Conclusions THE PARTIES resolved all disputed issues and executed a Settlement Agreement. The parties are directed to comply with the terms of the attached settlement agreement. Based on the foregoing, this file is CLOSED. DONE and ORDERED on this the 2{, U, day of - J lJ_h (2 ---' 2014, m Tallahassee, Florida. ELIZ RETARY Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BYLAW. 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. Copies furnished to: Shena Grantham, Esquire Agency for Health Care Administration 2727 Mahan Drive, MS#3 Tallahassee, Florida 32308 Peter A. Lewis, Esquire Law Offices of Peter A. Lewis, P.L. 3023 North Shannon Lakes Drive, #101 Tallahassee, Florida 32303 (U.S. Mail) CERTIFICATE OF SERVICE == ' I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to ------==-- the above named addressees by U.S. Mail on this th f 2014. Richard Shoop, Esquire Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403
The Issue The issues involved in this case, as stipulated to by the parties, are as follows: Issues Remaining to Be Litigated Again, because of their inability to separate the purely factual issues from those which also involve legal determinations, the parties have combined below all issues which remain to be litigated. 1A. Was it proper for DHRS to compute the formula for need contained in FACs 10- 5.11(25)(a)1-3 on a subdistrict basis? 1B. Even if the answer is "yes", did DHRS properly use the result of such a computation as a reason for denying Charter- Ocala's application in this case? 2A. Was it proper for DHRS to take into account both existing and approved beds in computing the occupancy standard formula contained in FACs 10-5.11(25)(d) 5? 2B. Even if the answer is "yes," did DHRS properly use the results of such a computation as a reason for denying Charter- Ocala's application in this case? Does the level of Charter-Ocala's indigent care commitment cause its application not to fully meet the requirement in subsection 8 of Fla. Stat. s 381.494(6)(c) that the proposed services "be accessible to all residents of the service district"? Is the proposed project financially feasible in the long term? Will the proposed project result in an increase in health care costs? In light of all factors, should Charter-Ocala's application be granted?
Findings Of Fact GENERAL Procedural. On or about October 15, 1985, the Petitioner filed an application for a certificate of need with the Respondent. On or about December 26, 1985, the Petitioner filed amendments to its application. On or about February 27, 1986, the Respondent issued a State Agency Action Report proposing to deny the Petitioner's application. On March 27, 1986, the Petitioner filed a Petition for Formal Administrative Hearing with the Respondent. The Petition was forwarded to the Division of Administrative Hearings and was assigned case number 86-1466. On November 12, 1986, the parties filed a Prehearing Stipulation in which they agreed to certain facts and conclusions of law. The facts agreed upon by the parties are hereby adopted as findings of fact. The Parties. The Petitioner is a free-standing 68-bed short-term psychiatric and substance abuse specialty hospital located in Ocala, Florida. The 68 beds consist of 48 short-term psychiatric beds and 20 substance abuse beds. The Petitioner began operating on October 17, 1985. The Respondent is the agency responsible for determining whether the Petitioner's proposal should be approved. The Petitioner's Proposal. In its application, the Petitioner has proposed an expansion of its existing 48 short-term psychiatric beds by 24 beds. The Petitioner proposed that the 24 additional beds consist of 10 beds in a geriatric psychiatric unit and 14 beds in an adult psychiatric unit. The total proposed cost of the additional beds was $1,491,850.00. The Petitioner amended the total proposed cost to $1,213,880.00 on December 26, 1985. At the final hearing, the Petitioner represented that it will operate an adult eating disorder program in the new 14-bed psychiatric unit. NEED FOR ADDITIONAL SHORT-TERM PSYCHIATRIC BEDS. A. General. The Petitioner's existing facility for which additional beds are sought is located in Ocala, Marion County, Florida. Marion County is located in the Respondent's planning district 3. District 3 consists of Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee and Union Counties. The existing providers of short-term psychiatric services in district 3 in addition to the Petitioner consist of Alachua General Hospital, Shands Teaching Hospital, Lake City Medical Center, Munroe Regional Medical Center and Lake Sumter County Mental Health Clinic. The District III Health Plan divides the district into 2 subdistricts: southern and northern. The southern subdistrict includes Citrus, Hernando, Lake, Marion and Sumter Counties. The northern subdistrict consists of Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee and Union Counties. Marion County is located in the northern portion of the southern subdistrict. Ocala, which is located in the northern portion of Marion County is approximately 20 miles from the border of the subdistricts. B. Rule 10- 5.011(1)(o), Florida Administrative Code. The projected population of district 3 in 1990 is 972,450. Based upon the projected population of district 3 in 1990, there is a gross need for 340 short-term psychiatric beds for district 3 in the relevant planning horizon year 1990. There are 316 licensed and approved short-term psychiatric beds for district 3. There is a net need for 24 short-term psychiatric beds for district 3 in 1990. Of the 316 licensed and approved short-term psychiatric beds located or to be located in district 3, 149 are located in hospitals holding a general license and 167 are located in specialty hospitals. Multiplying the projected 1990 district 3 population by a ratio of .15 beds per 1,000 population indicates a gross need for 146 short-term psychiatric beds in hospitals holding a general license. There will be a net surplus of three beds located in hospitals holding a general license in 1990 (146 beds needed less 149 licensed and approved beds). Multiplying the projected 1990 district 3 population by a ratio of .20 beds per 1,000 population indicates a gross need for 194 short-term psychiatric beds which may be located in specialty hospitals. There will be a net need of 27 beds which may be located in specialty hospitals (194 beds needed less 167 licensed and approved beds). The approval of the Petitioner's proposal will not create an imbalance between specialty beds and general beds in district 3 for 1990. There is sufficient need for additional beds in district 3 for approval of the Petitioner's proposal. Occupancy. Objective 1.2 of the State Health Plan provides: dditional short-term inpatient hospital psychiatric beds should not normally be approved unless the average annual occupancy rate for all existing and approved adult short-term inpatient psychiatric beds in the service district is at least 75 percent ... [Emphasis