STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
SHANDS TEACHING HOSPITAL )
AND CLINICS, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 96-4075
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, )
)
Respondents. )
)
This case was heard by Eleanor M. Hunter, Administrative Law Judge, designated from the Division of Administrative Hearings, on December 2-4, and 11, 1996, in Tallahassee, Florida.
For Petitioner, James M. Barclay, Esquire Shands Teaching Cobb, Cole and Bell Hospital and 131 North Gadsden Street Clinics, Inc.: Tallahassee, Florida 32301
For Respondent, Moses E. Williams, Esquire Agency For Health 2727 Mahan Drive Care Administration: Fort Knox Building 3, Suite 3431
Tallahassee, Florida 32308-5403
Whether the application for certificate of need number 8391, filed by Shands Teaching Hospital and Clinics, Inc., to establish a Medicare certified home health agency in
District 4 meets, on balance, the statutory and rule criteria for approval.
The Agency For Health Care Administration (AHCA) reviewed and preliminarily denied the application of Shands Teaching Hospital and Clinics, Inc. (Shands) for certificate of need (CON) 8391 to establish a Medicare-certified home health agency in AHCA District 4. In this proceeding, Shands challenges AHCA’s preliminary action. Home Health Integrate Health Services of Florida, Inc. also challenged the preliminary denial of its application, but voluntarily dismissed that challenge on December 6, 1996.
At the final hearing, Shands presented the testimony of Robert D. Hutson; William Miller; Sandra B. Davis; Laura Waltrip, R.N.; Keith Moore, R.N.; Libby McGriff; Edward Myers, expert in management accounting; Patricia M. Pierce, R.N., Ph.D., expert in nursing and nursing administration; and Gene Nelson, expert in health planning. Shands’ exhibits 1 and 2 were received in evidence.
AHCA presented the testimony of Cheryl Clark, expert in health planning. AHCA’s exhibits 1 and 2 were received in evidence.
The final volume of the transcript was filed on February 13, 1997. Proposed recommended orders were filed by AHCA on March 10, 1997, and by Shands on March 13, 1997.
The Agency For Health Care Administration (AHCA) is the state agency authorized to administer the certificate of need (CON) program for health care services and facilities in the state.
Shands Teaching Hospital and Clinics, Inc. (Shands) is the applicant for CON 8391 to establish a Medicare - certified home health agency in AHCA District 4. AHCA health planning District 4 includes Duval, Nassau, Baker, Clay, St. Johns, Flagler and Volusia Counties.
Shands operates a 576-bed statutory teaching hospital for the University of Florida Medical School in Gainesville, four other acute care hospitals, one rehabilitation hospital, a psychiatric facility, and out- patient clinics. Shands Home Care Division has 20 licensed home health care offices in 10 of the 11 AHCA districts in Florida. It is authorized to provide Medicare-certified services in 7 of the districts.
In District 4, Shands currently operates a licensed home health agency, or what is called a “private duty” agency (Shands-Jacksonville) which is Medicaid-certified. A CON is a prerequisite to Medicare certification. Shands proposes to condition its CON on the provision of 5 percent Medicaid and 2 percent indigent care. The project costs are estimated to total $24,285, of which $11,000 in capital
costs are intended to purchase additional computer equipment.
AHCA preliminarily denied Shand’s application because it determined that an additional Medicare certified home health agency is not needed in District 4. At the hearing, AHCA maintained that Shand’s proposal will not increase the accessibility, quality of care, efficiency, appropriateness, or adequacy of services available to Medicare recipients in District 4. AHCA has also adopted guidelines which require applicants for home health agencies to demonstrate an access problem, a payor group not being served, limited availability, and linkages with health care providers. Shands concedes that it is unable to demonstrate an access problem, that any payor group is denied service, or that home health services are not available, however, Shands has substantial linkages with other health care providers.
