STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARING

ADVENTIST HEALTH SYSTEMS/SUNBELT ) d/b/a MEDICAL CENTER HOSPITAL, )

)

Petitioner, )

and ) CASE NO. 83-2512

)

FAWCETT MEMORIAL HOSPITAL, )

)

Intervenor, )

)

vs. )

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

) FAWCETT MEMORIAL HOSPITAL, )

)

Petitioner, )

)

vs. ) CASE NO. 83-2626

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice this cause came on for formal hearing before P. Michael Ruff, duly designated Hearing Officer, on November 13-14, 1984 in Punta Gorda, Florida. The appearances were as follows:

APPEARANCES

For Petitioner: William B. Wiley, Esquire

666 Lewis State Bank Building Tallahassee, Florida 32301

Gary L. Wilkins, Esquire

590 Harbor Boulevard Northwest, Suite 204 Port Charlotte, Florida 33952

For Respondent: John M. Carlson, Esquire

Department of Health and Rehabilitative Services

1317 Winewood Boulevard

Building 2, Room 407

Tallahassee, Florida 32301

For Intervenor: E. G. Boone, Esquire, and

Robert T. Klingbeil, Esquire 1001 Avenida del Circo Venice, Florida 34284

This case (No. 83-2512) arose upon the application of Adventist Health systems/Sunbelt d/b/a Medical Center Hospital (Medical Center) for a Certificate of Need (CON) to establish a cardiac catheterization laboratory (cath lab) in its hospital, facility in Punta Gorda, Florida. Case No. 83-2626 was initiated upon the filing of an application by Fawcett Memorial Hospital for a similar cardiac catheterization laboratory. Both applications were denied initially by the Department of Health and Rehabilitative Services (HRS) and both applicants petitioned for a formal proceeding to contest that denial, and Fawcett Memorial Hospital was granted intervention in the case arising upon the petition of Medical Center Hospital (83-2512). Because of the similar issues, subject matter and witnesses, the two cases were consolidated and heard together.

Shortly after the commencement of the hearing, it was learned that a decision had been reached in another case involving the application of a medical facility in Venice, Florida for a cardiac cath lab which prompted Fawcett Memorial Hospital to withdraw its application and voluntarily dismiss its petition in Case No. 83-2626 as well as its petition intervention in Case No.

83-2512. The remaining Petitioner, Medical Center, presented 13 exhibits, all of which were admitted into evidence. It presented witnesses Mark Druash, Louis Rosenfield, M.D., Melvyn J. Katzen, M.D., William A. Haupt and Kenneth Price.

Mr. Druash was tendered and accepted as an expert in the field of health care planning. Dr. Rosenfield was tendered and accepted as an expert in the field of internal medicine and cardiology. Dr. Katzen was tendered and accepted as a radiological expert. The Respondent, Department of Health and Rehabilitative Services (HRS), presented six exhibits, all of which were admitted into evidence. The Respondent presented one witness, Eugene Nelson, who was tendered and accepted as an expert in the field of health care planning in Florida. The general issue involved concerns whether the Petitioner's CON application for a cath lab should be approved and more specifically, whether that CON should be granted or denied using the straight mathematical need calculation formula contained in Rule 10-5.11(15)(1) and (0), Florida Administrative Code or whether the factual situation established in this case renders it a "not normal" situation in that rule, such that the application for a cath lab certificate should be granted in spite of an insufficient need as determined by strict adherence to the rule's formula.

At the conclusion of the proceeding, the parties requested a transcript and an extended briefing schedule, after which proposed findings of fact and conclusions of law and memoranda were timely filed. All proposed findings of fact, conclusions of law, and supporting arguments have been considered. To the extent that they are in accordance with the findings, conclusions and views stated herein, they are accepted. To the extent that the proposed findings, conclusions and arguments asserted are inconsistent herewith, they are rejected. Certain proposed findings and conclusions are omitted as not relevant nor as necessary to a proper determination of the material issues presented. To the extent that the testimony of various witnesses is not in accord with the findings herein, it is not credited. See, Sonny's Italian Restaurant v.

Department of Business Regulation, 414 So.2d, 1156, 1157 (Fla. 3rd DCA 1982); Sierra Club v. Orlando Utilities Commission, 436 So.2d 383 (Fla. 5th DCA 1983).

