STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
CHARTER MEDICAL-JACKSONVILLE, INC. )
)
Petitioner, ) CASE NO. 83-0335
)
v. )
) JACKSONVILLE PSYCHIATRIC CENTER, INC. ) and STATE OF FLORIDA, DEPARTMENT OF ) HEALTH AND REHABILITATIVE SERVICES, )
)
Respondents. )
) HEALTHCARE JACKSONVILLE, INC., )
)
Petitioner, ) CASE NO. 83-0477
)
v. )
)
STATE OF FLORIDA, )
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, )
)
Respondents. )
) HEALTH CARE JACKSONVILLE, INC., )
)
Petitioner, )
)
v. ) CASE NO. 83-0478
) JACKSONVILLE PSYCHIATRIC HOSPITAL, INC., ) and DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, )
)
Respondents. )
CHARTER MEDICAL-JACKSONVILLE, INC., Petitioner, v. | ) ) ) ) ) CASE | NO. | 84-1431 |
STATE OF FLORIDA, DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES AND ATLANTIC TREATMENT CENTER, INC., Respondents. | ) ) ) ) ) |
)
)
)
HEALTH CARE JACKSONVILLE, INC., )
)
Petitioner, )
)
v. ) CASE NO. 84-2300
) STATE OF FLORIDA, DEPARTMENT OF HEALTH ) AND REHABILITATIVE SERVICES and ATLANTIC ) TREATMENT CENTER, INC., )
)
Respondents, )
and )
) COMMUNITY PSYCHIATRIC CENTER OF FLORIDA, ) INC. d/b/a CPC ST. JOHNS RIVER HOSPITAL, )
)
Intervenor. )
)
RECOMMENDED ORDER
Notice was given and an administrative hearing was held before Charles C. Adams, Hearing Officer with the Division of Administrative Hearings. On April 17, 18, 19, 20, 23, 24, 25, and 26, 1984, the first session of the hearing was conducted in Jacksonville, Florida. A further session of the hearing was held on December 4 and 5, 1984, in Daytona Beach, Florida. Finally, the concluding session of the hearing was held on December 6 and 7, 1984, in Tallahassee, Florida. The parties to this action have filed proposed recommended orders and associated memoranda. This information has been considered prior to the entry of the Recommended Order, and has been utilized to some extent. Where rejected, that rejection is based upon a determination that it was lacking in credibility or was found to be cumulative or subordinate to other facts found.
APPEARANCES
For Petitioner: William E Hoffman, Jr., Esquire Charter Medical James A. Dyer, Esquire Jacksonville, 2200 First Atlanta Tower
Inc. Two Peachtree Street, North West Atlanta, Georgia 30383-4501
George N. Meros, Jr., Esquire Post Office Drawer 190 Tallahassee, Florida 32302
E. G. Boone, Esquire Post Office Box 1596 Venice, Florida 33595
For Respondent: James M Barclay, Esquire Department of Jay Adams, Esquire Health and 1321 Winewood Boulevard Rehabilitative Building 2, Suite 256
Services Tallahassee, Florida 32301
For Respondent: Charles D. Hood, Jr., Esquire Jacksonville 444 Seabreeze Boulevard Pediatric Post Office Box 191
Center, Inc. Daytona Beach, Florida 32015
For Petitioner: Dudley McCalla, Esquire Healthcare 200 Perry Brooks Building Jacksonville Austin, Texas 78701
Inc.
James M. McLean, Esquire 1300 Gulf Life Drive Jacksonville, Florida 33207
For Respondent: Charles D. Hood, Jr., Esquire Atlantic 444 Seabreeze Boulevard
Treatment Post Office Box 191
Center Daytona Beach, Florida 32015
For Intervenor: Thomas D. Watry, Esquire Psychiatric 1200 Carnegie Building Centers of 133 Carnegie Way Florida, Inc. Atlanta, Georgia 30303
Morgan L. Staines, Esquire Community Psychiatric Centers 2204 East Fourth Street
Santa Anna, California 92705 STATEMENT OF THE ISSUES AND PROCEDURAL FACTS
Petitioner, Charter Medical-Jacksonville, Inc. ("Charter') applied, pursuant to Section 381.494, Florida Statutes, and Rule 10-5, Florida Administrative Code, for a Certificate of Need to construct a 64-bed psychiatric hospital to be located in Jacksonville, Florida. In the same batching cycle Healthcare Jacksonville, Inc., ("HCI"), a Petitioner, applied for a Certificate of Need to construct a 104-bed psychiatric hospital to be located in Jacksonville, Florida.
Respondent Jacksonville Psychiatric Hospital, Inc., ("JPC"), applied, in that batching cycle, for a Certificate of Need to construct a 95-bed psychiatric hospital in Jacksonville, Florida.
Respondent Atlantic Treatment Center ("ATC"), applied to build a 75-bed psychiatric and substance abuse hospital in Daytona Beach, Florida, and was considered within the aforementioned batching cycle.
HRS denied the applications of Charter, HCI and ATC, and approved JPC for
51 beds.
Charter and HCI then instituted proceedings pursuant to Section 120.57, Florida Statutes, to contest their denials and to contest `PC's approval. ATC also instituted a proceeding pursuant to Section 120.57, Florida Statutes, to contest its denial however, its proceeding was settled by HRS's proposed intent to grant a Certificate of Need for 50 beds (45 psychiatric and 5 substance abuse). Charter and HCI then instituted Statutes, to contest this action of partially approving ATC. All proceedings were consolidated, making the issue in
the consolidated proceedings which, if any, of the four applicants should be A granted Certificates of Need. All petitions were timely filed.
Community Psychiatric Centers of Florida, Inc., d/b/a CPC, a freestanding psychiatric hospital facility in Jacksonville, Florida, is an intervenor in the consolidated proceedings.
FINDINGS OF SUBSTANTIVE FACT I.
DESCRIPTION OF PROJECTS
Charter
Charter Medical-Jacksonville, Inc.("Charter") proposes to construct and operate Charter Glen Hospital, a 64-bed psychiatric hospital, for children and adolescents to be located in Jacksonville, Florida. Charter Glen Hospital will have 8 beds for short-term child care, 16 beds for short-term adolescent care, and 40 beds for adolescent long-term care. Charter Medical-Jacksonville, Inc. is a wholly-owned subsidiary of Charter Medical Corporation ("Charter Medical"), which was founded in 1969, and presently operates 26 psychiatric hospitals and has 16 under construction.
Charter currently operates one child and adolescent facility, Charter Colonial in Newport News, Virginia. In addition, Charter has obtained certificate of need approval for construction of two more exclusively child and adolescent psychiatric hospitals in Fort Lauderdale, Florida and in Fort Wayne, Indiana.
A number of Charter hospitals have either adolescent units: or children's units Charter Barclay in Chicago, Illinois; Charter Lake in Macon, Georgia; Charter Lakeside in Memphis, Tennessee; Peachford Hospital in Atlanta, Georgia; Charter Southland in Mobile, Alabama; Charter Ridge in Lexington, Kentucky; and Charter Glade in Fort Myers, Florida.
Charter has been awarded Certificates of Need to build other psychiatric hospitals in Ft. Myers, Florida Broward County, Florida and Ocala, Florida. The Ft. Myers facility, awarded a Certificate of Need in 1981, is currently open and operating.
