STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
HOSPICE CARE OF BROWARD )
COUNTY, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 86-2109
)
DEPARTMENT OF HEALTH AND ) REHABILITATIVE SERVICES, and ) VISITING NURSE ASSOCIATION ) OF BROWARD COUNTY, INC., )
COMMUNITY HOSPICE, )
)
Respondents. )
) HOSPICE CARE OF BROWARD )
COUNTY, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 86-2579
)
DEPARTMENT OF HEALTH AND ) REHABILITATIVE SERVICES, and ) VISITING NURSE ASSOCIATION OF ) BROWARD COUNTY, INC., )
COMMUNITY HOSPICE, )
)
Respondents. )
)
RECOMMENDED ORDER
This matter was heard by William R. Dorsey, Jr., the Hearing Officer designated by the Division of Administrative Hearings in Tallahassee, Florida, on February 25-27 and April 21, 1987. A transcript of the proceedings was filed and the parties have submitted proposed recommended orders. Rulings on the proposed findings of fact are made in the Appendix to this Recommended Order.
Gerald M. Cohen, Esquire, Miami, Florida, for Hospice, Inc. (Broward County)
John Rodriguez, Esquire, Tallahassee, Florida, for Department of Health and Rehabilitative Services
Kenneth F. Hoffman, Esquire, Tallahassee, Florida, for Hospice, Inc. Charles Stampelos, Esquire, Tallahassee, Florida, for Hospice Care of
Broward County, Inc.
The following witnesses testified during the hearing:
For Visiting Nurse Association of Broward County: Maria M. Pascal; Kurt Blair; Pauline Steel; Nancy A. Persily; Pamela Sutton, M.D. and Robert Simione.
For Hospice, Inc., of Broward County: Donald Gates, Eugene Nelson and Reverend Hugh Westbrook.
For Hospice Care of Broward County: Susan G. Telli, Eleanor Charland and Trudy Webb.
ISSUE
The issue is whether certificate of need No. 4370 should be issued to the Visiting Nurse Association of Broward County to operate a hospice program, which will include five inpatient beds.
STIPULATON CONCERNING APPLICABLE STATUTES
The joint stipulation filed by the parties indicates that not all statutory criteria for evaluating certificate of need applications for hospices apply to this case. Section 381.494(6)(c)6, 10, and 11, Florida Statutes, do not apply. Section 400.601, et. seq. Florida Statutes, and Rules 10A- 5.001(1)(j), 10- 5.011(1)(b), and Rule 10A-12.001, et. seq., Florida Administrative Code, apply. There is a dispute over whether Section 381.494(6)(d), Florida Statutes, applies.
FINDINGS OF FACT
General
Procedural Background
The Visiting Nurse Association of Broward County, Inc. Community Hospital (VNA) applied on December 12, 1985, for a certificate of need to operate a hospice program, including five inpatient beds, in Broward County, Florida. A State Agency Action Report was issued by the Department of Health and Rehabilitative Services (HRS) preliminarily approving the application, which was published in Volume 12, No. 21 of the Florida Administrative Weekly on May 23, 1986, at page 1966. Hospice, Inc., Broward County (Hospice) and Hospice Care of Broward County, Inc. (Hospice Care) filed petitions to contest the preliminary approval of the application, and those petitions were consolidated for hearing.
Brief Description of the Parties
Visiting Nurse Association
VNA is a not-for-profit charitable organization established in 1959. It is a Medicare and Medicaid certified home health agency which provides comprehensive home health services to residents of Broward County regardless of age, ability to pay, or payor source. VNA has a somewhat complex corporate structure. The parent corporation is Visiting Nurse Health Services, Inc. This corporation provides management, administrative support and consultative services to its subsidiary corporations which are:
The Visiting Nurse Association of Broward County Foundation, Inc., a not-for-profit corporation which raises funds to fulfill VNA's goal of providing health care to the indigent.
Visiting Nurse Home Care, Inc., a Florida not-for-profit corporation which provides private duty nursing care, physical therapy and other home health services, including homemaker services and personal care services to non-Medicare patients in Broward County.
Visiting Nurse Association of Dade County, a not-for-profit Medicare and Medicaid certified home health agency which provides comprehensive home health services in Dade County.
VNA Foundation, a not-for-profit corporation which raises funds for VNA's operations in Dade County.
Visiting Home Services, Inc., a licensed home health agency which provides services to non-Medicare patients in Dade County, Florida.
VNA is governed by a board made up of community members who serve voluntarily. VNA has provided service to indigents even before inception of the Medicare program. VNA has maintained long term relationships with publicly funded hospitals, with particular emphasis on providing continuity of care to patients and providing alternatives to hospital care.
In fulfillment of its mission, VNA has contracted with the North Broward Hospital District to provide a full range of services to indigent Medicaid patients in the northern two-thirds of Broward County, where that District operates three hospitals, North Broward Medical Center, Broward General Medical Center and Imperial Point Medical Center.
VNA employs nurses who work with the district hospitals to improve the accessibility of health care to indigents by assisting in planning care for indigents after discharge from the hospital.
In 1985 and 1986 VNA served about 2,900 patients each year.
VNA also receives referrals from other hospitals in Broward County, including hospitals operated by Humana Corporation; Memorial Hospital, which is operated by the South Broward Hospital District; and Pembroke Pines General Hospital. It receives referrals in Dade County from Jackson Memorial Hospital, the public hospital for Dade County operated by the Public Health Trust, and the Veterans Administration Medical Center.
VNA operates special pediatric programs for children whose health care is covered by Medicaid.
VNA also had assisted the Public Health Trust to develop in Dade County a comprehensive proposal seeking a grant from the Robert Woods Johnson Foundation for the treatment and prevention of Acquired Immune Deficiency Syndrome.
VNA has operated a specialized subunit since 1984 which provides palliative care. This unit is staffed with registered nurses who are experienced in working in hospices, in symptom control for terminally ill patients and in providing supportive therapy for the patients and their families. In 1985 the palliative care unit provided services to about 129
patients; approximately 63 percent were Medicare patients and 10 percent were Medicaid patients. The program's average daily census was approximately 30 patients.
In 1986 the palliative care unit provided service to approximately 134 patients; 68 percent Medicare patients and 14 percent Medicaid patients.
The number of physicians referring patients to the palliative care unit has increased from fewer than 100 to more than 150 currently. Referring physicians include internists, surgeons, general practitioners and oncologists (physicians specializing in the treatment of cancer). After only three months of operation, the patient census reached 35 patients. The greatest concentration of the palliative care patients reside in the areas near North Broward Medical Center and Broward General Medical Center, which are also the areas with high indigent populations.
VNA's palliative care unit will serve patients in Broward County who have physicians who are located in Dade County, and also will serve patients having no family members or others to serve as caretakers. It also has treated a number of terminally ill pediatric patients.
The palliative care program is not as diverse a program as a hospice, in that it does not offer inpatient care or bereavement services to the families of the terminally ill, and the palliative care unit's access to funding from the government or third party payors is limited without a certificate of need to operate a hospice program.