FINDINGS OF FACT

1. The Petitioner, Medical Center Hospital, is a 208 bed not-for-profit hospital located in Charlotte County, Florida. Its primary service area is Charlotte County. It has secondary service areas including DeSoto County and the peripheral areas of Lee and Sarasota Counties, which adjoin Charlotte County. It has filed an application for a Certificate of Need authorizing it to establish a cardiac catheterization (cardiac cath) lab at its facility in Punta Gorda, Florida. After review by HRS staff personnel, the Department initially elected to deny the Certificate of Need application.

   
   

2. HRS District 8 includes Collier, DeSoto, Lee, Sarasota, Hendry and Charlotte Counties. Charlotte County is in the approximate geographic center of that district and is the third most populous county in the district. There are 622 acute care beds in Charlotte County divided among three acute care hospitals. There are no cath labs in Charlotte County and in all of District 8, there are only three: (1) Memorial of Sarasota in Sarasota County, (2) Lee Memorial in Lee County and (3) Ft. Myers Community Hospital in Lee County.

   
   

3. Charlotte County has a significant population of elderly citizens. This elderly portion of the population is that portion composed of persons of the age of 60 years or older. The population growth of the county and the

   surrounding areas has been very rapid and continues to be. Charlotte County has historically grown at a rate faster than that of the State of Florida. The county has the largest percentage of elderly persons of any county population in the United States, with approximately 34 percent of its citizens being in the elderly category. Statistically, this elderly age group has the highest degree of damage to coronary arteries and major vessels of the heart. The population of persons over 45 years of age is the broader age group of candidates for cardiac catheterization, comprising approximately 55 percent of the total population of the county.

   
   

4. Approximately 40 percent of Petitioner's hospital patient volume, based upon its total admissions, consists of cardiac patients. This percentage is actually higher when computed in terms of patient days of care. Significantly, Medicare eligible patients, the more elderly patients, constitute the predominant number of Petitioner's hospital admissions. The 1981 and 1982 Medicare patient days were 67.16 percent of the Petitioner's total patient days.

   
   

5. Patients in the primary and secondary service areas of the Petitioner's hospital, as well as the other two acute care hospitals in Charlotte County, who require cardiac cath services must now be referred out of that county. This referral process, with attendant delays in providing sometimes critical emergency care to patients, disruption of their living routines and those of their families attending them, causes a significant adverse impact on patients in terms of costs, personal health risks, stress and overall adverse effects on the quality of patient care. The economic costs of this referral process are significantly higher than if a cardiac cath facility were located in Charlotte County, especially in terms of the duplicated services and duplicated expenses involved in care for such cardiac patients since many of the aspects of care provided by the Petitioner as the initial admitting facility are duplicated when the patient arrives at the referral facility.

   
   

6. A referral for cardiac cath to another physician and hospital involves transfer of the patient, if the patient is already an inpatient at the Petitioner's facility or one of the other two Charlotte County hospitals. The cost of an ambulance or helicopter transfer is significant and must be borne by

   the patient or the patient's reimbursement provider. The patient must be admitted to the referral facility as an inpatient. This leads to an additional facility charge, not to mention additionalmental and physical stress, on the patient. In turn, another physician at the referral facility must admit the patient to that second facility. He, in turn, will charge a fee. Further, additional laboratory tests and procedures are performed at the referral facility as part of the standard patient "work-up." These include all manner of blood examinations and tests and analyses, chest x-rays, EKG's and the like.

   Fees are charged for all of these tests and procedures which, in the case of an inpatient requiring cardiac cath, would have already been performed at Use referring facility. Added to this duplication of costs is the stress occasioned the cardiac patient by simply having to go to another hospital at a distance from his home, to a new doctor, to have that new doctor with whom he is unfamiliar, perform a procedure that the patient is apprehensive about.

   Additional real-life, practical problems involving equipment breakdown can result in additional inpatient time and expense at can result in additional impatient time and expense at the referral facility, since, in the present scenario, that is the only facility in the area with a cardiac cath lab and appropriate equipment.

   
   

7. The transporting of a high risk patient, who should not be subjected to the transfer process due to the stress an risk it poses, but must be because the cath procedure cannot be legally performed by the referring facility (Petitioner), presents a clinically significant and often unacceptable risk of death for such patients. Without the cardiac cath lab capability at Petitioner's facility, optimal care to cardiac patients cannot be provided by the physicians and facilities attempting to treat such patients in the Charlotte County area.