Charter Glen will locate in the southeast quadrant of Jacksonville, on Phillips Highway, where Charter has an option to purchase 7.5 acres. The location of the site for Charter is appropriate. It is located off a major interstate highway making it easily accessible to the patient population. It is desirable for a psychiatric hospital to be located near a general medical facility in the event that patients need to be transferred for general medical care. Charter Glen will be approximately two miles from St. Luke's Hospital, a general medical facility.
The Charter Glen site is appropriate for the hospital design proposed by Charter. There will be room on the site for the planned outdoor recreational facilities.
Lawrence Lammers, the architect of Charter's proposed facility, has extensive experience in architecture, specifically as it relates to the design of free-standing psychiatric hospitals.
Charter Glen will be entirely contained within one building, a single story unit.
Charter's facility was designed by Mr. Lammers in close conjunction with Dr. Jack R. Morgenstern, a triple board certified psychiatrist and consultant to Charter, who provided the programmatic considerations governing the design of the building. The concept, utilized was to separate, the various patient units from each other and the rest of the hospital facilities. Under this design, patient rooms are only night-time usage areas. During the day, patients move toward the center of the hospital facility (the "hub") where the program activity areas are located. These activity areas are centrally located to facilitate usage by all, patient units. The indoor facilities include a gymnasium, occupational therapy areas, classrooms, and a cafeteria for patient dining. The design of the Charter Glen separates the children from the adolescents by the use of the self contained units.
Mr. Lammers has designed other facilities for Charter which are similar to the one designed for Charter Glen. The Charter Glen facility is based on a prototype design. The Charter, Glen design represents a suitable arrangement for treatment of the type patients contemplated for admission.
The design of the hospital provided for Charter Glen will be able to meet licensure codes and standards of the State of Florida.
Atlantic Treatment Center ("ATC")
ATC will be owned and operated by healthcare Services of America ("HSA"). HSA operates 5 free-standing psychiatric hospitals Havenwych Hospital, in Pontiac, Michigan; Cumberland Psychiatric Hospital in Fayetteville, North Carolina; Brynn Marr Hospital in Jacksonville, North Carolina; Hillcrest Hospital in Birmingham, Alabama; and Heartland Hospital in Nevada, Missouri.
HSA has 3 hospitals under construction and has been provided certificates of need to build 2 additional psychiatric hospitals, excluding the proposed Certificates of Need for the Atlantic Treatment Center ("ATC") sought to be constructed in Daytona Beach, Florida, and JPC in Jacksonville, Florida, which are under challenge in this hearing.
HSA specializes in psychiatric and substance abuse facilities.
ATC in Daytona Beach, Florida would provide specialized psychiatric services for children and adolescents in Volusia and surrounding counties. The treatment program would also address the bio-psycho-social needs of the patients' families.
The ATC facility will offer a continuum of treatment services including
10 beds for child short-term psychiatric services, 5 beds for child long-term psychiatric services, 15 adolescent beds for short-term psychiatric services, 15 adolescent beds for long term psychiatric services, and 5 adolescent short term substance abuse beds.
ATC has an option to purchase a 10 acre site at the corner of Jimmy Ann and Mason Streets in Daytona Beach. This site is close to the Daytona Community Hospital and the Halifax Hospital in Daytona Beach.
If the site proposed by ATC at the intersection of Jimmy Ann Drive and Mason Avenue in Daytona Beach is not used for construction of that facility,
there are a number of other sites available for a price of $500,000 or less which would be ` appropriate for the location of ATC.
ATC will be a single story building with an administrative wing and an activity wing. The dining area will be located adjacent to the administrative area, and ties the administrative wing to the residential area. Office and educational areas are provided. The site plan for the ATC facility includes an outdoor recreation area.
The design philosophy for the ATC facility deemphasizes the institutional ambiance associated with hospitals. To this end, ATC has attempted to make the facility more like a residential school rather than a hospital, maintaining a campus atmosphere while still permitting appropriate supervision of patients. ATC's provision of courtyards in landscaped areas is consistent with this philosophy.
The ATC facility is based on a prototype hospital concept developed by HSA over a period of years.
The ATC facility will meet all applicable state and local handicapped patients.
Healthcare International
HCI was originally formed in 1979 as a subsidiary of the Brown Schools. The Brown Schools are well known psychiatric facilities with an average length of stay for patients much in excess of 90 days. In 1982, the sole stockholder of the Brown Schools sold the school's interest in Healthcare International to the management of that Healthcare International. In that transaction, HCI became the parent organization, and the Brown Schools a subsidiary and operating division.
Other than the three Brown School facilities, HCI owns four psychiatric facilities - one in South Carolina, two in Texas, and one in Hawaii. The company operates three medical/surgical facilities, one in Tennessee, another in California, and the Tucson Community Hospital in Tucson, Arizona, acquired a few weeks prior to this hearing.
As mentioned, the Brown Schools facilities which were established prior to the formation of HCI have substantially longer lengths of stay than other psychiatric hospitals subsequently developed by HCI. HCI's proposal for Jacksonville more closely resembles its new psychiatric hospitals which have just recently been developed, as contrasted with the Brown Schools concept which had been in existence several years prior to the creation of HCI.
The facility proposed by HCI for Jacksonville, Florida, Willowood Hospital ("Willowood"), is a 104-bed psychiatric hospital intended to provide inpatient psychiatric services to child, adolescent, and young adult patients. Services provided by Willowood include psychiatric crisis intervention, inpatient diagnosis and evaluation, short-term and long-term ,psychiatric treatment, a day hospital program, ,and discharge planning and after care. The facility has 16 beds for long-term child psychiatric care, 16 beds for short- term adolescent psychiatric care, 32 beds for long-term adolescent-child psychiatric care, 16 beds for short-term young adult psychiatric care, 16 beds for short-term diagnosis and evaluation, and 8 short-term psychiatric intensive care beds, for a total of 56 short-term psychiatric beds and 48 long-term psychiatric beds.
No evidence was presented by HCI to demonstrate physician input into, the design of its facility.
Mr. Shook, the project architect for the Willowood facility, has worked on two psychiatric hospital projects.
The HCI design for its Willowood facility is constituted of a number of buildings, to include several buildings with patient living areas, a main building with an administration and education wing, dining and support wing and a crisis intervention unit building. This ,arrangement is a campus setting with the buildings being connected by uncovered sidewalks. Outdoor recreation will be offered.
A real estate broker has located an eleven-acre site for the facility in an area known as East park. HCI does not have a signed contract or option on the property. Thus, HCI has not yet made its final selection of a site.
Jacksonville Psychiatric Center
The principals in Jacksonville Psychiatric Center ("JPC"), who were initially awarded a proposed Certificate of Need by the Department of Health and Rehabilitative Services, have changed subsequent to the issuance of the proposed Certificate of Need. JPC was purchased by HSA on November 17, 1983. (Information related to the HSA organization is reflected in the discussion of the ATC proposal supra.)
JPC would be located in Jacksonville, Florida and would offer 35 adolescent and 10 child short-term psychiatric beds, 6 short-term psychiatric crisis beds, for a total of 51 beds.
