STATE OF FLORIDA

DIVISION OF ADMINSTRATIVE HEARINGS

RHPC, INC. d/b/a RIVERSIDE )

HOSPITAL, INC., )

)

Petitioner, )

)

vs. ) Case No. 85-1447

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent, )

)

and )

)

BAYONET POINT REGIONAL )

MEDICAL CENTER, )

)

Intervenor. )

)

RECOMMENDED ORDER

Pursuant to notice, a final administrative hearing was held in New Port Richey, Florida, on September 30, October 1 and 2, 1986, and in Tallahassee, Florida, November 4, 1986, before Diane

D. Tremor, Hearing Officer with the Division of Administrative Hearings. The issue for determination in this proceeding is whether petitioner is entitled to a Certificate of Need to equip and operate a cardiac catheterization laboratory at its hospital in New Port Richey, Florida.

APPEARANCES

For Petitioner: Leonard A. Carson and

Robert P. Daniti Carson & Linn, P.A. 1711-D Mahan Drive

Tallahassee, Florida 32308

For Respondent: Darrell White

Assistant General Counsel Department of Health and

Rehabilitative Services 1323 Winewood Blvd.

Building 1, Room 407

Tallahassee, Florida 32399-0700

For Intervenor: Thomas M. Beason and

Donna H. Stinson Moyle, Flanagan, Katz,

Fitzgerald & Sheehan

118 North Gadsden Street Tallahassee, Florida 32301

INTRODUCTION

In support of its position of entitlement to a Certificate of Need to equip and operate a cardiac catheterization laboratory at Riverside Hospital in New Port Richey, petitioner presented the testimony of the following witnesses: Harold Annis, accepted as an expert in the area of hospital equipment, specifications and procurement; Robert A. Reynolds, accepted as an expert in the satisfaction of certification and licensure requirements for emergency transport of patients; Dr. Willard Lawrence Brown, the Chief of Medical Staff at Riverside; Mary L. Thompson, accepted as an expert in the procedures employed in Joint Commission Accreditation and- professional nursing; Leslie Rodgers, R.N., accepted as an expert in the clinical aspects of cardiac catherization laboratories, quality assurance including JCAH procedures, and professional nursing; Dr. Clifford D. Colin, accepted as an expert physician with a specialty in cardiology; Guy Wayne Dayhoff, accepted as an expert helicopter pilot; Joseph

M. Winick, accepted as an expert in the areas of health care

planning, facility planning and construction cost estimates; Dr. Ricardo Ubillus, accepted as an expert in cardiology; Dr. Stephen Goldman, accepted as an expert in cardiology; Jerry Dabkowski, accepted as an expert in traffic engineering; Dr. Jeffrey Mark Reines, accepted as an expert in cardiology; Bradley C. Reid, the Administrator at Riverside; and Wilma Newton, accepted as an expert in the fields of hospital accounting and hospital finance. Petitioner's Exhibits 1 through 12, 14 through 21, and 25 through

28 were received into evidence.

The Department of Health and Rehabilitative Services presented the testimony of Gary Silvers, accepted as an expert in health care planning, health care administration and health care finance; Edwin Standtke, accepted as an expert in emergency medical transport; Charles Duncan Hitchcock, accepted as an expert in prehospital medical care and emergency medical

transportation; and Reid Jaffy, accepted as an expert in the fields of health planning and Certificate of Need review. HRS's Exhibit 1 was received into evidence.

Bayonet Point Regional Medical Center presented the testimony of G. Natarajan, accepted as an expert in cardiology; and Dan Chambers, Jr., and Edward Patrick Smith III, both of whom were accepted as experts in the field of hospital administration.

Subsequent to the hearing, all parties filed proposed findings of fact and proposed conclusions of law. The factual findings proposed by the parties have been accepted and/or incorporated in this Recommended Order except as noted in the Appendix hereto.