   
   

8. The minimum service volume requirement (as delineated in the cardiac cath rule at paragraph (i)(4)) requires that a minimum of 300 cardiac cath procedures be performed annually in a cardiac cath lab within three years following the initiation of those services. The number of cardiac cath procedures generated from the Charlotte County area is and has been significantly high for a long period of time. Dr. Rosenfield established that from his practice alone in Charlotte County, 175 to 160 cases have been referred for cardiac cath services since January, 1983. Based on the practices of other cardiologists and physicians in the area, Dr. Rosenfield was able to establish that 400 to 500 cardiac cath procedures a year could be performed in Petitioner's lab, if authorized.

   
   

9. In addition to the actual patients referred out of the area, for instance to Lee County, for cardiac cath services, are those patients who refuse referrals. In these instances, patients, although recommended to undergo a cath procedure, refuse to because they are afraid or otherwise unwilling to go to an unfamiliar hospital outside of their county or to an unknown physician. Dr. Rosenfield had approximately 50 to 100 cases in his practice, in 1984, he would have referred to a cardiac cath facility in Lee County or other areas, but his patients refused to accept that arrangement. In short, it was established that the Petitioner can meet the minimum service volume requirement embodied in the so-called "cardiac cath rule."

   
   

10. The frequency of cardiac caths being performed in District 8 facilities is increasing in an unbroken trend. Catheterizations are typically performed earlier in a patient's illness and hospital stay than in former times in order to earlier and better diagnose the patient's condition. This results in a higher quality of care for the cardiac patient and lessening of the overall

    cost of that patient's care both by reducing the number of hospital days and avoidance of unnecessary, sometimes duplicative diagnostic tests. There is a clear national and District 8 trend in cardiac medical practice which consists of performing more therapeutic cardiac caths as a useful tool of preventive cardiac medicine.

    
    

11. Actual recent historical utilization and demand for cardiac cath service in District 8 has not been consistent with the prediction embodied in the calculations provided for in Rule 10-5.11(15)(1), Florida Administrative Code. That rule seeks to predict future cardiac cath procedures required in a future year (here 1986) by multiplying the 1981 actual cardiac cath use rate by the 1986 projected population in the District. The resultant figure is then divided by 600 to yield the number of cardiac caths needed as determined by the rule methodology. In the instant situation however, that abstract mathematical calculation projects that 1,833 procedures would be performed in 1986, yielding "need" for three cardiac cath labs. However, in District 8, in 1983, the actual cardiac cath procedures performed, without consideration of the six months of cardiac cath procedures performed by the Lee Memorial Lab in 1983 (annualized), were actually 2,089 procedures, significantly in excess of the need calculation the rule demonstrates for the year 1986, three years later. Utilizing the Department's rule-based mathematical calculation of need, it would be 1990 before enough procedures are projected to warrant a fourth cardiac cath lab in the District. In 1990, 2,128 procedures would be projected by the rule. Actual 1983 procedures, again only including six months of operation of the Lee Memorial Lab without annualizing that six month's experience, fall only 39 procedures short of what the formula shows to be the 1990 "need." If Lee Memorial's 1983 procedures were annualized, the resultant number of District 8 procedures in 1983 is 2,255, more than the Respondent's projected 1990 "need." Thus, the situation established for District 8 in Charlotte County is clearly a "not normal" factual situation, in that the Department's rule methodology shows for 1986, the "horizon" year at issue, and indeed even for 1990, that less procedures will be "needed" than the Petitioner established have already been performed in a single year, i.e. 1983.

    
    

12. Thus, due in part to the high percentage of elderly patients who have more frequent need of cardiac cath procedures in the Charlotte County and District 8 population, the need calculation provided for in the above rule clearly does not mesh with nor address what the actual need is already.

