STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

VENICE HOSPITAL, INC., )

)

Petitioner, )

)

vs. ) CASE NO. 90-2738

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

) VENICE HOSPITAL, INC., )

)

Petitioner, )

)

vs. ) CASE NO. 90-3575

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

)

RECOMMENDED ORDER

A hearing was held in this case in Tallahassee, Florida on July 16, 1990, before Arnold H. Pollock, a Hearing Officer with the Division of Administrative Hearings.

APPEARANCES

For the Petitioner: Jeffery A. Boone, Esquire

1001 Avenida del Circo

P. O. Box 1596 Venice, Florida 34284

For the Respondent: Richard A. Patterson, Esquire

Department of Health and Rehabilitative Services

2727 Mahan Drive, Suite 103

Tallahassee, Florida 32308 STATEMENT OF THE ISSUES

The issue for consideration in this case is whether the Department of Health and Rehabilitative Services, (Department), properly denied Venice Hospital's, (Venice), Letter of Intent, (LOI), to add a certain number of skilled nursing facility, (SNF), beds to its facility by converting existing medical/surgical, (med/surg), beds, and properly rejected Venice's Certificate of Need, (CON), application which was based on the referenced LOI.

PRELIMINARY STATEMENT

By letter dated March 13, 1990, Sharon M. Gordon-Girvin, Director of Community Health Services and Facilities of the Department's Office of Regulation and Health Facilities, notified Petitioner that its Letter of Intent to add 42 skilled nursing facility beds to its facility, located in Department District 8, did not constitute a valid Letter of Intent. Thereafter, on April 4, 1990, Petitioner filed a Petition for Formal Administrative Hearing to contest that determination, and on April 26, 1990, the file was forwarded to the Division of Administrative Hearings for appointment of a Hearing Officer.

By undated letter, Ms. Gordon-Girvin also rejected Venice's application for a CON to establish a 36 bed SNF unit at its facility. On May 10, 1990, Venice filed a Petition for Formal Administrative Hearing to contest that Department action, and on June 5, 1990, the file was forwarded to the Division of Administrative Hearings for appointment of a Hearing Officer.

By Notice of Hearing dated May 29, 1990, the LOI case was set for hearing in Tallahassee on July 16, 1990. On July 9, 1990, Counsel for Petitioner moved to consolidate the two cases, and by comprehensive Order dated July 10, 1990, the undersigned granted the Motion For Consolidation and Petitioner's Motion to Amend its Petition. By that same Order he denied Respondent's Motion to Relinquish Jurisdiction which was based on Petitioner's purported failure to include in its Petition regarding the rejection of the LOI, any statement of disputed issues of material fact. The Amended Petition corrected any such deficiency, and the hearing on the consolidated cases was heard on July 16, 1990 as scheduled.

At the hearing, Petitioner presented the testimony of Larry G. Bebee, a hospital planner with Venice Hospital and an expert in health planning, and Armand D. Balsano, a health care consultant and expert in health planning.

Petitioner also introduced Petitioner's Exhibits 1 through 8 and 10. Petitioner's Exhibit 9 for identification was not admitted.

Respondent presented the testimony of Sharon Gordon-Girvin, the Department's Director of Health Services and Facilities, and Amy M. Jones, the Department's Deputy Assistant Secretary for Health Facilities, and an expert in health care facility licensing and certification in Florida. Respondent also introduced Respondent's Exhibits A through E and G through I. Respondent's Exhibit F for identification was not admitted.

A transcript was provided and subsequent to the hearing, both parties submitted Proposed Findings of Fact which have been ruled upon in the Appendix to this Recommended Order.

FINDINGS OF FACT

1. Venice Hospital, a general acute care hospital offering 342 medical/surgical beds and 30 bed's for general psychiatric care, services a population of approximately 110,000 people in Southern Sarasota and Northern Charlotte Counties. Approximately 80% of its patients are covered by Medicare. This figure being higher than average, puts it somewhere in the top 5% of Medicare providers in Florida. The hospital's services are concentrated on geriatric patients and it is developing several programs devoted to that type of patient. It has recently received approval for nursing home development and

   operates a home health agency. Missing from the geriatric spectrum of services is the hospital based skilled nursing facility, (SNF), which is the subject of this action.