FINDINGS OF FACT

Upon consideration of the oral and documentary evidence adduced at the hearing, as well as the parties' stipulations of fact, the following relevant facts are found:

1. The petitioner RHPC, Inc., d/b/a Riverside Hospital (Riverside) is licensed to operate a 102-bed general, acute care hospital located in New Port Richey, Pasco County. Formerly a public hospital known as West Pasco Hospital, Riverside was acquired by American Healthcare Management, Inc. (AHM) of Dallas, Texas, in December of 1983. By the prior issuance of Certificate of Need (CON) Number 2859, Riverside was authorized to construct and equip a new hospital building for patients and ancillary services at a cost of $14.8 million, including a special procedures room. The new building was approved for occupancy and use as a hospital in September of 1986. Riverside was able to complete construction and equipping of its new facility for an amount approximately $2.5 million less than the approved capital expenditure budget for CON No. 2859.

   
   

2. Riverside now seeks to upgrade the existing equipment in its special procedures room so as to be capable of performing cardiac catheterization procedures. The room would not be a dedicated cardiac catheterization laboratory, but would serve the dual function of both cardiac catheterization and non-cardiac angiography. While the cost of creating a brand new cardiac catheterization laboratory would normally amount to approximately

   $1.4 million, petitioner proposes an expenditure of only

   $512,474. This lower figure results from the fact that Riverside's existing special procedures room was equipped during the renovation and reconstruction authorized pursuant to Certificate of Need Number 2859, and now needs only to be upgraded to achieve cardiac catheterization capacity.

3. In 1982, prior to its acquisition by AHM, Riverside lost its accreditation through the Joint Commission on Accreditation of Hospitals (JCAH). The removal of accreditation was occasioned by code and physical plant deficiencies and documentation deficiencies related to quality assurance, infection control, medical record-keeping and staff credentialling. Riverside has attempted to eliminate all such deficiencies which led to the prior loss of accreditation. In September of 1986, Riverside submitted its application for a JCAH accreditation survey of its facility. As of the dates of the administrative hearing, the survey dates had not yet been scheduled. It generally takes JCAH approximately so days after a survey to render its accreditation decision. Riverside does not intend to offer cardiac catheterization services until JCAH accreditation is received by the hospital, and is willing to condition its proposed Certificate of Need upon receipt of such accreditation. Riverside has been certified by HRS for Medicaid/Medicare participation. While those conditions of participation are similar to JCAH accreditation standards, they are not identical.

4. Riverside's active medical staff includes six board- certified or board-eligible cardiologists, none of whom currently perform cardiac catheterizations. There are no cardiovascular surgeons on staff, and Riverside does not immediately intend to offer open heart surgery at its facility. Approximately nine local cardiologists in Pasco County, including those on the medical staff of Riverside, have formed a corporation to promote and implement a quality assurance program for the catheterization laboratory at Riverside and to recruit and hire a board-certified cardiologist to perform the catheterizations. No specific physician has yet been recruited as catheteer.

   
   

5. Riverside currently has on its staff certified critical care registered nurses and registered nurses with advanced cardiac life support (ACLS) training. It also has radiological support staff, staff trained-in photographic processing and staff available to handle blood samples and observe and monitor patients. It is expected that there will be cross-training at other AHM facilities having cardiac catheterization laboratories, such as St. Luke's Hospital in San Antonio, Texas. In addition to the cardiologists, Riverside intends to staff the proposed laboratory with one registered nurse, one radiology technician, a scrub technician and a technician responsible for the operation of the physiological monitoring during a procedure. The former two positions will be hired exclusively for the cardiac catheterization laboratory, and the latter two are already on the staff and will be assigned for catheterization procedures.

   
   

6. Riverside currently offers the following noninvasive cardiac/circulatory diagnostic services: hematology studies,

   coagulation studies, electrocardiography (EKG), chest x-rays, blood gas studies, clinical pathology studies, blood chemistry analysis, nuclear studies pertaining to cardiology, echocardiography, pulmonary function testing and microbiology studies.

