The Issue Whether the Agency for Health Care Administration (AHCA) should take the final agency action it announced, in its July 18, 2001, letter to Petitioner, it intended to take with respect to certain Medicaid claims Petitioner had filed.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following findings of fact are made: The Medicaid program is a cooperative federal-state venture designed to provide health care to the needy. States participating in the program receive federal financial assistance for compensating enrolled providers for the goods and/or services they provide Medicaid recipients in accordance with the program's requirements. Florida is a participant in the Medicaid program. AHCA is the state agency responsible for making payments to enrolled Medicaid providers in Florida. In discharging this responsibility, it is assisted by a fiscal intermediary with whom it contracts. Florida has applied for, and been granted by the federal government, "waivers" in order to use Medicaid funds to pay for certain "home and community-based services" (HCBS), including, among others, adult day health care, to individuals who, if not provided these services, would require institutionalization. Among Florida's HCBS "waiver" programs is the Aged/Disabled Adult (ADA) "waiver" program, which targets needy individuals 65 years of age or older, as well as needy disabled adults aged 18 to 64, who qualify for nursing home placement. The Florida Department of Elder Affairs (DOEA), with the help of the 11 Area Agencies on Aging throughout the state and their contractors, coordinates the provision of services to these targeted individuals (which services AHCA pays for). At all times material to the instant case, the Alliance for Aging, Inc., has been the Area Agency on Aging serving Miami-Dade County. Before an individual may receive ADA "waiver" services, (s)he must undergo an assessment by DOEA or its designee to determine whether (s)he needs the required level of care to be eligible for such services. This assessment is referred to by the acronym "CARES," which stands for "Comprehensive Assessment and Review for Long Term Care Services." Individuals determined to be eligible to receive ADA "waiver" services must have a plan of care established for them by an authorized case management agency. Having such a plan of care is a prerequisite to their receiving any services (other than case management services from an authorized case management agency). They may receive only those services identified in the plan of care. At all times material to the instant case, the only two agencies authorized to provide case management services to ADA "waiver" recipients residing in Miami-Dade County were United Home Care Services, Inc. (United) and Miami-Dade County's Elderly Services unit (Miami-Dade Elderly Services). To be entitled to paid by AHCA for rendering ADA "waiver" services to eligible individuals with an authorized case management agency-developed plan of care, a provider must not only have a Medicaid provider number and be a party to a Medicaid provider agreement with AHCA enabling it to bill Medicaid for the type of services rendered, the provider must also have a referral agreement with the authorized case management agency that developed the recipient's plan of care and, in addition, the recipient must have been referred to the provider by the case management agency for purposes of receiving the services rendered (pursuant to the request of the recipient, who has the right to choose among enrolled providers qualified to provide the services). At all times material to the instant case, AHCA had in effect a rule describing Florida's HCBS "waiver" programs, including the ADA "waiver" program. The rule, Florida Administrative Code Rule 59G-8.200, provided as follows: Purpose. Under authority of Section 2176 of Public Law 97-35, Florida obtained waivers of federal Medicaid requirements to enable the provision of specified home and community-based (HCB) services to persons at risk of institutionalization. Through the administration of several different federal waivers, Medicaid reimburses enrolled providers for services that eligible recipients may need to avoid institutionalization. Waiver program participants must meet institutional level of care requirements. The HCB waiver services are designed to allow the recipients to remain at home or in a home- like setting. To meet federal requirements, Medicaid must demonstrate each waiver's cost-effectiveness. Definitions. General Medicaid definitions applicable to this program are located in Rule 59G-1.010, F.A.C. Additional descriptions of services available under this program are provided in subsection (3) of this rule. The following definitions apply: "Agency" means the Agency for Health Care Administration, the Florida state agency responsible for the administration of Medicaid waivers for home and community- based (HCB) services. "Department" means the Florida Department of Elderly Affairs (DOEA). Home and Community-Based (HCB) Waiver Services are those Medicaid services approved by the Health Care Financing Administration under the authority of Section 1915(c) of the Social Security Act. The