About 60 percent of the patients currently cared for in the palliative care unit would qualify for hospice services if VNA were authorized to provide those services. About 21 of VNA's home health patients chose to enter a hospice program out of the 263 patients seen during the first few years of operation of the palliative care unit.
2. Hospice, Inc.
Hospice, Inc. is authorized to operate in Broward County, and has a 20-bed inpatient unit with an average daily census of 11 patients. About 10 percent of its services are inpatient services.
Eleven percent of Hospice, Inc's patients are charity patients; that is, patients who are provided services without charge. Other patients have reimbursement sources which are not adequate to cover the cost of providing care.
Hospice, Inc. does not discriminate on the basis of inability to pay. The two different kinds of indigent are those poor to start with and those who become medically indigent because they have paid all of their money to fight their disease.
Hospice, Inc. has worked with AIDS patients since the early 1980's and has continually cared for AIDS patients, beginning with Haitian refugees. Hospice, Inc. has been called upon to write the policy and protocols for AIDS care for hospices nationally by the National Hospice Organization and is the only hospice in Florida with a specific contract to provide service to AIDS patients. That contract is with the State of Florida through Jackson Memorial Hospital and the Public Health Trust using State dollars.
Hospice, Inc.'s programs in Dade and Broward Counties were selected as demonstration sites by the federal government to demonstrate the efficacy, including cost effectiveness, of hospice services, in a study conducted by the Health Care Financing Administration between 1980 and 1983.
3. Hospice Care
Hospice Care is a not-for-profit hospice program licensed in Broward County which operates five inpatient beds. It does not have a parent company and is supported by donations raised in Broward County. It provides an array of nursing, pastoral and spiritual services to its patients and necessary medical care. The program has a Medical Director, Nurses Aides, Licensed Practical Nurses, a Coordinator of Education and Bereavement, a Director of Volunteers, and a Patient Care Coordinator. About 125 volunteers provide emotional support and assistance which a family might need while the patient is in the hospice program; the program offers the family ongoing bereavement support after the patient's death.
Hospice Care also offers homemaker services, pharmaceutical services and occupational and physical therapists, at no extra cost to the patient.
A pastor or minister provides spiritual assistance to the patient and family on request.
Hospice Care accepts AIDS patients (it served approximately 17 in 1986) and provides support for families of those patients. Hospice Care also is developing a program to educate single people about AIDS. As is the case with other hospices, Hospice Care participates with the Robert Woods Johnson Foundation.
Hospice Care provides educational materials regarding hospice programs throughout Broward County. Brochures are sent to physicians in Broward County four times a year. A newsletter is distributed quarterly. Hospice Care provides in service educational programs for its registered nurses and seminars for its social workers.
Hospice Care accepts patients without regard to the patient's ability to pay, and places a patient in a program within 24 to 48 hours of referral. Hospice Care became Medicaid-certified in January of 1987 and accepts Medicaid patients.
During fiscal year 1986, Hospice Care served 227 patients. It could serve additional patients without adding additional staff.
During fiscal year 1986 approximately 25 patients treated by Hospice Care were referred to it from North Broward Hospital District hospitals. Based upon referral patterns, Hospice Care would probably lose some patients to VNA if VNA's application is approved. Hospice Care received at least one referral from VNA's palliative care unit last year.
Hospice Care refers patients to other hospices in Broward and Palm Beach Counties based on the needs of those patients.
4. Hospice-By-The-Sea
Another hospice operating in Broward County is Hospice-By-The-Sea. It has received a certificate of need and operates as a non-profit program. It was Medicare certified in January of 1987.
Hospice-By-The-Sea accepts patients from Palm Beach and Broward counties, as it is authorized to do under its certificate of need. Its program is similar to that of Hospice Care and consists of nurses, social workers, clergy, volunteers, homemaker aides, home health aides, a clinical psychologist and a hospice physician. Its nurses receive specific training in the care of terminally ill children. Hospice-By-The-Sea has a bereavement program for family members for a minimum of one year following a patient's death.
Hospice-By-The-Sea also offers the services of a dietician, a physical therapist, a speech therapist and an occupational therapist, as well as providing pharmacological and medical supplies and services. Pastoral counselors meet with patients and their families regularly. It has never denied a prospective patient admission to its program for inability to pay. The program accepts AIDS patients and works with the Robert Woods Johnson Foundation.
During fiscal year 1986 Hospice-By-The-Sea served 263 patients, and had an average daily census of between 35 and 45 patients. It could increase the number of patients served without the increase in inpatient beds.
Hospice-By-The-Sea does not have a waiting list and places new patients in its program within 24 to 48 hours after referral.
Hospice-By-The-Sea refers patients to other hospices based upon the patient's need.
Since about 1985 Hospice-By-The-Sea has had a program to educate the community about the availability of hospice services. The testimony of Ms. Webb, that the market for hospice services has leveled out, and now is saturated, is not accepted.
In the Hospice-By-The-Sea program, inpatient beds play a minor role in its overall program. Only six patients since 1980 have used inpatient services.
Volunteers are an important component of the Hospice-By-The-Sea program. About 25 to 30 percent of hospice volunteers reside in Broward County. Hospice-By-The Sea may experience some increase difficulty attracting volunteers if an additional hospice program is approved in Broward County but there is insufficient proof that it would not be able attract an adequate number of volunteers to continue a quality program.
Hospice-By-The-Sea receives funds on an annual basis from Palm Beach and Broward county communities. About 30 percent of its fund raising monies comes from Broward County. The approval of the VNA hospice might make it somewhat more difficult for Hospice-By-The-Sea to attract funds. The Hearing Officer is not persuaded that competition for fund raising will result in either Hospice-By-The-Sea or VNA providing less than a quality program.
5. Hospice Of The Gold Coast
Hospice Of The Gold Coast is another not-for-profit hospice which holds a certificate of need to serve Palm Beach and Broward counties which is Medicare certified. It has four licensed inpatient beds located at Holy Cross
Hospital in Broward County. The hospice is licensed separately from its parent corporation, Gold Coast Home Health Services, a Broward County home health agency.
As with the other hospices, the Gold Coast program offers a wide array of services to patients and their families. These include a medical director who serves as the consultant to the patient's primary care physician, who may assume total care for the patient when the primary physician chooses not to provide terminal care.
Gold Coast has a team of nurses available 24 hours a day, seven days a week to meet the medical and psychological needs of patients. The nurses provide pain and symptom control, and are trained in providing psychological care to the patient and the patient's family.
The Gold Coast home health aides provide personal and respite care to the patient. A psychologist provides counseling services to the patient and the family, while a bereavement specialist works under the direction of the hospice psychologist in a program which can last for a year or longer after the patient's death.
Volunteers are trained to work with the terminally ill. Volunteers are an integral part of the hospice team. Gold Coast has 80 active volunteers.
Clergymen on Gold Coast staff provide spiritual care to the patient and family. A medical social worker sees each family to be sure that community resources available to the patient and family are obtained. Gold Coast offers homemaker services which are used to maintain the patient's household. Physical therapy services are provided if required by a patient.