   
   

7. Riverside proposes to upgrade its existing General Electric angiographic system with a new General Electric multi- purpose diagnostic system, and will also purchase a physiological monitor. A maintenance agreement will be purchased under which General Electric, which maintains an office in Tampa, will be responsible for maintaining the equipment. It is anticipated that a GE service technician will be on call, if not on site, during all cardiac catheterization procedures. GE also provides in-service training in the use of its equipment, and it is anticipated that GE training personnel will remain on site during the first several times the equipment is operated.

   
   

8. Funds for the proposed cardiac catheterization laboratory are available through the prior financing arranged by AHM for the hospital reconstruction and renovation authorized by Certificate of Need No. 2859. Assuming that the proposed lab will perform 219 catheterization procedures at an average charge of $1,794 during the first year of operation, and 417 procedures at an average charge of $1,884 during the second year, Riverside projects a net income of $20,593 for year one and $117,288 for year two. The proposed charges are comparable to those of existing providers. The pro formas assume a payor mix of approximately 15 percent Medicare patients. Inasmuch as a large majority of patients requiring cardiac catheterization are elderly, the Medicare patient mix projections are probably low. Since Medicare does not generally fully reimburse a hospital for its actual charges, the net income projections are likely overstated. The pro formas do not include any expenses associated with a helicopter ambulance service. The expenses projected for employee benefits, seventeen percent of salary, appear to be a little low for the Pasco County area. Riverside anticipates that the net income generated from the proposed catheterization lab will also help offset and reduce the overall losses experienced by it in the past several years.

9. HRS District V includes Pasco and Pinellas Counties. Although the HRS methodology for determining the numeric need for cardiac catheterization laboratories indicates, no additional need in District V, the parties have stipulated and the evidence demonstrates that there is a need for such a lab in Pasco County. The five existing catheterization laboratories in District V are all located in Pinellas County. There are currently no existing or approved labs in Pasco County, and approximately 1,200 Pasco County residents per year are being sent out of Pasco County for

   cardiac catheterization, mostly to Tampa General Hospital in District VI.

   
   

10. The physicians who testified at the hearing would prefer to perform cardiac catheterization procedures and send their catheterization patients to a facility which also has open heart surgery capacity. When open heart surgery is necessary and a patient is referred or transferred to another hospital for such surgery, that facility often performs its own cardiac catheterization procedures. This results-in duplicate costs, services and potential risk to the patient who is cashed in one facility and referred to another facility for surgery. It has been the experience of local cardiologists in Pasco County that between 50% and 70% of patients upon whom a catheterization procedure is performed ultimately also have open heart surgery. Nevertheless, each of the cardiologists who testified indicated his desire and willingness to utilize Riverside's proposed laboratory for low-risk diagnostic cardiac catheterization procedures. Until Riverside is able to offer open heart surgery services at its facility (which is within Riverside's long-range plan)' it proposes to screen patients for risk, and perform only elective, diagnostic catheterization procedures. Neither pediatric, emergency nor therapeutic catheterization, such as balloon angioplasty, will be performed in Riverside's proposed cardiac cath lab.

11. Three hospitals offering open heart surgery have entered into formal transfer agreements with Riverside. These include Morton F. Plant Hospital in Clearwater, Bayfront Medical Center in St. Petersburg, and Tampa General Hospital in Tampa. None of the three are within thirty minutes driving time from Riverside by emergency vehicle. Morton F. Plant' the closest of the three, is 27 miles from Riverside. During a "red run" or "hot run" with sirens and lights flashing, and following normal emergency driving procedures, it would take between 45 and 50 minutes for an ambulance to travel between Riverside and Morton

    F. Plant Hospital. There are large traffic volumes which utilize the road systems between Riverside and Morton F. Plant Hospitals, and a great number of lighted intersections. While petitioner presented testimony that an emergency vehicle traveling 10 miles per hour over the speed limit could reach Morton F. Plant from Riverside in 30 minutes, 18 seconds, such testimony is not deemed credible. The witness had not actually traveled that distance in an emergency vehicle. An actual emergency run was made from Tarpon Springs General Hospital to Morton F. Plant Hospital a distance of about 15 miles. That run, travelling a portion of the same route proposed by Riverside's witness, took about 22 minutes. Given the fact that Riverside is some 10 to 12 miles further away from Morton F. Plant Hospital than is Tarpon Springs General Hospital, it is concluded that an ambulance could not

    travel the 27 miles from Riverside to Morton F. Plant Hospital in

    30 minutes in average travel conditions.