definitions of the following services are provided in the respective HCB services waiver, as are specific provider qualifications. Since several similar services with different names may be provided in more than one waiver, this section lists them as a cluster. A general description of each service cluster is provided. Individuals eligible for the respective HCB services waiver programs may need and receive the following services: * * * (b) Adult Day Health Care and Day Health Care are services provided in an ambulatory care setting. They are directed toward meeting the supervisory, social, and health restoration and maintenance needs of adult recipients who, due to their functional impairments, are not capable of living independently. * * * (e) Case Management, Waiver Case Management, and Support Coordination are services that assist Medicaid eligible individuals in gaining access to needed medical, social, educational and other services, regardless of funding source. * * * (i) Counseling, Mental Health Services, Education and Support, and Behavioral Analysis are services provided for the diagnosis or treatment of mental, psychoneurotic, or personality disorders, or providing assistance to recipients in identifying feasible goals, providing emotional support and guidance, providing advice about community resources, or exploring possible alternative behavior patterns. * * * Respite Care is the provision of supervisory, supportive, and short-term emergency care necessary to maintain the health and safety of a recipient when the primary caregiver is not available to provide such care or requires relief from the stress and demands associated with daily care. Risk Reduction services provide care and guidance to caregivers, based on a plan of specific exercises for the recipient to increase physical capacity, strength, dexterity, and endurance to perform activities of daily living. This service also includes assessment and guidance for the recipient and caregiver to learn to prepare and eat nutritious meals and promote better health through improved nutrition. This service may include instructions on shopping for appropriate food, preparation, and monitoring of same. This service also provides guidance for budgeting and paying bills, which may include establishing checking accounts and direct deposits to lessen the risk of financial exploitation and abuse of the recipient. * * * Covered Services -- General. Services provided under the HCB services waivers include those described in paragraphs (3)(a) through (ff). The availability of these services to waiver program participants is subject to approval by the Medicaid office and is subject to the availability of the services under the specific waiver program for which a recipient has been determined eligible. Service Limitations -- General. The following general limitations and restrictions apply to all home and community-based services waiver programs: Covered services are available to eligible waiver program participants only if the services are part of a waiver plan of care ("care plan", "individual support plan", or "family support plan"). Care plan requirements are outlined in subsections (6) and (8) of this rule. The agency or its designee shall approve plans of care based on budgetary restrictions, the recipient's necessity for the services, and appropriateness of the service in relation to the recipient, prior to their implementation for any waiver recipient. Additional service limitations applicable to specific waiver programs are specified in subsections (10) through (14) of this rule. Program Requirements -- General. All HCB services waiver providers and their billing agents must comply with the provisions of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, which is incorporated by reference and available from the Medicaid fiscal agent. The following requirements are applicable to all HCB services waiver programs: The Medicaid program will deny an applicant's request if the proposed enrollment could cause the program to exceed the maximum enrollment level authorized by the Health Care Financing Administration in the applicable HCB services waiver. To be eligible to receive HCB waiver services, each applicant must receive case management services, plus at least one other HCB waiver service. * * * The Department or its designee will perform an evaluation of the level of care needed by an applicant for services when there is a reasonable indication that the applicant might need institutionalization in the near future, if the covered HCB services were not available. The Department or its designee will perform reevaluations of level of care at least annually, or as changes in the recipient's condition or community care setting may warrant. The plan of care will identify the type of services to be provided, the amount, frequency, and duration of each service, and the type provider to furnish each service. Reimbursement claims for the provision of Medicaid services not listed in the plan of care of HCB services waiver program participants are subject to denial or recoupment. In providing applicants or participants freedom of choice, the Agency or its designee must: Inform all prospective