings to Columbia acute care hospitals which would feed patients to Palm Beach Regional, and ultimately, the profit to be enjoyed by the applicant, a commitment of 1% is lacking.
That recognized, it must be said that the modesty of the commitment is consistent with the advantage Medicare's cost- reimbursement system provides long-term care hospitals. It is not to be expected that there will be many Medicaid or indigent patients utilizing long-term care hospitals. "The vast majority of the population utilizing the facility will be the elderly, virtually all of whom are covered by Medicare." (Palm Beach Regional's Proposed Recommended Order, p. 23, Tr. 339.) Still, a greater commitment, more along the lines of the commitment provided by St. Petersburg Health Care Management, Inc., with which Palm Beach Regional has drawn comparison, (See Findings of Fact, 123- 128, below,) would lend this criterion to favor the application rather than disfavor it.
There is no long-term hospital available in District 9. But whether that means Palm Beach Regional is adding a level to the continuum of care available for patients in the district is uncertain.
There is no data to support the conclusion that long-
term care hospitals provide a level of care between that of acute and subacute. Despite the earnestness with which Dr. Griffin and Dr. Williams hold their opinions to the contrary, their opinions are simply not yet accepted widely enough at this point to support such a conclusion.
Long-term care hospitals have existed for years by Act of Congress. "[W]hile there has been an active discussion of alternatives, so far they have not come up with one which has been moved into rule or legislation." (Tr. 421).
Certainly keeping long-term care hospital patients covered by Medicare in acute care hospitals would be a less costly alternative. Whether caring for these patients in one facility or another is more cost-efficient, however, is unknown. At bottom, there is no determinative data on the issue of cost-efficiency.
As for more appropriate alternatives, there is a group of long-term care hospital patients for whom it is less appropriate to be in a free-standing skilled nursing unit. But, the size of this group is uncertain. Certainly, from the point of view of care to the patient, it is at least equally appropriate for all long- term care patients to remain in acute care hospitals rather than be discharged to long-term care.
As the result of renovations, the facility requires little capital to convert it to a 60 bed long-term care hospital.
The capital outlay of $500,000 is an indication of how little actual construction is necessary to complete the project.
With the exception of inappropriately premature discharges of patients from the acute care hospital's acute care setting, there are beds available for appropriate care in the absence of approval of the application. There is an abundance of beds in acute care hospitals available to patients who might otherwise be discharged to the long-term care hospital. As for the patient for whom discharge from the acute care setting is appropriate who might be admitted to a long-term care hospital, there are available for inpatient care skilled nursing beds in one type of facility or another.
Palm Beach Regional contends that it has been treated differently by the agency, without reasonable explanation, from St. Petersburg Health Care Management, Inc., a successful applicant for the conversion of a general acute care hospital to a long-term care hospital in another district. Initially approved by the agency, the "St. Petersburg" application, CON 8213, was not subjected to the scrutiny of a formal administrative hearing at the Division of Administrative Hearings.
Nonetheless, in support of its claim of unfair treatment, portions of the St. Petersburg application and omissions response for Certificate of Need number 8213 were introduced into evidence by petitioner as well as the State Agency Action Report.
There are similarities between the two applications. For example, both proposed conversion of underutilized facilities to long-term acute care beds, as well as reduction of the hospitals' complements of 200 acute care beds to 60 long-term care beds.
But there are differences as well. The St. Petersburg commitment to indigent and Medicaid care is 500% of the commitment by Palm Beach Regional. St. Petersburg's commitment is a combined 5%: 2% to indigent and 3% to Medicaid. In contrast, Palm Beach Regional's commitment is 1%, to indigent care only.
Palm Beach Regional stated in its application that "[p]atients classified as Medicaid payers are projected to equal 5.0% of total patient days in 1999, 2000, and 2001." Petitioner's Ex. No. 1, p. 79. As reasonable as this projection may be, it is just that: a projection, nothing more and a projection is a far cry from a commitment.
There is another difference between the two applications. While the facilities from which Palm Beach Regional's application received letters of support were limited to Columbia's affiliated facilities, St. Petersburg received letters of support from three disproportionate share providers as well as numerous unaffiliated hospitals and nursing homes in the Pinellas and Pasco County areas. The difference is critical to an understanding of the likelihood that the facility will, in fact, meet its commitment to the historically underserved. As Ms.
Elizabeth Dudek, Chief of the Certificate of Need and Budget Review Office at the Agency for Health Care Administration testified,
"You have, in the case of having the support of all the disproportionate share providers
... more of an assurance that the historically underserved, the Medicaid and the indigent patients, will be served and get access to the service."