added]. The occupancy rates in 1985 for the existing short-term psychiatric beds in district 3 were as follows: Facility Beds Occupancy Alachua General Hospital 30 77.5 percent Shands Teaching Hospital 42 77.8 percent Lake City Medical Center 9 69.2 percent Munroe Regional Medical Center 18 56.4 percent Lake/Sumter County Mental Health 18 88.0 percent. The average occupancy rate for the existing facilities listed in finding of fact 27 is 75.5 percent. There are 151 short-term psychiatric beds approved for district 3 which are not yet operational. The occupancy rate of the existing and approved beds of district 3 is less than 75 percent. The approved beds should be assumed to have a 0 percent occupancy since they are not in use. Planning Guideline 2 of the District III Health Plan provides: Additional inpatient psychiatric services should not be developed until existing or approved services reach the occupancy standards Specified in the State Inpatient Psychiatric ... Rule. The occupancy standard Specified in the State Inpatient Psychiatric Rule is 75 percent. It is reasonable to expect that approved beds will affect existing occupancy rates when the beds become operational. Consumer demand for short-term psychiatric beds cannot expand indefinitely to meet supply. Since 48 percent of the licensed and approved beds for district 3 are approved beds, it does not make sense to ignore approved beds. Applying the occupancy standard on a subdistrict basis, licensed beds in the southern subdistrict had an average occupancy rate of 72.2 percent for 1985 (excluding the Petitioner's existing beds). If the 51 approved beds at Community Care of Citrus, 35 approved beds in Hernando County and the 15 approved beds at Lake/Sumter Mental Health are taken into account, the occupancy rate is Substantially lower. The Petitioner's proposal does not meet the occupancy standards of the state health plan or the district health plan (on a district or subdistrict basis). Subdistrict Allocation of Bed Need. Planning Guideline 4 of the District III Health Plan provides: Needed inpatient psychiatric ... beds will be allocated within the District based on the proportion of need generated in each planning area using the State methodology. The northern and southern subdistricts are the appropriate planning areas under the district health plan. The projected population for the southern subdistrict for 1990 is 549,536. Applying the state methodology to the southern subdistrict, there will be a gross need for 192 short-term psychiatric beds in 1990. Subtracting the 84 licensed and 101 approved beds yields a net need for 7 short-term psychiatric beds for the southern subdistrict for 1990. Of the 192 gross beds needed for the southern subdistrict in 1990, 82 should be located in hospitals holding a general license and 110 may be located in specialty hospitals. There are 66 licensed and 101 approved beds located or to be located in specialty hospitals in the southern subdistrict. Therefore, under the district health plan, there will be a surplus of 57 short-term psychiatric beds located in specialty hospitals in the southern subdistrict in 1990. All existing and approved short-term psychiatric specialty hospitals for district 3 are or will be located in the southern subdistrict; there are no specialty hospitals located or approved for the northern subdistrict. The Petitioner is the closest specialty hospital to the northern district. There is insufficient need for the Petitioner's proposal in the southern subdistrict of district 3 under the district health plan. Until December, 1985, or early 1986, the Respondent's policy and practice was to apply the need formula of Rule 10-5.11(25)(d), Florida Administrative Code, on a district-wide basis, not on a subdistrict basis. In approximately December, 1985, or early 1986, the Respondent implemented a new policy of reviewing the need for proposed short-term psychiatric services on a subdistrict basis in the applicable district health plan recognized subdistricts. This new policy was based upon a new interpretation of existing statutes and rules. Specifically, the Respondent relied upon Rule 10-5.011(1), Florida Administrative Code, and Section 381.494(6)(c)1, Florida Statutes, which direct an evaluation of the relationship between proposed services and the applicable district health plan in reviewing certificate of need applications. The evidence failed to prove: (a,) when the policy was formulated; (b) who was responsible for the formulation and implementation of the policy; and (c) whether any sort of investigation, study or analysis was performed or relied upon in connection with the policy. The effect of this policy can be outcome-determinative in that it can cause an application for a certificate of need to be denied. Prior to the adoption of the policy, the Respondent Promulgated Rule 10-17, Florida Administrative Code, which Provided for sudistricting of district This rule was repealed. Geographic Access. A small portion of the population of district 3 is within a maximum travel time of 45 minutes from the Petitioner's facility. Only 36 percent of the district 3 population is within 45 minutes driving time from the Petitioner's facility. The Petitioner's facility is located near the center of district 3. Approximately 60 percent of the population of district 3 is located within 60 minutes travel time from Ocala. There are excellent transportation routes from parts of the northern subdistrict to Ocala, including Interstate Highway 75 and U.S Highways 27, 301 and 441. Approximately 73 percent of the Petitioner's Patients during its first year of operation came from the southern subdistrict. Of those Patients, approximately 58 percent were from Marion County and 15 percent were from other southern subdistrict counties, including 10.5 percent from Citrus County and none from Hernando County. Approximately 15 percent of the Petitioner's patients during its first year of operation came from the northern subdistrict: 8 percent from Alachua County, 1.7 percent from Putnam, 1.2 percent from Bradford, .2 percent from Union, Suwannee and Gilchrist, .7 percent from Columbia and none from Hamilton, Lafayette, and Dixie. Approximately 12 percent of the Petitioner's patients during its first year of operation came from outside of district 3. Other Factors Approximately 16 percent to 17 percent of Marion County's population was 65 years of age or older in 1980. By 1990, the 65 and older population is projected to increase to approximately 22 percent. Approximately 28 percent of the population of the southern subdistrict is projected to be 65 or older in 1990. Top of the World, a retirement community, is being developed 10 to 15 miles from the Petitioner's present location. There is a large population of females aged 18 to 30 attending the University of Florida. The University is located in Gainesville which is within a 40 to 50 minute drive time from the Petitioner's present location. There are over 83,000 females aged 15-44 