waiver program participants of the feasible alternatives available under the respective waiver program and afford recipients a freedom of choice to participate in the community program in lieu of institutional placement; Afford recipients the opportunity to choose from those enrolled providers capable of providing the covered services identified in the recipient's plan of care; and Afford all enrolled recipients the right to disenroll at any time. * * * Provider Qualifications and Provider Enrollment. To enroll and participate in the waiver programs, providers must comply with the provisions of Chapter 59G-5, F.A.C. Additional provider requirements are specified in subsections (10) through (14) of this rule. Case Management Requirements. Case managers advocate for recipients during the eligibility determination process and assist applicants in complying with requests for information, interviews, or activities required for a determination of Medicaid eligibility. Case managers will conduct a comprehensive needs assessment and identify areas in the person's life that require supports or services to reduce the risk of having to be placed in an institution. In addition, each case manager will: Begin the initial needs assessment before services are provided and complete it within 30 days of enrollment in the waiver program; Make a home visit as part of the needs assessment process; Prepare a written plan of care for each program participant and maintain the plan in the participant's case record; Reassess the plan of care at least every six months to review service goals, outcomes, and functional changes that may warrant the modification of the plan and reassessment of the recipient's level of care; After the needs assessment has been completed, maintain in each client's record case progress notes that document the provision of services; Make legible entries in the case progress notes in sufficient detail to document the case management service rendered and to allow an audit of the appropriateness of charges; Date and sign all written case record entries; Notify the Agency of all disenrollments by waiver program participants within 30 days after the effective date; and Maintain records in an accessible location for review by authorized federal and state representatives for monitoring and auditing purposes; ensure that recipient specific information is maintained as "confidential"; ensure that program, administrative, and financial information is maintained for a period of at least five years after termination of participation as a waiver service provider. If an audit has been initiated and audit findings have not been resolved at the end of five years, the records will be retained until resolution of the audit findings. Home and Community-Based Services Waiver Programs. The following are authorized HCB services waivers: (a) Aged and Disabled Waiver; * * * (c) Developmental Services Waiver; * * * Aged/Disabled Waiver. Program Summary. The aged/disabled waiver is a long-term care initiative providing HCB services to the aged and disabled as an alternative to institutional care. Services are available statewide to recipients who meet the eligibility requirements as specified in paragraph (10)(c) of this rule. Covered Services and Provider Qualifications. Providers must meet the criteria specified in Chapter 59G-5, F.A.C. In addition, providers must be under contract with the Department for the provision of HCB services available under this waiver. Provider qualifications for services are: 1. Adult Day Health Care providers must be licensed adult day health care centers in accordance with Rule 59A-16.003, F.A.C. * * * 4. Case Management providers must be CCE contractors, or community care for the disabled adults contractors, or staff of the Department who serve the community care for the disabled adults program, pursuant to Ch. 10A-10, F.A.C. * * * 7. Counseling providers must be licensed psychologists or mental health counselors pursuant to s. 490.001-490.015, F.S., licensed social workers pursuant to pursuant to s. 491.002-491.015, F.A.C., or licensed mental health centers, pursuant to s. 394.65-394.907, F.S. * * * Respite Care providers must be licensed Medicaid participating home health agencies, CCE agencies, or residential providers, pursuant to s. 400.011-400.332, F.S., s 400.401-400.454, and s. 400.616-400.629, F.S. Risk Reduction Services providers must be community care agencies, Medicaid participating home health agencies, or independent contractors, pursuant to Section 61F11-4, F.A.C. * * * Recipient Eligibility. Individuals must meet Medicaid eligibility requirements as defined by Chapter 409, F.S., and Florida's Title XIX State Plan; or be physically disabled or aged as defined by Chapter 10C-8, F.A.C., and 42 C.F.R. 435.217 and 435.726, as of October 1, 1994, the latter two hereby incorporated by reference. Recipients must be assessed as meeting level of care criteria for skilled or intermediate nursing home care as defined in Sections 59G-4.290 and 59G-4.180, F.A.C., and must be at risk for nursing facility placement without the provision of HCB services. Recipients must receive waiver case management and at least one other