Home health services are provided by physical, occupational, respiratory, and speech therapists, registered nurses, licensed practical nurses, home health aides and homemakers. The cost of a home health visit to the patient’s residence differs greatly depending on whether a highly skilled nurse or therapist, or a less skilled aide or homemaker provides the service.
There are thirty-seven licensed and three approved home health agencies in District 4. Unlike health care services delivered in health care facilities, there are no physical capacity limitations on expansion. As demand increases, agencies hire or contract for the services of additional staff. As a practical matter, however, to avoid the time and expense of driving, home health agencies tend to serve patients in relatively close proximity to their offices. The available information shows 11 agencies with offices in Duval, 7 in Volusia, 3 in St. Johns, and 1 each in Clay and Flagler, and none in Nassau County. The offices of Shands-Jacksonville are located in southeast Duval county, near Interstates 295 and 95, on Baymeadows Road. The location is close to Clay and St. Johns Counties.
Numeric Need
AHCA has no rule methodology to determine the need for Medicare-certified home health agencies. The prior methodology was invalidated in Principal Nursing v. AHCA, DOAH case no. 93-5711RX, reversed in part, 650 So.2d 1113 (Fla. 1st DCA 1995).
In an attempt to establish need, Shands presented its own methodology for the July 1997 planning horizon. Shands examined hospital discharges to home health care agencies, from 1994-1995, in District 4. The methodology considers the projected growth in population over 65, actual
hospital discharges to home health agencies, and the most cost effective size of home health agencies.
Approximately 70 percent of the hospital discharges referred for home health care were patients age
65 or older. In District 4, approximately 15 percent of the population is 65 or over, as compared to 18.7 percent statewide. The population in District 4 and statewide will grow approximately 9 percent from 1996 to 2001. However, the 65 and over population of District 4 is projected to grow by 10.82 percent, as compared to statewide projected growth of 7.36 percent for the 65 and over population. By July 1997, the projected population of District 4 is 1,514,655, of which 234,404 will be over 65.
Shands also analyzed the cost effective agency size (CEAS) of home health agencies, finding the home health agencies in a range between 30,000 to 95,000 visits a year are the most cost effective, which is consistent with the average size of 46,496 visits a year for District 4 agencies. Costs for each visit to a patient are greater for smaller home health agencies, until business increases to 25,000 to 30,000 visits. After that, economies of scale allow the additional costs for each additional visit to become negligible. In large part, the costs are higher because smaller agencies have disproportionately more skilled staff, particularly nurses. Within the range of the
CEAS, the proportion of visits provided by nurses and home health aids is more balanced. When agencies become very large, over 125,000 visits, each visit begins to add costs, and home health agencies begin to increase the proportion of home health aide visits.
Factors which tend to increase use rates for home health agencies include all of those which are resulting in lower lengths of hospital stays, including the use of Diagnostic Related Group (DRG) categories, increased managed care, and other financial disincentives to hospitalization. Advances in medical care also have expanded the types of procedures or treatments administered in the home rather than in a hospital.
Medicare-certified home health agency use rates in District 4 have consistently increased from 1.65 in 1989, to 2.18 in 1990, to 2.61 in 1991, to 3.97 in 1992, to 5.46 in 1993, and 7.01 in 1994.
Shands used a blended use rate rather than assuming that the historical trend in growth will continue and, from that, projected total visits of 1,969,666 in July 1997, as compared to 1,527,000 actual visits in 1994. When divided by the mean District 4 home health agency size of 46,496 visits, the result is a need for 43 agencies in the district. After subtracting the existing 37 licensed and 3 approved agencies, Shands' expert reasonably found a need,
after rounding off 2.53, for up to 3 additional home health agencies in District 4. Of the over 400,000 projected additional visits from 1994 to 1997, Shands reasonably projects 11,000 visits in year one, and 16,000 in year two, when compared to the experiences of existing providers in the District.
Subsection 408.035(1)(a) - the need for health care facilities and services and hospices being proposed in relation to the applicable district plan and state health plan.