residing in Alachua and Marion Counties. Young adult females have the highest incidence of eating disorders such as bulimia and anorexia. From a clinical and programmatic perspective, to provide optimal therapy for geriatric and eating disorder patients: (1) the patients should be separated from the general psychiatric population; (2) the staff should be specially trained to deal with the unique problems posed by the two types of patients; and (3) the program and physical surroundings should be specially designed to accommodate the needs of the patients and to facilitate the rendition of services to patients. The Petitioner represented in its application that the Petitioner has a 16-bed geriatric program. Munroe Regional and Marion-Citrus Mental Health Center and Lake/Sumter Mental Health Supported the Petitioner's original application for its present facility based in part on the Petitioner's representation that 16 beds would be designated as geriatric beds. A facility for Citrus County with 51 beds has been approved which will have a gerontology program. In Hernando County 35 beds have been approved which includes a gerontology program. Seven letters of Support were submitted with the Petitioner's application. Only one of those letters mentions geriatric beds. No mention of an alleged need to provide an eating disorder program was mentioned by the Petitioner in its application. Eating disorder patients are treated at Shands in Gainesville, Alachua County, Florida. There are no existing or approved Specialized geriatric or eating disorder programs in district 3. The Petitioner Should be able to recruit physicians and other medical professionals to staff its proposed programs. ECONOMIC ACCESS. The Petitioner's admissions criteria include the ability to pay. The Petitioner has projected that 1.5 percent of patient revenues from the operation of the 24 additional beds will be attributable to indigent care. This amount is low. Applicants generally propose 3 to 7 percent indigent care. Generally, Short-term psychiatric Services are accessible to all residents of district 3. The evidence failed to prove, however, that short-term psychiatric Services in specialty hospitals are readily accessible to indigent residents. Munroe Regional Medical Center and Lake/Sumter County Mental Health provide psychiatric services to indigents. Lake/Sumter was recently granted a certificate of need authorizing it to move to Leesburg and to expand its hospital to include 33 short-term psychiatric beds which will be devoted almost exclusively to the treatment of indigents. These facilities are not specialty hospitals, however. The Petitioner's projected care of indigents does not include free evaluations and assessments provided at the Petitioner's counseling centers. In light of the fact that the Petitioner takes into account the ability to pay, however, this service will not significantly increase the care provided to indigent patients or accessibility of services to indigents. During the Petitioner's first year of operation it provided indigent care of approximately 4 percent of total revenues. It is therefore likely that the Petitioner will exceed its projected 1.5 percent indigent care. The Petitioner did not prove how much of an increase can be expected, however. The Petitioner has a corporate policy never to deny admission to a patient in need of emergency treatment because of inability to pay. The Petitioner's proposal will not significantly enhance services available to indigents. FINANCIAL FEASIBILITY AND IMPACT ON COSTS. 8O. If the Petitioner's proposal is considered based upon the need for additional beds in the district, it will be financially feasible. Its projected patient day projections are reasonable based upon district-wide need. If need is determined only on a district-wide basis, the opening of approved beds will not negatively affect the Petitioner's referral patterns or patient base. If need is determined only on a district-wide basis, the cost of psychiatric services in district 3 will not be negatively impacted by the Petitioner's proposal. If need is determined on a subdistrict basis, the Petitioner's proposal will not be financially feasible. There is insufficient need in the southern subdistrict for the Petitioner to achieve its patient day projections on a subdistrict basis. Planning Guideline 6 of the District III Health Plan provides: Providers proposing to expand or establish new psychiatric facilities should document that these services will not duplicate or negatively affect existing programs in the region. In light of the existence of an excess of 57 short-term psychiatric beds for the southern subdistrict based upon a subdistrict allocation of bed need, the Petitioner's proposed new beds will duplicate beds in existence or approved beds. If need is determined on a subdistrict basis, the cost of psychiatric services in the southern subdistrict will be negatively impacted.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Petitioner's application for the addition of 24 short- term psychiatric beds be approved. DONE and ORDERED this 13th day of March, 1987, in Tallahassee, Florida. LARRY J. SARTIN Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 13th day of March, 1987. APPENDIX TO RECOMMENDED ORDER The parties have submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted. Paragraph numbers in the Recommended Order are referred to as "RO ". Petitioner's Proposed Findings of Fact: Proposed Finding RO Number of Acceptance or of Fact Number Reason for Rejection 1 RO 7, 9-10 and 12. 2 RO 13-14. 3 RO 13 and 16. 4 RO 17. 5 RO 51. 6 RO 54 and 61. 7 RO 54. 8-10 Irrelevant. 11 RO 58-59. 12 RO 59. 13 The first sentence is accepted in RO 60. The second sentence is irrelevant. 14 RO 61-63. 15 Irrelevant. 16 RO 20 and 22. 17 RO 43. 18 RO 19. 19 RO 19-21. 20 RO 23. 21 RO 24. 22 RO 28. The last sentence is irrelevant. 23 RO 1, 9-10 and 12. 24 Irrelevant. It has been stipulated that the quality of care criterion has been met. 25 RO 64. 26 RO 71. The first sentence is accepted in RO 70. The second sentence is not supported by the weight of the evidence. Not supported by the weight of the evidence. 29-30 Irrelevant. 31 RO 55-56. 32 RO 74. RO 75. The last sentence is not supported by the weight of the evidence. RO 73 and 76. The Petitioner did not commit to provide 1.5 percent of total revenues it committed to provide 1.5 percent of revenues from the 24 beds. The last sentence is irrelevant. 35 RO 77. 36 RO 78. 37 Not supported by the weight of the evidence. 38-39 and 41 If need is determined on a district- wide basis these proposed findings of fact are true. If, however, need is determined on a subdistrict basis these proposed findings of fact are not supported by the weight of the evidence. See RO 80 and 83. 40 Irrelevant. 42-44 Cumulative. See RO 80 and 83. 45 and 46 Not supported by the weight of the evidence. 