    
    

13. It is also significant to note that the actual numbers of cardiac cath procedures performed in District 8 cath labs in 1981, as compared to the numbers of unverified procedures reported to HRS, clearly result in a showing of a need for a fourth cath lab consistent with the need determination formula. Six- hundred thirty-three cardiac cath procedures were performed in 1981 at the Ft. Myers Community Hospital and Memorial Hospital of Sarasota. These procedures were "right heart" cath procedures which were included within complete Catheterizations or other Catheterizations procedures, which were counted as one procedure for reporting to HRS, but which in actuality involve separate procedures and billing. The addition of 633 procedures to the 1,482 procedures reported to and employed by HRS in its calculations herein results in a total of 2,115 actual 1981 procedures. Thus, the revised 1981 use rate results in a total of 2,511 projected procedures, for a 1986 horizon year need of 4.2 cath labs. The 1984 real utilization rate reveals in turn, as projected through the year end of 1984, an immediate need in District 8. This is predicated on the Department's acknowledged policy of granting one cath lab for each 600 procedures. If the 2,274 procedures actually experienced in 1984 in District 8 is divided by 600 there results a need of 3.79, or four, cath labs for 1984

    based upon the 1984 actual utilization rates. It is also noteworthy that if 1983 actual use rates are utilized, the resulting computation reveals the need for four cath labs for the year 1986.

    
    

14. The additional basis upon which the Respondent, HRS opposes the grant of the application is the feared inability of the Petitioner to meet the requirement of Rule 10-5.11(15)(i)5.a. which requires that cardiac cath labs in a facility not performing open heart surgery must submit with their CON applications a written referral agreement with a facility providing open heart surgery within 30 minutes travel time by emergency vehicle under average travel conditions. The Petitioner's application however, (Exhibit 5 in evidence) shows that indeed written referral agreements for open heart surgery between the Petitioner and Memorial Hospital of Sarasota and Ft. Myers Community Hospital have been executed. Ft. Myers Community Hospital is accessible from the Petitioner's location in 20 to 25 minutes travel time by an emergency vehicle, with normal driving time of 30 to 35 minutes.

    
    

15. In the context of financial feasibility and control or economy in health care costs to the public, it is established that the Petitioner presently has space available in its existing facility and substantially all of the equipment necessary to perform cardiac catheterization procedures. The cost of its proposed lab will be a maximum of $87,000. That cost includes purchase of new equipment and modifications to the existing examination table.1

    
    

16. It is significant that the cost of this project is substantially less than that which existing health care providers may spend without undergoing certificate of need review, as long as they do not seek to offer a new service. The cost of the project is minimal in relation to the benefits to be derived by patients of the health care service area by institution of the additional cardiac cath service represented by this application. In a similar vein, no issue has been raised concerning the financial feasibility of the Petitioners installation and operation of the proposed cardiac cath lab service.

    
    

    CONCLUSIONS OF LAW

    
    

17. The Division of Administrative Hearings has jurisdiction of the subject matter of and the parties to this proceeding. Section 120.57(1) Florida Statutes (1983).

    
    

18. This proceeding is governed by Section 381.493 and 494, Florida Statutes (1983) and Rule 10-5.11, Florida Administrative Code. Those provisions are as follows:

    
    

    Florida Administrative Code Rule 10-5.11: Criteria Against Which Applications Are Evaluated.

    (15)(f) Departmental Goal. The Department will consider applications for cardiac catheterization laboratories in context with applicable statutory and rule criteria. The Department will not normally approve applications for new cardiac catheterization laboratories in any service

    area unless additional need is indicated, as calculated by the formula in paragraph (1) below, and unless the application satisfies the requirements set forth in paragraph (O)

    below. (Emphasis added)

    Section 381.493(2), Florida Statutes (1983):

    Every consideration shall be given to

    the elimination of unnecessary duplication of health services and the provision of health services which are not currently available for which are insufficiently provided within the community. . . It is intended that strengthening of competitive forces in the health services industry be encouraged.

    
    

19. Section 381.494(6)(c), Florida Statutes (1983) provides specific review criteria that must be weighed and considered in deciding whether certificates of need should be granted and under what conditions they should be granted. In view of the prehearing stipulation signed by all parties, and in evidence herein as Joint Exhibit 1, the following criteria of Section 381.494(6)(c), Florida Statutes (1983) remain at issue:

    
    

    1. The need for the health care facilities and services 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.

    2. 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.

       5. Probable economies and improvements

       in service that may be derived from operation of joint, cooperative, or shared health care resources.

       12. 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.