The design of the building reflects the treatment philosophy by providing day rooms which would encourage patients to leave their bedrooms and mingle, decreasing the institutional feeling, and providing a place to spend unstructured time. The building is a single-story design with all indoor services being housed in that structure.
Outdoor activities would be provided.
JPC has not yet chosen a site for its Jacksonville, Florida facility.
The hospital design for the JPC facility is a prototype model by HSA.
Education for Children and Adolescents
All four proposals would meet educational needs of child and adolescent
`patients, as well as addressing their mental health.
II.
NEED FOR PROPOSED SERVICES
Short Term Psychiatric Beds
Service Area
HRS District IV is comprised of the following counties Baker, Clay, Duval, Nassau, Flagler, St. Johns and Volusia.
HRS has designated 3 subdistricts in District IV as follows:
Subdistrict 1: Baker, Clay, Duval and Nassau counties;
Subdistrict 2: Flagler and St. Johns counties
Subdistrict 3: Volusia county.
In determining need on a districtwide basis, the Subdistrict populations are taken into account in deciding which applicant or combination of applicants will best meet the needs of the district. To that end, from a health planning point of view, Subdistrict 1 is more representative than District IV as a whole, when describing the service area for short-term psychiatric facilities located in Jacksonville because: (a) historically, most patients in hospitals in the Jacksonville area have resided in Subdistrict 1 [A recent study by the Health Planning Council of Northeast Florida, showed that Baptist Hospital in Jacksonville had 84.8 percent of its patients coming from Subdistrict 1, St. Vincents Hospital had 89.9 percent of its patients coming from within Subdistrict 1, and University Hospital had 96.6 percent of its patients coming from within Subdistrict 1.] (b) Subdistrict 1 population is within the 45 minutes travel time of the proposed short-term psychiatric beds for Jacksonville, while beds in the southern part of District IV are not and (c) Subdistrict 1, has, population density sufficient to support the facility being proposed.
Likewise, Subdistricts 2 and 3 are more acceptable from a health planning point of view than District IV as a whole in describing a service area for a short-term psychiatric facility located in Daytona Beach.
Population
The University of Florida, Bureau of Economic and Business Research (BEBR) population projections show a large growth from 1970 to 1980 in District IV and a slightly smaller growth rate projected for 1990. The counties for Subdistrict 1 had 16.2 percent increase from 1970 to 1980, and from 1980 to 1990 the increase is anticipated to be 11 percent.
For the entire District IV the projected 1988 population is 1,163,540. The total projected 1980 population of Subdistrict 1 is 744,860; for Subdistrict
2 is 89,380 and for Subdistrict 3 is 329,300. The projected child and adolescent population of the entire District IV is 278,189. The projected child and adolescent population of Subdistrict 1 of District IV in 1988 is 178,087.
The population statistics show that for Subdistrict 1, approximately one-fourth of the population within Subdistrict 1 is age 0 to 19. The same approximate ration would apply to the entire District IV.
Existing Inventory and Occupancy Rates
There are currently 346 licensed short-term psychiatric beds A in District IV. All of these beds are located in general hospitals, other than 66 psychiatric beds which are located at St. Johns River Hospital, a free standing psychiatric and substance abuse hospital in Jacksonville. All of those beds, other than 30 adolescent beds at St. Johns River Hospital, are utilized as adult psychiatric beds.
The occupancy rate for all psychiatric beds in District IV (excluding
15 beds at Riverside Hospital for which no data is available) was 66.1 percent in 1983. On the other hand, the 30 A adolescent beds at, St. Johns have
operated in excess of 81 percent occupancy in recent months and most recently have run between 85 percent to 90 percent occupancy.
The JPC and ATC approvals by HRS are at issue in this hearing and are not considered as part of the inventory of beds in District IV.
Determination of Need
HRS Rule 105.11(25), Florida Administrative Code, establishes a fixed ratio for psychiatric inpatient bed need in 1988 of .35 beds per 1000 population of the applicable service area.
Multiplying the 1988 District IV population by the state bed need ratio of .35 beds per 1,000 for short-term psychiatric beds yields a gross need of 407 beds. Subtracting existing licensed beds (excluding JC and ATC) of 346 yields a net need of 61 short-term psychiatric beds in District IV.
Applying the fixed ratio of .35 beds per thousand on a subdistrict population basis yields a gross bed need of 261 in Subdistrict 1, 31 in Subdistrict 2 and 115 in Subdistrict 3. Subtracting the existing beds of 235, 12, and 99, respectively, yields a need of 26 additional beds in Subdistrict 1,
19 beds in Subdistrict 2, and 16 beds in Subdistrict 3.
HRS does not normally approve beds in a District if the total number of such beds exceeds the maximum established by application of the .35 beds 1000 population ratio, but will approve an excess if it is necessary to afford access to patients.
If the JPC facility in Jacksonville, which would contain 51 short-term beds, and the ATC facility, which would contain 25 short-term beds, were both approved as a result of this hearing process, there would be an excess of 15 short-term psychiatric beds above the 61 beds shown to be needed by the state bed ratio.
Similarly, approval of the ATC proposal and the HCI proposal which contains 56 short-term beds would also be inconsistent with application of the state fixed ratio because that combination would show a total of 81 beds, 20 beds over the 61 beds needed in District IV.
Approval of the 24 short-term beds proposed by Charter in Jacksonville and the 25 short-term beds proposed by ATC in Daytona Beach would bring on line
49 beds, within the 61 bed maximum established by application of the state fixed ratio, leaving a total 12 beds under need.
While approval of only Charter, only HCI or only JPC would be within the .35 per thousand ratio applied to District IV, it would not address the problem of accessibility to psychiatric services for residents of the Daytona Beach area.
The existing ratio of general hospital psychiatric beds in District IV is significantly above the .15 minimum required in Rule 1O5.11(25)(d)(1), Florida Administrative Code. Accordingly, new beds in District IV could be placed in a free standing hospital.
If the .35 per thousand ratio is applied to Subdistrict 1, only Charter Glen is consistent with that ratio. The net need for short-term psychiatric beds in Subdistrict 1 is 26, and it has requested 24 short-term
psychiatric beds. HCI and JPC will both have substantially more than 26 short- term beds. Accordingly, approval of HCI or JPC would create a misallocation of short-term psychiatric beds in District IV, for the area reasonably served by those proposed facilities, i.e., Subdistrict 1 In that regard approval of ATC in Subdistrict 3 would yield an excess of 9 beds however, as described before, ATC can be expected to serve Subdistrict 2 which has a need of 19 additional short term psychiatric beds.
Occupancy projections
Charter Glen and ATC can achieve in excess of 60 percent occupancy for their child and adolescent short-term beds in the second year of operation and in excess of 70 percent occupancy in the third year of operation.
The possibility of HCI and JPC achieving 60 percent for the second and
70 percent for the third years of operation, as referred to above, is less likely to occur, given the number of excess beds requested by both. Similarly, there is a question whether young adult beds proposed by HCI are needed even though they would benefit a particular element of the adult population.
Long Term psychiatric Beds Service Area
Within District IV there are two dense population centers at the geographic extremes of the district, one in Jacksonville and the other in Daytona Beach. If a single facility was located in either Jacksonville or Daytona Beach, it could not be expected to serve 90 percent of the district population within a 2 hour drive. Therefore, long term psychiatric care in both locales would be appropriate. A single facility in the geographic middle of the district, given the isolated circumstance and small population base, is not a reasonable alternative to the two hospital concept.
