The Issue Each of the petitioners disputes respondent's contention that Port St. Lucie and vicinity do not need hospital beds beyond the number that might practicably be added to Martin's Stuart facility and HCA's Lawnwood Medical Center in Ft. Pierce. The petitioners agree that a need for hospital beds in or near Port St. Lucie exists and each petitioner takes the position that it can best meet the need. As to which of the petitioners might best meet a need it does not concede to exist, respondent takes no position.
Findings Of Fact The parties stipulated that a "population explosion" is taking place in Port St. Lucie and environs. The town was developed by General Development Corporation; 75,000 residential lots were offered for sale and 90 percent have been sold. At the time of the hearing, Port St. Lucie's population was approximately 14,000 to 16,000 persons, even though only some seven or eight thousand residential lots had been built on. In addition, approximately 10,000 persons reside in developments contiguous to Port St. Lucie. The population of Port St. Lucie may increase several fold in the next ten or fifteen years. While the population in other parts of Martin and St. Lucie Counties is also expected to grow, the greatest increase in population in the area is anticipated in Port St. Lucie and its immediate vicinity. Already Port St. Lucie's population is greater than the population was in Stuart when a hospital was first built in that community and than the population was in Ft. Pierce when a hospital was originally built in that community. ACCESSIBILITY Port St. Lucie lies in south St. Lucie County more or less equidistant from Ft. Pierce to the north and Stuart, county seat of Martin County, to the south. Most residents of Port St. Lucie live ten miles or more from a hospital. The nearest hospitals are in Ft. Pierce and Stuart, which each have a single hospital. PATIENTS AND VISITORS St. Lucie County Fire Districts provide emergency services to residents of Port St. Lucie and vicinity. Time that emergency personnel and vehicles spend transporting patients to hospitals is time they are unavailable to respond to other emergency calls. Under favorable traffic conditions, it takes 20 to 30 minutes to drive from Port St. Lucie to either of the hospitals nearby. Road building in St. Lucie County is not expected to keep pace with increasing population in the near term; traffic is likely to become more congested in the next few months and years. (Testimony of Commissioner Enns.) There is no public transportation in the area. A railroad track crosses the highways connecting Port St. Lucie and Ft. Pierce's Lawnwood Medical Center. In a typical 24-hour period, trains using this track block U.S. Highway 1 for six minutes. Traveling from Port St. Lucie to Martin's hospital in Stuart, a somewhat shorter distance, requires crossing more than one railroad track as well as a drawbridge which, earlier this year, was stuck open stopping automobile traffic for an hour and a half. In the summer of 1979, a patient on route from Port St. Lucie to Stuart died in an ambulance stopped at a railroad track. PHYSICIANS In 1972, Bernard Daniel Ross, an internist, was the only physician in Port St. Lucie. At the time of the hearing, approximately 30 doctors had offices in Port St. Lucie, some of whom also had offices in Ft. Pierce. Dr. Ross makes up to three round trips daily between his office and Lawnwood Medical Center, which are ten miles apart. Dr. Asuncion Luyoa, a general practitioner who has lived in Port St. Lucie for three years, seas ten to fifteen new patients a day. She also makes frequent trips to the hospital. Dr. John B. Sullivan, who has staff privileges at Lawnwood Medical Center and who has practiced in St. Lucie County for 16 years, opened an office in Port St. Lucie a little more than two years ago. UTILIZATION OF EXISTING HOSPITALS St. Lucie, Martin, Indian River, Okeechobee, and Palm Beach Counties comprise Florida Health Service Area Region VII, the jurisdiction of Health Planning Council, Inc., (HPC), the local health systems agency. For the most part, residents of each county use hospital facilities in their own county. Lawnwood Medical Center served 12.3 percent of Okeechobee County residents needing hospitalization, 1.9 percent of Indian River County residents needing hospitalization, and 1.3 percent of Martin County residents needing hospitalization. The bulk of its patients came from St. Lucie County; of St. Lucie County residents needing hospitalization, 71 percent were hospitalized at Lawnwood. Ninety percent of Martin County residents needing hospitalization and 15.8 percent of St. Lucie County residents needing hospitalization were hospitalized at Martin's Stuart facility. Most of the remaining St. Lucie County residents needing hospitalization, 10.8 percent, went to Indian River Memorial Hospital in Vero Beach. At the time of the hearing, more than 90 percent of the 225 hospital beds at Lawnwood Medical Center were occupied. Twenty-four authorized beds at Lawnwood Medical Center were in fact unavailable until the latter part of 1979 when 18 were opened; the final six beds (in the intensive care unit) were opened in late December of 1980. Even so, the occupancy rate at Lawnwood Medical Center, as a percentage of 225 beds, was 70.5 for 1979. The overall occupancy rate for 1980, as a percentage of 225 beds, was 79.9. In 1980, monthly occupancy rates, as a percentage of 225 beds, were 80.2 for January, 79.7 for February, 81.1 for March, 81.8 for April, 75.7 for May, 72.7 for June, 78.6 for July, 81.1 for August, 80.9 for September, 87.3 for October, 76.9 for November, and 82.3 for December. Except for 20 obstetric, 15 pediatric, and 18 intensive or coronary care unit beds, all of the beds at Lawnwood Medical Center are medical or surgical. The overall 1980 occupancy rate for medical and surgical beds was 83 percent. At the time of the hearing, eight obstetric beds, four pediatric beds, four beds in the intensive care unit, and four medical/surgical beds were unoccupied at Lawnwood Medical Center. Not all medical/surgical beds can always be occupied; men and women patients are segregated and patients with respiratory diseases, among others, require isolation. On one day in January of this year, admission of 13 patients had to be delayed. These patients were put on a waiting list for elective surgery, which, in some instances, was postponed three or four weeks. Martin's Stuart hospital has expanded five times in recent years (1960, 1963, 1970, 1976, and 1978-1979) and a sixth expansion to add 50 beds is now in progress. On January 15, 1979, when the last expansion was