Date: 5/21/02 Time: 4:22 PM Pages: Sender: 850 413 9313 17 Remot, iB AGS!Q-20880 443-9813 AGENCY FOR HEALTH CARE AD esa 413 9313 PBZ ep at STATE OF FLORIDA Fu AGENCY FOR HEALTH CARE ADMINISTRATION yy 25, 02 CON NOS. 9295, 9296, & 9298 aHoA 4 RENDITION NO. ALC A-02-02 FOF-CONE snRT MEAT CLERK fs HCA HEALTH SERVICES OF FLORIDA, aw INC., d/b/a OAK BILL HOSPITAL, Petitioner vs. ° CASE NO. 00-3216CON AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. CITRUS MEMORIAL HEALTH FOUNDATION; INC., Petitioner, vs. , CASE NO. 90-3217CON AGENCY FOR HEALTH. CARE MINISTRATION and HCA HEALTH SERVICES OF FLORIDA, INC., d/b/a OAK HILL HOSPITAL, Respondents. HERNANDO HMA, INC, ab/a BROOKSVILLE REGIONAL HOSPITAL, Petitioner, VS. CASE NO. 90-3218CON AGENCY FOR HEALTH CARE ADMINISTRATION and CITRUS MEMORIAL WEALTH FOUNDATION, INC. Respondents. _ ecelve' ven vent succee ie Date: 5121102 Time: 4:22 PM re 17 Sender: 850 413 9313 ; emote FSIBi-22820 4¢3 9313 AGENCY FOR HEALTH CARE AD esa 413 9313 =P CITRUS MEMORIAL HEALTH . FOUNDATION, INC., , Petitioner , CASE NO. 00-3220-CON vs. AGENCY FOR HEALTH CARE ‘ADMINISTRATION and HERNANDO HMA, INC. d/b/a BROOKSVILLE REGIONAL HOSPITAL, Respondents. CITRUS MEMORIAL HEALTH FOUNDATION, INC., Petitioner, v. CASE NO. 90-3221-CON AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER nae This cause Was referred to the Division of Administrative Hearings (DOAH) for the assignment of an Administrative Law Judge (ALJ) to conduct @ formal administrative hearing. At issue in this proceeding ig whether the Agency for Health Care Administration (Agency) should grant the Certificate of Need (CON) applications of Citrus Memorial Health Foundation, Inc. (Citrus Memorial), HCA Health Services of Florida, Inc., d/b/a Oak Fill Hospital (Oak Hill), and Hernando HMA, Inc., d/b/a Brooksville Regional Hospital (Brooksville Regional) for adult open heart gurgery programs. The assigned ALJ, David M. Maloney, submitted to the Agency 4 Recommended Order dated October 4, 3001, which is incorporated herein by reference (except as noted, infra). ecelve: ven ven ucceede Time: 4 Sender: Date: 5/24 102 22 PM Pi Pages: 47 g60 413 9313 ; eS S1B:-20850 443 9313 aGency FOR HEALTH CARE AD gs@ 413 9315 p.a4 RULINGS ON EXCEPTIONS ON Brooksville Regional filed exceptions te which Oak Bill filed a response. Likewise, Oak y Hill filed exceptions to which Brooksville Regional filed a response: Citrus Memorial filed no exceptions, put filed @ single response to the separate exceptions filed by Brooksville Regional \ and Oak Hill. The Agency filed neither exceptions nor responses to the exceptions filed. : pROOKSVILLEREGIONAS : Brooksville Regional excepts to several of the ALJ’s findings of fact as being unsupported by competent substantial evidence in the record. TO the contrary, the Agency finds that these ndings of fact are supported by competent substantial record evidence Brooksville Regional’s exceptions in this regard to the findings of fact in paragraphs 21, 187, 188, 189, and 490 are accordingly denied. See generally § 120.5701), Fla. Stat. (providing in pertinent part that ‘“[t}he agency may not reject OF modify the findings of fact unless the agency first determines from a review of the entire record . . - that the findings of fact were not based upon competent substantial evidence”); eifetz v Department of Bus. Regulation, 475 $0. 24 1277, 1281 (Fila. 1935) (holding that an agency “May not reject the hearing officer’s finding {of fact| unless there js no competent, substantial evidence from which the finding could reasonably be inferred”). Brooksville Regional also excepts to several of the ALS’s findings of fact as being contrary to the record evidence. However, the Agency has no authority to reject findings of fact for being contrary tO the record evidence; rather, aS discussed above and pertinent here, the Agency may not reject oF modify 30 ALI’s findings of fact unless jt determines that such findings are not based upon competent substantial evidence in the record. See § 120.5710» Fla. Stat; Heifetz. The Agency finds the challenged findings of fact to be supported by competent substantial evidence in the record. Brooksville Regional’s exceptions based on eceive ven ven uccee Date: | §/21102 Time: 4:22 PM nae oa 47 Sender: 850 413 9313 eG 