Existing Inventory and Occupancy Rates
There are no existing long-term psychiatric beds in District IV.
While not part of the licensed and approved inventory, existing psychiatric beds at the state facility at MacClenny, Florida, will all be closed by July 1, 1988 with the child component being closed by July 1, 1985, and may not be considered as an alternative to long-term bed needs in District IV.
Daniel Memorial Center, a nonhospital residential treatment center for emotionally disabled children, presently has a waiting list of 63 patients in the District, and is not an appropriate alternative to long term care proposed by the applicants. Determination of Need
There is no required arithmetic methodology for calculation of long- term beds under the MRS rules. HRS does consider all available needs assessment data. In addition, all existing long-term beds must be operating at 80 percent occupancy for the preceding year and an applicant has to be able to project 80 percent occupancy for the third year of operation. Further, as alluded to before, long-term psychiatric services should be accessible within a two hour driving time to 90 percent of the population of the service district.
Dr. Howard Fagin, who was accepted as an expert in health planning and psychiatric bed need assessment, used a methodology for calculating need for long-term psychiatric beds which is based upon research by the Office of
Graduate Medical Education (OGME). This methodology is an adjusted need based methodology for projecting physician requirements in psychiatry, is grounded in mental health incidence and prevalence, and involves the consensus of a national panel of experts regarding true needs and appropriate treatment interventions.
Under the GONE methodology, existing incidence and prevalence with regard to mental health conditions were determined. True needs by 1990 were then anticipated and noted by health care setting. Admission rate were also determined. Three different types of conditions were listed psychosis, neurosis, and mental retardation which together constitute 513 acute hospital admissions per 100,000 population. With regard to the applications here, no admissions for mental retardation are anticipated, and therefore, 50 admissions per 100,000 population are subtracted to get a rate of 463.
The total child and adolescent population for District IV is 278,189. This was multiplied by the 463 per 100,000 rate to project 1,288 admissions. Then the percent that were long-term was determined, based upon the definition of long-term in Florida, which is 90 days or longer. Based on statistics received from the National Institute of Mental Health which showed that for the diagnoses being considered. 18.4 percent of all patients is years of age and younger were hospitalized longer than 90 days in private psychiatric hospitals and psychiatric units in general hospitals. Dr. Fagin estimated the number of long-term (in excess of 90 day ALOS) admissions for long-term child and adolescent psychiatric care for District IV (1288 x 18.4 percent 237). Dr. Fagin then utilized a conservative length of stay of 90 days to 120 days. Utilizing this 90 to 120 day range, projected patient days were computed to range from 21.330 (237 x 120). Dividing this by 365, an expected average daily census of 58.4 to 77.9 was derived. Applying an appropriate 80 percent standard for occupancy, Dr. Fagin concluded the total number of long-term child and adolescent beds needed in District IV in 1988 to be 73 to 97. Dr. Fagin's methodology is reliable and the projected long term bed need of 73 to 97 child and adolescent beds in 1988 for District 4 is accepted as a reasonable approximation.
Daniel Sullivan, who was accepted as an expert in health planning, also applied an OGME based methodology to quantify the need for long-term child and adolescent beds in District IV. After investigation, Mr. Sullivan reasonably concluded that the OGME methodology is the most reasonable and recent methodology for projection of long-term beds available. Although Mr. Sullivan originally criticized Dr. Fagin for using this methodology, after investigation he determined that Dr. Fagin's failure to make any adjustments for the actual utilization in Florida actually resulted in an understatement of need in Florida since Florida's utilization rate is higher than the national average.
Using other OGME data, Mr. Sullivan testified that 103 admissions to long-term psychiatric facilities per 100,000 population can be expected related to child and adolescent patients. Applying these admission rates to the total 1988 District IV population for that age cohort, Mr. Sullivan projected 275 long-term psychiatric discharges. Multiplying these discharges times the average length of stay, Mr. Sullivan estimated a total of 24,480 expected
patient days for long-term psychiatric care in District IV in 1988. Dividing by
365 and taking into account an 80 percent occupancy rate, the total long-term bed need for subdistrict IV was found to be 85 beds for child and adolescents 1/ Mr. Sullivan's testimony is a reliable and acceptable approximation.
Applying the 103 admissions per 100,000 standard on a Subdistrict basis, the long-term psychiatric bed need for Subdistrict 1 in 1988 would be 57,
for Subdistrict 2 would be 8, and for Subdistrict 3 would be 20, for a total of
85 beds, per Mr. Sullivan.
Granting the long-term beds proposed by ATC and Charter would yield a total of 60 approved long-term beds for children and adolescents in District IV. HCI in combination with ATC would yield 68 long-term beds for children and adolescents. Both combinations are less than the indicated bed need. All three applicants would yield 108 beds in this category. These totals are contrasted with the calculations by Dr. Fagin of 7397 beds and Mr. Sullivan of 85 beds for the child and adolescent population. ( Approval of these beds would not limit approval of additional adult long-term psychiatric beds in the future.)
Eugene Nelson, on behalf of HRS, originally testified that no additional long-term beds should be granted in the Jacksonville area because the Daniel Memorial residential treatment facility was already operating in Jacksonville and the state facility at MacClenny had some child and adolescent beds. Nelson's testimony was in part based on the analysis of an application in a subsequent batching cycle which was for 70 long term psychiatric beds which was proposed to be located in St. Augustine. Even so, Nelson acknowledged that he had undertaken no mathematical computation of the need for beds in District IV, and that the actual number of beds needed could be substantially in excess of the 20 beds approved for ATC.
At a later date in the hearing, Mr. Nelson reconsidered his earlier testimony and encouraged the addition of 40 long-term beds in Jacksonville as well as 20 long-term beds in Daytona Beach. Mr. Nelson's reconsideration was based on the States decision to close the child and adolescent units at MacClenny and based on the filing of an application by Daniel Memorial to convert its residential beds to long-term psychiatric hospital beds, which is perceived by the trier of fact to be recognition on its part that they are not an alternative, at present, to hospital care. Mr. Nelson's current opinion that such beds are needed in Jacksonville as well as Daytona Beach is reliable and credible based on the change in circumstances and other evidence in the record.
More specifically, , Daniel Memorial hospital is a residential facility and does not have the same type of control of patients as does an acute care hospital. It has less professional staff available to service those patients, and lower physician involvement in its residential facility than in a psychiatric hospital.
Individually all applicants for long-term beds could achieve an 80 percent occupancy rate within 3 years however, only one facility of this type in Jacksonville and one in Daytona Beach are needed.
Substance Abuse
Applying the ratio of .06 per 1O0O population as required by Rule 105.11(27), Florida Administrative Code to the 1988 forecast of population for District IV there is a need for two short-term beds in District IV in 1988. While the proposed 5 bed complement at ATC is not consistent with the need formula, given the accessibility problems and the fact that ATCs beds will treat dual diagnosis psychiatric and substance abuse patients, the 5 bed substance abuse unit proposed by ATC is needed.
Accessibility
The population within District IV is unevenly distributed. As stated, there are two population centers within District IV, greater Duval County at the northern extreme of District IV, and Volusia County at the southern extreme of District IV.