47-48 Irrelevant. If need is determined on a district-wide basis these proposed findings of fact are true. If, however, need is determined on a subdistrict basis these proposed findings of fact are not supported by the weight of the evidence. See RO 82 and 85. Irrelevant. The first sentence is statement of the law. The last sentence is irrelevant. This is a de novo proceeding. How the Respondent reached its initial decision is irrelevant. The rest of the proposed finding of fact is accepted in RO 50. Statement of law. 52 RO 45. 53 RO 46. 54 RO 47. 55 Irrelevant. 56 RO 48. 57 RO 49. Irrelevant. Conclusion of law. Irrelevant. 61-62 Prehearing Stipulation. Irrelevant. The parties have stipulated that the portion of the rule mentioned in the first sentence is met. The proposed finding of fact is also a discussion of law. It is therefore rejected. 65-67 Consideration of the state health plan is statutorily required. The Respondent does not apply the occupancy standard of the state health plan as a matter of policy, therefore. These proposed findings of fact are therefore irrelevant to the extent that they apply to the determination concerning the state health plan. To the extent that they pertain to the occupancy standard of the district health plan, they are hereby adopted. Conclusion of law. Irrelevant. The first sentence is irrelevant. The second sentence is contained in the Prehearing Stipulation as a stipulated fact. 71 RO 30. 72 Irrelevant and conclusion of law. 73-82 Irrelevant. Respondent's Proposed Findings of Fact 1 RO 1, 3-4, 9 and 11 2 RO 7 and 13. 3 RO 19. 4-6 Prehearing Stipulation. 7 8 and 9 RO 26. RO 27-28. The last sentence is 10 contrary to the facts stipulated to by the parties. The parties have stipulated that existing beds meet the occupancy standard. This proposed finding of fact is therefore unnecessary. RO 29. 11 RO 30 and 32-33. 12 RO 31. 13 RO 16 and 36. 14 RO 34. 15 RO 37-41. There are 84 licensed beds not 81. 16-17 Irrelevant. 18 RO 55-56. The evidence established that "at least" 73 percent of the Petitioner's patients originate from the southern subdistrict not that more than 73 percent. 19 RO 43. 20 Hereby accepted. 21 RO 51. RO 10 and 64. The first sentence is accepted in RO 65. The rest of the proposed finding of fact is uncorroborated hearsay. 24 RO 67. RO 12 and 68. Irrelevant or based upon uncorroborated hearsay. Not a finding of fact. Not supported by the weight of the evidence. 29 RO 84-85. 30 Statement of law. 31 RO 72-73. 32 RO 85. 33 RO 83. COPIES FURNISHED: Sam Power, Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Gregory Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Sandra Stockwell, Esquire Culpepper, Pelham, Turner & Mannheimer 300 East Park Avenue Post Office Drawer 11300 Tallahassee, Florida 32302-3300 J. Kevin Buster, Esquire Ross O. Silverman, Esquire King & Spalding 2500 Trust Company Tower Atlanta, Georgia 30303
Findings Of Fact Seven Rivers Community Hospital is located in Crystal River, Florida. Seven Rivers contracted with Kron Medical Enterprises in Chapel Hill, North Carolina, to supply a locum tenens (temporary physician assistance) to Seven Rivers. Seven Rivers needed the services of a temporary anesthesiologist on staff while one of its two regular staff anesthesiologists took an examination for board certification in this speciality. Kron made arrangements for Dr. Sheila Fischer, who held Florida license No. ME 50235, to provide temporary staff anesthesiology services at Seven Rivers. Kron made Dr. Fischer's travel and living arrangements while at Seven Rivers. While at Seven Rivers, Dr. Fischer lived in a small apartment located on the hospital's grounds, approximately 25 yards from the hospital. This apartment was equipped with a telephone and was used by temporary physicians employed by the hospital. The end of Dr. Fischer's two weeks temporary service at Seven Rivers ended on Friday, October 30, 1987, at 3:00 p.m. The travel arrangements by Kron for Dr. Fischer were for a flight on Saturday morning, October 31, 1987, from Tampa Airport to New York City. Patient R.B. was admitted to Seven Rivers Hospital on October 28, 1987. R.B.'s admitting physician was Dr. Callueng. R.B.'s medical history indicates that he was five feet, two inches tall, weighed a 163 pounds, was a former smoker, and was diabetic and hypertensive. R.B. was taking Diabinese, Minipress, and Procordia for these medical problems. R.B. had a history of transient ischemia attacks (mini strokes). R.B. was scheduled for a right carotid endarterectomy on October 30, 1987. A carotid endarterectomy is the surgical removal of plaque from the interior of the carotid artery. These plaques or deposits restrict the flow of blood through the carotid artery. One carotid artery runs up each side of one's neck and has two branches, the vertebral branch which serves the temporal region of the head and the internal branch which serves the brain. Both carotid arteries are interconnected at the base of the brain so that blood flow to the brain can be maintained under normal circumstances by either carotid artery. The carotid endarterectomy on R.B. was dictated by his history of transient ischemia which results from the reduction in arterial blood flow. The work-up on R.B. revealed blockages in both R.B.'s carotid arteries in excess of 90 percent. R.B. was visited on the evening of October 29, 1987, by Dr. Ernesto Donaire, staff anesthesiologist at Seven Rivers Hospital. Dr. Donaire conducted a pre-operative assessment of R.B. and reviewed R.B.'s medical history; see paragraph 4 above. Dr. Donaire also observed that R.B. was moderately obese, had a short neck, and wore dentures. In addition, Dr. Donaire explained to R.B. the operation, the risk of surgery and anesthesiology, and obtained R.B.'s release for the anesthesiology and surgery to be performed the next day. Subsequent to talking with R.B., Dr. Donaire spoke with another surgeon who added a new case to the following day's surgical schedule. As a result of the change in schedule, Dr. Donaire switched R.B. to another operating room where the Respondent, Dr. Fischer, was scheduled to provide anesthesia the following day. Dr. Donaire returned to R.B.'s room and explained to R.B. that Dr. Fischer would be handling his anesthesia the following day. This was acceptable to R.B. and Dr. Donaire charted this second meeting with R.B. in a separate progress note. Dr. Fischer's last day as a locum tenes anesthesiologist at Seven Rivers Hospital was on October 30, 1987. After handling surgeries in the morning, Dr. Fischer began to chart the anesthesia for R.B. at 1135 hours when he was brought into the operating room for a right carotid endarterectomy. A 16 gauge needle was placed in R.B.'s left hand; a blood pressure cuff was placed on him, together with electrocardiogram leads; an oximeter was applied; his eyes were taped and lubricated; and he was interbated with a #7 E.T. tube. This was easily done and subsequently his chest sounds were equal. A 20 gauge catheter was placed in the left radial artery and the patient prepped and draped. At this point, the nurse noticed a slit