8!Bt-20820 4tA 9313 AGENCY FOR HEALTH CARE AD gs@ 413 9313 contrary record evidence to the findings of fact in paragraphs 184, 185, 187, 188, 189, and 190 are accordingly denied. Its exceptions in this regard to the conclusions of Jaw in paragraphs 226, 228, 229, and 234 are likewise denied. Brooksville Regional additionally excepts to some of the ALJ’s findings of fact as Jacking relevance. Again, however, the Agency has no authority to reject findings of fact for Jacking relevance; rather, a5 discussed above and pertinent here, the Agency may not reject or modify an ALS’s findings of fact unless it determines that such findings are not based upon competent substantial evidence in the record. See § 120,574)» Fla. Stat.; Heifetz. In any event, the Agency finds the challenged findings of fact to be relevant to the comparative review that is both required in this context and within the Agency’s substantive jurisdiction. The Agency further finds that the challenged findings of fact are supported by competent substantial evidence in the record. Brooksville Regional’s exceptions based on relevance to the findings of fact in paragraphs go and 184 are accordingly denied. Brooksville Regional further excepts to several of the ALI’s findings of fact as being contrary to the parties’ Stipulation Agreement. However, the Agency finds that the challenged findings of fact are not contrary to the Stipulation Agreement. The Stipulation Agreement simply set forth a baseline of facts not im dispute and confirmed that, a5 a result, the minimum requirements of various revieW criteria had been satishied by each applicant. That baseline established, the Stipulation Agreement did nothing to obviate the practical aspect of what it means to be comparatively reviewed. The Stipulation Agreement did not preclude the introduction of evidence as to the stipulated criteria, nor did it prohibit a comparison among the applicants with regard to those criteria. None of the findings of fact in the Recommended Order finds that a stipulated criteria was not met or satisfied. P.@s RECETTETEVEM TEV is EN Date: 5/21/02 :22 PM et os 17 Sender: 850 413 9313 . ex SIDE-20850 4ta 9313 AGENCY FOR HEALTH CARE AD esa 413 9313. P86 Further, the Stipulation Agreement itself explicitly provides that “{nJotwithstanding these stipulations, it is agreed that any Applicant may introduce testimony OF evidence regarding its plans or ability to develop and operate high quality open heart and angioplasty services.” Such “testimony OF evidence” Was indeed introduced below and provides the necessary competent at substantial evidence to support the findings of fact at issue. Brooksville Regional does not contend otherwise, and its exceptions to the findings of fact in paragraphs 80, 184, and 185 as contradicting the Stipulation Agreement are accordingly denied. Brooksville Regional’s exceptions tO the ALI’s conclusions of Jaw in paragraphs 22% and 229 as contradicting the Stipulation Agreement are likewise denied. However, based on the Stipulation Agreement and the ALJ's findings of fact thereon, Brooksville Regional’s exception to the ALJ's conclusion of Jaw in paragraph 232 is well taken. Specifically, the ALJ in that paragraph concluded. in pertinent part that “Brooksville’s 91-bed facility .- - is not a facility large enough to adequately support an open heart surgery program.” This conclusion of law is directly contrary to the parties’ Stipulation Agreement and the ALJ’s findings of fact thereon in paragraphs 27 and 32, respectively, that “each applicant has the ability to provide adequate and reasonable quality of care for [the] proposed services” and that “it is undisputed that each applicant will have the support services, operational houts, open heart surgery team mobilization, acoreditation, availability of health personne! necessary for the conduct of open heart surgery, and post-surgical follow-up care required by the {applicable} Rule in order to operate an adult open heart surgery program.” Generally speaking, both the ALJ and the Agency ate pound by the parties’ stipulations, see, 6-2.» Doyle v- Department of Bus. Regulation, 7194 So. 2d 686, 689-93 (Fla. 1st DCA 2001); Schrimsher Vv: School Bd. of Palm Beach County, 694 So. 2d 856, 863 @ia. 4th DCA 1997), and, ecelve ven ven