(Tr. 902). Such an assurance is omitted unfortunately from Palm Regional’s application.
The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this proceeding. Sections 120.57(1) and 408.039(5), Florida Statutes.
Standing to intervene in administrative CON proceedings is conferred by statute as follows:
Existing health care facilities may ... intervene in ... administrative hearings upon a showing that an established program will be sustantially affected by the issuance of a certificate of need to a competing proposed facility or program within the same district
... .
Section 408.039(5), F.S.
Palm Beach Regional asserts two positions in opposition to Integrated's standing. For one, it argues that as a nursing home, a type of facility licensed and regulated pursuant to an entirely different chapter of the Florida Statutes, separately defined by AHCA rules, and governed by a rule methodology inapplicable to Palm Beach Regional, Integrated is not a facility
similar enough to Palm Beach Regional's proposed long-term care hospital to be able to challenge Palm Beach Regional attempt to obtain approval of its application. For another, it argues Integrated's injuries do not fall within the zone of interests protected by the Florida Statutes.
Integrated provides the same complex services, including skilled nursing in the areas of wound care, treatment of infectious disease, complex medical and rehabilitative care and care of ventilator patients for extended lengths of stay that Palm Beach Regional hopes to provide. There is significant overlap in the type of patients as well. The overlap is probably not complete.
It is reasonable to assume, although it is by no means certain, that patients at Palm Beach Regional would have a slightly higher level of acuity on average than do patients presently at Integrated. But by and large, the patients treated by Integrated are similar and certainly overlap substantially with the patients Palm Beach Regional hopes to treat.
131. Integrated would experience a significant decrease in the volumes of patients treated and a concomitant loss in revenues if Palm Beach Regional's application is approved. These combined effects amount to a substantial impact. Economic injury, alone, is a sufficient substantial interest for standing to intervene in a CON proceeding. Baptist Hospital v. Department of Health and Rehabilitative Services, 500 So.2d 620, 625 (Fla. 1st DCA 1987); Florida Medical Center v. Department of Health and Rehabilitative Services, 484 So.2d 1292, 1294 (Fla. 1st DCA 1986). There is,
therefore, no "zone of interest" analysis that would defeat standing in this proceeding, a proceeding in which the prospective intervenor has proved economic injury.
While "competing proposed facility" is not defined by rule, other terms used in the CON standing provision of the statutes have been defined by rule. The agency has defined both "[e]xisting health care facilities" and "established program":
"Existing health care facility" means a licensed health care facility.
"Established program" means a program for the provision of a certificate of need regulated institutional health service which has a valid certificate of need for the program ...
Rule 59C-1.002(19) and (20), Florida Administrative Code.
Despite the claims of Palm Beach Regional, there is nothing in the CON "standing" statutory provision or in any of the definitional rules of the agency which restricts or operates to restrict standing to facilities with identical licensure. Nor do different bed need methodologies of competing facilities have any bearing on standing. See, e.g., First Hospital Corporation of Florida v. Department of Health and Rehabilitative Services, 589 So.2d 310, 312 (Fla. 1st DCA 1991).
Since Integrated is an existing health care facility offering an established program, the only matter left to be decided for purposes of whether Integrated has standing is whether approval of Palm Beach Regional's application would make it a "competing facility ... within the same district." Section 408.038(5)(b),
F.S. The services offered by Integrated and to be offered by Palm
Beach Regional are substantially similar. And although patients to be treated in Palm Beach Regional's long-term hospital might not meet precisely the same profile, there can be no doubt that Palm Beach Regional would be in competition with Integrated for patients from a substantially similar patient base.
Integrated meets the statutory requirements to intervene in this proceeding. It is a health care facility existing in the same district as Palm Beach Regional. It has shown that its established program will be substantially affected through economic and other injury by the issuance of a certificate of need to Palm Beach Regional's long-term care hospital, a proposed facility that will compete for patients from largely the same patient base as Integrated's.
Integrated has standing to intervene.
Palm Beach Regional, as the applicant, carries the burden of proof to demonstrate its application, on balance, meets the rule criteria for approval of the CON it seeks. Boca Raton Artificial Kidney v. Department of Health and Rehabilitative Services, 475 So.2d 260 (Fla. 1st DCA 1985). The award of a CON must be based upon a balanced consideration of all statutory and rule criteria. Department of Health and Rehabilitative Services v. Johnson Home Health Care, Inc., 447 So. 2d 361 (Fla. 1st DCA 1994); Balsam v. Department of Health and Rehabilitative Services, 486 So.2d 1341 (Fla. 1st DCA 1986); St. Joseph's Hospital v. Department of Health and Rehabilitative Services, 536 So.2d 346 (Fla. 1st DCA
1988). The weight to be given each criteria is not fixed, but varies depending on the facts of each case. Collier Medical Center, Inc. v. Department of Health and Rehabilitative Services,
462 So.2d 83 (Fla. 1st DCA 1985); North Ridge General Hospital, Inc. v. NME Hospitals and Department of Health and Rehabilitative Services, 478 So.2d 1138 (Fla. 1st DCA 1985).