   
   

2. Sarasota County currently has four med/surg hospitals, including Petitioner which is the only hospital in the Venice area. Petitioner has a licensed psychiatric unit which operates under separate rules and which is licensed separately but within the hospital cycle. The patients which are treated in that unit are of a different demographic make up than those treated in the med/surg beds and the staff which treats them is different.

   
   

3. Petitioner completed a study of the potential need for SNF beds in the hospital which led to the conclusion being drawn by it that this service should be established. Mr. Bebee's review of the applicable rules and statutes indicated to him that the hospital could elect to designate a special care unit within the hospital without even having to go through Certificate of Need, (CON), review. A letter was submitted by the hospital to the Department on February 8, 1990, asking for an exemption from CON review for that project. Because no response to that letter was forthcoming, and because the hospital review cycle was fast coming up, on February 22, 1990, Mr. Bebee submitted a LOI to the Department seeking to convert 42 med/surg beds to a hospital based SNF facility at a cost of $310,000.00. After the LOI was sent, on February 26, 1990, Ms. Gordon-Girvin, on behalf of the Department, responded by letter to Bebee's inquiry letter, indicating the CON review process was a necessary part of the process for Petitioner's facility, but that the LOI and application should be filed in the next nursing home batching cycle by April 30, 1990. Shortly thereafter, by letter dated March 13, 1990, Ms. Gordon-Girvin rejected the LOI which Petitioner had submitted in the hospital cycle since, according to the Department, it was properly "reviewable under the nursing home review cycle rather than the hospital review cycle."

   
   

4. Notwithstanding that rejection, and understanding the Department's position as to which cycle was appropriate, on March 26, 1990, Petitioner submitted its CON application for this project, modified to seek only 36 beds. By undated letter, the envelope for which was postmarked April 16, 1990, Ms. Gordon-Girvin declined to accept that application for the same reason she had rejected the LOI. Petitioner has since filed a CON application for the same project in the current nursing home cycle, on a nursing home application form. It did this to keep its options open but considers that action as being without prejudice to the application at issue.

   
   

5. Though numerical bed need is not in issue in this proceeding, a brief discussion of general need is pertinent to an understanding of why Petitioner has applied for approval of this project. Petitioner is of the opinion that SNF beds within the hospital setting will provide better care for the patients than could be provided in a nursing home. Many of the patients in issue are receiving intravenous applications of medicines; taking antibiotics; require orthopedic therapy; or are in respiratory distress calling for ventilator or other pulmonary procedures. These patients need a continuing level of nursing care on a 24 hour basis but no longer qualify for a hospital continued length of stay. Petitioner currently has and is taking care of such patients in the facility, but would like to do so in a more organized, systematic manner which could be accomplished in a hospital based SNF.

   
   

6. In addition, reimbursement rules dictate that patients no longer needing full hospital care but who remain in the hospital, become, in part, a cost to the hospital because no meaningful reimbursement is received for

   thatlevel of care. They would qualify for Medicare reimbursement, however, if the unit were designated and certified as a SNF. Medicaid does not recognize these beds as reimbursable because they are in a hospital.

   
   

7. Certification for the hospital based SNF would be through the Health Care Financing Administration, (HCFA), and the Medicare program. To secure this certification, the hospital based unit would have to be a distinct part of the facility and not merely consist of beds scattered throughout the facility. Once certified, the unit is not referred to as a nursing home by HCFA or Medicare, but is classified as a hospital based unit. Because Petitioner sees this as a hospital project - a service that the hospital would be providing under its license, it chose to file for the approval in the hospital cycle rather than in the nursing home cycle.

   
   

8. Bebee is familiar with the certification process for both hospitals and nursing homes. The latter is a lengthier process and is substantially different from that used for hospitals. In his opinion, it does not give the hospital based applicant the opportunity to properly justify the approval of a hospital based SNF since it deals more with the requirements of a community based facility. The nursing home form is highly structured whereas the hospital form makes it easier to identify and supply the appropriate supporting information for the project applied for. Further, Bebee does not consider the hospital based SNF bed in the same context as a community nursing home bed. The type of patient is not the same nor are the resources required to treat that patient.