Hyperalimentation can also be provided if needed. Hyperalimentation is a supplemental feeding done intravenously. The hospice may also provide morphine drips for pain control where required.
Gold Coast accepts patients terminally ill from the AIDS virus, and has no policy which would discourage the admission of such patients. It participates in the activities funded to the Robert Woods Johnson Foundation in the southeast Florida area for AIDS patients.
During calendar year 1986 Gold Coast received about 26 patient referrals from North Broward Hospital District hospitals.
During calendar year 1986 Gold Coast served 304 patients and had an average daily census of between 50 to 55. A substantial number of additional patients could be served without adding additional inpatient beds, for only five percent of the patients served used inpatient beds. About 15 to 20 additional patients could be served without adding additional staff. Gold Coast does not experience a waiting list of patients and serves them within 24 hours after a physician's referral. Gold Coast will refer patients to other hospices in Broward and Palm Beach Counties if those hospices are closer and therefore could better meet the patient's needs.
Gold Coast Home Health Agency provides administrative and other support to the Gold Coast hospice.
The experience of Gold Coast in admission to its hospice program of those served by the home health agency is that many patients eligible for
hospice services do not wish to obtain them. In 1986, of 139 patients the home health agency served with diagnoses which would make them eligible for hospice services, 39 chose the hospice program.
Gold Coast makes efforts to educate the community about the availability of hospice services. Methods include lectures given by the hospice's executive director to local nursing college students and to psychology courses on death and dying. Gold Coast also publishes a newsletter distributed throughout the community and participates in health fairs, distributing brochures on hospice care.
Factual Findings Concerning Rule Criteria Against Which The Application Must Be Evaluated
Rule 10-5.011(1)(j), Florida Administrative Code, contains the rule methodology governing hospice services. It is the same methodology used by the
U.S. Office of Management and Budget and other states in determining the appropriate level of hospice care in a community.
All parties have stipulated that this methodology shows a need for five additional hospice beds in Broward County.
The Broward Regional Health Planning Council calculates a need for
45.8 hospice beds in Broward County. With the current hospice beds of Hospice Care, Hospice-Of The Gold Coast, Hospice, Inc., and Hospice-By-The-Sea, there are 33 beds now licensed.
The rule methodology understates the actual need for hospice services. It was developed before the increased number of terminally ill patients as a result of Acquired Immunity Deficiency Syndrome. Twenty percent of all AIDS patients in Florida are Broward County residents. The representatives of Hospice-By-The-Sea, Hospice Care and Hospice Of The Gold Coast all anticipate an increased need for hospice services for AIDS patients in Broward County.
The incidence of cancer is substantially higher in Broward County than in Florida generally. Broward County's population is older than the national population. Twelve percent of the population nationwide is over age 65. Almost
24 percent of Broward County's population is over 65.
The most current reliable data available demonstrates that the hospice-eligible population exceeds the population now being served. The rule methodology would indicate there should be at least 400 hospice-eligible patients more than are actually being served currently.
Unlike rule methodologies for other health services, minimum utilization thresholds do not apply to hospice services. The inpatient component of the hospice program is used for acute care and respite care. The availability of the beds at times of peak demand is more important than the average daily census of inpatient hospice beds filled on a given day.
Statutory Criteria For Evaluating The Application Under Section 381.494(6)(c), Florida Statutes.
Consistency with the State Health Plan and the Local Health Plan. Section 381.494(6)(c)1., Florida Statutes.
The State Health Plan does not address the need for hospice services. The testimony and cross-examination of Kurt Blair, the planning supervisor for the Broward Regional Health Planning Council, establishes that the VNA proposal is not inconsistent with the Local Health Plan.
Availability, Utilization, Efficiency, Geographic And Economic Accessibility Of Facilities In The
District. Section 381.494(6)(c)2., Florida Statutes.
The utilization of hospice services in Broward County is less than the rule methodology would project. The first step of the methodology estimates a hospice eligible population, and that estimate is that between 1,400 and 1,450 people are hospice eligible. Currently, approximately 955 are being provided hospice care. Thus, under the rule methodology there are approximately 400 people in Broward County who are hospice eligible and who may be receptive to hospice services if appropriate additional education were provided.
In addition, the second portion of the rule which determines hospice inpatient bed need shows the need for at least the five additional inpatient beds which this application proposes. The rule utilizes the assumption that about 20 percent of hospice patients will be inpatients. In Broward County, only about 10 percent are inpatients. Unlike rule methodologies for other health services, the hospice rule does not use minimum utilization thresholds as a proxy for quality, or for financial viability. The fact that current utilization of inpatient beds is less than the rule would predict does not mean there is not a need for additional programs in Broward County. The reason for the lower inpatient utilization in Broward is not clear but inpatient services are only a portion of the total continuum of services provided by a hospice, so that the lower inpatient utilization cannot be properly thought to show a lack of need.
The VNA will operate hospice education for groups that are currently underserved, especially indigents. VNA provides a substantial amount of care to indigents, providing over $740,000 of free care in 1986. Physicians refer a substantial number of indigent patients to VNA for services. VNA's ability to provide care to indigents is enhanced by the array of services that VNA offers through the VNA network. Moreover, the indigent patient population has less awareness of the availability of hospice services, and increased education regarding these services for both patients and their physicians is likely to result in additional persons choosing hospice care.
VNA's palliative care unit's physician referral base is highly concentrated in the geographic areas close to the North Broward Hospital and Broward General Medical Center, which are operated by the North Broward Hospital District. An unmet need for hospice services exists in the geographic area served by the North Broward Hospital District, especially in zip code area 33311, which has a high concentration of indigent persons.
The VNA hospice would be more accessible because it will accept patients without an identified family member or care giver to assist in the program, while other hospices believe that such patients are not appropriate for hospice care. Other hospices also will not accept a patient whose physician is located in Dade County.
When a physician refers a patient to VNA for care, options are
discussed with the patient. If the VNA cannot give appropriate care and the patient chooses another community provider, the patient is referred to another provider of care.
While other providers do exist in Broward County to serve the unmet need for hospice services in Broward County, VNA's existing relationships with the North Broward Hospital District and physicians serving indigent patients positions it especially well to serve that need.
The Ability To Provide Quality Care, Section 381.494(6)(c)3., Florida Statutes.
VNA employs several registered nurses with hospice experience who are well qualified to provide a hospice program.
Registered nurses are the backbone of the hospice program because they are responsible for pain and symptom control, providing emotional support to patients and families, and education regarding medications. VNA therefore has an existing corps of nursing staff from which the hospice program could begin. Moreover, VNA's palliative care unit provides a quality program which is similar to (though more limited than) a hospice program, which also gives reason to believe it can provide a quality program.
The VNA program will also foster a continuity of care because patients have ready access to other VNA programs, and all programs have uniform recordkeeping and assessment techniques. The VNA conducts inter-team conferences to ensure continuity of care between programs. This continuity is helpful because it avoids the dislocations which can occur when a patient and family begin to be served by a different provider after the decision to utilize hospice care has been made.