ucceede Date: | 5/21/02 Time: 4:22 PM naan 17 Sender: B50 413 9313 ; ote SIB:-20880 44a 9313 AGENCY FOR HEALTH CARE AD a58 413 9313 further, the Agency is bound by the ALJ's findings of fact thereon a5 necessarily being supported by competent substantial evidence in the record. Having stated with particularity these reasons for rejecting the ALJ’s conclusion of law in this regard, the Agency accordingly grants Brooksville’s exception thereto in paragraph 232. In conformance with section 120.5701): Florida Statutes, the Agency specifically finds that it has substantive jurisdiction over the conclusion of Jaw at issue and that its substituted conclusion of law as set forth above is a8 OF more reasonable than that which was rejected. Finally, Brooksville Regional excepts to the ALJ's conclusion of jaw in paragraph 223 as peing jegally jncorrect and misplaced. Accord Oak Hill’s Response at 7 (concurring with this exception). The Agency has substantive jurisdiction over the administrative rule at issue and finds the ALI’s interpretation of same to be both reasonable and correct. See generally § 120.57(1)(). Fla. Stat. Brooksville Regional’s exception (and Oak Hill’s concurrence therewith) to the conclusion of law in paragraph 223 18 accordingly denied. OAK HILL Oak Hill wariously excepts to several of the ALJ's findings of fact as failing to recognize certain record evidence or as being conjectural, speculative, jtlogical, or contrary to other factual findings of the ALJ. The Agency has 00 authority to reject findings of fact for any of these reasons; rather, a5 discussed above and pertinent here, the Agency may not reject oF modify an AL)’s findings of fact unless jt determines that such findings 4° not based upon competent substantial evidence the record. See § 120.5701)@), Fla. Stat; Heifetz. Qak Hill in its exceptions does additionally agsert that the findings of fact at issue are not supported by competent substantial evidence in the record, but the Agency finds to the contrary that these P.a? vs ic Récewea vent fevent Succeeded) Date: . 5/21/02 Time: 4:22 PM P + Pages: 17 ; Sender: 850 413 9313 ; eS SID:-20850 463 9313 AGENCY FOR HEALTH CARE AD g59 413 9313 ——P. 88 findings are all supported by competent substantial record evidence. Oak Hill’s exceptions to the findings of fact in paragraphs 121, 134, 143, 191 and 195 are accordingly denied. Oak Hill also excepts to several of the ALJ’s findings of fact as being mislabeled conclusions of law that “should be rejected because they are incorrect legal interpretations and determinations as to what constitutes 4 ‘typical’ not normal circumstance, or statements 48 to whether a circumstance rises to the jevel of ‘not normal’ as 4 matter of Jaw.” Oak Hill’s Exceptions at 12. The Agency agrees that the determination of “not normal” circumstances “typical” or otherwise) is 4 conclusion of law. As the Agency ruled in pertinent part in a recent open heart surgery case: The Agency’s determination whether considerations other than Rule need constitute “not normal” cixcumstances sufficient to justify approval despite a lack of numeric need js a conclusion of law and a matter left to the sound discretion of 1 the Agency. See Federal Property Mesnt. V. Dep’t of Health and Rehab. Servs.» of Health 482 So. 24 475 (Fla. ist DCA 1986); Humana v. Dep't ‘and Rehab. win Servs., 492 So. 2d 388 (Fla. 4th DCA. 1986). “Not normal” circumstances and the weight to be given them are determined on a case-by-case basis. See Halifax Hosp. v. Agency for Health Care Admin., 19 F.ALR. 2484, 2487 (ABCA), aff'd curiam, 698 So. 2d 841 (Fla. ist DCA 1997). BY their nature, then, “not normal” circumstances cannot be classified as typical. As such, the word “typical” is inappropriate as used by the ALJ. Florida Health Sciences Center, tne. v_ ABCA, Rendition No. AHCA-01-203-FOF-CON (Aug. 6, 2001). The same is true in the present case. Having stated with particularity these reasons for modifying the ALI’s conclusions of Jaw in this regard, the Agency accordingly partially grants Brooksville’s exceptions thereto by striking the words “. . . 