   
   

9. Petitioner has purchased a CON to construct a 120 bed community nursing home within the Venice area which will have some SNF beds in it. Nonetheless, because of the basic difference between the services, it still plans to pursue the hospital based SNF. A Florida Hospital Association study concluded that SNF in hospitals are different and there is a lack of this type of service in the hospitals throughout the state. This study, dated May, 1989, at Page 5 reads:

   
   

   Conversion of hospital beds to nursing home beds could improve the financial viability of hospitals, reduce purchasers' and consumers' health costs, and improve access to care for patients requiring higher levels of nursing care, [if they are needed and meet quality care requirements].

   
   

10. Bebee also points out that if this project is considered in the nursing home cycle rather than in the hospital cycle, it would result in a hospital competing with nursing homes which are seeking a different type of bed

    - community versus SNF. Current community nursing home bed need is set at 0. Petitioner's nursing home cycle application was filed under the "not normal circumstances" provision, but there may still be substantial contest. This type of litigation, he believes, adds unreasonably and unnecessarily costs and is a resultant financial burden to the hospital.

    
    

11. Mr. Balzano, a health care consultant and Petitioner's other expert, confirmed and amplified the substance of Mr. Bebee's thesis. He compared hospital based SNFs with those in community nursing homes and found notable differences aside from the statutes and rules governing each. Petitioner's current beds are controlled under Chapter 395, Florida Statutes, and Rule 10D- 28, F.A.C. If some were converted to SNF beds under the pending application, they would still fall under the purview of that statute and rule. On the other

    hand, community nursing home SNF beds would be controlled by the provisions of Chapter 400, Florida Statutes, and Rule 10D-29, F.A.C. There is a substantial difference between them.

    
    

12. Other differences are:

    
    

    1. Patients in hospital based SNF beds generally have greater nursing requirements than those in SNF beds in community nursing homes.

       
       

    2. Staffing in hospital based SNF is generally higher than in free standing nursing homes.

       
       

    3. The average stay is shorter in a hospital based SNF. Patients are not there for continuing care but for restorative care.

       
       

    4. The size of a hospital based SNF unit is generally smaller than that in a free standing unit.

       
       

    5. Costs are usually greater in a hospital based SNF unit reflecting the greater needs of the patient. Therefore, reimbursement is generally higher.

       
       

    6. Health services in the different systems are different and a comparative review would be difficult. The questions in the different application forms reflect a different approach and in the nursing home application, relate to residential type care. This is not the case in the hospital form.

       
       

    7. Costs relating to the use of an existing facility would be cheaper for the hospital based unit when compared with building a new nursing home facility. However, the costs of hospital construction are usually higher than nursing home construction though the quality of construction is generally better.

       
       

    8. The operating costs for the more complex services provided in a hospital based unit are higher and Petitioner would have trouble competing if reimbursement were based on the classification as a nursing home.

       
       

    9. Higher staffing levels and higher staffing costs in a hospital based facility would act in disfavor of that facility.

       
       

    10. The state generally looks with greater favor on projects for Medicaid patients. Hospital based units are not oriented toward that group and would, therefore, not be given the same consideration, as would be a nursing home which catered to Medicaid patients.

        
        

    11. The type of patient, (residential vs. subacute) has an impact. The hospital based unit provides treatment to the more acutely ill patient. SNF patients who need that higher degree of care would get it better at a hospital based facility which has greater resources to meet patient needs.

    
    

13. Mr. Balzano feels it is unfair to compare the two types of properties. The differences in the programs would have an impact on the issue of need when comparative review is done. A SNF in the hospital setting is different but would be compared, if the nursing home cycle were used, against the total pool of community nursing home beds even though the patients are different and their need for services are different. Need methodology looks at historical utilization. Hospital based SNF patients turn over more frequently than do

    community nursing home patients and the occupancy level is not as high in the hospital based setting. This would bring the average occupancy rate in an area down and could affect the need for community beds across the board.

    
    

14. It is also noted that hospital based SNF beds would not be appropriate to house community nursing home patients who could not be accommodated in a nursing home, and vice-versa. SNF patients could normally not be appropriately treated in a community nursing home because of their greater needs. If compared in a batched review, however, they would be considered together without that distinction being made.

    
    

15. Since all other hospital services are reviewed under the provisions of Chapter 395 parameters as hospitals, Balzano sees it as inconsistent to review hospital based SNF beds under the nursing home criteria. He can find no statutory or rule provision requiring this. The Department has drafted a proposed rule on the subject but that proposal is presently under challenge. Further, Medicare considers hospital based SNF beds and community nursing home based SNF beds as different entities with the hospital based beds earning a higher reimbursement ceiling due to the increased services and the different type of patient.