Volusia County population is more than 45 minutes from Duval county, and each county having more than 10 percent of the population of the district, beds in Duval County are not accessible to Volusia residents, nor are beds in Volusia County accessible to Duval County residents. Consequently, to meet accessibility standards of Rule 105.11(25), Florida Administrative Code, short- term beds must be located in Duval and Volusia Counties.
Rule 105.11(26), Florida Administrative Code, requires long-term psychiatric services to be available within a maximum travel time of 2 hours for
90 percent of a districts population. Based on this standard, the problems of access in District IV would not be met by approving only the 20 bed long-term facility in Daytona Beach, as HRS had originally intended. This would not serve all Duval County which has more than 10 percent of the residents of the district taking into account driving times between points in Duval and Volusia counties which approach or exceed 2 hours Conversely, long-term beds in Duval County cannot reasonably be used by Volusia residents.
To reiterate, the accessibility problems posed by the two different population centers at the extremes of District IV would not be met by locating a single facility in the middle of those two population centers Mr. Nelson's testimony that this would be a great injustice and provide insufficient services to District IV is accepted. From a health planning perspective, it would make more sense to locate both long-term and short-term psychiatric services and short-term substance abuse services in the population centers in Jacksonville and Daytona Beach.
Analyzing the need for additional services in District IV on a subdistrict basis, which is a reasonable depiction of the Jacksonville and Daytona Beach population centers, results in the appropriate technique for bed deployment on this occasion. Specifically, there is a need for 26 short-term psychiatric beds in Subdistrict 1, 19 beds in Subdistrict 2 and 16 short-term psychiatric beds in Subdistrict 3. As for the long-term child and adolescent beds, per Sullivan, there is a need for 57 beds in Subdistrict 1, 8 beds in Subdistrict 2 end 2O beds in Subdistrict 3. 2/
Approval of the 24 short-term beds and 40 long-term beds at the Charter facility in Subdistrict 1 and the 25 short-term beds, 2O long-term beds, and 5 short-term substance abuse beds at the ATC facility in Subdistrict 3 would, when compared to the other alternatives presented in this case, most closely meet the needs and alleviate the access problems for patients and families served in District IV. JPC offers no long term beds and while HCI presents a closer approximation to the need for long-term beds in Jacksonville (48), or as combined with ATC district wide, its excessive number of short-term beds (56), to include unneeded adult beds and no meaningful service to Daytona Beach outweigh its viability as a choice based on the criteria of need and access in this connection, JPC offers too many short-term beds (51) in Jacksonville. Finally, the only adolescent substance abuse beds in District IV are located in Jacksonville. These beds are not accessible to the residents of Daytona Beach because of the travel time involved.
Specific Need for Child and Adolescent psychiatric Services
Children and adolescents with psychiatric disorders constitute an underserved group in District IV.
The bed need shown needed by application of the .35 per thousand rule should be allocated to children and adolescents. District IV currently experiences a gross misallocation of short term psychiatric beds between adults on the one hand and children and adolescents on the other. Evidencing this fact, of the 346 licensed short-term beds now existing, only 30 beds are devoted to the care of adolescents and none to children. As already noted, these beds are located at St. Johns River Hospital in Jacksonville and are operating at between 81 percent and 90 percent occupancy.
A large number of child and adolescent patients from the Jacksonville area have been sent to Georgia, southern Florida, and to, the Northeast Florida State Hospital because of the unavailability of psychiatric care for them in the Jacksonville area. Existing facilities are geared toward adults rather than children and adolescents.
The treatment of children and adolescents with psychiatric and substance abuse problems must involve the family unit to be successful. To participate in this treatment plan the family must have access to the treatment facility, which is not presently the situation.
The testimony of the following local witnesses called by various parties is persuasive and found to be a reliable indication of the need for child and adolescent services in District IV.
Dr. Acosta Rua is a child psychiatrist in the Jacksonville area. Presently, she admits very few patients to hospitals in the Jacksonville area because there is no unit appropriate for the admission of children with emotional problems. She occasionally refers children or adolescents out of the area for treatment because of lack of facilities. She supports the addition of child and adolescent beds in a hospital setting in Jacksonville, and believes that the construction of a child and adolescent psychiatric hospital providing both short-term and long-term beds would improve the quality of care for children and adolescents in Jacksonville.
Dr. David Sall, a Jacksonville area psychiatrist, testified that there is a tremendous need for adolescent psychiatric beds in Jacksonville. The need is not only for long term beds of which there are none, but also for short-term.
John Dupree is employed by the Mental Health Association of Volusia County. Mr. Dupcee described the BETA program which has been instituted in the Volusia County schools for the past two years The BETA program was created as a means of identifying children in the schools with substance abuse problems and make sure they were steered to or referred to the appropriate community agencies. During the first year of operation, about 320 students were referred to such agencies. To date the second year of operation, 450 to 500 referrals are anticipated being made. The BETA program has also identified a number of children with emotional and behavioral problems as well as substance abuse problems. It is estimated that as many as 15 percent of the numbers identified by the BETA program are in need of some sort of inpatient psychiatric service. patients in need of inpatient care that have been identified by the BETA program have often been referred outside of the community.
Mr. Dupree further testified that there is no reason to believe that the underlying problems identified by the BETA program in Daytona Beach are any
different for the children and adolescents in Jacksonville. Mr. Dupree has been approached about duplicating the BETA program in the Duval County school system.
Dr. Lawrence Walley, a Daytona psychiatrist testified on the need of children's adolescent psychiatric services in Daytona Beach.
Mr. Nelson testified that assuming that the application of the short- term psychiatric bed need rule yielded a need for additional beds, given the fact that the existing beds in a community were primarily adult beds with an occupancy level below 75 percent, with the few exiting adolescent beds having occupancy level in excess of 80 percent, the additional beds needed in the community ought to be allocated for children and adolescents. Nelson's testimony is reliable and credible.
Community Witnesses Who Support Various Proposals Charter
Dr. Kathleen Wall is a psychologist and the Executive Director of The Mental Health Resources Center (the MHRC). The MHRC is a comprehensive community mental health center whose mission is to provide services to the southeast section of Duval County, and most recently to provide geriatric services for Clay, Baker, Nassau and Duval Counties.
Dr. Dan percentel Stinson is a local adult and adolescent psychiatrist in Jacksonville, has been involved in discussions with representatives of Charter Medical concerning the Jacksonville proposal.
Dr. Acosta Rua is a child and adolescent psychiatrist in Jacksonville.
Dr. Taylor King is a child and adolescent psychiatrist in Jacksonville.
Mr. Barry Sales is the administrator of Nemours Children's Hospital.
ATC
Dr. Lawrence Wylie is a psychiatrist who practices in Daytona Beach.
Mr. Leo G. Salter is a clinical psychologist in Daytona Beach.
Mrs. Helen M. Gettemy is a family therapist in Daytona Beach.
Earnest Cantley is the director of the Stewart Treatment Center in Daytona Beach which is the primary alcoholism treatment center for Volusia County.
HCI
Dr. Pushpa Lata Menorta, is a Jacksonville psychiatrist.
Dr. R. Taylor King is a Jacksonville psychiatrist.
Dr. Robert Edward Grable is a Jacksonville psychiatrist.