    
    

12. Riverside does have a helipad at its facility, but does not own a helicopter and does not have a contract for air ambulance services. Although one of Riverside's witnesses believed that a helicopter would be at Riverside on all days upon which cardiac catheterizations are performed, no expenses for a helicopter or a contract with a helicopter ambulance service are included within Riverside's pro forma. Riverside intends to offer cardiac catheterization services 24 hours a day, seven days a week. While patients are generally directly charged for the actual costs associated with emergency transport, it is not reasonable to assume that the costs of either purchasing or maintaining an on-site helicopter could legitimately be directly charged to patients.

    
    

13. The actual flight time from ground takeoff at Riverside to ground landing at Tampa General Hospital in average travel conditions is 15 minutes. There is a licensed air ambulance service, known as Suncoast, which operates out of Tampa International Airport and maintains two helicopters. Unless a hospital has a contract for air ambulance services, Suncoast does not dedicate a helicopter to be on standby and ready to respond to a call for an emergency flight. Even if a helicopter were available, it would take between 30 to 45 minutes to place a helicopter on the ground at Riverside after the need has been communicated to Suncoast. Given the fact that Riverside does not own or maintain a helicopter on site, it is reasonable to consider the time which could be expected to lapse between the summons for an emergency transport vehicle and its arrival, as well as the time of transport between two hospital facilities.

    
    

14. Emergency runs, whether by ground ambulance or air transport, are tremendously stressful on a patient. This factor becomes particularly important when the patient is one who has recently undergone a cardiac catheterization procedure and is being transported for emergency open heart surgery.

    
    

15. Even when patients are screened for risk, complications can arise during a diagnostic cardiac catheterization procedure necessitating an immediate transfer of the patient to open heart surgery or, in some events, a therapeutic catheterization procedure. Such complications include a possible artery dissection during insertion of the catheter or the occurrence of an eschemic episode as a result of the displacement of oxygenated blood with the dye injected into the coronary arteries. While these events are rare, occurring in possibly only 1% of all diagnostic procedures, they do necessitate immediate, more advanced treatment.

16. The 1985-87 Florida State Health Plan favors co-located cardiac catheterization laboratories and open heart surgery programs in the same facility. Quoting from the Inter-Society Commission on Heart Disease Resources, the State Health Plan notes:

    
    

    ". . . there can be little justification for the development of these highly specialized facilities (cash labs) unless expertise in cardiology, cardiovascular radiology, and cardiovascular surgery are immediately available. Optimally therefore, catheterization laboratories should be located only in institutions with well organized and closely related programs of cardiovascular surgery.

    
    

    ". . . such an arrangement not only facilitates close interdisciplinary cooperation and minimizes unnecessary, repetitive, inadequate, or unsafe diagnostic studies, but it also allows prompt intervention should life threatening complications develop during catheterization studies . . . It should be emphasized . . . that separation of the diagnostic laboratory from the surgical facility is less than optimal and may present serious problems."

    
    

    (Riverside Exhibit 5, Volume II, pages 95-96). The State Plan recognizes that some within the medical community feel that independent, "satellite" labs can perform studies as adequately as labs associated with open heart surgery programs. However, it also recognizes the literature demonstrating that such independent labs usually have lower utilization rates.

    
    

17. The District v Health Plan does not stress co-location, but suggests that cath labs be developed in areas which have the potential of justifying open heart surgery capability within three years. Other than considerations of timely access, there was no evidence that an additional open heart surgery facility is needed in District V or specifically, in Pasco County. The District Health Plan does stress the provision of services to the indigent. Riverside is committed to serving all patients regardless of ability to pay.