4 jn the case of ‘not normal’ circumstances typically recognized by the Agency. (An example of guch a circumstance would be an access problem for a specific population.)” in paragraph 24; the words “{t]here are no typical ‘not normal’ circumstances that support any of the applications” in paragraph 25; and the words “. . - typically recognized by the Agency, and...” in paragraph 224. In conformance with ecelve ven vent succecde Date: , 5/21/02 Time: 4:22 PM Pages: gst 17 Sender: 850 413 9313 . eG SIDi-20850 46 9313 AGENCY FOR HEALTH CARE AD g59 413 9313 —~P.B9 section 120.57 (yO, Florida Statutes, the Agency specifically finds that it pas substantive jurisdiction over the conclusions of law at issue and that its substituted conclusions of law as set forth above are as or more reasonable than those which were rejected. Qak Hill’s exceptions to paragraphs 24, 25, 84, 154, and 202 are denied in all other respects insofar as the Agency finds that the ALJ’s disputed conclusions of law contained therein are otherwise both reasonable and correct, See generally § 120.5701)(D, Fla. Stat. Oak Hill also excepts to several of the ALJ’s conclusions of law as indicating that the ALJ incorrectly “reinstitutted] . - - the raw, unadjusted fixed need pool calculation of a need for one new program jn the district” and incorrectly “believed [that] only one of the three applicants could be approved.” Oak Hill’s Exceptions at 19-20. The face of the Recommended Order is ambiguous in this regard--on the one hand, the ALJ in some parts of the Recommended Order seems to acknowledge that more than one applicant may be approved, put in other parts of the Recommended Order appears to suggest that only one applicant may be approved. Compare, €.2. Recommended Order at 15, | 22 (ALJ recognizing that “all [parties] agree that there are circumstances that support the approval of at least one application (and perhaps two) for an adult open heart surgery (prograra} in District 3 for the July 2002 planning horizon”), with, 8 Recommended Order at 80, 1 225 (ALJ concluding that “Tulitimately, then, the issue in this case is, in the presence of the ‘not normal’ circumstance of an approval having no effect on the volume of the sub-350 existing providers, which of the three applicants, based on comparative review, meets the need criteria to support approval of its application”) (emphasis added). The Agency clarifies this ambiguity by concluding as @ matter of law that more than one application may be approved in this context. AS urged by Oak Hill, “(w]hile the regulatory scheme requires comparative review of co-batched applications, it does not prohibit approval of eceive vent (event succee ed) Date: 5/21/02 Time: 4:22 PM Paaer 17 Sender: 850 413 9313 ote GSHA:-20850 443.2315 AGENCY FOR HEALTH CARE AD g50 413 9313 two applications. Multiple applications submitted on the basis of ‘not normal’ circumstances are not mutually exclusive in terms of their approval.” Oak Hill’s Exceptions at 22. The Agency agrees. Having stated with particularity these reasons for rejecting the AL]’s conclusions of law in this regard, the Agency accordingly grants Oak Hill’s exceptions thereto in paragraphs 224, 225, and 231 to the extent that they can be read together ot alone 8s concluding that only one application may be approved in this context. In conformance with section 120.57(1)(), Florida Statutes, the Agency specifically finds that it has substantive jurisdiction over the interpretation of the administrative rules and the conclusions of law at jsoue and that its substituted interpretation and conclusions as get forth above are as or more reasonable than those which were rejected. Oak Hill also excepts to the ALJ's conclusion of law in paragraph 931 that “Oak Hill. .- [has not] demonstrated need to justify approval of [its] application,” urging that “Oak Hill’s proposal . . - merits approval.” Oak Hill’s Exceptions at 23. The Agency agrees. Based on the ALI’s findings of fact, the Agency reaches the opposite conclusion of law that Oak Hill has demonstrated need to justify approval of its application. See, ¢g. Eulo_v- Florida Unemployment. Appeal Comm’n, 724 So. 24 636, 637 (Fla. 2d DCA 1999) (“While the [subject agency] must accept a referee’s factual findings if they are supported by substantial, competent record evidence, it may reject the teferee’s legal conclusions based on that evidence.”); Florida Public Employees Council. 