Dr. David L. Sall is a Jacksonville psychiatrist.
Ms. Sylvia Patten is a Jacksonville social worker.
Ms. Joan Hubbard is a Jacksonville marriage and family therapist.
Ms. Yvonne Gatz is a clinical social worker and teacher in universities in Florida.
Dan Cook is the administrator at the Daniel Memorial Treatment Center.
JPC
Some professional witnesses called by other applicants said they would support this applicant if found to be a quality facility.
III
LESS COSTLY OR MORE EFFECTIVE ALTERNATIVES
There are no less costly or more effective alternatives available that would provide the same quality of care proposed by Charter and ATC. The other applicants have desirable attributes but are less compelling than the Charter and ATC combination.
Use of psychiatric beds in general hospitals is not an alternative to approval of beds in a freestanding psychiatric hospital. Generally, hospital psychiatric units are of a comparable design to medical/surgical units. General hospitals usually do not provide a complete range of recreational, occupational and physical treatment modalities, due to their restrictive physical plants.
The freestanding unit, as applied for here, by contrast, has a capability to provide a flexible environment for physical, occupational, recreational and other types of therapies which require the use of significant space, both indoors as well as outdoors
Dr. Davis testified that in a general hospital, mental health services and psychiatry are often given a low priority, either on account of the stigma associated with service or for fiscal reasons. In a freestanding psychiatric hospital, the primary focus is the mission of treating the mental health disorder. Dr. Davis s opinion is reliable and credible. 25
Residential treatment beds are no substitute for long-term hospital care. Residential facilities are limited regarding the severity of patient symptoms they may accept and in general tend to have a lower staff to patient ratio than long-term hospitals. The range of treatment modalities at residential facilities also tends to be much more limited. A nonhospital licensed residential bed could not fully substitute for the type of program that is intended for the long-term units proposed by the present applicants.
Child and adolescent psychiatric patients are often referred outside of Jacksonville for treatment as a result of not having local long-term facilities. In child psychiatry, the family unit must be intensively involved in the treatment of children and adolescents as much as possible. When a youngster is sent far from his home, it is impossible to provide as much family intervention as is feasible when the family is within a reasonable driving distance. A child and adolescent psychiatric hospital in Jacksonville would be both more convenient and a superior treatment milieu for patients and families.
Patients in Daytona Beach needing child and adolescent psychiatric services are currently sent out of the District. Because of the lack of facilities, the local psychiatric community has to treat patients in an outpatient basis that could be better handled in an appropriate inpatient
setting. It would improve the quality of care for children and adolescents in the Daytona Beach area if a facility dedicated to psychiatric treatment exclusively for children and adolescents was built there. A facility in Jacksonville which is located more than 80 miles away from Daytona Beach would not be an appropriate alternative to having a facility located in the Daytona Beach community.
The St. Johns River Hospital facility is inadequate in some ways. The staffing ratio is less in comparison to what is offered by Charter and HCI. The full-time equivalent per bed ratio at St. Johns River Hospital is usually 1.41. Dr. Taylor King, former medical director at St. Johns Hospital believes that the full-time equivalent per bed ratio of a hospital of 100 for adolescent services would have to be in the general range of 1.9 to 2.2 to be effective and this testimony is accepted. St. Johns River Hospital has limited recreational facilities.
Halifax Hospital in Daytona Beach has 48 inpatient beds on A three units and treats adult patients and on occasion, adolescents, but without particular regard for the needs of the adolescent patients. No children are treated at that facility. The Halifax Hospital is a short-term facility with lengths of stay not exceeding 30 days. The Humana Hospital in Daytona Beach is also a fairly short stay acute care treatment facility which does not treat children and adolescents except on very rare occasions.
Any treatment of children and adolescents at Halifax and Humana Hospital is only for the purpose of holding such patients until a more appropriate placement may be arranged.
The Human Resources Center (HRC) in Daytona Beach is the community mental health center providing mental health and drug abuse services for Volusia County to both indigent patients and private paying patients. At the present time, HRC has referred 10 to 15 children out of Volusia County for treatment at various types of facilities, as the only long-term treatment facilities available in the area are residential care facilities.
Dr. James White, a Daytona Beach pediatrician established that to allow children and adolescents to be treated in psychiatric beds in the Daytona Beach general hospitals was not desirable.
Charter considered existing facilities in the Jacksonville area for conversion purposes, and it was unable to find an appropriate existing facility due to the demands of the programs that Charter proposes and the specialized type of building required to accommodate then.
All applicants have the necessary expertise and resources to provide necessary support services in an efficient and cost effective manner, when compared to alternative provision of treatment.
IV
FINANCIAL FEASIBILITY AND AVAILABILITY OF FUNDS
All applicants have available necessary financing to cover project costs in construction and operation of the facilities sought for certification. 3/ Nonetheless, given the overabundance of beds sought by HCI and JPC, as previously described in this Recommended Order, expected occupancy rates within those facilities may not be sufficient to insure an adequate return on the investment in those projects, placing in question the financial feasibility of
those proposals. Differences in per diem charges for patient stay are not noteworthy when comparing the various applicants. All applicants will offer indigent care, with Charter, ATC and JPC being comparable and HCI somewhat less in its commitment.
V QUALITY OF CARE
All facilities are capable of providing high quality care, appropriate to the needs of the service area to include programs to promote assurance of the quality of care. Although HCI would allow the association of young adult, adolescent and child patients in its programs the HCI treatment programs as well as 7 those programs promoted by the other applicants in which the age groups are segregated viable in the sense of affording quality care.
VI
LOCAL HEALTH PLANS
The recommendation of the local Health Council for District IV as found as HRS Exhibit number 1 admitted into evidence indicating that no long-term beds need to be approved, is not acceptable given that the grounds given for the recommendation were:
University Hospital was scheduled to open a 15 bed adolescent crisis stabilization unit in 1984, if state funds were available.
Approval of JPCs 51 bed facility.
A new 100 bed long-term facility opened in Citra, Florida, in February, 1984.
Daniel Memorial Home, a residential treatment facility for emotionally disturbed children, is remodeling and expanding its physical plant to accommodate more residential beds for a percentage of emotionally disturbed adolescents presently being sent out of the District for psychiatric care.
These reasons are not an acceptable basis for denial of long-term beds in the district, in that University Hospitals Crisis Stabilization Unit is not a long-term facility. Secondly, the proposed JPC beds are short-term beds.
Third, the 100-bed long-term facility is outside of the district and was determined not to be an appropriate alternative on this occasion. Finally, the Daniel Memorial alternative is not an acceptable choice for reasons as discussed in the Recommended Order.
Otherwise there is no local health plan which would aid in considering the applications.
VII PLANNING HORIZON
Although the planning horizon for considering these applications could arguably have been 1989, following discussion with counsel and in view of the protracted nature of the hearing in which several sessions were necessary to conclude this process and in the interest of the utilization of consistent population information, 1988 was used as a planning horizon.
VIII
OTHER REVIEW CRITERIA
Criteria related to economies derived from joint cooperative and shared health care resources the need for special equipment, and the need for research and educational facilities have no application in this instance. The applicants are willing to seek affiliations with student nursing programs and consider clinical internship programs for physicians. The applicants do not contemplate facilities, the thrust of which would be for purposes of research and education.