completed, 50 beds were opened to the public. They were filled within 24 hours. When the expansion now under way is accomplished, the Stuart hospital will have 302 beds. Martin "defines emergency bed status as. . .five or less medical/surgical beds available. . .mean[ing] that the hospital medical/surgical beds are at least 97.5 percent occupied." Martin's application, p. 30. During the period of January, 1979, through March, 1979, Martin's hospital in Stuart was on "emergency bed status" 16.7 percent of the time. During the same period in 1980, the hospital was on "emergency bed status" 45 percent of the time. A waiting list of up to 60 patients is not uncommon in the winter season. Indian River Memorial Hospital in Vero Beach, 25 miles north of Lawnwood Medical Center, had 99 percent of its 216 available beds occupied in mid-January of this year. According to John Hoyt, executive director of Indian River Memorial Hospital, an occupancy rate as high as 90 percent suggests that pediatric and obstetric beds were pressed into service for medical and/or surgical patients. For the year ending September 30, 1980, the overall occupancy rate averaged 83 percent. The monthly occupancy rates for the calendar year 1980 were 89.9 for January, 90.1 for February, 90.8 for March, 83.9 for April, 78.8 for May, 79.3 for June, 77.1 for July, 79.0 for August, 86.0 for September, 88.0 for October, 84 for November, and 82.0 for December. Indian River Memorial Hospital plans to open another 24 beds in March of 1981, but does not anticipate having the ability to provide service for people in Port St. Lucie and vicinity. Only a few patients from southern St. Lucie County have been admitted to Indian River Memorial Hospital, which is more than 30 miles and some 45 minutes away. In the opinion of Mr. Hoyt, any patients Indian River Memorial Hospital might lose to an expanded Lawnwood Medical Center or to a new facility in Port St. Lucie would be more than offset by patients from the growing population in Vero Beach and vicinity. HEALTH SYSTEMS PLAN The HPC has adopted an amended health systems plan 1980-1984, which includes the following goals and objectives: Health Systems Goal The number of acute care hospital beds should be no more than four (4) licensed beds per 1,000 population in HSA Region #7. Application of this goal throughout the area should take into consideration the following factors: Changes in patient origin patterns; Age differences within a hospital primary service area; Emergency Scheduling; Geographic isolations (95 percent of population not within 30 minutes of services), economic efficiency and quality assurance. Long-Range Objectives For the next four (4) years, any net increases in licensed acute care general hospital beds should be limited to the expansion of medical/surgical beds. In order to meet the projected need for medical/surgical beds, a reallocation of existing beds from pediatric, obstetrical, ICU, CCU, monitored and intermediate care will have to take place. For the next four (4) years, existing hospitals should be encouraged to expand in order to meet the projected demand for services in their primary service area either through expansion of the main facility or satellite outpatient facilities. Health Systems Goal Region-wide (HSA #7), the overall average annual occupancy rate for acute care general hospital licensed beds should equal 75 percent. Long-Range Objectives By 1984, the region-wide annual occupancy rate for licensed acute care hospital beds should increase to 75 percent. By 1984, the region-wide annual occupancy rate for each of the following bed categories should be as follows: Medical/Surgical 75 percent Obstetrical 65 percent Pediatric 65 percent ICU, CCU, Monitored & Intermediate Care 80 percent By 1984, any hospital with less than 50 percent annual occupancy rate should be consolidated with other hospitals in the same service area as defined by the Health Planning Council. By 1982, all hospitals should have developed a five-year plan that contains the following: Statement of Purpose; Description of Present Facilities and Programs; Statement of Goals; Proposed Major Programs and Resources Necessary to Reach Goal. Health Systems Goal Average daily service charge for all acute care hospitals in HSA Region #7 should not increase at a rate greater than 1 1/2 times the annual cost-of-living increase. Long-Range Objectives By 1981, information should be made available to the community on gross patient revenues and total cost of hospital services within HRS #7 for the purpose of monitoring the goal. By 1982, at least six (6) presently existing acute care hospitals in HSA Region #7 should establish cooperative arrangements for the provision of specialized services. BED NEED PROJECTIONS According to the preliminary 1980 census figures, St. Lucie County had a population of 86,969 and Martin County had a population of 62,979. Joint Exhibit No. 1. The Bureau of Economic and Business Research of the University of Florida projects populations for St. Lucie County of 89,500 for 1981; 92,300 for 1982; 95,700 for 1983; 99,100 for 1984; and 102,500 for 1985. Joint Exhibit No. 1 (medium projections). The Bureau of Economic and Business Research of the University of Florida projects populations for Martin County of 62,100 for 1981; 64,600 for 1982; 67,600 for 1983; 70,600 for 1984; and 73,600 for 1985. Joint Exhibit No. 1 (medium projections). The Martin County projections presumably require revision upward in light of the 1980 census results. Preliminary 1980 census figures put the population of Okeechobee County at 20,324, and the population of Indian River County at 57,217. Joint Exhibit No. 1. The Bureau of Economic and Business Research projects 1984 populations of 23,700 for Okeechobee County and 67,300 for Indian River County. Joint Exhibit No. 1 (medium projections). The 1980 population of Palm Beach County is on the order of 594,900 and is projected to rise to 684,400 by 1984. Joint Exhibit No. 1 (medium projections). As of December 31, 1980, Palm Beach County had 2,654 licensed and approved acute care hospital beds; Okeechobee County had 75; and Indian River County had 343. HCA's Exhibit No. 1. The 302 beds authorized for Martin's hospital in Stuart were the only acute care hospital beds licensed or approved in Martin County as of the time of the hearing. All 225 beds approved for St. Lucie County were open at Ft. Pierce's Lawnwood Medical Center, at the time of the hearing. The ratio of hospital beds to population is lower in Region VII than in any other health service area in Florida. Although the amended health systems plan 1980-1984 specifies four hospital beds