Economies of Scale. Section 381.494(6)(c)5., Florida Statutes.
The VNA network will help create an efficient hospice program since management services such as accounting, marketing, billing and collection, and administration are done by the parent organization which spreads the cost of these services across the subsidiaries while avoiding duplication of effort. The placement of the proposed hospice program within the VNA network allows it to benefit from the economies of scale that result from such organization.
The presence of VNA community liaisons within the North Broward Hospital District facilities should also increase the efficiency by which VNA can guide patients appropriately into hospice programs earlier which should lower the overall cost of in-hospital care.
Availability Of Resources For Project Accomplishment And Operation. Section 381.494(6)(c)8.,
Florida Statutes.
The VNA has been very successful in obtaining grants and other forms of financial assistance from a variety of local, state and federal sources including the Area-wide Agency on Aging and the Community Care For the Elderly Program.
The fundraising mechanism for the VNA, the VNA Foundation, raised
$31,000 in private contributions in 1986, and it is projected that this amount will increase as a result of implementation of more aggressive fundraising activities.
The Visiting Nurse Association movement in the United States has historically been heavily supported by the United Way.
The VNA received $273,000 from the Broward County United Way in both 1985 and 1986 and anticipates receiving approximately $300,000 for 1988. Susan Telli, Executive Director of Hospice Care of Broward, acknowledged VNA's strong fundraising capacity.
The VNA initially anticipates receiving funds for its hospice program from the United Way and the VNA Foundation.
The VNA would be able to handle any unanticipated decrease in revenue or unanticipated increase in expenses through the solicitation of additional charitable contributions or renegotiations of its hospital contract.
Financial Feasibility In The Short And Long Terms. Section 381.494(6)(c)9., Florida Statutes.
The VNA hospice program is financially feasible in both the short term and long term. The project involves no capital expenditure.
Mr. Robert Simione is an expert in health care financial planning and management, and is a principal with Simione and Simione, a certified public accounting firm. Many of the firm's clients are home health agency and hospices.
Mr. Simione has extensive experience in the development of hospice programs including budgeting, financial feasibility analysis and financial management. He has recently completed an extensive survey of ten hospices nationwide.
Subsequent to VNA's preparation and submission of its hospice certificate of need application, Simione and Simione merged with- the accounting firm of Holstein and Lechner, which therefore had not been involved in either the preparation or submission of the certificate of need application.
In November, 1986, after Simione and Simione merged with Holstein and Lechner, the VNA asked Mr. Simione to conduct a feasibility analysis of its proposed hospice program in preparation for both the final hearing and implementation of the program, and to account for extrinsic changes that occurred subsequent to the preparation and submission of the application in October of 1985.
The extrinsic changes included an increase in Medicare reimbursement rates for hospice services on or about April 1, 1986, and the availability of Medicaid reimbursement for hospice services in Florida as of January 1, 1987.
1. Patient Census Projections
The VNA hospice application, filed with the Department in October of 1985, included a two-year financial projection. The projection was broken into two periods and assumed a projected patient census of 30 for the first six months of operation and 50 thereafter for the next 18 months.
Mr. Simione's reliance at final hearing on an anticipated census of 40 during the second period of the analysis (rather than 50) was based on management decisions, and was not intended to reflect the availability of patients or need for hospice services.
The proposed patient census in the application is reasonable as a result of the following:
The VNA is not starting from "ground zero"; it has systems in place and existing resources and capabilities that would facilitate development of a high quality hospice program.
The VNA has experience in implementing its palliative care unit, including community education.
The VNA has existing ties and relationships with various charitable and other organizations in Broward County, as well as Dade County.
Since 1952, the VNA has historically had large numbers of patient and family contacts throughout Broward County.
The VNA has mature relationships with publicly funded entities such as the Public Health Department.
Other hospices in Broward County have realized significant patient growth experience during the previous two years.
Broward County's morbidity and mortality rates demonstrate demand for hospice services.
2. Outpatient-Inpatient Ratio
The VNA hospice certificate of need application, filed with the Department in October of 1985, included financial projections assuming an 80 percent outpatient population and 20 percent inpatient population (80:20 ratio).
Projected out-patient to inpatient care ratio of 80:20 reflects a Medicare-imposed ceiling for inpatient care. A 90:10 ratio is more likely in Broward County.
The proposed 80:20 ratio is reasonable for planning purposes because:
The VNA's existing palliative care unit's statistical experience reflects high inpatient utilization by these patients.
The VNA's historical experience with the North Broward Hospital District, as a result of a demonstration project and otherwise, reflects longer hospitalization for Broward patients that come from low income families, often due to their overall poor health status, both nutritionally and physically.
The federal government, based on the results of a Medicare demonstration project, has adopted regulations that allow for an 80:20 inpatient hospital ratio for hospice programs.
Certificate of need applications recently submitted by other applicants for hospice programs in Broward County utilized an 80:20 ratio. Indeed, Hospice, Inc.'s certificate of need application filed in 1980 projected an outpatient-inpatient ratio of 80:20.
The proposed 80:20 ratio had been commonly used by other hospices for financial planning at the time the VNA prepared its certificate of need application.
The survey conducted by Mr. Simione revealed that the inpatient utilization component of a participating hospice was as high as 19 percent.
3. Revenue Projections
The experience of the palliative care unit supports the VNA's projected payor mix for its hospice program as indicated by the 1986 VNA breakdown by payor source:
Medicare 76.8 percent
Medicaid 9.0 percent
Private Insurance 6.1 percent
Private Pay 5.6 percent (sliding scale used) Veteran's Administration 1.2 percent
The payor mix projected by Mr. Simione for the VNA hospice is as follows:
Medicare 75 percent
Medicaid 7 percent
Insurance and Private
Pay 10 percent
Indigent 8 percent
Mr. Simione's projections regarding payor mix are not significantly different from those set forth in the VNA certificate of need application, and reflect the availability of Medicaid funding for hospice care.
The VNA's projection that ten percent of its projected revenue will be "insurance and private pay" is reasonable because:
The amount is supported by VNA's history and the projections of other visiting nurse associations that have recently established hospice programs.
An increasing number of private and commercial insurance carriers, including carriers providing coverage in Broward County, are offering hospice benefits.
Hospice, Inc. projected that 11 percent of revenue would be "insurance and private pay" in its application for hospice beds in Palm Beach County.
As many as 35 percent of Hospice Care of Broward's patients are privately insured for hospice services.
Ten percent of Hospice-By-The Sea patient census is composed of private pay patients.
The VNA's projections regarding Medicare and Medicaid reimbursement are reasonable in light of the following:
As testified by Ella Charland, Executive Director of Hospice Of The Gold Coast, 90 percent of its patients are Medicare reimbursable.
Contractual adjustments are not normally considered for projected Medicare revenues since Medicare reimburses hospice on a prospective flat rate.
A 2.5 percent Medicare and/or 5 percent Medicaid contractual allowance, if necessary, will not have a significant impact on the financial feasibility of the VNA's proposed hospice program.