Sufficient manpower is available within the applicant organizations or within the locale to operate the facilities.
The special needs of health maintenance organizations and the needs of providers who serve clients from outside the service district do not have application to this circumstance.
The impact of these proposals on cost of the delivery of health care is not expected to be significant in that the charges for patient care are within the range of charges of existing health care providers offering similar services. Thus, the applicants are not expected to have an adverse impact on the cost of providing services compared to current charges.
In recognizing another facility to provide long-term and short-term psychiatric beds in Jacksonville, Florida, in keeping with identifiable need as established in this Recommended Order, no adverse affect will be caused to St. Johns River Hospital.
None of the proposals by the applicants break any new ground in the sense of improvement or innovation in financing or delivery of services, but they may be expected to foster competition and to aid in the establishment of quality assurance and cost effectiveness
The cost related to construction, within the various applications ranges from $49,400 for Charter to $50,000 for JPC, per bed, with the only questionable cost of construction being that of JPC. This cost by JPC standing alone would not be a sufficient cause for concern however, in combination with the fact that JPC has requested an excessive number of short-term beds, compared to the needs of its service area, the Jacksonville area, JPC is not as strong a candidate for recognition through the Certificate of Need process when compared to the other applicants. The construction methods proposed by all applicants are acceptable.
CONCLUSIONS OF LAW
The Division of Administrative Hearing has jurisdiction over the parties and the subject matter in this proceeding, pursuant to Section 120.57, Florida Statutes Section 381.494, Florida Statutes, and Rule 105.11, Florida Administrative Code.
The applicants in this cause made a timely request for formal Section 120.57(1). Florida Statutes hearing.
The Intervenor petition for intervention was timely. See Rule 285.207, Florida Administrative Code.
JPC and the Intervenor moved to dismiss the application of Charter, based upon a perception that a substantial amendment to the application had been made, which should not be considered in the de novo hearing. That motion was denied as is reflected in the transcript of proceedings pertaining to the final hearing in this cause.
To be granted a Certificate of Need, it was incumbent upon the applicants, in the course of the final hearing designed to formulate the agency's response to the various applications, to address applicable criteria set forth in Section 381.494(6)(c), Florida Statutes, see also Florida Department of Transportation v. J.W.C. Company, Inc., 386 So2d 778 (Fla. 1
D.C.A. 1981). It was also necessary for the applicants to comport with Rule
(1) through (12), Florida Administrative Code, to the extent those criteria pertained to the applications at issue. Moreover, all applicants sought short-term psychiatric beds and in considering those applications the criteria identified in Rule 105.11(25), Florida Administrative Code, must be considered. Long-term beds were sought by Charter, HCI, and ATC and the rule associated with the recognition of the request for long-term psychiatric bed certification has application. That rule is Rule 1O 5.11(26), Florida Administrative Code. Finally, ATC sought the certification of its request for short-term hospital inpatient substance abuse beds and the consideration of that request is made in keeping with the criteria established in Rule 1O 5,11(27), Florida Administrative Code. Rules specifically related to subdistricting as found at 1016.001 and 1016.005, Florida Administrative Code, were not considered per se. Nonetheless, given the facts of this case review of these issues was made with regard to subdistrict boundaries within District IV.
The criteria set forth at Section 31.494(6)(c), Florida Statutes, are as follows:
The need for the health care facilities and hospices being proposed in relation to the applicable district plan and state health plan adopted pursuant to Title XV of the Public Health Service Act, except in emergency circumstances which pose a threat to the public health.
The 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 of the applicant.
The ability of the applicant to provide quality of care.
The availability and adequacy of other health care facilities and services and hospices in the service district of the applicant, such as outpatient care and ambulatory or home care services, which may serve as alternatives for the health care facilities and services to be provided by the applicant.
Probable economies and improvements in service that may be derived from
operation of joint, cooperative, or shared health care resources.
The need in the service district of the applicant for special equipment and services which are not reasonably and economically accessible in adjoining areas.
The need for research and educational facilities, including, but A 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.
The availability of resources, including health manpower, management personnel, and funds for capital and operating expenditures, for project accomplishment and operation the effects the project will have on clinical needs of health professional training programs in the service district the extent to which the services will be accessible to schools for health professions in the service district for training purposes if such services are available in a limited number of facilities. The availability of alternative uses of such resources for the provision of other health services and the extent to which the proposed services will be accessible to all residents of the service district.
The immediate and long-term financial feasibility of the proposal.
The special needs and circumstances of health maintenance organizations.
The needs and circumstances of those entities which provide a substantial portion of their services or resources,
or both, to individuals not residing in the service districts. Such
entities may include medical and other health professionals, schools,
multidisciplinary clinics, and specialty services such as open-heart surgery, radiation therapy, and renal transplantation.
The 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 the
financing and delivery of health services which foster competition and service to promote quality assurance and cost-effectiveness.
The cost methods of the proposed construction, including the costs and methods of energy provision and the availability of alternative, less costly, or more effective methods of construction.
Of the criteria reflected, numbers 5, 6, 7, 10, and 11, do not pertain to this dispute. The companion criteria set forth in Rule 105.11(1) through (12),
Florida Administrative Code are as follows
The relationship of health or hospice services being proposed to the applicable Health Systems Plan and Annual Implementation Plan and State Health Plan adopted pursuant to Title XV of the Public Health Service Act, except in emergency circumstances which pose a threat to the public health.
The relationship of health services proposed to the long-range development plan of the person providing or
proposing such health services.
The need that the population served or to be served has for such proposed health or hospice services.
The availability of alternative, less costly, or more effective methods of providing such proposed health or hospice services upon consideration of factors including, but not limited to, effects of competition of the supply of health services being proposed and Improvements or innovations in the financing and delivery of health services which foster competition and service to promote quality assurance and cost effectiveness
The immediate and long-term financial feasibility of the proposal.
The availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing health care services and hospices in the applicants health service area.
The availability of resources (including health manpower, management personnel, and funds for capital and operating needs) for the provision of the proposed services and the availability of alternative uses of such resources for the provision of other
health services.
The relationship of the proposed health services to ancillary or support services.
Special needs and circumstances of those entities which provide a substantial portion of their services or resources, or both, to individuals not residing in the health service areas in which the entities are located or in adjacent health service areas. Such entities may include medical and other health professions schools, multi disciplinary clinics, and centers for specialized services such as open heart surgery, radiation therapy, and renal transplantation.
The special needs and circumstances of health maintenance organizations.
The need for research and educational facilities, including, but not limited to, institutional training programs for doctors of osteopathy and medicine at the student internship, and residency training levels to include the effects the project will have on clinical needs of health professional training programs in the service area, the extent to which the services will be accessible to health professional schools in the service area for training purposes if such services are available in limited number of facilities, the availability of alternative uses of
such resources for the provision of other health services, and the extent to which the proposed services will be accessible to all residents of the service area.
(12)(a) The costs and methods of the proposed construction including the costs and methods of energy provision and the availability of alternative, less costly, or more effective methods of construction.
(b) The probable impact of the proposed construction project on the cost of providing health services proposed by the applicant upon consideration of factors including, but not limited to, effects of competition on the supply of health services being proposed and improvements or innovations in the financing and delivery of health
foster competition and service to promote quality assurance and cost-effectiveness.