per 1,000 population, the HPC sometimes applies a rule of thumb designed to reflect the additional need for hospital beds in an area which has a larger component of elderly persons than the national average and which has seasonal swings in population. Under this rule of thumb, 1,055 patient days in hospitals are assumed for each 1,000 persons annually, along with the 75 percent average utilization rate for hospital beds. But applying this rule of thumb actually results in lower bed need projections than using the four beds per 1,000 population criterion which is used throughout the nation for populations without unusually high numbers of older persons and which do not fluctuate seasonally. As compared to four per 1,000, 1,055/365 X 100/75 yields 3.85+ beds per 1,000 population. Using the four bed per 1,000 approach, based on the medium population projections forecast by the University of Florida's Bureau of Economic and Business Research, Indian River County will require 269 hospital beds by 1984; Okeechobee County will require 95 hospital beds by 1984; Palm Beach County will require 2,738 beds by 1984; Martin County will require 282 beds by 1984; and St. Lucie County will require 396 beds by 1984. HCA Exhibit No. 1. Using the same four bed per 1,000 population formula, a region-wide deficit of 181 beds is forecast for 1984. HCA Exhibit No. 1. On the average, elderly people require more hospitalization than younger people require. The population of south St. Lucie County has a large component of elderly persons. Most of Port St. Lucie's residents are retirees. According to one estimate, 28 percent of the population of St. Lucie County residing south of Midway Road is older than 65. In Indian River, Okeechobee, Martin, and St. Lucie Counties, as a group, the proportion of persons over 65 to the whole population is higher than the national average. Approximately 29 percent of the population of Martin County is over 65. For Port St. Lucie and vicinity, hospital bed needs should be projected at four beds per 1,000 residents, at a minimum. On this basis, if no new beds are opened in Martin and St. Lucie Counties beyond those already certificated, and if the medium population projections are correct, there will be a deficit in the two-county area of 151 general acute care hospital beds by 1984, assuming residents of the area choose hospital care in the area. HCA Exhibit No. 1. In evaluating the need for hospital beds for residents of Port St. Lucie, Martin and St. Lucie Counties are the logical primary service area, instead of the four-county region that respondent used, which included Okeechobee and Indian River Counties, in addition to Martin and St. Lucie Counties. Less than ten percent of the residents of Martin and St. Lucie Counties requiring hospitalization leave the two-county area to be hospitalized. Palm Beach County is properly excluded and no party contends otherwise. Indian River and Okeechobee Counties should be excluded for the same reasons that Palm Beach County should be excluded. The distance from Indian River Memorial Hospital to Port St. Lucie is approximately the same as the distance from Port St. Lucie to the nearest hospital in Palm Beach County. Sebastian River Medical Center, the only other hospital in Indian River County, and Raulerson Hospital in Okeechobee County are further from Port St. Lucie than at least one and possibly two hospitals in northern Palm Beach County. No hospital could open its doors in Port St. Lucie until well into 1982, even if approved today. On the basis of four beds per 1,000 population, assuming that the medium population projections of the University of Florida's Bureau of Economic and Business Research are accurate, and assuming that Martin's expansion of its Stuart facility is accomplished this year, St. Lucie and Martin Counties will have a hospital bed deficit of 79 in 1981; 100 in 1982; 126 in 1983; and 177 in 1985. NEW CONSTRUCTION v. EXPANSION Martin has no plans to expand its Stuart facility beyond the 302 beds for which it has already obtained certificates of need. The final 50-bed expansion now going on will utilize the hospital's ancillary services facilities fully, and fill up all available parking areas. Any further expansion would require building a new, seventh floor without interrupting the operation of the hospital; and would necessitate construction of a multi-story parking garage at a cost of $4,200 per space. Adding 50 beds to its Stuart hospital would, moreover, require 28,000 square feet of new floor space and renovation of 2,000 additional square feet in order to house necessary ancillary facilities, all at a total projected cost of $10,556,001. Martin's Exhibit No. 1. Martin projects the cost of a 50-bed complex it proposes for Port St. Lucie at $9,768,001. Martin's Exhibit No. 1. The only other hospital that could be expanded to meet the needs of the burgeoning Port St. Lucie population is Lawnwood Medical Center, owned by HCA. Lawnwood Medical Center was designed and built with a view toward expansion, ultimately to more than 300 beds. HCA's employees project a need in 1984 for enough beds at Lawnwood Medical Center, over and above the 75 beds HCA proposes for Port St. Lucie, to justify an expansion of Lawnwood Medical Center in the near future. HCA personnel testified to plans to apply, within a year, for a certificate of need authorizing expansion of Lawnwood Medical Center by an unspecified number of beds. Adding to a hospital takes more time than constructing equivalent facilities from the ground up. Each department of the hospital must continue its work, even if delays in construction result. A 75-bed expansion of Lawnwood Medical Center would take 18 to 20 months, HCA's architect estimates, as opposed to the 12 to 14 months the same architect estimated would be necessary to build a new 75-bed hospital in Port St. Lucie. In general, larger hospitals require more floor area per bed than smaller hospitals require. Construction costs of adding 75 beds to Lawnwood Medical Center would be greater than the costs of constructing the 75-bed hospital HCA proposes for Port St. Lucie, but acquiring land for a new hospital would cost $500,000, which, when added to construction costs, would make a 75-bed new hospital more expensive than a 75-bed addition to Lawnwood Medical Center, by some 139,219 in 1980 dollars, a per-bed differential of 1,856 in 1980 dollars. HCA's Exhibit No. 4. Because the space available for ancillary services in Lawnwood Medical Center is such that a 50-bed expansion can more readily be accommodated than an expansion half again as large (which would involve an additional floor of the hospital