    
    

16. According to Mr. Balzano, in Florida, hospital based SNF beds account for 1/2 of 1% of all hospital beds. Nationwide the figure is 4%. Balzano feels this is because in Florida there is no criteria to judge need against and therefore these beds are compared to all nursing home beds. He considers this wrong, especially in a state where there is such a high percentage of elderly patients. It is, in his opinion, poor health planning, and when compared against other nursing homes, the hospital based SNF unit will always be at a disadvantage.

    
    

17. The testimony of Ms. Sharon Gordon-Girvin, Director of the Department's Office of Community Health Services and Facilities, reveals the Department's rationale in its rejection of the Petitioner's LOI for the instant project and the subsequent return of its application. The application was rejected because there was no underlying LOI for the project. The LOI was initially rejected as having been filed in an inappropriate cycle, (hospital).

    
    

18. The Department's policy, calling for applications for all extended care or hospital based skilled nursing facility beds to be filed in a nursing home batching cycle has been in place for an extended period going back before 1984. The Department looks at extended care beds and SNF beds as somewhat equivalent but different. The designation of extended care facility beds initially used by HCFA, (Medicare), in hospital situations is no longer applicable. Now, Medicare recognizes SNF beds in hospitals, but does not distinguish them from other types of hospital based beds. The service is considered the same and the patients must meet identical admissions criteria.

    
    

19. The reasons relied upon by the Department, from a health planning standpoint, for reviewing applications for hospital based SNF beds in the nursing home cycle are:

    
    

    1. Medicare conditions of service and admission criteria are the same, and

       
       

    2. The State nursing home formula rule projects a need for all nursing home beds, (SNF and ICF) , and does not differentiate between type. Providers compete for the beds, not where they will be used or under what conditions.

20. The mere need for special treatment such as ventilators or intravenous antibiotics is not controlling. If the patient does not need the acute care provided to hospital acute care patients, since a "subacute" status is no longer recognized by the state, it is the Department's position that that patient should be in intermediate care status. This position is incorporated in the Departments proposed rule which is currently under challenge. It had been elucidated, however, in both the 1988 and 1990 editions of HRSM 235-1, relating to Certificates of Need, where at section 9-5 in both editions the text reads:

    
    

    9-5 Skilled Nursing Unite in Hospitals. Beds in skilled nursing units located in hospitals will be counted in the nursing home bed inventory, even though they retain their licensure as general medical surgical beds.

    
    

21. In addition, the Florida State Health Plan for 1989 and for each year since 1984, has counted hospital based SNF beds in the nursing home bed inventory. The parties stipulated to that point.

    
    

22. Ms. Gordon-Girvin admits that it is sometimes difficult for an applicant to apply for hospital based SNF beds on a nursing home application for, but claims that is as it should be. She asserts that the patients are the same, (disputed), and since, she claims, a hospital cannot provide the same services that a full service nursing home could provide, the applicants should be differentiated on the basis of services rather than patient category to justify the additional cost inherent in the hospital based setting. In short, she believes the current situation is appropriate since it requires the applicant, a hospital, to look more carefully at the terms and conditions of the services to be provided. In so far as this results in health care cost savings, her position is accepted.

    
    

23. She also contends that the Florida Hospital Association study relied upon by Petitioner to support its position that hospital based SNF bed applications for distinct units cannot compete fairly against nursing homes in a comparative CON review, is not pertinent here considering it was prepared to examine an excess of hospital bed inventory and possible alternative uses as income sources. Regardless of the purpose of the study, absent a showing that it is unreasonably slanted or biased, its conclusions have not been successfully rebutted.

    
    

24. Ms. Gordon-Girvin also contends that the low percentage of hospital based SNF beds as compared to total hospital beds is a positive result of the state's efforts to reduce costly services in favor of less costly alternatives. The Department has the exclusive charter to determine which services are to be reviewed and how the review is to be conducted.

    
    

25. Even if the proposed rule formalizing the procedure questioned here is stricken, the policy currently being utilized by the Department would still be valid and appropriate. Psychiatric, substance abuse, and rehabilitation beds in hospital inventories are considered distinct from acute care beds, but are still classified as hospital beds because there are no reasonable alternatives for treatment of those conditions. With regard to those patients using hospital based SNF beds, however, the Department claims there is an alternative, the community nursing home based SNF beds.