The 1993 State Health Plan (SHP) includes preferences for home health agency applicants proposing to
(1) serve AIDS patients, (2) provide a full range of services, including high technology services, (3) provide a disproportionate share of Medicaid and indigent care, (4) serve underserved counties, (5) use surveys to measure patient satisfaction, and (6) become JCAHO-accredited.
The district health plan (DHP) includes preferences for applicants which (1) economically meet acceptable quality standards, (2) will alleviate geographic access problems, (3) will treat HIV infected patients, (4) have adequate health manpower, (5) will serve rural county residents, (6) have letters of support from other health care providers, (7) will serve areas without CON-approved agencies, (8) will locate in counties with averages of less than 4,000 home health visits per 1,000 persons 65 years or
older, and (9) commit to having personnel on-call during evenings and weekends.
SHP(1) and DHP(3) - AIDS/HIV positive patient care
Shands provided 191 discharges for 1,514 inpatient days of care to AIDS/HIV positive patients from October 1994 through September 1995. Shands is affiliated with the Northeast Florida AIDS Network and participates in the Medicaid AIDS waiver, having qualified separately for that program. Extensive out-patient services are provided by Shands to allow AIDS patients to avoid institutionalization. All Shands nurses and home health personnel receive orientation and in-service training in the care of AIDS/HIV positive persons.
SHP (2) - a full range of services, including high technology services, is needed
Shands offers ventilator, intravenous or infusion, wound care, and high technology drug therapies, as well as pediatric care, which usually involves extremely high technology services. The high technology services are provided by licensed practical nurses or registered nurses, as opposed to home health care aides or homemakers. Shands also operates pharmacies to provide the drugs or equipment needed for high technology services.
SHP (5) - surveys for patient satisfaction; and DHP (6) - letters of support from other health care providers
and agreements with hospitals, nursing homes and other providers.
Because of its existing Medicare - certified home health agencies, Shands already uses and reports to the state the results of its surveys. Shands also has agreements with doctors, hospitals and managed care organizations. Shands' application also includes the required letters of support.
Subsection 408.035(1)(b) - availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing health care services and hospices in the service district; SHP (4)- underserved counties, DHP(2) - to alleviate geographic access problems; DHP(5) - serve rural county residents;
(7) - areas without other CON - approved agencies; and (8) - counties with less than 4,000 visits per 1,000 persons 65 and over.
No geographic access data is available to determine whether or not any problem exists in District 4. There is no evidence that counties in the district are underserved, although portions of Clay and Flagler Counties are rural areas. There is no evidence that any counties in District 4 have had fewer than 4,000 home health visits per 1,000 persons 65 and over.
The existing supply of comparable services in District 4 can theoretically and legally expand to provide the projected 1,969,666 visits in 1997. However,
competition from new providers encourages quality improvements and maintains cost-efficient agency sizes.
Most Medicare-certified agencies in Jacksonville take care of only Medicare patients. Some have related entities to care for private pay or commercial insurance patients. Visiting Nurses Association (VNA) and St. Vincents in Duval County are the Medicare - certified agencies to which Shands refers patients. In 1994, VNA and St. Vincents reported 194,691 and 46,300 total visits, respectively.
Subsection 408.035(1)(c) - ability of the applicant to provide quality of care and the applicant's record of providing quality of care; and SHP (6) - JCAHO accreditation.
Shands Home Care agencies have received JCAHO accreditation, beginning in 1991. Shands successfully operates Medicare - certified home health agencies in AHCA Districts 3, 5, 6, 7, 8, 9 and 10. Shands-Jacksonville, which started in 1995, is currently being surveyed for JCAHO accreditation. Shands operates other home health agencies which, like Shands-Jacksonville, are not Medicare-certified in AHCA Districts 1 and 11.