HCB service to be Medicaid eligible at the institutional care placement (I.C.P.) level. Program Operations. The HCB services program under this waiver shall comply with the provisions of Chapters 10A-4, 10A-5, 59A-16, 10A-8, 10A-10, 10A-11, and 10A-14, F.A.C. * * * (12) Developmental Services Waiver Program Summary. This program provides HCB waiver services to recipients with developmental disabilities who are clients of the Department of Health and Rehabilitative Serves (HRS) developmental services (DS) program, and who are eligible for admission to an intermediate care facility for the mentally retarded- developmentally disabled (ICF/MR-DD). The recipients have elected services in the community rather than in an ICF/MR-DD. Covered Services and Provider Qualifications. Providers of DS waiver services must be certified by the HRS DS program in each district where it applies to provide services. . . . * * * The Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, which was incorporated by reference in Florida Administrative Code Rule 59G-8.200, stated the following, among other things, in its first chapter, about Florida's HCBS "waiver" programs: Description: The Social Security Act allows states to obtain waivers to provide home and community-based services (HCBS) to target groups of recipients. These services are designed to help the recipient avoid placement in expensive and restrictive institutional settings. To receive waiver services, a recipient must be enrolled in the specific waiver program. HCBS Waiver Provider Enrollment: In order for a provider to be reimbursed for rendering a home and community-based service to an eligible recipient, the provider must be enrolled as a waiver-specific HCBS provider. All home and community-based services must be prior approved by a waiver case manager. Note: See the waiver specific Coverage and Limitations Handbook for additional information about HCBS provider enrollment. Florida HCBS Programs: Florida has seven HCBS waiver programs. They are: Aged/Disabled Adult Waiver * * * Developmental Services Waiver * * * Aged/Disabled Adult Waiver: The Aged/Disabled waiver serves frail elderly and adults with disabilities who are at risk of placement in a nursing facility. * * * Developmental Services Waiver: The Developmental Services waiver serves people who are at risk of placement in an intermediate care facility for the developmentally disabled (ICF/DD). * * * Chapter 2 of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, included the following information about "[p]rovider [e]nrollment": Introduction: Every facility, individual and group practice must submit an application and sign an agreement in order to provide Medicaid services. HCBS and Targeted Case Management: Home and community-based services (HCBS) and targeted case management providers must enroll through the state agency or state-contracted entity that administers the waiver or targeted case management service. Note: See the waiver-specific or Targeted Case Management Coverage and Limitations Handbook for the specific enrollment requirements. Chapter 3 of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, included the following information about "Medicaid [r]ecipient [e]ligibility": Eligibility Determination Eligibility Requirements: To qualify for Medicaid an individual must meet specific eligibility requirements such as age, citizenship or resident alien status, Florida residency, and either having a Social Security Number of proof of having applied for one Who Determines Eligibility: Eligibility for Medicaid is determined by the Florida Department of Health and Rehabilitative Services (HRS), or by the federal Social Security Administration (SSA) for certain categories of elderly and disabled individuals. In January 1997, HRS will be divided into two departments: The Department of Health and the Department of Children and Families. The Department of Children and Families will be responsible for HRS' recipient eligibility functions. * * * Eligibility for HCBS and Targeted Case Management: In addition to being eligible for Medicaid, recipients must meet specific eligibility criteria to enroll in a HCBS waiver or to receive targeted case management. Note: See the program-specific Coverage and Limitations Handbook for the additional eligibility criteria. Eligibility Periods: . . . . A provider must verify a recipient's eligibility prior to rendering a service. The Medicaid Computer System Introduction: The Florida Medicaid Management Information System (FMMIS) is the system that processes claims, makes payments to Medicaid providers, and issues Medicaid identification cards. Medicaid will not reimburse a claim unless FMMIS shows that a recipient is eligible on the date of service. * * * Program Codes: The Medicaid program for which a recipient is eligible is identified on the FMMIS by a unique alpha identifier called a program code. The provider needs to know a recipient's program code before providing services . . . . * * * Verifying Eligibility, HMO and MediPass Introduction: Information about the recipient's eligibility and Medicaid coverage is maintained on the Florida Medicaid Management Information System (FMMIS). The