79, AFSCME V. Daniels, 646 So. 2d 813, 816 (Fla. 1st DCA 1994) (“An agency has the principal responsibility of interpreting statutes dealing with matters within their regulatory jurisdiction and expertise. . - - Therefore, [the subject agency] has authority to overrule statutory interpretation and applications made by its hearing officers.”). 10 P.18 eceivea Event (Even ucceeded) Date: . 5/21/02 Time: 4:22 PM nate — 17 Sender: 850 413 9313 a GSH-20880 463.9313 AGENCY FOR HEALTH CARE AD g58 413 9313 As found by the ALJ, almost all Hernando County residents (94 percent) jn need of open heart surgery and angioplasty services travel not only outside their county but also outside their district to receive such services at Bayonet Point Regional Medical Center (Bayonet Point). See Recommended Order at 11, 4 10; 13, qq 15-16; and 28, { 66. While the average drive time between the two hospitals is thirty minutes, a5 found by the ALJ, “it can take longer when on occasion there is traffic congestion” and, in any event, “[djrive time is but one component of the total time necessary to effectuate 4 patient transfer. Additional time is consumed in making transfer and admission arrangements with the receiving hospital, awaiting arrival of an ambulance to begin transport, and preparing and transferring the patient into and out of the ambulance.” See Recommended Order at 13, 415; 41, 4 104; 42, 4 106; 43, 4 110; and 57, 4 151 (emphasis added). Significantly, however, a5 generally found by the ALJ, “[rjevascularization within [a half hour of the onset of a heart attack] maximizes the chance of reducing permanent damage to the heart muscle from which the patient cannot recover,” while “{a}chievernent of revascularization between 30 minutes and 90 minutes of the attack results in some damage.” Recommended Order at 36, 9 87 (emphasis added). As more specifically found by the ALJ: 1f Oak Hill had an OHS program, most of the patients at Oak Hill determined to be in need of angioplasty or [open heart surgery] could receive those procedures at Oak Hill, Such an arrangement would avoid the inevitable delay and stress occasioned by 4 transfer to Bayonet Point or elsewhere. have immediate access to the interventional procedure. . + - The need is underscored for those patients presenting to Oak Hill’s [emergency yoom] with myocardial infarctions who do not respond to thrombolytics because, @8 stated earlier in this order, access to angioplasty within 30 minutes of onset is ideal. Recommended Order at 56-57, 1] 148-49; see also Recommended Order at 36, { 86 (ALJ finding acto that “(t]he faster revascularization is accomplished the better the outcome for the patient”); id. at 10 11 P. 41 Meceived Event TEvent Succeeded) Date: 5/21/02 Time: 4:22 PM Paar 7 Sender: 850 413 9313 emote GStQ:-20180 443-9815 AGENCY FOR HEALTH CARE AD esa 413 9313 P. 12 4l, 104 (ALJ finding that “[tlime delays that necessarily accompany hospital-to-hospital transfers can be critical, clinically”). “ ‘As also found by the ALJ, “[t]he need to travel outside the community carries other ; * adverse consequences for patients and their families.” Recommended Order at 41, 1 405. a7 Generally speaking, {clontinuity of care is disrupted when patients cannot receive hospital visits from their regular and trusted physicians. Separation from these physicians increases stress and anxiety for many patients, and patients heal better with lower jevels of stress and anxiety. Further, most [open heart surgety] patients are elderly, and travel by their spouses to another community to visit is stressful and difficult at best, sometimes impossible. The elderly loved ones of the patient also tend to have health problems and, even when able, the drive to the hospital 1$ stressful. Id.; accord id. at 48-49, 4 123-24. Specifically as to Oak Hill, the ALI found that “[o}nce the transfer [from Qak Hill to Bayonet Point] is achieved and [the] patient receives the required procedure, the drive can be difficult for the patient’s family and loved ones” and, as evidenced py the 7,628 resident signatures On petitions in support of Oak Hill’s efforts to obtain approval for an open heart surgery program, “(many believe travel outside Hemando County for those services is curnbersorme for loved ones who are important to the patient’s healing process.” Recommended