in the drape covering the instruments. The patient was redraped and prepped while the instruments were flash sterilized and the first incision made at 1242 hours. At 1318 hours, the surgeon, Dr. Boholst, clamped the right carotid artery. The clamp was removed at 1435 hours. During the period the clamp was in place, the right side of R.B.'s brain was dependent upon blood supply from cross circulation from the left carotid artery which was 90 percent blocked. The annotations at the bottom of the Respondent's surgical notes reflects that the blood supply to the brain through the right carotid artery was interrupted for 77 minutes. At 1520 hours, R.B. was received in the post- anesthesia care unit (PACU) by bed from the operating suite accompanied by Dr. Fischer and Nurse Camara, the operating room nurse. This was twenty minutes after the end of the normal shift. Dr. Fischer and Nurse Camara gave verbal reports of the operation to Gerry Auermann, the PACU nurse assigned to care for R.B. This was very normal and in accordance with regular procedures. Shortly after R.B. was received in the PACU, Dr. Boholst arrived and looked in on the patient. Drs. Boholst and Fischer were concerned about the possible neurological insult to R.B. caused by the extended clamping of the carotid artery. However, they could not assess the extent of insult while R.B. was under the effects of the anesthesia. R.B. was deeply sedated and did not recover quickly. His temperature was 30.60 (870F). Assessment was further complicated by the pre-surgical conditions of R.B.'s left leg caused by a childhood illness. An assessment of the patient's neurological state is important to the surgeon in determining whether it is necessary to return a patient to surgery to correct problems resulting from circulatory blockages caused by a separation of plaque and internal flaps. (Cross deposition, page 60) Neurological insult caused by the clamping can not be corrected surgically. Dr. Fischer indicated that the damage from clamping would be apparent immediately, but would worsen over several hours. Gerry Auermann, the PACU nurse, did not record the presence of Drs. Fischer or Boholst in PACU. She indicates in her deposition that she had not independent recollection of events, but did not feel they were present because her notes would have reflected that they were present if they had been. However, her notes also reflect that she administered Narcan to R.B. There were no doctor's orders covering the administration of this medication to the patient. It is inconceivable that a nurse with Auermann's background and experience would have administered these medications without a doctor's order. Dr. Fischer indicated that it was not unusual for nurses in an intensive care situation to make partial notes on adhesive tape, clothes, or even the backs of their hands for transfer subsequently into the official record. Auermann's notes were not complete regarding the presence of Dr. Fischer and Dr. Boholst and their orders regarding R.B. Both Dr. Fischer and Dr. Boholst saw one another and spoke to one another as they monitored the progress of their patient R.B. While in the PACU, both physicians shared responsibility for R.B. in the PACU. Dr. Fischer was responsible for his satisfactory recovery from anesthesia and Dr. Boholst was responsible for assessing R.B. surgically and making a determination, if necessary, to return him to surgery. The on- call anesthesiologist would have been responsible for anesthesiological assistance if surgery was required after Dr. Fischer's normal end of shift and release of the patient to Dr. Boholst. At approximately 1605 hours, Auermann administered one quarter cc (5 mg) of Narcan to R.B. Narcan is a medication which cancels the effects of narcotics and anesthesia. At 1608 hours, another one quarter cc of Narcan was administered to R.B. At 1610 hours, Auermann initially noted that the patient was moving, however, she voided this entry. At 1625 hours, Auermann recorded that the patient moved his right limbs and left shoulder. When she stimulated his left toes she received an involuntary reflexed action. The nursing notes reflects Narcan at 1605 hours and 1608 hours, and again at 1650 hours and 1655 hours. Nomaclene (phonetic) was not administered. Dr. Boholst and Dr. Fischer were present when R.B. was assessed, and Dr. Boholst was advised of the potential neurological deficient suffered by R.B. during the operation. Between 1625 hours and 1655 hours, Dr. Boholst faced the decision to return the patient to surgery or to wait and further assess the impact of the neurological insult resulting from the prolonged clamping of the carotid artery. At this time, Dr. Fischer's principal concern was getting the patient in a condition to be moved to ICU. At 1650 hours, a one- half cc of Narcan was administered to R.B. and at 1655 hours another one-half cc was administered. At 1700 hours the patient was responsive but unable to open his eyes. Dr. Boholst decided not to return to surgery. He consulted with Dr. Callueng, R.B.'s principal physician, who ordered an immediate CAT Scan. A CAT Scan would have identified the principal physical restrictions to the blood flow without further surgery. See. Dr. Cross' deposition. There was a delay in receiving R.B. in ICU because of a lack of beds. At sometime between 1600 hours and 1655 hours, Dr. Fischer gave the following verbal orders to Auermann concerning R.B.: 10/30/87 number 1, blood glucose now done PACU at 1600 (emphasis supplied); number 2, nitroglycerin drip to control B.P. systolic below 160, diastolic below 100; number 3, discharge from PACU at . Verbal order of Doctor Fischer taken by G. Auermann, RN. (A blank was left to permit Nurse Auermann to fill in the time when the actual transfer was made. The transfer was made at 1745.)(See page 28, Auermann deposition.) At 1720 hours, Auermann administered to R.B. 12 and a half mg of Demoral, on order of Dr. Boholst, and telephoned Dr. Boholst to report on the patient's condition. At that time, R.B. had a PARR of 8, slight movement in his left hand and no voluntary movement in his left leg. Dr. Boholst had left orders for administration of Demerol to R.B. for relief of pain in ICU. By protocol, surgeons don't administer drugs normally to patients in recovering room. However, at 1720 hours, a medication ordered only by Dr. Boholst was administered in the recovery room. As stated above, there was no room in ICU. Therefore, sometime between 1625 hours and 1720 hours, Dr. Fischer transferred primary patient care to Dr. Boholst. This was most probably not a formal matter because both doctors and Auermann had been participating in R.B.'s care, and all knew what was being done, why, and what the results were. Dr. Boholst had assumed responsibility for R.B. although R.B. remained in recovery because there was no room in ICU. Dr. Fischer's comments to the investigator many months after the event without reference to the record are not considered as admissions by Dr. Fischer.