outside any "shelled in" area) it would cost less to add 50 beds to Lawnwood Medical Center than to construct a new 50-bed hospital. Both Martin's Stuart facility and HCA's Lawnwood Medical Canter have costly specialized equipment which could not economically be duplicated at a new facility in Port St. Lucie. A new oncology center, for example, is planned for Lawnwood Medical Center at a cost of approximately $2,000,000. In order to use these specialized facilities, specimens and patients would have to be transported either to Stuart or to Ft. Pierce, and overnight stays would sometimes be required of patients. At least 80 percent of the patients at a new facility in Port St. Lucie would not require specialized services unavailable in Port St. Lucie, however. OSTEOPATHY ON THE TREASURE COAST The American Osteopathic Association has a membership of some 16,000 osteopathic physicians. Osteopaths practice in every state in the country, but 70 percent of them live in 15 states. The profession developed in Missouri, where it is now well established. Significant numbers of osteopathic physicians also live in Michigan, Ohio, Pennsylvania, and New Jersey, and, increasingly, Florida and California. At the time of the hearing, there were no osteopaths resident in St. Lucie County, and none maintained an office there. Outside of Palm Beach County, only seven osteopaths lived in HSA Region VII. No osteopath had applied for staff privileges at Lawnwood Medical Center or its predecessor since January 1, 1967. Under the by-laws of Lawnwood Medical Center, dental surgeons, podiatrists, and osteopaths, as well as allopathic physicians, are eligible for admitting privileges, but only if the practitioner resides in St. Lucie County and has an office in St. Lucie County. More than one osteopath has applied for admitting privileges at the hospital in Stuart, but none has been granted such privileges. Martin's Stuart facility's by-laws require two years' post-graduate education, for medical and osteopathic graduates alike, as a prerequisite to admitting privileges. Although neutral in form, this requirement is a barrier to most osteopaths, who typically complete one year of post-graduate education before entering general practice. One osteopath, a diplomate of the American Medical Association's Board of Family Practice with two years' education beyond osteopathy school was denied admitting privileges because his character did not measure up to Martin's credentials committee's standards, or so they stated. Many of the medical graduates on staff at the hospital in Stuart had only a single year of post- graduate training, but they were grandfathered in when the two years' requirement was adopted in the late 1970s. The hospital in Stuart does employ an osteopath on its emergency room staff, but he does not have admitting privileges at the hospital. Bruce C. Equi, an osteopathic physician, has an office in Stuart and 2,500 to 3,000 patients in the area. In 1979, he sent 300 patients to the Community Hospital of the Palm Beaches 45 miles away, where he has full staff privileges. A round trip from his office to visit a single hospital patient consumes two and a half hours. Loren Shefter, an osteopath whose office is in Port Salerno, Martin County, traveled an average of 160 miles a day the week before the final hearing, partly because he lives 28 miles from his office, but partly because his office is 40 miles from the Community Hospital of the Palm Beaches, the only hospital at which Dr. Shefter has admitting privileges. He is responsible for the care of about 3,000 families. After practicing in Miami for 20 years, Arthur A. Lodato, another osteopath, opened an office in Palm City just west of Stuart. Dr. Lodato has seen about 900 patients in his Martin County office. If a patient is hospitalized under Dr. Lodato's care, it is in Miami, where he still practices half-time. Dr. Textor in Jupiter, Florida, has six osteopathic patients from Martin and St. Lucie Counties. Upon admission to an osteopathic hospital, a "structural chart" is prepared for each patient. Depending on the results, certain "modalities of manipulative treatment" may be administered. Otherwise, the practice of osteopathic medicine resembles the practice of medicine by medical graduates; there are osteopathic radiologists, osteopathic pediatricians and so forth, but most osteopaths do not specialize. The Southeastern College of Osteopathic Medicine, the 15th such college in the United States, was chartered in 1979 and is located in Miami, where the first class is to matriculate in the fall of this year. Beginning In the fall of 1981, the plan is, students will leave the campus for the "clinical phase" of their education, which will take place in an osteopathic hospital. If there is an osteopathic hospital in Port St. Lucie by that time, and if it meets the College's standards, such students, as well as interns and residents, might work under the supervision of the hospital staff as part of their training. The opening of an osteopathic hospital would probably attract osteopathic physicians. There were 15 osteopaths in Palm Beach County when the Community Hospital of the Palm Beaches was originally planned. When it opened in 1975, there were 35, and now there are 65 osteopathic physicians in the area. APPLICATIONS REVIEWED HPC board members resident in counties other than Palm Beach County constitute the Indian River Area Committee, which considered all three of the applications at issue in the present proceedings. The Indian River Area Committee voted in favor of HCA's application (by a two-to-one margin), and voted disapproval of both StLHC's and Martin's applications to build a new facility in Port St. Lucie. Subsequently, the HRC recommended against HCA's application and against the StLHC application; and made no recommendation on Martin's proposal. Respondent's Office of Community Health Facilities then turned down all three applications, on grounds that there was no need for additional beds, that existing hospitals were under utilized, that a new facility would be inconsistent with the "objective of expanding existing facilities or use of primary satellite facilities," and, in the case of StLHC's application, that no lack of osteopathic facilities had been documented. THE APPLICANTS' PROPOSALS Martin would build a 50-bed inpatient facility, an ambulatory care center, and a physicians' office building in Port St. Lucie, at a total projected cost of $11,708,255. HCA would build a 75-bed hospital with emergency room facilities that would be the functional equivalent of Martin's proposed ambulatory care center, at a total projected cost of $ 8,357,848. A related company might build a physicians' office building nearby. StLHC would build a 125-bed hospital, with emergency room facilities that would be the functional equivalent of Martin's proposed ambulatory care center, at a total projected cost of $11,700,000. At the hearing, StLHC indicated a willingness to scale down its proposal. StLHC relies for financing (as a backup for unspecified primary financing) on a letter (typed on stationery without any letterhead) from an individual, one Joseph Iozia, dated September 17, 1980, addressed to Bruce Equi, M.D. [sic], stating: Please be informed that a mortgage loan of $18,000,000 has [been] set aside for the building of the St. Lucie Hospital in Stuart [sic], Florida. StLHC has given nothing as consideration for this supposed commitment to lend $18,000,000 at an unspecified interest rate at an unspecified time for an unspecified term. Martin has substantial assets, mainly in the form of the hospital in Stuart. It proposes to finance the satellite medical complex it plans for Port St. Lucie by issuing parity bonds; additional indebtedness would be secured by the same property that serves as collateral for an already outstanding bond issue, says Martin. But the existing indenture between Martin and its bondholders provides in part: Section 11.02 Parity Bonds. Additional Bonds may be issued on a parity and equality of rank with any Outstanding Bonds with respect to the security afforded by this Indenture, under the following conditions, but not otherwise: without regard to the requirement of subsection (c) of this section, not exceeding $750,000 for the purpose of completing the Project; without regard to the requirements of subsection (c) of this section, for the purpose of refunding any Outstanding Bonds which shall have matured or which shall mature not later than three months after the date of delivery of such additional Bonds and for the payment of which there shall be insufficient money in the Principal and Interest Fund, the Bond Redemption Fund and the Bond Reserve Fund; for the purpose of refunding any Outstanding Bonds or extending, improving, equipping or replacing the Hospital, including expenses of issuing such Bonds interest during any construction period and additional amounts to be deposited in the Bond Reserve Fund, if all of the following conditions shall have been met: either (A) the average annual Net Revenues for the two Fiscal Years immediately preceding the issuance of such additional Bonds, as evidenced by the annual audit required by Section 9.04(b) hereof, must have been equal to at least 1.20 times Maximum Annual Principal and Interest Requirements including the requirements of the additional Bonds; or (B) the average annual Net Revenues for the two Fiscal Years immediately preceding the issuance of such additional Bonds as evidenced by the annual audit required by Section 9.04(b) hereof, must have been equal to at least 1.10 times the average Annual Principal and Interest Requirements for such years; and the Net Revenues, as estimated in writing by a Hospital Consultant, for each of the two completed Fiscal Years next succeeding the date of completion, as estimated in writing by the Corporation's independent architect, of the improvements, extensions or replacements financed by the additional Bonds, will be not less than 1.25 times Maximum Annual Principal and Interest Requirements, including the requirements of the additional Bonds; the Corporation shall not be in default hereunder and the payments required by Section 6.01 hereof to be made into the various funds therein provided must be current; there shall be on deposit in the Bond Reserve Fund an amount equal to not less than Maximum Annual Principal and Interest Requirements, including the requirements for such additional Bonds; . . . For purposes of Section 11.02(c) of the indenture, "Hospital" is defined in Section 1.01 of the indenture to mean "the Hospital Site and any hospital facilities now or hereafter situated on the Hospital Site, and the Hospital Equipment." HCA called as a witness bond counsel, who testified that it was legally impossible for Martin to issue parity bonds to build a new and distinct facility in Port St. Lucie, because issuance of parity bonds for such a purpose is proscribed by Section 11.02 of the indenture. It was not clear from the evidence, moreover, that Martin could finance construction of the facility it proposes, even if it could sell every bond it planned to issue. HCA could finance construction of the 75-bed hospital it proposes for Port St. Lucie with cash from its operations; its revenues last year totaled 1.4 billion dollars. Alternatively, HCA, which is listed on the New York Stock Exchange, could borrow money from a bank, write commercial paper, or issue bonds. HCA has completed 159 projects since 1969. It spent $160,000,000 constructing hospitals in 1980. HCA has adequate financial, manpower, and management resources to build and operate a hospital at Port St. Lucie. HCA is second only to the federal government as a purchaser of hospital supplies and equipment. Because it purchases in large volume, it enjoys certain advantages. In every year since 1973, expenses per adjusted admission to HCA hospitals have increased, but every year the increase has been less than the average increase in expenses per adjusted admission for all members of the American Hospital Association for two same years. The same is true for increases in net revenue per adjusted admission. HCA Exhibit No. 14. None of HCA's hospitals in Florida has increased its annual daily service charge at a rate greater than 1.5 times the annual cost of living increase. (T. 1019.) In 1979, gross inpatient revenue per admission to HCA's Florida hospitals was slightly less than gross impatient revenue per admission to community hospitals in Florida in 1979. HCA Exhibit No. 14. HCA proposes that the new hospital in Port St. Lucie share laundry, CAT scanning, radiation therapy, and other services with Lawnwood Medical Center in Ft. Pierce. The Red Cross, the St. Lucie County Welfare Association, Inc., a nursing home in the area, and others have expressed a willingness to work with the staff of a new hospital in Port St. Lucie. All parties made posthearing submissions. Martin filed (proposed) findings of fact and conclusions of law as did HCA and respondent. StLHC addressed the issues in its brief. The parties' proposed findings of fact have been considered and, in large part, adopted in the foregoing findings of fact. To the extent proposed findings have not been adopted, they are deemed irrelevant or unsupported by the evidence adduced at hearing.