    
    

18. Bayonet Point Hospital is a 200-bed hospital located in Hudson, also in Pasco County. In an earlier batching cycle, Bayonet Point applied for a Certificate of Need to add both a

    cardiac catheterization laboratory and open heart surgery at its Hudson facility. After an administrative hearing, it was recommended that the application be granted. (Division of Administrative Hearings Case No. 85-3569) The Department of Health and Rehabilitative Services rejected that recommendation by Final Order filed on August 22, 1986, and the matter is currently on appeal to the District Court of Appeal, First District. If Bayonet Point were to offer cardiac catheterization services at its facility in Hudson, a cardiac cath lab at Riverside would have an adverse impact upon Bayonet Point's program.

    
    

    CONCLUSIONS OF LAW

    
    

19. While there is no "numeric" need, as calculated under Rule 10-5.011(1)(e), Florida Administrative Code, for an additional cardiac catheterization laboratory in District V, there is a need for such a service in Pasco County. The issue is whether Riverside's application to fill that need complies with the applicable statutory and rule criteria. More specifically, the issues in this case are whether Riverside's proposal satisfies the criteria for approval related to consistency with the State and District Health Plans, the applicant's ability to provide quality of care, the availability of resources and the short and long-term financial feasibility of the proposal. Sections 381.494(6)(c) 1, 3, 8 and 9, Florida Statutes, and Rule 10-5.011(1) (e) (7)c and d; (9)a, b, e; (10) and (11), Florida Administrative Code.

    
    

20. A co-located cardiac catheterization lab and open heart surgery program is the medically ideal situation. It is preferred by local cardiologists and is stressed in the State Health Plan. Since cardiac catheterization is the primary diagnostic technique used to determine the extent of heart damage and the advisability of heart surgery, it is imperative that there be a close physical proximity and relationship between a diagnostic facility and a cardiovascular surgical program. However, there is no statutory or regulatory prohibition against a facility which lacks open heart surgery capability from offering cardiac catheterization services. The prime consideration is patient safety, expressed in terms of quality of care or service quality. In recognition of the potential risk to a patient who undergoes a catheterization procedure in a facility which does not offer open heart surgery services, HRS has required applicants to submit a written referral agreement with a facility providing such services which is located "within 30 minutes travel time by emergency vehicle under average travel conditions." Rule 10-5.011(1)(e)(9)e(I), Florida Administrative Code.

21. Riverside has attempted to prove compliance with this criterion by obtaining referral agreements with three facilities However, the evidence does not demonstrate that any of the three facilities are within 30 minutes travel time from Riverside Absent a helicopter available on site at Riverside, the closest facility timewise is between 45 and 50 minutes by ground ambulance. Riverside did not establish that it intended to either purchase a helicopter or enter into a contract with an air ambulance service. Even if an off-site helicopter emergency service were available to Riverside during the performance of a cardiac catheterization procedure, the only evidence in the record on this matter is that it would take as long as 30 to 45 minutes to reach Riverside after being summoned, thus increasing the time for a patient to be transferred to between 45 to 60 minutes.

    
    

22. Riverside suggests that since the language of the rule is "within thirty minutes travel time by emergency vehicle," only the patient time spent inside the vehicle during transport should be counted. Riverside urges that the time spent awaiting the arrival of the emergency vehicle should not be considered. Given the all-important factor of patient safety, Riverside's interpretation of this requirement is unreasonable. The evidence demonstrates that there are occasions when a cardiac catheterization patient requires immediate open heart surgery. The thirty minute travel time requirement is intended to protect such a patient when open heart surgery is not available at the cashing facility. To discount the time which lapses before an emergency vehicle is available would completely thwart the intent of the rule with regard to patient safety. The rule requires, and the evidence supports the necessity for, access to surgery capability for patients receiving a catheterization procedure in an isolated lab. Lack of such access would unnecessarily endanger patient lives, particularly in view of the fact that Riverside does not intend to perform emergency or therapeutic catheterization procedures. This factor of patient safety justifies a strict interpretation of the travel time rule to include a consideration of the time elapsing between a call for an emergency vehicle and its arrival on the scene.