While there are numbers of findings of fact under the statutory criteria in favor of this application, the greater balance is with those that do not favor it.
Most fundamentally it has not been established that there is a need for this facility. There are numerous alternatives to the proposal. Like and existing providers, acute care hospitals and nursing homes with skilled nursing units, presently utilized for much the same patient base as the applicant would serve, are available, and accessible. Subacute units in hospitals and nursing homes serve as a cost-effective, high quality alternative to Palm Beach Regional’s proposal. As to those patients for whom subacute care is not appropriate, acute care beds are available. The applicant failed, moreover, despite a determined attempt, to establish that the quality of care now being received by patients it intends to serve will be improved should the application be granted.
Palm Beach Regional has made a minimal commitment to
Medicaid and indigent patients. The lack of Medicaid commitment, on its own, can serve as justification of the denial of a CON application. Kensington Manor Inc., v. Department of Health and
Rehabilitative Services, 13 FALR 1754, 1755 (HRS 1991). Nor does the applicant’s past provision of Medicaid services and services to the indigent favor the application.
The probable impact of the proposed project on costs of providing health services is that the costs of serving many of Palm Beach Regional’s proposed patients will be dramatically increased.
There is no indication that the proposed facility will foster competition and service to promote either quality assurance or cost effectiveness.
The applicant, despite able presentation of its case, has not shown that the proposed provision promotes a continuum of care in a multilevel health care system. In the long run, Dr. Griffin and Dr. Williams may be proven right. But for now, there is simply not enough data to determine that long-term care hospitals do, in fact, provide a level of care between acute and subacute. At best, long-term care hospitals occupy an inchoate niche in the spectrum of levels constituting continuum of care. It is a niche which is emerging more because of the financial pressure on acute care hospitals to improve their bottom line in financial profit than because it clearly represents the best means or most cost-effective method of treating patients hospitals wish to discharge from acute care. As the agency concluded in its Proposed Recommended Order,
Because the very nature of [long-term care] hospitals is changing, and because it is a very costly service, it is prudent to exercise caution in awarding more beds at this time, when there is not indication that the existing supply is insufficient, or that people in need of the service will go unserved if this application is not approved.
Recommended Order Proposed by AHCA, p. 22.
Administrative Due Process
Given the differences between the St. Petersburg application, one never subjected to a formal administrative hearing pursuant to Sections 120.57 and 408.036, Florida Statutes, and Palm Beach Regional's, there has been no showing of a violation of administrative due process.
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(904) 488-9675 SUNCOM 278-9675
Fax Filing (904) 921-6847
Eric Tilton, Esquire
Filed with the Clerk of the Division of Administrative Hearings this 24th day of March, 1997.
Gustafson, Tilton & Henning, P.A.
204 South Monroe Street, Suite 200 Tallahassee, Florida 32301
Lesley Mendelson, Senior Attorney Agency for Health Care Administration 2727 Mahan Drive, Suite 3431
Fort Knox, Building III Tallahassee, Florida 32308-5403
Thomas F. Panza, Esquire Seann M. Frazier, Esquire
Panza, Maurer, Maynard & Neel, P.A. 3600 North Federal Highway
Fort Lauderdale, Florida 33308
Sam Power, Agency Clerk
Agency for Health Care Administration 2727 Mahan Drive, Suite 3431
Fort Knox, Building III Tallahassee, Florida 32308-5403
Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431
Fort Knox, Building III Tallahassee, Florida 32308-5403
All parties have the right to submit written exceptions within 15 days from the date of this recommended order. Any exceptions to this recommended order should be filed with the agency that will issue the final order in this case.