Findings Of Fact On July 15, 1985, Petitioner, Arbor Health Care Company, Inc., d/b/a Indian River Health Care Center, Inc. (Arbor) filed an application with Respondent, Department of Health and Rehabilitative Services (Department) for a certificate of need (CON) to construct a 60-bed nursing home in Indian River County, Florida. 1/ That application was deemed complete on September 30, 1985. On December 11, 1985, the Department denied Arbor's application, and Arbor timely petitioned for formal administrative review. The facility proposed by Arbor would offer a wide range of services for its residents, including: 24-hour skilled and intermediate nursing care, full- time recreational, physical, speech, hearing and occupational therapy services, as well as psychological and social services. Additionally, Arbor proposes to offer subacute services, such as intravenous care and forced feeding, as needed. The parties agree that Arbor meets all statutory and rule criteria for issuance of a certificate of need for additional nursing hone beds in Indian River County (a subdistrict of District IX) except need and the impact such lack of need would exert on the other criteria. The Department has adopted Rule 10-5.11(21), Florida Administrative Code, to determine need for additional community nursing home beds. Using a planning horizon of July 1988, which is three years after the date of application, the rule calculates a net surplus of 61 community nursing home beds for Indian River County. Existing nursing home beds in Indian River County are underutilized and there are a number of nursing home beds available to the public. For the six month period ending June 30, 1986, Indian River County nursing homes were reporting an average occupancy of 85.5 percent, which reflects an average vacancy rate of approximately 47 licensed beds per day. 2/ Arbor concedes that there is no numeric need for additional nursing home beds in Indian River County under the need methodology prescribed by Rule 10-5.11(21), Florida Administrative Code, but contends that special circumstances exist which warrant the issuance of the requested certificate of need. The gravamen of Arbor's assertion is that existing facilities are not geographically accessible to the patients it proposes to serve, that the present patient base is unable to access currently licensed and approved facilities, and that existing facilities do not provide needed services. Arbor's assertions are unpersuasive. Rule 10-5.11(21)(b)10, Florida Administrative Code, establishes a methodology whereby an applicant can establish the existence of special circumstances which could warrant the issuance of a certificate of need when no numeric need is demonstrated. Under the provisions of that subsection, an applicant must demonstrate that: ... those persons with a documented need for nursing home services have been denied access to currently licensed but unoccupied beds or that the number of persons with a documented need exceed the number of licensed unoccupied and currently approved nursing home beds....Patients' need for nursing home care must be documented by the attending physician's plan of care or orders, assessments performed by staff of the Department of Health and Rehabilitative Services, or equivalent assessments performed by attending physicians indicating need for nursing home care. (Emphasis added.) Arbor failed to establish by competent evidence ("document") through any of the methods mandated by the rule, or their equivalent, that any person in need of nursing home services has been denied access to currently licensed but unoccupied beds, that the number of persons with a documented need exceeds the number of licensed unoccupied and approved beds, or that any patient has been denied needed services. Further, the proof offered by Arbor was inadequate, as discussed infra, to demonstrate any special circumstances which would support approval of its application. Geographic accessibility. Arbor proposes to locate its nursing home in the Sebastian area of Indian River County. Currently, all licensed and approved nursing homes are located in Vero Beach, 16 miles south of Sebastian. To support its claim of geographic inaccessibility, Arbor commissioned a time/distance study to identify its potential patient base for the year 1988 that would be outside a 30-minute drive time to existing and approved facilities in 1988. As commissioned, Arbor's study identifies approximately 9,000 residents of north Indian River County, slightly more than 10 per cent of the County's population, who will be outside a 30-minute drive time to existing and approved facilities in 1988. Of that population, Arbor estimates that approximately 2,250 people will be 65 years of age or older. While Arbor offered proof which would, if accepted, support recognition of a 30-minute drive time standard for patients needing to access nursing home beds, it offered no proof of what portion of the identified population in north Indian River County that was 65 years of age or older would need such services. Accordingly, the most favorable conclusion that can be drawn from Arbor's proof is that the number of such persons will be proportionate to the relationship that exists between the identified population (9,000 residents) and the County's population as a whole; approximately ten percent. Applying that percentage to the number of beds numerically needed in the County in 1988 (347 beds) could austensibly demonstrate a need for 35 beds in Sebastian. However, Arbor offered no proof that its proposed 60-bed facility would be financially feasible in either the short term or long term in the face of such limited need, nor did it propose a facility of less than the 60-bed standard established by the local health plan. Concerning the 30-minute drive time standard advocated by Arbor, it is worthy of note that the local health plan contains no such standard. While it is true, as noted by Arbor, that the local health plans for District III and District VI contain a 25 and 30 minute standard respectively, it is also true that the local health plan for District VIII contains a one hour drive time standard. Accordingly, reference to the standards established in other districts is not germane to an evaluation of the needs of District IX, or the Indian River subdistrict. While Arbor did submit proof which established the reasonableness of a 30-minute drive time standard, it is worthy of note that not one patient, family member, physician, or provider offered any evidence that geographic accessibility was a problem in Indian River County. Accordingly, while a 30- minute drive time standard may be reasonable, the proof does not establish an accessibility problem in Indian River county if that standard is exceeded. Patient access to current facilities. To support its assertion that patients were being denied access to current facilities, Arbor offered the testimony of its health planning expert, Harold E. Knight. Mr. Knight testified that he spoke with the discharge planner of Humane Hospital Sebastian and was advised that she had experienced difficulty in placing three nursing `home candidates in January 1986, two in February, four in March, two in April, zero in May, three in June, and zero in July. According to the planner it took, on average, one week to place these candidates. Mr. Knight also spoke with the discharge planner of Indian River Memorial Hospital who advised him that she was having difficulty placing five to eight nursing home candidates each month, and that their average wait for admission was three weeks. While Arbor's proof demonstrated some delay in placing potential nursing home candidates, it failed to offer competent evidence to establish the cause of such delay. Since a delay in placement can result from the personal preference of a patient for a particular nursing home, as easily as it can from a lack of available facilities, Arbor's proof was inadequate to establish that residents were being denied, pertinent to Arbor's claim of special circumstances, access to needed services. Arbor also suggests that Medicaid patients are being denied admission to the Vero Beach nursing homes, thereby creating an economic access barrier. To support its assertion, Arbor offered proof that two of the nursing homes did not accept Medicaid patients, that Medicaid utilization in District IX was the second lowest in the State at 44.9 percent, and that the Indian River subdistrict utilization rate was at 32.52 percent. Such facts are not, however, sufficient to support a finding that Medicaid access is unavailable in the County. The two nursing homes which do not admit Medicaid patients account for only 96 beds out of the 326 licensed beds in the County. Additionally, there are 91 approved beds in the County. Lack of utilization, absent competent proof of its cause, does not establish a lack of accessibility. Arbor failed to establish that a Medicaid access problem existed in Indian River County. Lack of needed services. Finally, Arbor suggested that its agreement to provide subacute services as needed, such as intravenous care and forced feeding, would alleviate a problem of accessibility to and availability of needed services. While the implementation of diagnostically related groups (DRGs) has resulted in the release from hospitals of patients requiring more acute nursing care services, Arbor failed to establish that the existing nursing homes did not, or would not if needed, supply such services. Other considerations. In evaluating Arbor's application none of the criteria established by Section 381.494, Florida Statutes, have been overlooked. However, need is the key criteria in the instant case and Arbor's failure to satisfy that criteria is, on balance, dispositive of its application for licensure.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the application of Arbor for a certificate of need to establish a 60- bed nursing home in Indian River County, Florida, be DENIED. DONE and ORDERED this 25th day of November, 1986 in Tallahassee, Florida. WILLIAM J. KENDRICK 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 25th day of November, 1986.