system is maintained by the state Medicaid fiscal agent. The provider verifies eligibility and obtains benefit information by accessing the system. This section discusses how a provider can access the system to obtain this information. Ways to Access Recipient Information: Eligibility and benefit information are available to providers via the following: Medicaid eligibility verification terminals (MEVS) Computer software that can be added to an office computer Automated fax response Automated voice response Human operator Information Available: The following recipient eligibility information is available for all the above sources: Denture limitations Drug caps and other service limitations HMO or MediPass membership Third party insurance coverage and policy number Medicare number Medicare part A & B coverage * * * Automated Fax Response -- FaxBack: This verification method requires a fax machine and a touch tone telephone. To obtain eligibility information, the provider enters the 9-digit provider number and one of the following: 10-digit recipient Medicaid ID number; 8-digit plastic card control number; or the recipient's social security number and date of birth. A voice response message will be received giving basic eligibility status, followed immediately by a hard copy report to the provider's fax location. The hard copy fax page serves as the provider's verification of eligibility. This method is available 24 hours a day, seven days a week. If a provider needs additional information on the recipient's eligibility for the service, he can call Unisys Provider Services at 1-800-289-7799. English and Spanish-speaking operators are available. * * * Human Operator Verification: A provider can verify eligibility and determine limitation by calling Unisys Provider Services at 1- 800-289-7799, Monday through Friday, 7:00 a.m. to 6:00 p.m., eastern standard time. This phone number is on the back of the Medicaid ID card. English and Spanish- speaking operators are available. The provider gives the Unisys operator the control number on the front of the recipient's Medicaid ID card or the recipient's ten-digit Medicaid ID number and requests information as needed. Providers are limited to two inquiries per phone call. The operator will tell the provider if the recipient is Medicaid eligible on the date of service, what the recipient's ten-digit Medicaid ID number is, and if the recipient has exceeded the Medicaid coverage limitations. The operator will not give the provider an audit number; therefore the provider will not have proof of the recipient's eligibility if a discrepancy arises. Chapter 6 of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, "describe[d] the Non-Institutional 081 claim form, the time limits for submission, and how to complete and submit the form for payment." It read, in pertinent part, as follows: Purpose and Description Purpose: This handbook is intended for use by providers who serve Medicaid recipients. It explains the procedures for obtaining reimbursement for services that are billed on the Non-Institutional 081 claim form. Coverage and Limitations Handbook: This handbook must be used in conjunction with the provider's program specific Coverage and Limitations Handbook, which contains policy information about the specific procedures that Medicaid will reimburse. Providers Who Bill on the Non Institutional 081: Targeted case management providers and the home and community based services providers must complete and submit Non- Institutional 081 claim forms to receive reimbursement from Medicaid. . . . Chapter 7 of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, described "[a]dditional filing requirements," including the following: Service Authorization Requirements Home and Community-Based Services: All home and community-based services (HCBS) must be service authorized by the recipient's case manager and be included in the recipient's plan of care. Medicaid may recoup reimbursement for services that were not service authorized or authorized in the recipient's plan of care. Note: See the waiver-specific Coverage and Limitations Handbook for additional information on the plan of care. * * * Appendix D of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, contained a glossary of terms used in the handbook, which read, in pertinent part, as follows: * * * Case Manager: A case manager for Home and Community-Based Waiver services is the person who writes a recipient's plan of care and authorizes, in advance, the services that will be provided to a recipient. * * * Home and Community-Based Services Waiver: A specific program and set of services authorized under Section 1915(c) of the Social Security Act that are designed to assist recipients to avoid institutionalization. * * * Recipient: A person who is eligible to receive services under Medicaid. Appendix E of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, listed "eligibility program codes." Of the codes listed, only two, MW A and MW C, were for "home and community based services." The Florida Medicaid Aged and Disabled Waiver Provider Handbook (first published in 1993) was the "waiver specific Coverage and Limitations Handbook" referred to in