       
       

20. The remaining criteria in Section 494(6)(c), Florida Statutes (1983) are not at issue in this proceeding. In this connection, concerning criterion 8, the parties stipulated and agreed that the applicant has the resources necessary to accomplish the project and operate the cath lab involved, including health manpower support staff, management personnel and funds for the capital and operating expenditures necessary. It was agreed that the applicant has the funds necessary to purchase proposed equipment for the cath lab. Although at the outset of the proceeding the portion of Criterion 8 concerning the accessibility of the proposed service to all residents of the service district remained arguably at issue, the unrefuted evidence adduced by the Petitioner and the above Findings of Fact reveal that the proposed cardiac cath lab would be in Charlotte County which is the fastest growing county in District 8 and in

    Florida, for that matter, and it lies between the location of the present cath labs in Lee County and Sarasota County. Given the above Findings of Fact concerning the demographic dynamics and population growth involved, especially of the elderly population in Charlotte County itself, it becomes obvious that the proposed lab will be readily accessible to the population centers of District 8 and indeed, lies within a 20 to 25 minute journey by emergency vehicle from facilities in Sarasota and Lee County offering open heart surgery capability. In short, it has been established that the proposed service will be readily accessible to the vast majority of residents of District 8.

    
    

21. The Petitioner has otherwise established through competent, substantial evidence of record, as reflected in the above Findings of Fact, that its application and proposed service is consistent with all remaining disputed statutory and rule criteria and has established that there is a need for the proposed cardiac cath lab in Charlotte County. The facts established above do not support the Respondent HRS' position that the need considerations and calculations with regard to this proceeding should be limited to the formula embodied in paragraph (1) of the above "cardiac cath rule." The actual facts proven with regard to this proceeding support a determination that there is indeed an actual need for the Petitioner's project in spite of the showing under the bare arithmetic calculation in the above rule that only a maximum of three labs appear to be needed in District 8. What is strikingly "not normal" here is the disparity between the naked mathematical calculation of "need" versus the real, actual demand and utilization presently being experienced for cardiac cath services and procedures in District 8. The undisputed trend is upward. For 1984, the number of procedures actually utilized exceeded those predicted by the rule methodology for the horizon year 1986. Thus, the actual case of utilization is significantly higher than one would predict by use of the bare arithmetic rule methodology. As stated by Hearing Officer Tremor in DOAH Case No. 83-3205R in a Final Order concerning a challenge to the Cardiac Cath Rule:

    
    

    Contrary to the contention of the challengers, Rule 10-5.11(15) does not preclude a considera- tion of factors other than the numerical need for additional facilities in the service area. The rule specifically states that the Department will consider applications in context with applicable statutory and rule criteria and will not normally approve applications unless additional need is indicated by the formula.

    The purpose of the rule is simply to prescribe a method for determining the numerical need for additional labs and to prescribe other require- ments for a new lab. It does not prohibit a consideration of the remaining criteria or standards for reaching certificate of need determinations, such as geographic or economic accessibility or availability, the quality of care provided by existing facilities, financial feasibility or other special circumstances. . . If the result of using the 1981 use rate is a clear underestimation of the need for

    additional services in an area, the applicant has the opportunity to demonstrate the existing facilities are unavailable or unacceptable, that quality of care in a service area is suffering from over-utilization or by providing over

    information to illustrate that the situation is not `normal' in a service area, so as to justify an application of the rules methodology. (at pages 10 and 11)

    
    

22. In other recent cases concerning "cardiac cath need" the Hearing Officers have looked at actual utilization and demand in order to determine if a definitive trend existed which exceeded the mathematical need shown by historical data. See DOAH Cases 82-1838, 82-2630, 82-2632 and 82-2636. This is precisely the situation involved at Use case at bar. Charlotte County has a large elderly and middle-aged population (over 45 years of age) which typically more frequently require such cardiac cath services, both as diagnostic preventive medicine as well as for therapeutic procedures. That population is showing a growth trend when compared to other counties in District 8 and to the state and nation as a whole. Additionally and concomitantly, there is a definite upward trend in actual utilization and demand for cardiac cath service in Charlotte County and District 8, which clearly was shown to exceed the mathematical "need" calculated by the bare use of the rule formula. This is clearly an out-of-the-ordinary situation, such that the "not normal" consideration of the cardiac cath rule should be triggered so that the actual utilization data and other actual historical data, in addition to the rule calculation itself, should be considered in determining need for the proposed lab in this case.