Recommendation It is, accordingly, RECOMMENDED: That respondent deny Martin's application for certificate of need. That respondent deny St. Lucie Hospital Corporation's application for certificate of need. That respondent grant HCA's application for certificate of need on condition that the by-laws of any hospital built pursuant to this certificate of need set no educational requirements for osteopaths, beyond the educational requirements necessary for licensure in Florida, as a prerequisite to conferring admitting privileges. DONE AND ENTERED this 28th day of April, 1981, in Tallahassee, Florida. ROBERT T. BENTON, II 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 28th day of April, 1981. COPIES FURNISHED: Jon C. Moyle, Esquire and Thomas A. Sheehan, III, Esquire Post Office Box 3888 West Palm Beach, Florida 33402 John Werner, Esquire Suite 110 1164 East Oakland Park Boulevard Fort Lauderdale, Florida 33334 Felix A. Johnston, Jr., Esquire Suite 112 1030 East Lafayette Street Tallahassee, Florida 32301 Claire D. Dryfuss, Esquire 1323 Winewood Boulevard Tallahassee, Florida 32301 ================================================================= AGENCY FINAL ORDER ================================================================= STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES HOSPITAL CORPORATION OF AMERICA, MARTIN MEMORIAL HOSPITAL, and ST. LUCIE HOSPITAL CORPORATION, Petitioners, vs. CASE NO. 80-1687 80-1715 DEPARTMENT OF HEALTH AND 80-1731 REHABILITATIVE SERVICES, Respondent. /
Conclusions THIS CAUSE crune on for consideration before the Agency for Health Care Administration ("the Agency"), which finds and concludes as follows: The Agency issued the Petitioner ("the Applicant") the attached Notice of Intent to Deem Application Incomplete and Withdrawn from Further Review (Ex. 1). The parties entered into the attached Settlement Agreement (Ex. 2), which is adopted and incorporated by reference. The parties shall comply with the terms of the Settlement Agreement. If the Agency has not already completed its review of the application, it shall resume its review of the application. The Applicant shall pay the Agency an administrative fee of $500.00 within 30 days of the entry of this Final Order. A check made payable to the "Agency for Health Care Administration" containing the AHCA number(s) should be sent to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, MS# 14 Tallahassee, Florida 32308 Any requests for an administrative hearing are withdrawn. The parties shall bear their own costs and attorney's fees. This matter is closed. Thomas . Agency for , Secretary Care Administration I Filed January 22, 2010 4:28 PM Division of Administrative Hearings.
Other Judicial Opinions A party that is adversely affected by this Final Order is entitled to seek 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 by law, with the District Court of Appeal in the appellate district where the agency maintains its headquarters or where a party resides. Review of 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the below named persons/entities by the method designated on this y of , 2010. & ry- Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone (850) 922-5873 Jan Mills Facilities Intake Unit Agency for Health Care Administration (Interoffice Mail) Steve Emling Field Office Manager Agency for Health Care Administration (Interoffice Mail) Finance and Accounting Revenue Management Unit Agency for Health Care Administration (Interoffice Mail) Jason H. Clark, Esq. Post Office Box 17486 West Palm Beach, FL 33416 (U.S. Mail) Thomas J. Walsh II, Esq. Office of the General Counsel Agency for Health Care Administration (Interoffice Mail) Administrative Law Judge Div. of Admin. Hearings (Interoffice Mail) 2
The Issue The issues for consideration are those allegations set forth in an Administrative Complaint brought by the State of Florida Department of Professional Regulation (Department), in which the Respondent, Scarlett Jones, R.N., is accused of various violations of Chapter 464, Florida Statutes. Through Count One it is said that the Respondent transcribed an order for Heparin to be administered to the patient K.W. as 15,000 units when the physician's order quoted the dosage as 5,000 units, and that the patient was given two dosages at 15,000 units as opposed to the required 5,000 units. In an additional accusation against the Respondent, related to patient care, Respondent is said to have failed to indicate in the patient K.W.'s nursing notes, on or about May 16, 1988, that an administration of Aminophylline was to be restarted during the 11:00 p.m. to 7:00 a.m. shift. Further, it is alleged that this substance was not restarted until 8:00 a.m. on the next day as discovered by a subsequent shift employee. As a consequence, Respondent is said to have violated Section 464.018(1) (f), Florida Statutes, related to alleged unprofessional conduct. Count Two to the Administrative Complaint alleges that on or about June 4, 1988, the Respondent who was assigned to care for the patient E.J., was told by a co-worker that the patient had fallen out of bed and soiled himself and that the Respondent failed to respond to the patient's needs after repeated requests. Eventually, it is alleged that the patient's wife assisted him back to bed and the co-worker took care of the patient's hygiene. As a consequence, Respondent is said to have violated Section 464.018(1)(f), Florida Statutes, related to unprofessional conduct and that she violated Section 464.018(1)(j), Florida Statutes, for knowingly violating a rule or order of the Board of Nursing. Finally, the third count of the Administrative Complaint alleges that the Respondent, on or about June 14, 1988, was found asleep while on duty in violation of Section 464.018(1)(f), Florida Statutes, an act of unprofessional conduct, including, but not limited to, the failure to conform to minimum standards of acceptable and prevailing nursing practice. For these alleged violations, the Department seeks to impose disciplinary action which could include revocation or suspension, the imposition of an administrative fine and/or other relief which the Board of Nursing might deem appropriate.