| Issue Date | Proceedings |
|---|---|
| Jul. 02, 2004 | Final Order filed. |
| Mar. 24, 1997 | Recommended Order sent out. CASE CLOSED. Hearing held August 14-16 and 22, 1996. |
| Feb. 12, 1997 | Notice of Filing Corrected Index; Index filed. |
| Nov. 13, 1996 | (Intervenor) Response to Petitioner`s Motion to Strike (filed via facsimile). |
| Nov. 07, 1996 | Petitioner`s Motion to Strike (filed via facsimile). |
| Nov. 05, 1996 | Central Park Lodges, Inc. d/b/a Integrated Health Services of Florida at West Palm Beach`s Proposed Recommended Order filed. |
| Nov. 04, 1996 | Recommended Order Proposed by AHCA filed. |
| Nov. 04, 1996 | (Petitioner) Proposed Recommended Order filed. |
| Oct. 29, 1996 | Order sent out. (PRO`s due by 11/4/96) |
| Oct. 28, 1996 | Joint Motion to Extend the Deadline for Submission of Proposed Recommended Orders (filed via facsimile). |
| Oct. 10, 1996 | Letter to E. Tilton, S. Frazier from L. Mendelson Re: Proposed Recommended Orders filed. |
| Sep. 30, 1996 | Notice of Filing; DOAH Court Reporter Final Hearing Transcript (Volumes 5, 6, 7, tagged) filed. |
| Sep. 25, 1996 | Notice of Filing; DOAH Court Reporter Final Hearing Transcript (Volume 4 of 7, tagged) filed. |
| Sep. 18, 1996 | (3 Volumes) Notice of Filing; DOAH Court Reporter Final Hearing Transcript filed. |
| Aug. 29, 1996 | (From S. Frazier) Notice of Filing Original Affidavit of Service; Subpoena Ad Testificandum (from M. Emanuele) filed. |
| Aug. 16, 1996 | (From S. Frazier) Notice of Taking Deposition filed. |
| Aug. 16, 1996 | (From S. Frazier) Notice of Taking Deposition filed. |
| Aug. 16, 1996 | (From S. Frazier) Notice of Taking Deposition filed. |
| Aug. 14, 1996 | CASE STATUS: Hearing Held. |
| Aug. 14, 1996 | Order sent out. (Ruling on Motions, Motion for Summary Recommended Order and Motion to Strike and Motion in Limine are DENIED) |
| Aug. 08, 1996 | Petitioner`s Response to Intervenor`s Motion to Strike and Motion in Limine (w/exhibit A-B) (filed via facsimile). |
| Aug. 08, 1996 | Central Park Lodges, Inc.`s Motion to Strike And Motion In Limine filed. |
| Aug. 07, 1996 | (Joint) Prehearing Stipulation filed. |
| Aug. 07, 1996 | Integrated Health Services of Florida At West Palm Beach`s Compliance With Order of Prehearing Instructions; Integrated Health Services of Florida At West Palm Beach`s Compliance With Order of Prehearing Instructions filed. |
| Aug. 07, 1996 | Petitioner`s Objections to Intervenor`s Exhibits; Petitioner`s Statement of Position (filed via facsimile). |
| Aug. 05, 1996 | Petitioner`s Witness and Exhibit List filed. |
| Aug. 05, 1996 | Response to Motion for Summary Recommended Order (Petitioner) (filed via facsimile). |
| Aug. 01, 1996 | (Eric Tilton) Notice of Deposition for Trial (filed via facsimile). |
| Jul. 30, 1996 | Order sent out. (Petitioner`s Motion to Compel is granted) |
| Jul. 26, 1996 | (Intervenor) Motion for Summary Recommended Order (filed via facsimile). |
| Jul. 24, 1996 | (Eric Tilton) Notice of Hearing On Petitioner's Motion to Compel (filed via facsimile). |
| Jul. 23, 1996 | (From S. Frazier) Cross-Notice of Taking Deposition filed. |
| Jul. 18, 1996 | (Eric Tilton) Amended Notice of Taking Deposition (filed via facsimile). |
| Jul. 17, 1996 | Order sent out. (joint Motion to Amend prehearing Order is granted) |
| Jul. 17, 1996 | (Eric Tilton) Amended Notice of Taking Deposition (fax) filed. |
| Jul. 15, 1996 | (From S. Frazier) (4) Notice of Taking Deposition; Petitioner`s Response to Intervenor`s 2nd Request to Produce filed. |
| Jul. 15, 1996 | Petitioner`s Motion to Compel; (Petitioner) Notice of Taking Deposition; Petitioner`s Response to Intervenor`s First Request for Admissions filed. |
| Jul. 15, 1996 | (From S. Frazier) Notice of Taking Deposition filed. |
| Jul. 12, 1996 | Joint Motion to Amend Prehearing Order filed. |
| Jul. 11, 1996 | (From S. Frazier) Re-Notice of Taking Deposition (Change in Time and Location Only); Notice of Taking Deposition filed. |