the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, November 1996, that provided additional information about Florida's ADA "waiver" program. Chapter 10 of the Florida Medicaid Aged and Disabled Waiver Provider Handbook discussed "[p]rovider [p]articipation" in the ADA "waiver" program. It read, in pertinent part, as follows: Becoming Enrolled as a Medicaid Provider: 10.4 To become a provider of Home and Community Based Aged/Disabled Waiver services in the Medicaid program you must: not be currently suspended from Medicare or Medicaid in any state; meet requirements described in Section 10C-7.0527, F.A.C.; maintain a contract with the Area Agency on Aging (AAA) or Lead Agency with standards for participation in the Community Care for the Elderly and/or the Community Care for the Adult Disabled Programs; and Maintain full compliance with Title VI of the Civil Rights Act of 1964 and the Rehabilitation Act of 1973. To request a provider enrollment package contact the Medicaid Waiver Specialist at the Area Agency on Aging located in your area. Refer to Chapter 13, Section 13-4 for the address and telephone number of the Area Agency on Aging offices. The enrollment package includes an application and a noninstitutional professional technical agreement. Complete and forward the completed application package to the Medicaid Waiver Specialist located at your local Area Agency on Aging. The Medicaid Waiver Specialist will sign the application and forward it to Consultec.[2] The specialist's signature verifies that the provider application information is complete and the criteria for enrollment have been met. Consultec will not accept any application that has not been signed by the Medicaid Waiver Specialist. After your application is approved, Consultec will send you a Medicaid provider number and a provider handbook for the Medicaid Aged/Disabled Waiver program. If you have a Medicaid provider number and request participation in this program, your 7-digit base number will remain the same; the 2-digit suffix will be different for each program. Use your provider number to bill Medicaid. Medicaid then pays you for covered services that you furnish to Medicaid eligible waiver recipients. Chapter 11 of the Florida Medicaid Aged and Disabled Waiver Provider Handbook described the "[c]overed [s]ervices and [l]imitations" of the ADA "waiver" program. It read, in pertinent part, as follows: * * * Program Purpose: 11.3 The purpose of the Aged/Disabled Home and Community Based Services Waiver program is to promote, maintain, and restore health, or minimize the effects of illness and disability in order to delay or prevent institutionalization. These services allow persons to remain at home or in a home-like setting Covered Services: 11.4 Individuals determined eligible for this program may be entitled to the following services: Adult Day Health Care Case Management Respite Care * * * Counseling * * * General Description of Covered Services: 11.5 There are specific problems experienced by the physically disabled or elderly who are at risk of nursing home placement. Supportive services which strengthen and foster their independence allow the elderly and disabled to remain at home or in a community setting. Waiver services are defined as follows: Adult Day Health Care: Adult Day Health Care (ADHC) is an organized day program of therapeutic, social, and health activities and services designed to restore or maintain the recipient's optimal capacity for self-care. These services are provided to persons who are at least 18 years of age and who have physical or mental functional impairments. Covered services under Adult Day Health Care include: Rehabilitation Services including: physical therapy occupational therapy speech therapy. Medical screening services, emphasizing prevention and continuity of care, which include routine blood pressure checks, diabetic maintenance checks, or rehabilitation therapies not covered under the regular Medicaid program and which are provided at the site. Nursing services which include periodic evaluation, medication supervision, and supervision of self-care services directed toward activities of daily living and personal hygiene. Nutritional services which include dietary and nutritional education. Social services to help with personal and family problems. Planned group therapeutic activities which are in accordance with the goals of the recipient's individual treatment plan. Transportation to and from Adult Day Health Care services. Meal services which provide at least one meal per day of suitable quality and quantity. Case Management Services: Case management is a way to identify an individual recipient's needs, develop intermediate and long term goals, and monitor the services provided to the individual. Case management provides specialized assistance to each individual who wants and needs help to choose and obtain resources and services. Case managers coordinate the delivery of the services in the best way to meet each individual's needs. The amount of assistance is adjusted for each individual recipient. The principle is to develop each individual's capability to negotiate and obtain needed and appropriate services on