    
    

23. The area to be served consists of a large and growing elderly and middle-aged population which most require cardiac cath services as opposed to other segments of the population and there are substantial problems associated with transfer of these patients out of the area for cardiac cath services at the present time as that relates to the Petitioner's ability to provide quality of care at its facility and these patients' ability to timely and safely receive quality of care in the context of cardiac catheterization service and related cardiac surgery services. These problems are quite significant in the context of the legislative intent expressed in the Certificate of Need Law to eliminate unnecessary duplication of health care services. When these patients have to be transferred to a Lee County or other hospital facility, many of the services already provided at the Petitioner's facility must be repeated upon their admission to the referral hospital. Thus, some unnecessary duplication of health care services could be eliminated by the installation of the proposed unit in Charlotte County itself, such that the Petitioner's facility could provide higher quality overall medical care of a more complete nature.

    
    

24. The avoidance of transferring cardiac cath patients out of the Charlotte County area for cardiac cath services is also significant in the context of the legislative intent to reduce health care duplicative services which must be performed at the receiving hospital when such patients are referred to neighboring counties are charged to the patients. Thus, if the Petitioner could perform these services at its facility in Charlotte County the patient could have all services needed provided at one location by one hospital and avoid duplicate billings for the same tests and other services which are typically performed routinely upon admission of such patients to the referred hospital. Additionally, a concomitant result approval of Petitioner's lab will be to enhance the competition for the provision of cardiac cath services, which ultimately should result in providing better quality of cardiac cath services to patients at a lower cost.

    
    

25. Further, regarding the topic of cost, it is noted that approval of the Petitioner's lab would not frustrate a primary purpose of the Certificate of

    Need Law which is to contain health care costs. Thus, compared to the relatively high capital expenditures allowable without CON review, so long as no "new service" is offered by existing providers, the relatively lowcost of

    $87,000 for the Petitioner's project is quite minimal inrelation to the benefits it will offer for patients of the Charlotte County area and District 8 as a whole. The new service would prevent the duplicative, more costly and more stressful method of provision of cardiac cath services which patients in the geographic area involved must bear at the present time, and its cost is particularly minor when considered in relation to the benefit in terms of better overall quality of care, safety to patients and cost effectiveness which will result from approval of the application.

    
    

26. The Respondent offered no evidence to refute the Petitioner's utilization figures through 1984 which show that the 1986 horizon year projected need revealed by the Respondent's adherence to the rule methodology has in fact already been exceeded. Thus, the Respondent's adherence to the mathematical calculation of need embodied in the rule is not supported by the evidence of record and the facts of this case. Thus, the need for another cardiac cath lab has been shown to exist by Petitioner in spite of the result dictated by strict adherence to the rule.

    
    

27. The remaining criteria which were putatively at issue at the outset of the hearing were not the subject of concrete testimony and evidence by the Respondent and thus, aside from the need issue, the other statutory and rule criteria involved were substantially undisputed at the conclusion of the hearing. The Petitioner established that the remaining statutory criteria denominated above have been complied with and thus the Certificate of Need should be granted.

RECOMMENDATION

Having considered the foregoing Findings of Fact and Conclusions of Law, the evidence of record and the candor and demeanor of the witnesses, as well as the pleadings and arguments of the parties, it is, therefore

RECOMMENDED:

That a Certificate of Need authorizing the installation and operation of a cardiac catheterization laboratory for its facility at Punta Gorda, Charlotte County, Florida be issued to Adventist Health Systems/Sunbelt, d/b/a Medical Center Hospital.

DONE and ENTERED this 9th day of May, 1985 in Tallahassee, Florida.

P. MICHAEL RUFF 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 9th day of May, 1985.

COPIES FURNISHED:

William B. Wiley, Esquire

666 Lewis State Bank Building Tallahassee, Florida 32301

Gary L. Wilkins, Esquire

590 Harbor Blvd., Northwest Suite 204

Port Charlotte, Florida 33952

John M. Carson, Esquire Department of Health and

Rehabilitative Services 1317 Winewood Blvd.

Building 2, Room 407

Tallahassee, Florida 32301

E. G. Boone, Esquire and Robert T. Klingbeil, Esquire

Post Office Box 1596 Venice, Florida 34284

David H. Pingree, Secretary Department of Health and

Rehabilitative Services 1323 Winewood Boulevard

Tallahassee, Florida 32301

Docket for Case No: 83-002512CON

Orders for Case No: 83-002512CON