Order at 58, 11 151-53. Based on the ALJ's findings of fact, much of the above regarding outmigzation, transfer time, and other adverse consequences for patients and their families also applies to Brooksville Regional. Significantly, however, other of the ALJ’s findings of fact are unique to and favor Oak Hill. Specifically, as to Oak Hill, the ALJ found that “[t}he number of affected residents is substantial. In 1999, for example, over 600 cardiac patients were transferred by ambulance from. Oak Hill to Bayonet Point. A greater number of patients traveled on a gcheduled basis to i 12 Received Event Tevent Succeeded) Date: 5/21/02 Time: 4:22 PM nie sia: 17 Sender: 850 413 9313 ote GStQ--20880 43-9813 AGENCY FOR HEALTH CARE AD e5B 413 9313 Bayonet Point for cardiac care.” Recommended Order at 29, { 66, Elaborating, the ALJ further found that [a] high number of residents of Oak Hill’s proposed service area present 10 its emergency room with myocardial infarctions. Many of them would benefit from prompt interventional therapies currently made available to them at Bayonet Point. Over 600 patients annually, almost two patients every day, must be transferred by ambulance from Oak Hill to Bayonet Point for cardiac care. A significant number of them would benefit from interventional therapy more rapidly available. Recommended Order at 55, 4 143; see also id, at 57, 4 150 (ALI finding that “Oak Hill teansfers an extremely high number of cardiac patients for angioplasty and open heart surgery. In 1999, Oak Hill transferred 258 patients to Bayonet Point for open heart surgery, and 311 for angioplasty/stent procedures.”); accord id. at 68, | 182 (ALJ further finding that Oak Hill transferred an additional 50 patients to Bayonet Point for cardiac catheterization) and 21, 4 38 (same). In contrast, aS found by the ALS, Brooksville Regional only “transferred a combined 383 patients after diagnostic cardiac catheterization to other hospitals for either angioplasty oF {open heart surgery.” Recommended Order at 68, 4 183; accord id, at 25, 4 53. Additionally, as found by the ALJ, “Oak Hill has the largest cardiology program among the applicants” (2,812 MDC-5 discharges jn 1999, compared to 1,130 at Brooksville Regional), and is also “the largest cardiac cath{eterization} provider among the applicants” (1,404 cardiac catheterization procedures for the 12-month period ending September 2000, compared to 812 at Brooksville Regional). Recommended Order at 66, 11 176-77; see also id. at 56, 4 147 (ALJ finding, that “Oak Hill performs an extremely high volume of cardiac cath{eterization] procedures for a hospital that Jacks an [open heart surgery) program. Tn 1999 for example, it performed 1,641 cardiac catheterizations. This is a higher volume than experienced by any of the six 12 13 P.13 sceived Event (Event succee! ed) Date: 5/21/02 Time: 4:22 PM nee 17 Sender: 850 413 9313 A GSID--208b0 469-9813 AGENCY FOR HEALTH CARE AD a50 413 9313 hospitals during the year prior to which they recently implemented new [open heart gurgery] programs.”). And geographically speaking, a5 found by the ALJ, while Brooksville Regional “is more centrally located in Hernando County than Oak Hill and proposes to serve a larger area than Oak Hill,” Recommended Order at 76, § 210, the fact remains that Oak Hill’s proposed service area “[eJontain{s] 75 percent of the county’s population, . - - encompasses the county’s concentration of recent growth,” and “is more elderly than the District 3 population as @ whole.” Recommended Order at 28, 9 64; 60, 4 159. As further found by the ALI, “‘[t}he neatness of [the Hemando County/Citms County) divide would be disrupted by the approval of the application of Brooksville Regional.” Recommended Order at 11,4 11- Finally, as comprehensively found by the ALS: Qak Hill’s physical plant, hospital size, pumber of beds, medical staff size, number of cardiologists, cath(eterization] lab capacity, number of catheterization] procedures, number of admissions, and facility accessibility to the largest local population are al) factors in its favor vis-a-vis Brooksville Regional. In sum, Oak Hill is a hospital more ready and appropriate for an adult open hear surgery program than Brooksville. Recommended Order at 68-69, ¥ 185. The Agency agrees with this