26. In further support of the Department's position, Amy M. Jones, the Department's Assistant Secretary for Health Care Facilities and an expert in facility licensing and certification in Florida, pointed our that the Department treats hospital based SNF beds and community nursing home SNF beds the same because:

    
    

    1. conditions of participation are the same and the Department wants to look at and compare similar activities in the same cycle, and

       
       

    2. pertinent statutes and rules both provide for comparison of similar beds and similar services.

    
    

27. Section 395.003(4), Florida Statutes, defines the various types of hospital beds as psychiatric, rehabilitative, and general medical/surgical acute care beds regardless of how they are used.

    
    

28. The HCFA Conditions of Participation call for certification of SNF beds as either a distinct part of another facility or as a free standing facility. The agency regulations, as outlined in The Federal Register for February 2, 1989, outlines the requirement that SNF beds in a hospital be surveyed just as are community nursing home SNF beds. Taken as a whole, it would appear that both federal and state regulatory agencies look at SNF beds, regardless of where located, as an integral part of a nursing home operation as opposed to a hospital operation.

    
    

    CONCLUSIONS OF LAW

    
    

29. The Division of Administrative Hearings has jurisdiction over the parties and the subject matter in this case. Section 120.57(1), Florida Statutes.

    
    

30. In the instant case, Petitioner, which operates a full service acute care hospital, seeks to convert a number of its med/surg beds to SNF beds to be operated within the hospital. In furtherance of that aim, it filed a LOI and a subsequent CON application for authority to effect this conversion in a hospital batching cycle, but both documents were rejected by the Department because of a long-standing departmental policy, memorialized in HRSM 235-1, which requires applications for certification of SNF beds, even those which are hospital based, to be filed in a nursing home batching cycle. Though Petitioner thereafter filed a CON application for the same service in a nursing home cycle as required, it nonetheless contests the Department's original action rejecting its hospital batch LOI and application.

    
    

31. Petitioner contends that it has shown ample rationale for considering hospital based SNF beds as a hospital operation rather than requiring them, different in scope as they may be, to be compared against all nursing home bed applications which, it claims, are a substantially different operation. Further, Petitioner argues that the Department's policy is not justified and, having been defined for so long a period, should have been incorporated in a rule.

    
    

32. It is clear no rule exists to indicate under what category SNF beds should be considered. The law is well settled that where no rule exists, or where existing rules are not applicable, the agency must present evidence to support and justify its nonrule policy. McDonald v. Department of Banking and Finance, 346 So.2d 569, (Fla. 1st DCA 1977).

33. Petitioner claims the form for use in applications in the nursing home cycle is totally inadequate and inappropriate to provide the Department with the specific information pertinent to the hospital based SNF scenario, necessary to fairly review the proposal.

    
    

34. Petitioner admits that up until this case, SNF bed CON applications were filed in the nursing home cycle utilizing the nursing home application, were generally denied, and were then usually granted after settlement conference at which information not available through the nursing home application form was provided. While the Department debates the routine nature of this procedure, it clearly has happened more than once.

    
    

35. While psychiatric, substance abuse, and rehabilitation beds are hospital beds, the statute specifically provides for them to be so considered. That is not the case with SNF beds. However, they are not acute care beds either, and even Petitioner admits as much. The typical SNF patient is one who needs special care, somewhat less than acute care, but sufficiently complex in nature that he may not easily be provided appropriately even in SNF beds found in some community nursing homes.

    
    

36. In support of its position, Petitioner has produced evidence to demonstrate what it feels is a definite need for the hospital based SNF in Florida and in its service area in particular. That is not in issue here. On the other hand, the Department justifies treating this type of bed as a nursing home bed under nursing home criteria on the basis of the cost and reimbursement criteria of HCFA, and on the basis that the existing statutes and rules require comparison of similar beds and similar services. Even though Petitioner would like to have SNF beds treated as are hospital based psychiatric, substance abuse, and rehabilitation beds, in comparison with other hospitals, the statutes and the Department rules do not so provide. Nonetheless, as Petitioner has already determined, an alternative avenue of approach exists for it. The hospital based SNF beds can be applied for in the nursing home cycle, even where no numerical need is shown to exist for "nursing home" beds, using the "not normal circumstances" provision of the existing rules.