Shands has an extensive quality assurance and quality improvement plan. Established standards of care apply to guide personnel in the procedures to follow in
providing each kind of therapy or service that Shands offers.
Subsection 408.035(1)(d) - availability, adequacy alternatives to facilities or services to be provided by the applicant.
Home health care is the preferable, lower cost alternative to longer acute care stays or to re-admissions caused by a lack of adequate care following an acute care hospital stay. Existing Medicare-certified home health agencies range from a low of 2,058 visits for Olsten in St. Johns County to a high of over 370,000 visits by Careone in Volusia County. The realistic alternative to Shands’ proposal is for Shands to continue referrals to Medicare- certified home health agencies, one of which exceeded the CEAS by more than 70,000 visits in 1994.
Subsections 408.035(1)(e) - probable economies and improvements in service that may be derived from operation of joint, cooperative, or shared health care resources; and Subsections 408.035(1)(f)
- need in the service district of applicant for special equipment and services which are not reasonably and economically accessible in adjoining areas.
The parties stipulated that the criteria in Subsections 408.035(1)(e) and (f) are not at issue or not in dispute in this case.
Subsection 408.035(1)(g) - need for research and educational facilities including, but not limited to, institutional training programs and community training programs for health
care practitioners and for doctors of osteopathy and medicine at the student, internship, and residency training levels.
As one of the six state statutory teaching hospitals, Shands meets the need for research, educational and training programs.
Subsection 408.035 (1) (h) - availability of resources; including manpower, management, personnel . . . effects on clinical needs of health professional training programs . . .; accessible to schools for health professionals . . . and the extent to which proposed services will be accessible to all residents of the district; DHP 1 - economically provide acceptable quality; DHP (4) - adequate health manpower and (9) - on- call personnel.
Shands Home Care has 2700 employees statewide. Shands Hospital and Shands Home Care have extensive recruitment and human resource capabilities. Fringe benefits include choices of several medical plans, dental insurance, legal insurance, and competitive vacation policies.
The existing Shands-Jacksonville operates from a 1500 square foot office, with a staff of 15 employees. Up to 185 contingent staff people are available to Shands - Jacksonville. The number of hours that the contingent staff works can be adjusted to meet the demands of the agency.
Shands will increase full time staff to 18 people. Shands can provide approximately $25,000 to fund the total
project cost, without affecting the costs of other services provided by Shands. In 1995, Shands’ net cash flow from operations exceeded $68 million. Shands already meets and, if CON approved, can continue to meet the requirement of having personnel on-call to provide services evenings and weekends.
Subsection 408.035 (1)(i) - immediate and long term financial feasibility of the proposal.
The parties stipulated that the long - term financial feasibility of Shands’ proposal is not in dispute and not at issue in this proceeding.
Subsection 408.035 (1)(j) - special needs and circumstances of health maintenance organizations (HMOs).
Shands maintains contractual relationships with 22 HMOs statewide, 5 of which include home health care. Shands claims that its application will meet the special needs of HMO patients. Shands does not have an HMO within its organization and is not an HMO. As AHCA has interpreted the criterion, the applicant must be an HMO to quality.
Subsection 408.035(1)(k) - needs and circumstances of entities which provide a substantial portion of their services or resources, or both, to individuals not residing in the service district in which the entities are located or in adjacent service districts.
The parties stipulated that the criterion is not in dispute or not at issue.
Subsection 408.035 (1)(l) - probable impact of the proposed project on the costs of providing health services proposed by the applicant, upon consideration of factors including, but not limited to, the effects of competition on the supply of health services being proposed and the improvements or innovations in financing and delivery of health services which foster competition and service to promote quality assurance and cost-effectiveness.
Medicare reimbursement is the same for all providers of home health services, so that the approval of an additional home health agency is not expected to affect costs. AHCA takes the position that an additional provider in District 4 will shift the market shares to the new provider to the detriment of the existing home health agencies.