Use of a wage index of 1.11249 as opposed to 1.1105 in calculating Medicare or Medicaid rates amounts to a difference of .0079 percent of total revenue in Mr. Simione's financial feasibility study.
The impact of a .0079 percent discrepancy in calculating Medicare and Medicaid rates for the VNA's proposed hospice program is insignificant.
4. Other Projections
The projection of an average length of stay (ALOS) of either 45 or 50 days for a hospice program is consistent with the national average for hospices as stated by the National Hospice Organization and with a survey done by the CPA firm of Simione and Simione.
Ambulance costs are not normally a "line item" in a hospice's budget, but if there were any, they would be insignificant in light of its overall operation.
The VNA's projection of a .25 full-time equivalent (FTE) for an M.D. Consultant is consistent with projections relied on by other hospices and not violative of any state or federal requirements.
The VNA's hospice program does not require an Inpatient RN Coordinator position or a full-time Admissions Assistant since responsibilities inherent in these positions could be assumed by employees budgeted for by the VNA.
Impact of VNA Hospice
Section 381.494((6)(c)12., Florida Statutes
Reverend Westbrook does not believe "...that one single organization could do a good job of caring for all the hospice patients."
The VNA will be a positive competitive force vis-a-vis quality, accessibility to indigents, public education, cost effectiveness, and training.
Mr. Gates acknowledges that the entry of a new competitor will generally not have a negative effect on existing providers when the new competitor meets unmet needs or provides services the existing providers are not designed to meet.
Competition and Regional Monopolies. Section 381.494(3), Florida Statutes.
Statutory Intent
The only health service for which the Florida statutes explicitly encourage competition and discourage regional monopolies is hospice care.
Section 381.494(3), Florida Statutes, encourages competitive forces in the market. The statute provides that the state need methodology should discourage regional monopolies and promote competition.
Existing Market Share
Hospice, Inc., the largest of all existing hospice competitors in Broward, has captured 60 percent of the Broward County hospice market, and has a market share that is greater than all three existing competitors combined.
Hospice Care of Broward retains 16.4 percent of the market share in Broward County.
Hospice Gold Coast retains approximately 20.6 percent of the market share in Broward County.
Hospice-By-The-Sea retains less than four percent of the market share in Broward County.
Hospice, Inc. has obtained certificate of need approval for hospice programs in Broward, Dade and Monroe Counties.
Hospice, Inc. is the only hospice in Dade County.
Hospice, Inc. has filed a certificate of need application for two hospice beds in Palm Beach County.
Hospice, Inc. intends to open and operate additional hospices.
HCI, Hospice, Inc.'s management corporation, was capitalized in 1983 for $3.5 million.
Venture capitalists who invested in HCI anticipate a reasonable return on their investment. Accordingy, there exists an expectation that profits are to be maximized by HCI, and its related entities, including Hospice, Inc.
Hospice, Inc.'s Income Statement dated September 30, 1986, for Hospice, Inc.'s Broward division for fiscal year ending 9/30/85 reflects the following:
Total Revenue $1,445,032.28 Total Operating Expenses 1,252,065.18
Division Income $ 192,967.10
Hospice, Inc.'s Income Statement dated September 30, 1986, for Hospice, Inc.'s Broward division fiscal year ending 9/30/86 reflects the following:
Total Revenue $2,773,242.48 Total Operating Expenses 2,568,972.14
Division Income $204,270.34
Hospice, Inc. experienced a 92 percent increase in the total revenue from fiscal year ending 9/30/85 to fiscal year ending 9/30/86.
In addition to management fees, Hospice, Inc. incurs substantial managerial and administrative costs relating to salaries and wages, director's fees, contract services, and consulting fees.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and the parties to this proceeding. Section 120.57(1), Florida Statutes (1985), and Section 381.494(8)(e), Florida Statutes (1985).
The criteria to be applied are those set forth in Section 381.494(6)(c), Florida Statutes (1985), and Rules 10A-12.001, et seq., 10- 5.011(j), and 10-5.011(1)(b), Florida Administrative Code.
Section 381.493(3)(k), Florida Statutes, and Section
400.601(3), Florida Statutes, define hospice in the following way: An autonomous, centrally administered,
nonprofit, as defined in Chapter 617,
medically directed, nurse-coordinated program providing a continuum of home, outpatient and inpatient care for the terminally ill patient and his family. It employs an inter- disciplinary team to assist in providing palliative and supportive care to meet the special needs arising out of the physical, emotional, spiritual, social,
and economic stresses which are experienced during the final stages of illness and during dying and bereavement. This care is avail- able 24 hours a day, seven days a week, and is provided on the basis of need regardless of inability to pay.
Section 381.494(3), Florida Statutes, addresses applications for certificates of need for hospice programs and states in part
When an application is made for a
certificate of need to establish or to expand a hospice, the need
for such hospice shall be determined on the basis of the need for and availability of hospice services
in the community. The formula on which the certificate of need is based shall discourage regional monopolies and promote competition.
Under Section 400.608(13), Florida Statutes, hospice programs must include "a continuum of care and a continuity of care givers throughout the length of care for the patient and to the family throughout the bereavement period." Programs of hospice care include home care, inpatient care and outpatient care.
Under Section 400.609(2), Florida Statutes, "the inpatient component of care is an adjunct to hospice home care and shall primarily be used only for short-term stays."
The decision must be based on a balanced consideration of all applicable statutory criteria. Department of Health and Rehabilitative Services
v. Johnson and Johnson, 447 So.2d 361, 373 (Fla. 1st DCA 1984); Northridge General Hospital v. NME Hospitals, Inc., 478 So.2d 1138, 1139 (Fla. 1st DCA 1985).
The testimony and exhibits support the addition of a new hospice program in HRS District 10, Broward County.
(1) Criterion (c)(1): The state plan is not applicable to hospice applications. The parties have stipulated that the need methodology found in Rule 10-5.011(1)(j), Florida Administrative Code, shows the need for five additional hospice beds. These beds are part of the program proposed by VNA.
Criterion (c)(2): Existing hospices are providing high quality programs. The VNA program traditionally has provided a substantial volume of free care. VNA will provide an unmet need for hospice services in a heavily concentrated geographic area served by the North Broward Hospital District, including zip code area 33311, which contains a high concentration of indigents. Moreover, the VNA hospice will accept patients who do not have an identified family member or caretaker to assist in the care.
Criterion (c)(3): The extensive experience of the VNA in its palliative care unit provides an adequate basis for determining that the program it will provide will be of high quality.
Criterion (c)(4): The only health care service which would serve as an alternative to the hospice service proposed by VNA is VNA's own palliative care program, which has served many terminally ill patients. There are no other existing types of facilities, such as nursing homes or ordinary home health agency services, which would be more appropriate environments to provide care to the terminally ill and families of the terminally ill.
Criterion (c)(5): Some economies of scale will be realized by VNA through the centralization of its management services, such as accounting, marketing, billing and collection which would not be achieved if the new hospice program were wholly independent from the VNA network. Moreover, the community
liaison personnel which VNA has placed in North Broward Medical Center should increase the efficiency of the proposed VNA hospice by placing patients into the program earlier, which should lower the cost of in-hospital care for those patients.