| Jul. 10, 1996 | (Petitioner) (2) Notice of Taking Deposition filed. |
| Jul. 09, 1996 | Respondent`s Response to Intervenor`s First Request for Admissions filed. |
| Jul. 08, 1996 | (From S. Frazier) (2) Notice of Taking Deposition filed. |
| Jun. 19, 1996 | (From S. Frazier) Notice of Service of Answers to Petitioner`s First Interrogatories; Intervenor`s Response to Petitioner`s First Request for Production of Documents filed. |
| Jun. 18, 1996 | Petitioner`s Response to Intervenor`s First Request for Production; Petitioner`s Notice of Serving Answers to Interrogatories filed. |
| Jun. 13, 1996 | Intervenor`s First Request for Admissions to Petitioner filed. |
| Jun. 13, 1996 | Intervenor, Central Park Lodges, Inc.`s Second Request for Production of Documents to Hospital Corporation of Lake Worth; Intervenor`s First Request for Admissions to Respondent filed. |
| May 06, 1996 | Notice of Service of Petitioner`s First Set of Interrogatories filed. |
| May 03, 1996 | Hospital Corporation of Lake Worth d/b/a Palm Beach Regional`s First Request for Production of Documents to Central Park Lodge, Inc. filed. |
| Apr. 29, 1996 | Intervenor, Central Park Lodges, Inc.`s First Request for Production of Documents to Hospital Corporation of Lake Worth; Intervenor, Central Park Lodges, Inc.`s Notice of Service of First Set of Interrogatories to Hospital Corporation of Lake Worth, rec`d |
| Apr. 22, 1996 | Order sent out. (Motion to Dismiss is held in abeyance; Central Park`s amended Petition is granted) |
| Apr. 19, 1996 | IHS`s Notice of Response to Filing Pursuant to Order the Hearing Officer filed. |
| Apr. 18, 1996 | (From L. Mendelson) Supplemental Certificate of Service w/cover letter filed. |
| Apr. 12, 1996 | (Respondent) Notice of Filing; Chapter 87-92 Laws of Florida filed. |
| Apr. 09, 1996 | Notice of Filing; Transcript Vol 1 of 1 filed. |
| Mar. 22, 1996 | Petitioner`s Supplemental Memorandum of Law in Support of its Motion to Dismiss Intervenor filed. |
| Mar. 21, 1996 | Petitioner`s Supplemental Memorandum of Law in Support of its Motion to Dismiss Intervenor filed. |
| Mar. 18, 1996 | (From S. Frazier) Notice of Hearing filed. |
| Mar. 01, 1996 | Central Park Lodges, Inc.`s Notice of Correction and Notice of Availability filed. |
| Feb. 27, 1996 | Central Park Lodges, Inc.`s Notice of Correction and Notice of Availability filed. |
| Feb. 27, 1996 | Central Park Lodges, Inc.`s Amended Petition for Leave to Intervene and Incorporated Memorandum of Law filed. |
| Feb. 27, 1996 | Central Park Lodges, Inc.`s Amended Petition for Leave to Intervene and Incorporated Memorandum of Law filed. |
| Feb. 26, 1996 | (Petitioner) Motion to Dismiss With Prejudice filed. |
| Feb. 22, 1996 | Central Park Lodges, Inc.`s Amended Petition for Leave to Intervene and Incorporated Memorandum of Law filed. |
| Feb. 20, 1996 | Notice of Hearing sent out. (hearing set for Aug. 14-16, 1996; 10:00am; Talla) |
| Feb. 16, 1996 | (Petitioner) Response to Hearing Officer`s Prehearing Order; Letter to Eric Tilton from Connie Oliver Re: Dates available for hearing filed. |
| Feb. 14, 1996 | Order sent out. (Central Park Lodges Petition for Leave to Intervene is Dismissed with Leave to file Amended Petition within 20 Days) |
| Feb. 12, 1996 | (Petitioner) Response Opposing Petition to Intervene filed. |
| Feb. 09, 1996 | Central Park Lodges, Inc.`s Petition for Leave to Intervene filed. |
| Feb. 07, 1996 | Prehearing Order sent out. |
| Feb. 06, 1996 | Central Park Lodges, Inc.`s Petition for Leave to Intervene filed. |
| Jan. 30, 1996 | Notification card sent out. |
| Jan. 25, 1996 | Notice; Petition for Formal Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Jul. 03, 1997 | Agency Final Order | |
| Mar. 24, 1997 | Recommended Order | Certificate of Need (CON) application for long-term care hospital should be denied because there is no need. Available alternatives are acute hospitals and sub-acute skilled nursing facilities. |