The available evidence indicates that only Shands, VNA, and St. Lukes serve pediatric patients. In that market, Shands competes with VNA which had 194,691 visits in 1994, the largest number in Duval County. If certified for Medicare reimbursement, Shands will also primarily compete with VNA, and additionally, St. Vincents.
The methodology previously used by AHCA to determine the numeric need for home health agencies was an invalid rule because it was anti-competitive and failed to consider cost efficiency. The methodology used by Shands takes those factors into consideration, and demonstrates
that an additional home health agency will foster competition and cost-efficiency in District 4.
Subsection 408.035 (1)(m) - costs and methods of proposed construction including costs and methods of energy provision and the availability of alternative, less costly, or more effective methods of construction.
The parties stipulated that the criterion is not in dispute or not at issue in this proceeding.
408.035(1)(n) - proposed provision of health care services to Medicaid patients and medically indigent; and SHP (3) - disproportionate share Medicaid and indigent care.
Shands is a disproportionate share Medicaid provider and proposes a commitment to provide 5 percent Medicaid and 2 percent indigent care. In 1994 and 1995, Shands provided approximately $27 million and $28 million, respectively, in charity care. Shands Home Care provided approximately 20 percent Medicaid in 1994, 27 percent in 1995, and 27 percent through March of 1996.
408.035(1)(o) - applicants past and proposed provision of services which promote a continuum of care in a multilevel health care system, which may include, but is not limited to, acute care, skilled nursing care, home health care, and assisted living facilities.
Shands is a multi-level provider, with a range of services from virtually every tertiary service, such as open heart surgery, bone marrow, and organ transplantations to out-patient clinics. In addition to the Gainesville
teaching hospital, Shands also operates 422-bed Alachua General Hospital, 83-bed Upreach Rehabilitation Hospital, and 40-bed Vista Pavilion in Gainesville, and 54-bed Bradford Hospital in Starke, 128-bed Lake Shore Hospital in Lake City, and 30-bed Suwannee Hospital in Live Oak. The continuum of care is enhanced by the use of “clinical pathways” which direct the plan of care through an illness from inpatient to rehabilitative to home care. It provides an effective communications tool for the health care providers in each setting. Shands resources include a large statutory teaching hospital, acute care community hospitals, psychiatric and rehabilitation facilities. The continuum of care is enhanced by allowing Medicare patients discharged from the hospitals to District 4 agencies to receive follow- up home health care within the same system. Shands- Jacksonville has an integrated system for health care personnel to care for Medicaid, HMO, or private pay patients. That same group will care for Medicare patients while maintaining its Medicaid and indigent commitment.
Subsections 408.035(2) and (3) - construction of new inpatient facilities and CONs prior to 1984
Based on the parties' stipulation, Subsections
408.035 (2) and (3) are not applicable or not in dispute in this proceeding.
Agency consistency and rule-making
In the preceding batching cycle, AHCA recommended approval of two additional home health agencies in District
AHCA rated both of those as completely or partially complying with fewer review criteria, and as not complying with more review criteria than the Shands application in this cycle.
The guidelines established by AHCA which require an applicant to demonstrate existing problems with access to and a lack of available home health services are given no independent weight in evaluating the application, having not been adopted by rule. The issues are considered to the extent that accessibility and availability are included in the applicable statutory review criteria. On balance, Shands meets the criteria for approval of its CON to provide home health care to Medicare recipients in District 4.
The Division of Administrative Hearings has jurisdiction over the parties to and subject matter of this proceeding, pursuant to Subsections 408.039(5) and 120.57(1), Florida Statutes.
As the applicant, Shands has the burden of proving entitlement to a CON based on a balanced review of the criteria. Boca Raton Artificial Kidney Center, Inc., v. DHRS, 475 So.2d 360 (Fla. 1st DCA 1985).
Using its own need methodology, Shands has demonstrated a numeric need for an additional home health agency in AHCA District 4. While not necessarily conclusive, a numeric need presumptively establishes need.