    
    

37. Petitioner cites significant case law in support of the position that an agency can properly act only within the limits of the power granted it by statute, and it cannot alter or amend those statutes. Agency rules and policies must be consistent with the pertinent statutes under which they are promulgated, and any doubt as to the extent of an agency's power must be resolved against the agency. This is not questioned.

    
    

38. The law also holds that once a policy is developed and solidified, it should be reduced to rule form. Here, this policy has been in existence for at least six years. Clearly, it should be reduced to rule form, but the failure to do so does not serve to justify overturning that policy if the agency has articulated a good reason for the policy.

    
    

39. It well may be that the applicatidn form for a hospital CON is more appropriate for a hospital based SNF bed project than is the nursing home application form. However, the issue here is whether the agency articulated a reasonable and justifiable basis for its policy requirements.

    
    

40. In the instant case, this long standing policy clearly appears to have been justified. Petitioner may not agree with the Department's rationale for its policy, but the Department is the controlling agency and its reasoning, if not clearly improper, should be given great weight. Whether its policy-stated

procedure is the best, most effective approach to the problem may be open to debate, but clearly, the Department can require the application for hospital based SNF beds be filed in the nursing home cycle, as it has done here.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore:

RECOMMENDED that a Final Order be entered by the Department affirming its rejection of the Petitioner's Letter of Intent and CON application for the conversion of medical/surgical beds to SNF beds filed in the hospital batching cycle.

RECOMMENDED this 30th day of August, 1990, in Tallahassee, Florida.

ARNOLD H. POLLOCK, Hearing Officer Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 30th day of August, 1990.

APPENDIX TO RECOMMENDED ORDER IN CASES NOS. 90-2738 & 90-3575

The following constituted my specific rulings pursuant to S 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case.

FOR THE PETITIONER:

1. Not a proper Finding of Fact.

2. Accepted and incorporated herein as it relates to Petitioner's filing of the LOI and the CON application. The balance is background information and is not a proper Finding of Fact.

3.-6. Accepted and incorporated herein.

1. Not a proper Finding of Fact but a statement of party position.

2. Accepted and incorporated herein except for first sentence.

3. Accepted and incorporated herein.

4. Accepted.

5. Accepted.

6. &13. Accepted and incorporated herein. 14.&15. Accepted.

   1. Accepted and incorporated herein.

   2. Accepted and incorporated herein. 18.-21. Accepted.

1. Not a Finding of Fact but merely a restatement of the testimony.

2. Accepted and incorporated herein.

3. Accepted and incorporated herein.

4. &26. Accepted and incorporated herein.

   1. Accepted.

   2. &29. Not a Finding of Fact but argument and a restatement of testimony.

      1. Not a Finding of Fact but argument.

      2. Not a Finding of Fact but a comment on the evidence.

      3. Accepted.

      4. Recitation of the witnesses testimony is accurate, but the conclusion drawn does not necessarily follow. Frequency of use does not necesarily determine the finality of the policy.

      5. Not a Finding of Fact but a comment on the evidence.

      6. Accepted as a presentation of the contents of the document.

      7. Accepted.

      8. Accepted as represented.

38.-40. Accepted and incorporated herein.

41. Accepted as a restatement of testimony. 42.&43. Accepted.

1. Accepted.

2. &46. Accepted.

   1. Accepted.

   2. Accepted.

FOR THE RESPONDENT:

1.&2. Accepted and incorporated herein.

3. Accepted.

4.-6. Accepted and incorporated herein.

1. Accepted and incorporated herein.

2. Accepted and incorporated herein.

COPIES FURNISHED:

Richard A. Patterson, Esquire Department of Health and

Rehabilitative Services 2727 Mahan Drive - Suite 103

Tallahassee, Florida 32308

Jeffery A. Boone, Esquire Post Office Box 1596 Venice, Florida 34284

Linda K. HarSris General Counsel DHRS

1323 Winewood Blvd.

Tallahassee, Florida 32399-0700

Sam Power Agency Clerk DHRS

1323 Winewood Blvd.

Tallahassee, Florida 32399-0700

Docket for Case No: 90-002738

Orders for Case No: 90-002738