Findings Of Fact Upon consideration of the oral and documentary evidence presented the following facts are found: Petitioners each made application for a certificate of need under the provisions of Sections 381.493 through 381.497, Florida Statutes, 1975, which applications were submitted to the Bureau of Community Medical Facilities and accepted as complete by the bureau. Each application seeks a certificate of need for a third generation computerized axial tomography scanner (whole body unit) hereinafter referred to as a CAT scanner. There is presently in Jacksonville a head scanner installed at St. Vincent Hospital in November, 1975, and a whole body scanner at St. Luke's Hospital which has been in full operation since January, 1976. All three Petitioners are located in Jacksonville, Florida. The applications were processed by the appropriate Health Systems Agency. After due consideration the Health Systems Agency recommended that each of the three applications be granted. At the request of the Bureau of Community Medical Facilities, Department of Health and Rehabilitative Services, the State Hospital Advisory Council reviewed the applications and upheld the Health Systems Agency's determination that the three applications should be granted certificates of need. After consideration of the applications, the Health Systems Agency's recommendation the State Hospital Advisory Council's recommendation, Mr. Art Forehand, Administrator, Office of Community Medical Facilities, Respondent herein, notified each of the three Petitioners that their applications were not favorably considered. Mr. Forehand's notification set forth three reasons for the unfavorable consideration. Those were (1) lack of demonstrated need for the requested scanner, (2) failure of each application to demonstrate positive action toward containment of cost for services rendered to the public, and (3) lack of demonstrated unavailability, unaccessability, and inadequacy of like services within the Jacksonville area. At the time of his decision Mr. Forehand had no material or information available to him which was not available to the Health Systems Agency or the State Hospital Advisory Council at the time of their decision. At the time the three applications were denied Mr. Forehand felt that there did exist a need for one additional scanner in the Jacksonville area but he did not feel that he should bear the burden of deciding which one of the three applications should be granted and therefore all three were denied. Except for those matters set forth in Mr. Forehand's denial and noted above, none of the parties to this proceeding disputed that the criteria for determining need found in Section 101-1.03(c), F.A.C., were met. A study of computerized axial tomography with suggested criteria for review of certificate of need applications was conducted by the staff of the Health Systems Agency of Northeast Florida relative to the Duval County area. This study was published in April of 1976 and its findings appear to have been accepted by the Health Systems Agency. As one of its suggested criteria for determining need it found that a hospital or applicant should have a potential case load of at least 1,000 CAT scans per year. The study went on to project a potential case load for the three Petitioners herein. That projection for Baptist Memorial Hospital shows a a potential case load of 2,512 scans per year. The study noted that Baptist Memorial projected 1,300 scans for the first year during start up operations and 2,080 scans during the second and third years of their forecast. The study found that Riverside Hospital has a potential case load of 1,196 scans per year compared to their own projections of 1,432 scans per year. The study finally found that the University Hospital has a potential case load of 1,558 scans per year compared to their projection of 2,904. Testimony on behalf of the Respondent shows that in the opinion of Respondent full use of a CAT scanner is 10 scans per day on a 20-day work month working five days a week. As shown by unrebutted testimony the existing scanner at St. Luke's Hospital in Jacksonville is presently averaging 10 scans per day, five-days a week. Further, according to the evidence presented by Respondent, the existing scanner at St. Vincent is being utilized to at least 85 percent of its capacity. Respondent took the position at the hearing that when existing scanners are being used to 85 percent or more of their capacity a need exists for more equipment. Thus, it appears that using the criteria of utilization adhered to by Respondent, the existing CAT scanners in Jacksonville are being utilized to the extent that there is a need for additional scanners. University Hospital has 310 licensed beds and is the community hospital in Duval County with the responsibility of serving the indigent on an emergency and short term basis. It is the trauma center of the city and has the most active emergency room. It is also the major teaching hospital in Duval County. Respondent agrees that it has the greatest need of any hospital in Duval County for a CAT scanner. The University Hospital has approximately 300 visits per month to its emergency room. In the four months prior to the date of final hearing the hospital did 586 skull x-rays due to trauma. In the case of acute trauma patients frequently may not be moved from one hospital to another for the purpose of a CAT scan nor, in some cases, should other dangerous invasive techniques be used for diagnosis. Baptist Hospital has 567 licensed beds and is a major oncology center or cancer center and does a large amount of surgical cancer work in additional to radiation therapy. With the possible exception of University Hospital, Baptist Hospital is the largest pediatric hospital in the area. According to the testimony of the administrator of the hospital it would take 14 to 18 months after receipt of a certificate of need to have a CAT scanner in service. Riverside Hospital has 183 licensed beds. The hospital has been a specialty hospital since its establishment in 1908 and serves the Riverside Clinic. The hospital has approximately 200 specialized physicians, all board certified, on-staff. Riverside is a unique hospital because of its degree of specialty and its relationship to Riverside Clinic. Riverside Hospital does 100 percent of the Riverside Clinic's radiology work. Riverside Hospital has been known as an established diagnostic center. Witnesses for Riverside Hospital testified that if they were not able to have a CAT scanner their reputation and ability to provide first class service would be seriously diminished. CAT scanners represent a significant development in diagnostic medicine. They reduce the need for many dangerous, painful and costly injections of dye, air and radioactive isotopes required by some of the more traditional diagnostic procedures. The three most common tests displaced by CAT scanners are pneumoencephalography, angiography and radioactive isotope scanning. The first two of the foregoing are particularly expensive procedures and require hospitalization. At present, patients at the three Petitioner hospitals have to be transported to another facility in order to use a scanner. The transfer of an inpatient to another hospital for a scan may effectively consume the better part of a patient's day and may require an extra day of hospitalization. The cost of transportation, increased hospital stay and ancillary matters increase the actual cost to the Patient. Patients suffering from severe trauma or otherwise in a critical state, may not be transported out of a hospital to a scanner. All three of the Petitioners have an active neurological and neurosurgical staff and qualified radiologists. The unrebutted testimony indicates that, although CAT scanners are a new development whose potential has not yet been fully explored and whose development may not yet be final, they nevertheless have become an essential diagnostic tool of regular use.