Criterion (c)(6): Is not applicable. Criterion (c)(7): Is not applicable.
Criterion (c)(8): VNA has shown that it has adequate funds for accomplishing its proposed hospice program in the long and short terms.
Criterion (c)(9): The facility would be financially feasible in the immediate and the long term due to the present palliative care program on which this program will build, and the continuity of care which will be available through the VNA community-liaisons who work with the North Broward Hospital District.
Criterion (c)(10): Is not applicable. Criterion (c)(11): Is not applicable.
Criterion (c)(12): While there are more hospices in Broward County than in other areas of the State of Florida, the other programs have experienced an increase in patient census, and With the increase in the need for palliative care as the result of Acquired Immune Deficiency Syndrome, there is every reason to believe that even with the addition of the VNA program, existing hospices will continue to provide quality programs.
Criterion (c)(13): Is not applicable because the VNA project does not involve a capital expenditure.
Section 381.494(6)(d) does not apply, because the hospice program proposed by VNA does not contemplate capital expenditures for inpatient care. Facilities for inpatient care will be provided on a contract basis.
It is
RECOMMENDED that a certificate of need be granted to VNA to operate a hospice program in Broward County, which includes five inpatient beds.
DONE AND ORDERED this 31st day of December, 1987, at Tallahassee, Florida.
WILLIAM R. DORSEY, JR.
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32301
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings
this 31st day of December, 1987.
APPENDIX TO RECOMMENDED ORDER
The following are my rulings on the proposed findings of fact submitted by the parties pursuant to Section 120.59(2) Florida Statutes (1985). As a preliminary matter I am constrained to point out that I generally found the testimony of the witnesses for VNA persuasive. While the testimony of the opponents was no doubt sincere, it was colored by undue pessimism about their ability to operate in a more competitive environment but the reasons stated for their fears about licensure of an additional competitor were unpersuasive.
While initially the Hearing Officer had some doubt about the financial viability of the project, after a review of the testimony of Mr. Semeoni I am satisfied that the reasons he gave to support his opinion that the project is financially viable and the short and long term, and that the projections found in the application are reasonable, is credible, and should be accepted. In rulings on the proposals filed by VNA and HRS.
Rejected as unnecessary.
Covered in Finding of Fact 1
Covered in Finding of Fact 21.
Covered in Finding of Fact 16.
Covered in Finding of Fact 103.
Covered in Finding of Fact 112.
Rejected as unnecessary.
8-10. Covered in Finding of Fact 2. 11-13. Covered in Finding of Fact 3.
Covered in Finding of Fact 4.
Covered in Finding of Fact 5.
Covered in Finding of Fact 6.
Covered in Finding of Fact 7.
Covered in Finding of Fact 8.
Covered in Finding of Fact 9.
20-22. Covered in Finding of Fact 10.
23. Covered in Finding of Fact 11.
24-27. Covered in Finding of Fact 12. 28-29. Covered in Finding of Fact 13.
Covered in Finding of Fact 14.
Covered in Finding of Fact 15.
Rejected as unnecessary.
Covered in Finding of Fact 79.
Rejected as subordinate to Finding of Fact 71.
Covered in Finding of Fact 84.
Rejected as subordinate to Finding of Fact 84. 37-40. Rejected as unnecessary.
41-42. Covered in Finding of Fact 53.
43. Covered in Finding of Fact 54.
44-45. Covered in Finding of Fact 55. 46-49. Covered in Finding of Fact 56. 50-52. Covered in Finding of Fact 57. 53-55. Covered in Finding of Fact 61.
56-57. Rejected as a recitation of testimony not a finding of fact. 58-59. Covered in Finding of Fact 59.
60. Rejected as unnecessary.
61-64. Covered in Finding of Fact 63.
65. Rejected as redundant.
66-67. Covered in Finding of Fact 63. 68-73. Rejected as unnecessary.
74-75. Covered in Finding of Fact 64.
76. Rejected as redundant.
77-80. Covered in Finding of Fact 65.
Covered in Finding of Fact 66.
Covered in Finding of Fact 60.
83-88. Covered in Finding of Fact 60. 89-91. Rejected as unnecessary.
92-103. Rejected because there are no adequate alternatives to hospice care for persons in need of hospice care. The findings are therefore unnecessary. See Conclusions of Law concerning section 381.494(6)(c)4.
104-105. Rejected as unnecessary.
106. Covered in Findings of Fact 10 and 68. 107-108. Covered in Finding of Fact 69.
109-119. Rejected as unnecessary.
120-122. Covered in Finding of Fact 70. 123-125. Rejected as unnecessary.
Covered in Finding of Fact 72.
Covered in Finding of Fact 71.
Rejected as redundant.
Covered in Finding of Fact 79.
Covered in Finding of Fact 80.
Covered in Finding of Fact 81.
Covered in Finding of Fact 82.
Rejected as unnecessary.
Covered in Finding of Fact 83. 135-136. Covered in Finding of Fact 84.
Rejected as cumulative to Finding of Fact 79.
Covered in Finding of Fact 85.
Covered in Finding of Fact 86.
Covered in Finding of Fact 87.
Rejected as unnecessary.
Covered in Finding of Fact 88.
Covered in Finding of Fact 89.
Covered in Finding of Fact 90.
Covered in Finding of Fact 91.
Covered in Finding of Fact 92.
Covered in Finding of Fact 93.
Covered in Finding of Fact 94.
Covered in Finding of Fact 95.
Covered in Finding of Fact 96. 151-152. Covered in Finding of Fact 97.
Covered in Finding of Fact 98.
Covered in Finding of Fact 99.
Covered in Finding of Fact 73.
Covered in Finding of Fact 74.
Covered in Finding of Fact 75.
Covered in Finding of Fact 76.
Rejected as unnecessary.
Covered in Finding of Fact 76.
Covered in Finding of Fact 77.
Covered in Finding of Fact 78.
Covered in Finding of Fact 103.
Covered in Finding of Fact 104.
Covered in Finding of Fact 105.
Covered in Finding of Fact 106.
Covered in Finding of Fact 107.
Covered in Finding of Fact 108.
Covered in Finding of Fact 109.
Covered in Finding of Fact 110.
Covered in Finding of Fact 111.
Covered in Finding of Fact 112.
Covered in Finding of Fact 113.
Covered in Finding of Fact 114. 175-176. Rejected as unnecessary.
Covered in Finding of Fact 115.
Covered in Finding of Fact 100.
Covered in Finding of Fact 101.
Covered in Finding of Fact 102.
Rulings on Finding of Fact proposed by Hospice Care of Broward County, Inc.
Rejected as inapplicable.
Covered in the Conclusions of Law. 3-4. Covered in Finding of Fact 40.
5-6. Rejected as unnecessary.
Covered in Finding of Fact 41.
Covered in Finding of Fact 42.
Covered in Finding of Fact 43.
Covered in Finding of Fact 44.
Covered in Finding of Fact 45.
Covered in Finding of Fact 45.
Covered in Finding of Fact 46.