Findings Of Fact During the relevant periods under consideration in this Administrative Complaint the Respondent was licensed by the Department as a registered nurse and subject to the jurisdiction of the Board of Nursing in disciplinary matters. The license number was 1702172. On April 11, 1988, Respondent took employment with Gadsden Memorial Hospital in Gadsden County, Florida, in a position of charge nurse on the Medical-Surgical Pediatrics Unit, also known as "Med-Surg. Ped." That unit provides short term acute care for post-operative patients, acute medical patients, and acute pediatric patients, some of which require 24-hour observation. Response to the needs of the patients is given by three nursing shifts in each day which begins with shifts of 7:00 a.m. to 3:00 p.m., followed by the 3:00 p.m. to 11:00 p.m. and then 11:00 p.m. to 7:00 a.m. on the following morning. Upon hiring, Respondent was assigned to the work the 11:00 p.m. to 7:00 a.m. and was the only registered nurse on duty during that shift. Among the responsibilities of the charge nurse at the time under examination here, was the assessment of patients on the unit as well as an awareness of the abilities of those other employees who were working in this shift. This was in an effort to provide direct supervision of critical care patients and included supervision of activities performed by a Nurse Technician. Respondent was more directly responsible for critical patients. Other duties included making frequent rounds and checking vital signs in an attempt to insure that the patients were stable. Respondent as charge nurse on "Med-Surg. Ped." could not leave the floor without notification of the house supervisor, another registered nurse. This person would replace the Respondent on those occasions where the Respondent would need to vacate the floor. In addition it was expected that the Respondent would notify those personnel who were working with her on the unit, where she intended to go and how long she would be gone. Before departing it was expected that the Respondent would check the stability of patients. physician's Orders were written on March 2D, 1988, in anticipation of the admission of patient K.W. to Gadsden Memorial Hospital to "Med. Surg Ped." The admission was under orders by Dr. Halpren. Among those orders was the prescription of Heparin, 5,000 units, subcutaneously every 12 hours. The Physician's Orders in terms of legibility are not immediately discernible but can be read with a relatively careful observation of the physician's orders. A copy of those may be found at Petitioner's Exhibit No. 5 admitted into evidence. The problem that tends to arise is that on the line which immediately follows the orders related to Heparin 5,000 units, is found the word hysterectomy written in such a fashion that the initial portion of the letter "H" might be seen as being placed on the prior line giving the unit dosage of the Heparin the appearance of being 15,000 units as opposed to 5,000 units. On April 11, 1988, K.W. was admitted to Gadsden Memorial Hospital as anticipated. At the time of admission the Physician's Orders previously described were provided. Surgery was scheduled and the patient file was made on "Med-Surg. Ped." Under the practices within this hospital, the ward clerk was responsible for transcribing physician's orders onto the patient's Medication Administration Record. This was done here by the ward clerk, S. Diggs. This is to be checked for accuracy by the charge nurse, to include Respondent, with the fixing of the signature to this Medication Administration Record verifying the accuracy of the clerk's entries. Respondent initialed the Medication Administration Record for the patient designating that Heparin in the amount of 15,000 units Q-12, meaning to be given every 12 hours was the requirement, and had been administered in that dosage. This may be seen in a copy of the Medication Administration Record which is part of Petitioner's Exhibit No. The patient was to undergo extensive abdominal surgery, to include the possibility of a hysterectomy and the incorrect administration of Heparin might promote problems with bleeding. The incorrect amount of Heparin as a 15,000 unit dosage was given to K.W. on two occasions. Another patient who was admitted to the ward which Respondent was responsible for as charge nurse was the patient A.W. Physician's Orders were written for that patient by Dr. Woodward on May 16, 1988. A copy of the Physician's Orders may be found at Petitioner's Exhibit No. 6 admitted into evidence. Among the substances prescribed was Aminophylline drip 20 milligrams per hour I.V. This patient had been admitted to the pediatric unit with a diagnosis of asthma and prescribed the Aminophylline to aid the patient's breathing. It was expected that patient A.W. was to be administered two dosages of Aminophylline, an intermediate dosage to be given every few hours in a larger quantity, and a continuous drip to run at 20 milligrams per hour. Within Petitioner's Exhibit No. 6 are nursing notes made by Respondent concerning A.W. On May 17, 1988, between the hours of 12:00 a.m. and 2:00 a.m. it is noted that Respondent was having trouble with patient A.W.'s I.V. She states that the I.V. site was assessed and had to be pulled and that she was not able to reinsert due to the uncooperative nature of this child. The I.V. was restarted by the house supervisor nurse. An entry at 6:30 a.m. made by the Respondent describes the I.V. position as acceptable. When the shift changed at 7:00 a.m. the new charge nurse did not find the Aminophylline drip in progress, as called for, and this is noted in a 7:30 a.m. entry made by this registered nurse, Sherry Shiro. Petitioner's Exhibit No. 4 admitted into evidence is a Confidential Incident Report prepared by the Gadsden Memorial Hospital concerning allegations against the Respondent. They have to do with an alleged incident that