Criteria numbers 9, 10 and 11 set forth in the rule do not pertain to this dispute.
When determining the question of the grant or denial of applications for recognition of short-term beds through the certification process, Rule 105.11(25), Florida Administrative Code, establishes a need formula, references existing utilization rates, and establishes accessibility requirements. By use of this rule, there is a demonstrated need of an additional 61 short-term psychiatric beds in 1988, the planning horizon. The majority of existing short- term psychiatric beds are for the benefit of adult patients and low occupancy rates are being experienced. The occupancy rate for the sole existing provider of short-term psychiatric beds for the benefit of child and adolescent needs, that is St. Johns River Hospital, is extraordinarily high. These facts together with additional facts as described in the facts section of this Recommended Order, indicate the need for the establishment of child and adolescent beds and no need for recognition of more adult beds upon the realization of the planning horizon. The placement of those beds should be in Jacksonville and Daytona Beach to provide access for the patients and their families. Under these circumstances, the 25 ATC beds and the 51 JPC beds would add up to a total of 76 beds, far in excess or the 61 beds indicated as needed. By contrast, HCI has requested 16 adolescent beds for short-term psychiatric treatment, aside from its diagnostic and evaluation beds (16) and intensive care unit beds (8) which may treat adults as well as child and adolescent patients. Adding in those latter units within the HCI facility, i.e.,short-term specialized beds, the total is 4O short-term beds which might possibly be used by either children or adolescents. There is an additional 16 bed short term psychiatric unit for young adults. Without the young adult beds the HCI proposal in conjunction with ATC yields 65 short term beds, with that unit the combination is 81 beds, both totals in excess of what is needed. The combination of 24 beds at Charter in Jacksonville, and 25 beds at ATC, in Daytona Beach, 49 total, would be the most appropriate combination to meet the needs for short term psychiatric beds in 1988. This determination is supported by the conclusion of law related to A an appropriate arrangement for provision of long-term psychiatric beds in District IV.
As mentioned, the consideration of long-term psychiatric beds is specifically addressed in Rule 105.11(26), Florida Administrative Code. No need formula is set forth In that rule. The rule does employ an occupancy standard, but that occupancy standard of 80 percent has no application in this instance in that there are no long-term psychiatric beds in District IV. JPC requests no long-term psychiatric beds and is a less acceptable proposal in view of the absence of a long term bed component. Charter has asked for the recognition of 4O long term psychiatric beds for the benefit of child and adolescent patients. HCl has requested recognition of 48 long-term psychiatric beds for the benefit of child and adolescent patients. ATC has sought the recognition of 20 long- term child and adolescent beds in Daytona Beach. No adult long-term care beds are sought by any of the applicants. There is a need for 73 to 97 long-term child and adolescent beds within the 1988 planning horizon related to District IV in the category of long-term psychiatric beds for child and adolescent patients. The mid-range of this estimate is 85 and is a number supported by a health planner who testified. As described in the findings of fact, these beds are best placed in Jacksonville and Daytona Beach. To that end recognition of all requests for long-term beds would mean that 108 long-term child and adolescent psychiatric beds would be located in District IV, in excess of the number needed. HCI and ATC combination would promote 68 beds which is closer to the threshold number of 73 long-term beds needed than would be found with the
combination of 40 long-term beds requested by Charter and 20 by ATC, total 60. Nonetheless, the Charter and ATC combination is more reasonable in view of the fact that the short-term bed requests of HCI and ATC together far exceed the number of short-term beds needed, coupled with the fact that the HCI requests includes unneeded adult short-term beds, making the combination of Charter and ATC a more acceptable arrangement for long-term psychiatric beds.
Consideration of the 5 short-term beds requested by ATC related to substance abuse is made in keeping with Rule 1O 5.11(27), Florida Administrative Code, while 5 beds are not needed in Daytona Beach, arguably 2 beds are needed and to allow a few additional substance abuse beds to foster the acceptability of the overall ATC project, is not a substantial deviation from this criterion, especially when the requirements of the subject rule are measured against statutory provisions and other rules provisions involved in this process Having found the Charter and ATC proposals to be more in line with the specific rules provisions related to short term, long-term, and substance abuse beds, those proposals are also found to be the most satisfactory when measured against applicable criteria set forth in Section 381.494(6)(c), Florida Statutes, and Rule 105.11(1) through (12), Florida Administrative Code, as identified previously.
Having considered the facts, and in the conclusions of law, it is, RECOMMENDED:
That a final order be entered which grants Charter a Certificate of Need to construct a 64-bed psychiatric hospital in Jacksonville, Florida grants a Certificate of Need to ATC to construct a 50-bed psychiatric and substance abuse hospital in Daytona Beach, Florida, and denies the applications of HCI and JPC for Certificates of Need to construct psychiatric hospitals in Jacksonville, Florida.
DONE and ORDERED this 19th day of March, 1985, at Tallahassee, Florida.
CHARLES C. ADAMS
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 19th day of March, 1985.
ENDNOTES
1/ Some question was raiaed about Mr.Sullivans use of population data for a 619 age range rather than 617 age range for children and adolescents. Even using the 617 population data, Mr. Sullivans methodology yields a gross need of 72 long term beds in District IV.
2/ The Fagin estimate was 73 and 97 for the entire District IV.
3/ Suggestion was nade in proposed recorded orders by Charter and HRS that legislation was not passed which would allow JPC to finance its project through issuance of industrial revenue bonds. This alleged fact not being proven in the hearing de novo, it is not found.
COPIES FURNISHED:
James A. Dyer, Esquire David Pingree, Secretary William E Hoffman, Esquire Department of Health and BONDURANT, MILLER. HISHON & Rehabilitative Services & STEPHENSON 1323 Winewood Blvd.
2200 First Atlanta Tower Tallahassee, Florida 32301 Two Peachtree Street, N.W.
Atlanta, Georgia 30383-4501 Information
Amy Jones, Esquire Charles O. Hood, Jr., Esquire Department of Health and Post Office Box 191 Rehabilitative Services Daytona Beach, Florida 32015 1323 Winewood Blvd.
Tallahassee, Florida 32301
Morgan L. Staines, Esquire Community Psychiatric Centers 2204 East 4th Street
Santa Ana, California 82705
James M. McLean, Esquire
ROGERS, TOWERS, BAILEY, JONES & GAY
1300 Gulf Life Drive Jacksonville, Florida 32207
Thomas D. Watry, Esquire 1200 Carnegie Building
133 Carnegie Way Atlanta, Georgia 30303
Dudley McCalla, Esquire
200 Perry Brooks Building Austin, Texas 78701
George Meros, Esquire
CARLTON, FIELDS, WARD EMMANUEL, SMITH & CUTLER, P.A.
Post Office Drawer 190 Tallahassee, Florida 32303
Jay Adams, Esquire Department of Health and Rehabilitative Services 1323 Winewood Blvd.
Tallahassee, Florida 32301
| Issue Date | Proceedings |
|---|---|
| Jun. 12, 1985 | Final Order filed. |
| Mar. 19, 1985 | Recommended Order sent out. CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Jun. 06, 1985 | Agency Final Order | |
| Mar. 19, 1985 | Recommended Order | Competitive applications for psychiatric beds. Recommended facilities in both Jacksonville and Daytona. |