finding of fact but, as stated above, disagrees with the ALI’s ultimate conclusion of law that Oak Hill has not demonstrated need to justify approval of its application. Based on all of the factual findings of the ALJ, especially those discussed above, the Agency concludes to the contrary that, on balance, Oak Hill has demonstrated need to justify approval of its application. See generally Collier Medical Center, Inc. v. State, Dep’t of Health and Rehab. Servs., 462. So. 2d 83, 84 (Fla. ist DCA 1985) (recognizing that “the appropriate weight to be given to each individual [CON] criterion is not fixed, but rather must vary on a case-by-case basis, depending upon the facts of each case”). Having stated with particularity these reasons for rejecting the ALI’s conclusion of Jaw in this 13 14 P.14 Date: 5/21/02 mnie ein: 17 Sender: 850 413 9313 eGSIQ-20850 443-9313 AGENCY FOR HEALTH CARE AD 858 413 9313 Received Event (Event Succeedeqa) Time: 4:22 PM P.AS regard, the Agency accordingly grants Oak Hill's exception thereto in paragraph 231. In is conformance with section 120.57(1)(D, Florida Statutes, the Agency specifically finds that it has ; : substantive jurisdiction over the conclusion of law at issue and that its substituted conclusion as set forth above is as or more reasonable than that which was rejected. FINDINGS OF FACT HAYS The Agency hereby adopts the findings of fact set forth in the Recommended Order as modified above and except where inconsistent with this Final Order. CONCLUSIONS OF LAW As especially pertinent here, the Agency rejects the ALI’s conclusion of law in paragraph 231 that Oak Hill has not demonstrated need to justify approval of its application. The Agency otherwise adopts the conclusions of law set forth in the Recommended Order as modified above and except where inconsistent with this Final Order. QRDER Based upon the foregoing, CON applications 9295 and 9296, submitted by Citrus Memorial Health Foundation, Inc. and HCA Health Services of Florida, Inc., d/b/a Oak Hill Hospital, respectively, for adult open heart surgery programs are granted. CON application 9298, submitted by Hemando HMA, Inc., d/b/a/ Brooksville Regional Hospital, for an adult open heart surgery program is denied. a DONE and ORDERED this Jf day of scenery 2002, in Tallahassee, Florida. ‘ONDA M. MEDOWS, MD, SECRETARY gency for Health Care Administration 4 15 Received Event (Event succeeucu) Date: 5/21/02 Time: 4:22 PM Pages. 17 Sender: 850 413 9313 A GSIQ- 29850 463-9313 AGENCY FOR HEALTH CARE AD 850 413 9313 P16 A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER JS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A " SECOND COPY ALONG WITH THE FILING FEE AS PRESCRIBED BY LAW, WITH C THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE r AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a te and correct copy of the foregoing Final Order has been furnished.by U.S. Maal, or by the method indicated, to the persons named below on this kh 4 A , 2002. i mene Tagua : Sot irginia Daire, Agency Clerk ae Agency for Health Care Administration 2727 Mahan Drive, Building 3 v Tallahassee, Florida 32308-5403 850/922-5865 COPIES FURNISHED TO: David M. Maloney, Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Stephen A. Ecenia, Esquire R. David Prescott, Esquire Thomas W. Konrad, Esquire Rutledge, Ecenia, Purnell & Hoffman, P.A. 215 South Monroe Street Suite 420 Tallahassee, Florida 32302-0551 16 KReCeIVeY CVEIIL [CVEML OULLECUrU) Date: 5/21/02 Time: 4:22 PM Pages: 17 Sender: 850 413 9313 _Remo OA SIBi 200800 4rex 9313 AGENCY FOR HEALTH CARE AD 858 413 9313 P.1? Michael J. Cherniga, Esquire Seann M. Frazier, Esquire Greenburg Traurig, P.A. 101 East College Avenue Post Office Box 1838 Tallahassee, Florida 32302-1838 James C. Hauser, Esquire Susan Hauser, Esquire Metz, Hauser & Husband, P.A. 215 South Monroe Street Suite 505 Post Office Box 10909 Tallahassee, Florida 32302-2902 John Gilroy, Esquire Agency for Health Care Administration 2727 Mahan Drive be Mail Stop # 3 Tallahassee, Florida 32308 (by interoffice delivery) Jeff Gregg Agency for Health Care Administration 2727 Mahan Drive i Mail Stop # 28 1 Tallahassee, FL 32308 y (by interoffice delivery) | 4 17 TOTAL P.1?7

Docket for Case No: 00-003218CON

Orders for Case No: 00-003218CON