Findings Of Fact Upon consideration of the oral and documentary evidenceadduced at the hearing, the following relevant facts are found: On or about September 20, 1976, petitioner submittedits application for a certificate of need to construct an acutecare general hospital in Delray Beach, Florida. Additional information was requested by respondent. On November 3, 1976, petitioner forwarded to respondent its "First Supplement to the Application for Certificate of Need." By letter dated November 16, 1976, respondent acknowledged receipt of petitioner's capital expenditure proposal effective November 8, 1976, referred the proposal to the Health Planning Council for Indian River, Martin, Okeechobee, Palm Beach and St. Lucie Counties, and informed petitioner that a decision on the proposal would be rendered by respondent not later than February 6, 1977. Petitioner is seeking a certificate of need to construct a new 300 bed hospital at an estimated cost of $10,695,000.00.The facility is to be a non-tax supported, investor-owned acute care medical/surgical hospital. Petitioner proposes to locate this hospital on chimerically zoned land on the southwest corner of Lake Ida Road and Congress Avenue in Delary Beach, Florida. The general service area is identified as Area 3, as defined in planning documents of the Health Planning Council, and comprises that portion of Palm Beach County within the boundaries of the Florida Turnpike to the West, Hypoluxo Road to the North, the Atlantic Ocean to the East and the Palm Beach/Broward County line to the South. Two other hospitals are currently in operation in this Area 3. The intervenor in this proceeding, Bethesda Memorial, a tax-supported acute care short-term hospital, is located within four miles to the northeast of petitioner's proposed hospital. The driving time between petitioner'sproposed location and Bethesda is five to eight minutes, or twenty minutes during heavy traffic. Boca Community Hospital is located approximately 9 1/2 miles from petitioner's location, with a driving time of between fifteen to thirty-five minutes. The existing two hospitals are accessible to residents within Area 3. Petitioner's location, being on an east-west artery, would be more accessible to those within the area defined by petitioner as its primary service area. This area excludes the area immediately surrounding the two existing hospitals (Exhibits A and C). Petitioner's application was reviewed and analyzed by a review committee of the Health Planning Council (HPC). Thiscommittee listed two factors supporting approval of petitioner'sapplication -- reasonable patient costs and patient charges andwider choices to physicians as to where they hospitalize theirpatients. It was noted that the by-laws of Boca Community Hospital do not allow staffing privileges to physicians practicing north of Atlantic Boulevard in Delray Beach. The five factors supporting disapproval of petitioner's application were as follows: Based on the HPC document entitled Acute Care General Hospital Bed Needs, 1980, March 1975, there will exist the appropriate number of beds to meet the needs of the 1980 population of Palm Beach County (including area 3). Thus, development of this proposed facility would result in an extensive, unnecessary, and costly excess of hospital beds in Palm Beach County (especially in area 3). In determining bed needs for Palm Beach County in 1980, the State of Florida's Medical Facilities Plan 1975 shows that the county currently has more than enough beds to meet the 1980 demand. Such need determination does not consider those hospital/hospital expansion projects which were approved by the HPC and are currently under construction or recently completed. Although development and subsequent population centers are anticipated in the area, the extent and completion dates for such developments are unknown. Regardless of such growth, however, the geographical proximity between Bethesda Memorial Hospital and the proposed facility would indicate that both these hospitals would be serving approximately the same population. This would result in costly competition between the two hospitals ultimately resulting in increased patient charges with no foreseeable benefits to the patient in terms of appropriateness, effectiveness, or availability of health care. Westerly population growth will necessitate the development of medical services and facilities; however, because this growth is expected to develop over a period of years and is dependent on economic factors, medical services must keep pace with population increases. In meeting the health needs of this population in the most effective and efficient manner, the HPC, in its document entitled Acute Care General Hospitals Long Range Growth, Position Statement and Recommendations, August 1975, states that: "Satellite facilities, both outpatient and inpatient, should be developed by the existing hospital system to provide necessary and appropriate health care in areas where the population does not justify a full service acute care general hospital." These centers and facilities will compliment the existing full service hospitals and not duplicate them. The proposed hospital will not provide such services and, at the same time, will foster duplication. If the proposed facility is unable to effectively implement its staff recruitment plan, costly salary competition and related recruitment factors will result among area hospitals, especially between Bethesda Memorial Hospital and the proposed new facility. By a vote of 13 to 7, the Board of Directors of the HPC recommended disapproval of petitioner's certificate of needrequest. The Board's decision was based on the reasons set forthin paragraphs 1, 2 and 3 quoted above. (Exhibit 2). By letter dated January 21, 1977, respondent'sadministrator, Mr. Art Forehand, notified petitioner that itscapital expenditure proposal was not favorably considered becauseit was not consistent with the standards, criteria or plans developed pursuant to the Public Health Service Act. (Exhibit 1). Specifically, it was noted that "The 1976 Florida State Plan for Construction of Hospitals and Related Medical Facilities, which is the current HEW approved plan, indicates a need for 191 additional hospital beds to be constructed in Palm Beach County by 1981. Subsequent to publication of this plan, a 94-bed addition to Boca Raton Community hospital and a 135-bed addition to the Palm Beach Gardens Hospital were placed under construction, and the 162-bed Community Hospital of the Palm Beaches was placed in operation. Considering these 391-bed additions against the 191 beds to be added by 1981 results in a projected overbedding of Palm Beach County by 200 beds by 1981." At the hearing, petitioner attempted to illustrate that the 1976 Florida State Plan was erroneous, and that a correctapplication of the Hill- Burton formula and the State Plan wouldresult in a showing of greater bed needs for the area in question. Based upon interpretation by the undersigned of the applicable federal and state rules and regulations, objections to this line of testimony were sustained. Thereafter, the petitioner rested and neither the respondent nor the Intervenor presented any witnesses. The 1976 Florida State Plan for Construction of Hospitals and Related Medical Facilities indicates a need for 191 additional hospital beds in Palm Beach County by the year 1981 (Exhibit 3). The Regional Health Administrator of the Department of Health Education and Welfare notified respondent by letter dated November 3, 1976, that said Plan had been approved (Exhibit 3).
Recommendation Based upon the findings of fact and conclusions of lawrecited above, it is recommended that the determination of theOffice of Community Medical Facilities to deny petitioner's application for a certificate of need to construct a 300- bed hospital in Delray Beach be upheld and affirmed. Respectfully submitted and entered this 27th day of May, 1977, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Donald H. Reed, Jr., Esquire Deschler and Reed Boca Raton Federal Building 555 South Federal Highway Boca Raton, Florida 33432 Eric J. Haugdahl, Esquire Department of HRS 1323 Winewood Boulevard Tallahassee, Florida 32301 Fred W. Baggett, Esquire LaFace and Baggett, P.A. Post Office Box 1752 Tallahassee, Florida 32304 Mr. Art Forehand, Administrator Office of Community Medical Facilities 1323 Winewood Boulevard Tallahassee, Florida 32301