Shands’ application meets all of the state health plan preferences, except the one for proposals to serve underserved counties. Shands also meets the preferences of the District 4 health plan, except those related to proposals alleviating geographic access problems, serving areas without CON-approved home health agencies, and operating in counties with less than 4,000 home health visits per 1,000 people 65 years of age and older. On balance, the application meets the preferences of the state and local health plans, as required by subsection 408.035(a).
Shands failed to demonstrate that home health services in District 4 are not available, high quality, efficient, appropriate or adequate. Shands did demonstrate that approval of CON 8391 will make home health services more available. Subsection 408.035(1)(b).
Shands provides and proposes to provide excellent quality of care. Subsection 408.035(1()c).
Home health care is one of the lowest cost alternatives to acute care, consistent with the objectives of subsection 408.035(1)(d).
Shands, as one of the six state statutory teaching hospitals, meets the requirements of subsection 408.035(1)(g).
Shands established that it has the financial resources and personnel to provide quality care in its District 4 home health agency, in compliance with subsection 408.035(1)(h).
Shands proposal to serve Medicare patients will not increase costs for home health care in District 4 and will foster competition and cost-effectiveness, which is desirable under subsection 408.035(1)(l).
Shands has a history of providing and proposes to continue to provide substantial services to Medicaid and indigent patients. Subsection 408.035(1)(n).
Shands offers an expansive continuum of care and meets the criterion of subsection 408.035(1)(o).
Shands application for CON 8391 meets all of the applicable and disputed statutory review criteria, except subsection 408.035(1)(b), and, on balance, should be approved.
Based on the foregoing Findings of Fact and Conclusions of Law, it is
Recommended that the Agency For Health Care Administration enter a Final Order issuing CON 8391 to Shands Teaching Hospital and Clinics, Inc., to establish a Medicare-certified home health agency in AHCA District 4 conditioned on providing 5 percent of total annual gross revenues by payor to Medicaid patients and 2 percent to indigent care.
DONE AND ENTERED in Tallahassee, Leon County, Florida, this 20th day of March, 1997.
ELEANOR M. HUNTER
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
Filed with the Clerk of the Division of Administrative Hearings this 20th day of March, 1997.
COPIES FURNISHED:
Moses E. Williams, Esquire
Agency For Health Care Administration Office of the General Counsel
2727 Mahan Drive
Tallahassee, Florida 32308
James M. Barclay, Esquire Cobb, Cole and Bell
131 North Gadsden Street Tallahassee, Florida 32301
Sam Power, Agency Clerk
Agency For Health Care Administration 2727 Mahan Drive
Fort Knox Building 3, Suite 3431
Tallahassee, Florida 32308
Jerome W. Hoffman, General Counsel Agency For Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308
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 |
|---|---|
| May 14, 1997 | (Respondent) Final Order filed. |
| Mar. 20, 1997 | Recommended Order sent out. CASE CLOSED. Hearing held December 2-4, & 11, 1996. |
| Mar. 13, 1997 | Proposed Recommended Orders; Shands` Proposed Recommended Order; Disk ; (Respondent) Notice of Filing; Respondent`s Proposed Recommended Order filed. |
| Mar. 10, 1997 | (Respondent) Notice of Filing; Respondent`s Proposed Recommended Order filed. |
| Feb. 13, 1997 | (4 Volumes) Transcript filed. |
| Feb. 13, 1997 | (Volume 5 of 5) Notice of Filing; DOAH Court Reporter Final Hearing Transcript filed. |