23. Riverside currently lacks accreditation by the Joint Commission on Accreditation of Hospitals. Rule 10- 5.011(1)(e)(9)a, Florida Administrative Code, requires any institution providing cardiac catheterization to have full JCAH accreditation for special care units. The evidence demonstrates that Riverside is attempting to regain such accreditation for its facility, and is willing to condition the provision of cardiac cath services upon its receipt of JCAH accreditation. It is concluded that lack of accreditation is not fatal to a proposal to offer cardiac catheterization services, as it would be to a

    proposal to offer open heart surgery, (compare Rule 10- 5.011(1)(f)(5)a, Florida Administrative Code), and that a condition requiring JCAH accreditation prior to beginning the service would be appropriate if all other criteria were met.

    
    

24. Riverside has demonstrated the availability at its hospital of all ancillary services required for the provision of cardiac catheterization services. The proposed co-use of its special procedures room for both cardiac catheterization and non- cardiac angiography was not demonstrated to be detrimental to patient safety, quality of care or availability of the service.

    
    

25. With the exception of a laboratory director and the physician who will actually perform the catheterization procedures, Riverside has demonstrated that it either already has on its staff the skilled support personnel required to operate the proposed cardiac cath lab or, being affiliated with a national health care corporation, can recruit skilled support staff for the lab. The evidence demonstrates that cardiologists presently on staff at Riverside do not have recent experience in the performance of cardiac catheterizations, but are willing to recruit a physician who does have such experience. An application for a Certificate of Need should not be denied solely on the basis of a lack of named personnel to staff a proposed new service. However, absent evidence of the present availability of adequate personnel to staff a new cath lab, a Certificate of Need, if issued, should be conditioned upon commitments from a lab director and a cashing physician meeting the requirements of Rule 10-5.011(1)(e)9, Florida Administrative Code, prior to the commencement of operation.

26. An applicant for a Certificate of Need is required to demonstrate that the proposed project is financially feasible on both a short-term and a long-term basis. Although Riverside demonstrated that it, or its parent, could fund the proposed project initially, it has failed to adequately establish the financial feasibility of the proposed new service on either a short-term or long-term basis. This is primarily due to the factors of understating the Medicare utilization mix and failing to include any expenses relating to a helicopter or an air ambulance service. The only manner in which Riverside could comply with the 30-minute travel time rule is to keep a helicopter on standby. The expenses associated with doing so must be taken into account when determining the financial feasibility of the project. While the actual costs of transportation might properly be passed on to the patient, the costs related to keeping a helicopter on standby on a 24 hour a day, seven days a week basis should be reflected in the financial projections for this project. Having failed to account for this

    necessary expense, Riverside has failed to demonstrate that the proposed cath lab would be financially feasible.

    
    

27. Finally, it is concluded that Bayonet Point Regional Medical Center, located in Pasco County, has standing to participate as an intervenor in this proceeding. While its application was submitted in an earlier batching cycle, and thus was not entitled to a comparative review with Riverside's application, a final determination on Bayonet Point's proposal is still pending. Its substantial interest in the outcome of this proceeding is apparent. If its laboratory is ultimately approved, the existence of a similar lab in close proximity would adversely affect Bayonet Point's proposal in terms of the number of patients available to both hospitals and the impact of that factor upon patient costs, efficiency of operation and quality of service.

    
    

28. In summary, while a cardiac catheterization laboratory is needed in Pasco County, Riverside's proposal does not appropriately or adequately fill that need. It is conceivable, and Riverside appears to have taken steps to assure, that its present lack of accreditation can be cured prior to the provision of cardiac cath services. However, without a commitment to provide air ambulance services in a manner which will meet the 30 minute rule, Riverside cannot cure the fact of its physical location in relation to other facilities which offer the capability of open heart surgery. Riverside has made no such commitment either in its application or during the course of this administrative proceeding. When balancing the various statutory and regulatory criteria, the criteria relating to patient safety and service quality must be accorded tremendous weight. HRS is charged with the responsibility of not only defining service needs in specific geographic areas, but also in assisting providers to develop programs of service which "will assure the best possible service to the community." Section 381.493(2), Florida Statutes. Patients who undergo cardiac catheterization at a lab located more than 30 minutes travel time from the nearest facility with open heart services would be unnecessarily endangered and would not receive the "best possible service."