Covered in Finding of Fact 47, to the extent necessary.
Covered in Finding of Fact 48.
Rejected as unnecessary.
17-18. Covered in Finding of Fact 49.
Covered in Findings of Fact 50 and 51.
Covered in Finding of Fact 52.
Rejected because the new hospice, while in competition with hospice of the Gold Coast which necessarily means that its programs would duplicate those of Gold Coast.
22-24. Rejected as unnecessary.
Covered in Finding of Fact 30.
Covered in Finding of Fact 31.
Covered in Finding of Fact 32.
Covered in Finding of Fact 33.
Covered in Finding of Fact 34.
Covered in Finding of Fact 35.
Covered in Finding of Fact 36.
Covered in Finding of Fact 37.
Covered in Finding of Fact 38.
Covered in Finding of Fact 39.
Rejected as unnecessary.
36-37. Covered in Finding of Fact 21.
Covered in Findings of Fact 21, 22, and 23.
Covered in Finding of Fact 24.
Covered in Finding of Fact 25.
Covered in Finding of Fact 26.
Covered in Finding of Fact 27.
Covered in Finding of Fact 28.
Covered in Finding of Fact 29.
Rulings on proposed findings of fact from Hospice, Inc.
Rejected as unnecessary.
Covered in Findings of Fact 2, 16, 21, 40, and 55.
Rejected because whether Broward has fewer or more hospices than other counties, HRS service districts or more per person than any county is not relevant, the relevant considerations are those set forth in applicable statutes and rules.
Covered in Finding of Fact 54 or rejected as unnecessary.
Rejected because I have found the need for an additional hospice program.
Rejected for the reasons stated in Finding of Fact
Rejected inconsistent with my view of the evidence.
Rejected as unnecessary.
Rejected for the reasons stated in Finding of Fact
Covered in Finding of Fact 49, to the extent necessary.
11-12. Covered in Finding of Fact 27, to the extent necessary.
Rejected as argument, not a finding of fact.
Rejected as inconsistent with my view of the testimony of Mr. Blair. The local plan does not state that there is a need for a hospice in South Broward, but that if there were two competing applications, preference would be given to the hospice proposing to locate in South Broward, which is not at issue here.
Covered in Finding of Fact 60.
Rejected as inconsistent with my view of the evidence.
Rejected for the reasons given for rejecting finding of fact 3.
Rejected as unnecessary.
Rejected as unnecessary, the criteria for approving a new hospice is not that existing hospices must have waiting lists.
Rejected as unnecessary.
To the extent necessary covered in Finding of Fact 87(f).
Rejected as unnecessary.
To the extent that Broward presents a "not normal" situation, see Findings of Fact 56 and 57.
Rejected as unnecessary.
Rejected as a recitation of testimony not a finding of fact.
Rejected as unnecessary.
Covered in Finding of Fact 15.
Rejected as recitation of testimony not a finding of fact.
Rejected for the reasons stated in Findings of Fact 61 through 67.
Rejected as unnecessary because I do not believe that the VNA application should be approved because of unique "high tech" care to be available from it alone.
Rejected as unnecessary.
To the extent necessary covered in Finding of Fact 17.
Covered in Finding of Fact 18.
Covered in Finding of Fact 19. 34a. Covered in Finding of Fact 20.
Rejected as unnecessary.
Rejected as cumulative to the Finding of Fact made in the description of the parties for each of the existing hospices.
Rejected as inconsistent with my view of the evidence.
Rejected as inconsistent with my view of the evidence.
Rejected because hospices may be approved without evidence of "serious problems" seeking admission to hospice programs.
Rejected as inconsistent with the evidence which I have credited. See Findings of Fact 73 through 78.
Rejected because I do not accept Mr. Nelson's premise that approval of additional hospice means that that a new hospice will have to cut into the existing market share of current hospices. The rule methodology provides reason to believe that there is a substantial pool of unmet need from which patients may be drawn.
Rejected as unnecessary.
Rejected because I do not share Hospice Care's pessimistic view of the potential loss of revenue it would experience if the VNA hospice were granted.
As a general matter, I found the testimony of Mr. Simeone on the reasonableness of the projections in the VNA more persuasive than the criticisms of the application by Reverend Westbrook. No useful purpose will be served by going through a line by line analysis of proposed findings 46 through 92 which generally relate to criticism of the financial projections made by VNA because I have resolved the disputes in favor of VNA's application and against the criticisms of the application raised by Hospice. Inc. The projections of VNA is financially feasible in the long and short terms. See Findings of Fact 79 through 99.
COPIES FURNISHED:
Howard Hochman, Esquire Gerald M. Cohen, Esquire Wood, Lucksinger & Epstein
200 South Biscayne Boulevard Suite 3700
Miami, Florida 33131-2359
Kenneth Hoffman, Esquire Martha Edenfield, Esquire OERTEL & HOFFMAN, P.A.
2700 Blair Stone Road Post Office Box 6507
Tallahassee, Florida 32314-6507
John Rodriguez, Esquire Department of Health and Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407
Tallahassee, Florida 32399-0700
Sam Power, Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407
Tallahassee, Florida 32399-0700
John Miller, Esquire Acting General Counsel Department of Health and Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
Charles Stampelos, Esquire
215 South Monroe Street Suite 666
Tallahassee, Florida 32301
Gregory L. Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, Florida 32399-0700
=================================================================
AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
HOSPICE CARE OF BROWARD COUNTY, INC.,
Petitioner,
CASE | NO.: | 86-2109 | |
vs. | CON | NO.: | 4370 |
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES and VISITING NURSE ASSOCIATION OF BROWARD COUNTY, INC. COMMUNITY HOSPICE, |
Respondents.
/ HOSPICE CARE OF BROWARD
COUNTY, INC.,
Petitioner, CASE | NO.: | 86-2579 | |
CON | NO.: | 4370 | |
vs. | |||
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, and VISITING NURSE ASSOCIATION OF BROWARD COUNTY, INC., COMMUNITY HOSPICE, | |||
Respondents.
/
FINAL ORDER
This cause came on before me for the purpose of issuing a final agency order. The Hearing Officer assigned by the Division of Administrative Hearings (DOAH) in the above-styled case submitted a Recommended Order to the Department of Health and Rehabilitative Services (HRS). A copy of that Recommended Order is attached hereto.
RULING ON JOINT EXCEPTIONS FILED BY
HOSPICE, INC. AND HOSPICE CARE OF BROWARD COUNTY, INC.
FINDINGS OF FACT
Petitioners take exception to finding of fact number 54. Exception number one (1) is denied as the finding merely recites a stipulation.
Petitioners take exception to finding of fact number 56. An application for hospice care beds is reviewed on the basis of all applicable rule and statutory criteria. The finding is supported by competent, substantial evidence; therefore, exception number two (2) is denied.
Petitioners take exception to finding of fact number 58. The finding is supported by competent, substantial evidence; therefore, exception number three (3) is denied.
Petitioners take exception to finding of fact number 59. An application for hospice care beds is reviewed on the basis of all applicable rule and statutory criteria. The finding is supported by competent, substantial evidence; therefore, exception number four (4) is denied.