| Dec. 11, 1996 | CASE STATUS: Hearing Held. |
| Dec. 09, 1996 | Case No/s: 96-4075 & 96-4076 unconsolidated. |
| Dec. 06, 1996 | Petitioner, Home Health Integrated Health Services of Florida, Inc.`s Notice of Voluntary Withdrawal (filed via facsimile). |
| Dec. 02, 1996 | Agency for Health Care Administration`s Amended Witness and Exhibit List filed. |
| Nov. 29, 1996 | (Joint) Prehearing Stipulation (filed via facsimile). |
| Nov. 26, 1996 | Order Denying Motion to Continue and Scheduling Presentation of Cases-In-Chief at Final Hearing sent out. |
| Nov. 26, 1996 | (Home Health) Notice of Telephonic Hearing (filed via facsimile). |
| Nov. 25, 1996 | Shands` Amended Exhibit and Witness Lists filed. |
| Nov. 21, 1996 | Home Health Integrated Services of Florida, Inc.`s Supplemental Motion to Continue (filed via facsimile). |
| Nov. 20, 1996 | Shands` Exhibit and Witness Lists filed. |
| Nov. 20, 1996 | Home Health Integrated Health Services of Florida, Inc.`s Amended Exhibit List; Petitioner, Home Health Integrated Health Services, Inc.`s Amended Witness List (filed via facsimile). |
| Nov. 15, 1996 | (From M. Williams) Notice of Appearance and Substitution of Counsel; Agency for Health Care Administration`s Witness and Exhibit List filed. |
| Nov. 14, 1996 | Order Granting Home Health Integrated Health Services of Florida, Inc.'s Amended Motion for Enlargement of Time to Exchange Exhibit and Witness Lists sent out. (prehearing stipulation due 11/20/96) |
| Nov. 14, 1996 | Home Health Integrated Health Services of Florida, Inc.`s Motion to Continue (filed via facsimile). |
| Nov. 13, 1996 | Letter to EMH from Mark Emanuele (RE: Mr. Gilroy has no objection to motion for enlargement of time) (filed via facsimile). |
| Nov. 13, 1996 | Shands` Response in Opposition to Integrated`s Motion for Continuance filed. |
| Nov. 12, 1996 | Home Health Integrated Health Services of Florida, Inc.`s Amended Motion for Enlargement of Time to Exchange Exhibit and Witness Lists; Cover Letter (filed via facsimile). |
| Nov. 12, 1996 | Home Health Integrated Health Services, Inc.`s Motion for Enlargement of Time to Exchange Exhibit and Witness Lists (filed via facsimile). |
| Oct. 18, 1996 | Shands Teaching Hospital & Clinics, Inc.`s First Request for Production of Documents to Home Health Integrated Health Services of Florida, Inc.; Notice of Service of Shands Teaching Hospital and Clinics, Inc`s First Set of Interrogatories to Home Health I |
| Oct. 15, 1996 | (Petitioner) Notice of Service of Home Health Integrated Health Service of Florida, INC.`S First Set of Interrogatories to Shands Teaching Hospital & Clinics, Inc. filed. |
| Oct. 15, 1996 | Home Health Integrated Health Services of Florida, Inc.'s First Request for Production of Documents to Shands Teaching Hospital & Clinics, Inc.; Notice of Service of Home Health Integrated Health Services of Florida, Inc.'s First Set of Interrogatories to |
| Oct. 07, 1996 | Notice of Hearing sent out. (hearing set for Dec. 2-6, 1996; 10:00am; Tallahassee) |
| Oct. 03, 1996 | Petitioner`s Motion for Continuance (filed via facsimile). |
| Sep. 23, 1996 | (From M. Emanuele) Notice of Unavailability filed. |
| Sep. 11, 1996 | Letter to EMH from James Barclay (RE: response to initial order) filed. |
| Sep. 11, 1996 | Prehearing Order and Order of Consolidation sent out. (Consolidated cases are: 96-4075 & 96-4076) |
| Aug. 30, 1996 | Notification card sent out. |
| Aug. 28, 1996 | Notice; Petition for Formal Administrative Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| May 14, 1997 | Agency Final Order | |
| Mar. 20, 1997 | Recommended Order | Certificate of Need (CON) applicants' methodology established home health agency need in absence of agency's methodology. |