RECOMMENDATION

Based upon the findings of fact and conclusions of law recited herein, it is RECOMMENDED that Riverside's application for a Certificate of Need to equip and operate a cardiac catheterization laboratory at its hospital in New Port Richey be DENIED.

Respectfully submitted and entered this 19th day of March, 1987, in Tallahassee, Florida.

DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings 2009 Apalachee Parkway

Tallahassee, Florida 32399

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 19th day of March, 1987.

COPIES FURNISHED:

Leonard A. Carson, Esq.

and Robert P. Daniti, Esq.

Carson & Linn, P.A. 1711-D Mahan Drive

Tallahassee, Florida 32308

Darrell White, Esq. Assistant General Counsel Department of Health and

Rehabilitative Services 1323 Winewood Blvd.

Building 1, Room 407

Tallahassee, Florida 32399-0700

Thomas M. Beason, Esq. and Donna H. Stinson, Esq.

Moyle, Flanagan, Katz, Fitzgerald & Sheehan

118 North Gadsden Street Tallahassee, Florida 32301

Gregory L. Coler, Secretary Department of HRS

1323 Winewood Blvd.

Tallahassee, Florida 32399-0700

Sam Power, Clerk Department of HRS 1323 Winewood Blvd.

Tallahassee, Florida 32399-0700

APPENDIX

The proposed findings of fact submitted by the petitioner, respondent and intervenor have been fully considered and have been accepted and/or incorporated in this Recommended Order, except as noted below.

Petitioner

16. First sentence rejected as contrary to the evidence.

27. Last sentence rejected insofar as it contemplates the reasonableness of the pro forma with regard to the Medicare patient mix and the failure to include expenses relating to an air ambulance.

38,39. Rejected. Failure to account for a proper payor mix and air ambulance service renders the financial feasibility projections unreliable.

1. Rejected. Only the JCAH can render such a factual finding.

   
   

2. Last sentence rejected as unsupported by the record of this proceeding. See Order denying second motion to reopen record.

1. Rejected as to travel time. Not supported by competent, substantial evidence.

   
   

2. Accepted only insofar as it pertains to actual patient flight time.

   
   

3. Rejected as not supported by competent, substantial evidence.

   
   

4. Second sentence rejected as speculative.

   
   

5. Last sentence rejected as unsupported by competent, substantial evidence, although it is recognized that Riverside intends to offer only diagnostic procedures.

   
   

6. Last sentence rejected as an absolute statement of fact. Not supported by competent, substantial evidence.

64. Second sentence partially rejected as contradicted by competent, substantial evidence. See Finding of Fact 10 in this Recommended Order.

Respondent HRS

20. Rejected insofar as it applies to all ambulance drivers. Not supported by competent, substantial evidence.

Intervenor Bayonet Point

5. Rejected as irrelevant and immaterial.

1. Fourth sentence is rejected as not supported by competent substantial evidence.

   
   

2. Third sentence partially rejected. See Finding of Fact Number 11.

16. While accepted as an accurate statement of fact, it is concluded that such considerations should not be included within the 30 minute travel time rule.

17,18. Rejected as irrelevant and immaterial to the issues in dispute.

1. First sentence accepted as factually correct but not determinative of the reasonableness of the pro formas.

   
   

2. First sentence accepted as factually correct but not determinative of the reasonableness of the pro formas.

22,23. Partially rejected as speculative and unsupported by competent, substantial evidence.

1. Rejected as an improper finding of fact, as opposed to a conclusion of law after considering the factual circumstances.

   
   

2. Accepted only if the words "if approved" are added.

Docket for Case No: 85-001447

Orders for Case No: 85-001447