Petitioners take exception to finding of fact number 60, which states that the VNA proposal is consistent with the local health plan. The finding is supported by competent, substantial evidence; therefore, exception number five
(5) is denied.
Petitioners take exception to finding of fact number 60, which states that the utilization of hospice services in Broward County is less than the rule methodology would project. The finding is supported by competent, substantial evidence; therefore, exception number six (6) is denied.
Petitioners take exception to finding of fact number 62. The finding is supported by competent, substantial evidence; therefore, exception number seven
(7) is denied.
Petitioners take exception to finding of fact number 6, which states that VNA will provide hospice education for groups that are currently underserved and that increased education regarding the services for both patients and physicians is likely to result. The finding is supported by competent, substantial evidence; therefore, exception number eight (8) is denied.
Petitioners take exception to finding of fact number 64, which states there is an unmet need for hospice services in Broward County. The finding is supported by competent, substantial evidence; therefore, exception number nine
is denied.
Petitioners take exception to finding of fact number 65, which states that the VNA Hospice would be more accessible because it will accept patients without an identified family member or care giver, while other hospices feel such patients are not appropriate for hospice care, and that other hospices will not accept a patient whose physician is located in Dade County. The finding is supported by competent, substantial evidence; therefore, exception number ten
is denied.
Petitioners take exception to finding of fact number 67, with regard to the relationship VNA enjoys with the North Broward Hospital District and physicians serving indigent patients. The finding is supported by competent, substantial evidence; therefore, exception number eleven (11) is denied. 12. Petitioners take exception to finding of fact number 70, which states that continuity of care that can be offered by VNA will help avoid dislocations which can occur when a patient and family are served by a different provider. The finding is supported by competent, substantial evidence; therefore, exception number twelve (12) is denied.
Petitioners take exception to finding of fact number 71, regarding continuity of care within the VNA organization and the resulting economies of scale. The finding is supported by competent, substantial evidence; therefore, exception number thirteen (13) is denied.
Petitioners take exception to finding of fact number 72, regarding community liaisons within the North Broward Hospital District. The finding is supported by competent, substantial evidence; therefore, exception number fourteen (14) is denied.
Petitioners take exception to finding of fact number 74, which states that it is projected there will be increased private contributions as a result of implementation of more aggressive fund raising activities. The finding is supported by competent, substantial evidence; therefore, exception number fifteen (15) is denied.
Petitioners take exception to finding of fact number 78, which states that VNA would be able to handle any unanticipated decrease in revenue or unanticipated increase in expenses through additional contributions or renegotiations of its hospital contract. The finding is supported by competent, substantial evidence; therefore, exception number sixteen (16) is denied.
Petitioners take exception to finding of fact number 79, that the project is financially feasible in both the long term and short term. The finding is supported by competent, substantial evidence; therefore, exception number seventeen (17) is denied.
Petitioners take exception to finding of fact number 77, which states that VNA initially anticipates receiving funds for hospice programs from the United Way and VNA foundation. The finding is supported by competent, substantial evidence; therefore, exception number eighteen (18) is denied.
Petitioners take exception to finding of fact number 87, which states the proposed patient census in the application is reasonable. The finding is supported by competent, substantial evidence; therefore, exception number nineteen (19) is denied.
Petitioners take exception to finding of fact number 90 stating that an 80:20 ratio is reasonable for planning purposes. The finding is supported by competent, substantial evidence; therefore, exception number twenty (20) is denied.
Petitioners take exception to finding of fact number 94, regarding VNA's projection that 10 percent of its revenue will be "insurance and private pay". The finding is supported by competent substantial evidence; therefore, exception number twenty-one (21) is denied.
Petitioners take exception to finding of fact number 95, which states that VNA's projection regarding Medicare and Medicaid reimbursement are reasonable. The finding is supported by competent, substantial evidence; therefore, exception number twenty-two (22) is denied.
Petitioners take exception to finding of fact number 96, regarding average length of stay of 45 - 50 days. The finding is supported by competent, substantial evidence; therefore, exception number twenty-three (23) is denied.
Petitioners take exception to finding of fact number 98, which states that .25 full time equivalent is consistent with those projections relied on by other hospices. The finding is supported by competent, substantial evidence; therefore, exception number twenty-four (24) is denied.
Petitioners take exception to finding of fact number 99, regarding the requirement of a inpatient RN coordinator position. The finding is supported by competent, substantial evidence; therefore, exception number twenty-five (25) is denied.
Petitioners take exception to finding of fact number 101, which states that VNA will be a positive competitive force, vis a vis, quality, accessibility to indigents, public education, cost effectiveness and training. The finding is supported by competent, substantial evidence; therefore, exception number
twenty-six (26) is denied.
Petitioners take exception to finding of fact number 104. The finding is supported by competent, substantial evidence; therefore, exception number twenty-seven (27) is denied.
Petitioners take exception to finding of fact number 101. The finding is supported by competent, substantial evidence; therefore, exception number twenty-eight (28) is denied.
CONCLUSIONS OF LAW
The petitioners exceptions to the conclusions of law essentially reiterate the exceptions to the findings of fact. The exceptions to the conclusions of law are DENIED.
Based on a balanced weighing of all applicable rule and statutory criteria, it is
ADJUDGED, that VNA's application for CON 4370 to operate a hospice program in Broward County he approved.
DONE and ORDERED this 16th day of February, 1988, in Tallahassee, Florida.
Gregory L. Coler Secretary
Department of Health and Rehabilitative Services
by Assistant Secretary for Programs
COPIES FURNISHED:
John Rodriguez, Esquire Assistant General Counsel Department of Health
Rehabilitative Services 2727 Mahan Drive
Fort Knox Executive Center Tallahassee, Florida 32308
Howard Hochman, Esquire Gerald M. Cohen, Esquire WOOD, LUCKSINGER & EPSTEIN
Southeast Financial Center
200 South Biscayne Blvd., Suite 3700
Miami, Florida 33131-2359
William Dorsey, Hearing Officer DOAH, The Oakland Building 2009 Apalachee Parkway
Tallahassee, Florida 32301 Nell Mitchem
Kenneth Hoffman, Esquire Martha Edenfield, Esquire OERTEL & HOFFMAN, P.A.
Post Office Box 6507 Tallahassee, Florida 32314-6507
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing was sent to the above-named people by U.S. Mail this 19th day of February, 1988.
R. S. Power, Agency Clerk Assistant General Counsel Department of Health and
Rehabilitative Services 1323 Winewood Boulevard Building One, Room 407
Tallahassee, Florida 32399-0700 904/488-2381
NOTICE OF RIGHT TO JUDICIAL REVIEW
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF HRS, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
| Issue Date | Proceedings |
|---|---|
| Dec. 31, 1987 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Feb. 16, 1988 | Agency Final Order | |
| Dec. 31, 1987 | Recommended Order | Projection found in appl for Cert. of Need reasonable & acceptable. Cert of Need granted to operate a Hospice program which includes 5 inpatient bed. |