occurred around 5:00 a.m. and contain the purported observations by Lucinda Mack, a licensed practical nurse on duty at that time, and they were received on June 15, 1988, by Carol Riddle, R.N., Director of Nursing at Gadsden Memorial Hospital, and the person responsible for investigating this matter. The copy of the Confidential Incident Report contained observations about the alleged failure of treatment by the Respondent directed in the matter of the patient E.J. These remarks are hearsay. They do not corroborate competent evidence at hearing concerning any oversight by the Respondent in the treatment of the patient E.J. On or about June 14, 1988, the Director of Nursing, Carol Riddle, called the night supervisor Michelle Warring at 2:00 a.m. to ascertain if the Respondent was on duty. Respondent was working on that date. At 2:15 a.m. Warring advised Riddle that the Respondent could not be found and Riddle went to the hospital at that time. When she arrived at the facility at 3:00 a.m. she went to "Med-Surg. Ped." where she was informed by the communications clerk that Lucinda Mack, LPN, was the only nurse on duty in that unit, and that the clerk did not know where Respondent could be found. Riddle and Warring then looked through the patient rooms in "Med-Surg. Ped." but could not find the Respondent. One and a half hours after commencing the search Riddle located the Respondent in a different wing of the hospital which contains a respiratory therapy manager's office. Respondent was there with her husband asleep, with the door locked and lights off. At that time she was the only registered nurse on duty in "Med-Surg. Ped." which had six patients receiving care on that evening. Respondent was not performing her duties or supervising those other persons who worked with her on the unit. Respondent had been observed asleep at her nurses' station desk on several other occasions by Dale Storey, a registered nurse working at the Gadsden Memorial Hospital. Linda Reed, a nurse technician at Gadsden Memorial Hospital had observed the Respondent asleep on duty. As commented on by nurse Riddle, who is qualified to give expert opinion testimony about the performance of the Respondent in her nursing practice, the conduct set out before in these findings of fact constitutes unprofessional conduct in the practice of nursing, in a situation which the Respondent knew what her duties were as charge nurse and failed to perform them at an adequate level.
Recommendation Based upon the findings of fact and conclusions of law, it is RECOMMENDED: That a final order be entered which fines the Respondent in the amount of $1,000 for the violation related to the care of patient K.W. as set out in Count One and for sleeping on duty as set out in Count Three. And, finds that the violation related to patient A.W. as set out in Count One and the violation alleged in Count Two related to the patient E.J. were not proven. DONE and ENTERED this 19 day of April, 1989, in Tallahassee, Leon County, Florida. CHARLES C. ADAMS 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 19 day of April, 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 88-5719 Petitioner's fact finding is subordinate to the finding in the Recommended Order with exception of paragraph 16 which is not relevant and reference within paragraph 34 to the date June 24, 1988, which should have been June 14, 1988. COPIES FURNISHED: Lisa M. Bassett, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Scarlett Jones 2636 Mission Road, #138 Tallahassee, Florida 32302 Judy Ritter, Executive Director Florida Board of Nursing 111 East Coastline Drive, Room 504 Jacksonville, Florida 32202 Kenneth E. Easley, Esquire General Counsel Department of professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
Conclusions THIS CAUSE comes before the Agency For Health Care Administration (“the Agency") concerning Certificate of Need ("CON") Application No. 10202, which was filed by East Florida Healthcare, LLC (“East Florida”), and preliminarily denied by the Agency. 1. East Florida filed Application No. 10202 seeking a CON to establish a 100-bed acute care hospital to be located in Broward County, District 10. 2. On December 10, 2013, the Agency published notice of its decision to preliminarily deny East Florida’s CON Application No. 10202. 3. On December 30, 2013, East Florida filed a Petition for Formal Administrative Proceeding contesting the Agency’s preliminary denial of its CON Application 10202, which was forwarded to the Division of Administrative Hearings (“DOAH”) and assigned DOAH Case No. 14-0126CON. 4. On December 31, 2013, South Broward Hospital District d/b/a Memorial Healthcare System (“MHS”) filed a Petition for Formal Administrative Proceeding in support of the Agency’s preliminary denial of East Florida’s CON Application 10202, which too was forwarded to the DOAH and assigned DOAH Case No. 14-0120CON. Filed February 18, 2014 10:39 AM Division of Administrative Hearings 5. On January 13, 2014, MHS then filed a motion to intervene in the East Florida case, DOAH Case No. 14-0126CON, in support of the Agency’s preliminary denial of East Florida’s CON Application No. 10202. 6. On January 24, 2014, the Administrative Law Judge entered an order in the East Florida case, DOAH Case No. 14-0126CON, granting the motion to intervene and permitting MHS to intervene in the East Florida case subject to the terms of the order. 7. On January 27, 2014, MHS filed its Notice of Voluntary Dismissal of its Petition for Formal Administrative Proceeding in this case. It is therefore ORDERED: 8. The Petition for Formal Administrative Proceeding filed by MHS in this case is dismissed. This Final Order does not affect the intervention of MHS granted in the East Florida case, DOAH Case No. 14-0126CON. ORDERED in Tallahassee, Florida, on this / 7 day of Pela auss} , 2014. Deectete_ Elizabeth DuWek, Secretary Agency for Health Care Administration