his/her own behalf. Essential components of effective case management services are: screening of services needs; referring to available resources; conducting a comprehensive needs assessment; developing an individual service plan development; developing a plan of implementation; accessing resources to meet needs identified in service plan; monitoring and following up to assure continued appropriateness of the services; assessing progress toward the original goals; and reassessing recipient need and determining of ongoing service needs. Respite Care: Respite care is a demand-response service to provide supervision and companionship to physically disabled persons or infirm elderly persons for a specified period of time. Respite care may include personal care. The purpose of respite care is to relieve the primary caregiver from the stress and demand associated with providing daily care. Providing the caregiver with relief helps to maintain a healthy living environment. * * * Counseling Services: Counseling involves exploring a recipient's interests and skills, problem solving, emotional support and guidance and encouragement for adopting new behaviors, and setting of realistic goals. It also may include diagnosis and structured treatment of psychological and psychosocial problems. This service is provided by a licensed psychologist, a licensed clinical social worker, or a licensed mental health counselor. * * * Recipient Eligibility: 11.6 To become eligible for this Medicaid program an individual must meet the following eligibility criteria: be aged (65 or older); or be a disabled adult (18 to 64); be Supplemental Security Income (SSI) eligible; or meet the income and assets limits for the Institutional Care Program (ICP); meet level of care requirements as described in Section 11.7; have a plan of care executed by the case manager as described in Section 11.8 below; and have a waiver identification number assigned by the Medicaid Waiver Specialist. Level of Care Determination: 11.7 To determine if an individual is at risk of needing the care provided in an institution, a client assessment must be completed. The assessment is used to identify the individual's social resources and supports and his physical and mental ability to carry out the activities of daily living. This helps to determine the individual's functional impairment and risk of institutionalization. The case manager uses this information to develop a client- centered plan of care. The assessment procedures are: SSI eligibles must have a completed HRS Form 1055 signed by a registered nurse or medical doctor which verifies that the applicant is at risk of institutionalization. ICP eligibles must have a level of care determination provided by the Aging and Adult CARES team using the Nursing Home Level of care for Pre-Admission Screening, HRS Form 3049. For more information regarding the assessment process, please refer to the Client Assessment Manual. Plan of Care: 11.8 A plan of care is a written document which describes the service needs of a recipient and specifies the services to be provided (type), how often the service is to be provided (frequency), and how long the services will continue to be provided (duration). The purpose of the care plan is to enable the case manager and the recipient to summarize the findings of the recipient's evaluation; to identify realistic goals for the recipient; to recognize the barriers to attaining the goals; and then, to work toward removing these barriers and achieving the stated goals. It is an extension of the client assessment and identifies services required to maintain the recipient in the community, reduce the functional limitations noted in the assessment and meet other identified needs. The case manager and recipient work together to develop a plan of care. The recipient's family may help in the development of the plan of care. To assure appropriate case planning, the case manager will consult with the physician, physician's assistant, nurse, other health care providers working with the recipient, and other specialized consultants as needed. The case manager must establish a plan of care before services are rendered and Medicaid is billed. It must be signed and dated by the case manager and the recipient. The plan of care must: specify the level of care, and the needs or problems to be resolved to avoid institutionalization; specify improved or resolved problems by recording the date that services were no longer necessary and were stopped; specify the effective date for the start of in-home service; specify the type of services to be provided and who will provide them; specify the probable duration and desired frequency of service provision; be signed (certified) and dated by the case manager and recipient and, if the plan of care is still appropriate, recertified every 90 days; be updated any time the recipient's condition changes or every six months at a minimum; and be kept on file by the agency and available for review for a period of five years after the termination of services. * * * Service Limitation and Exclusions: 11.12 The plan of care must describe the services to be provided (type), how often the service is to be provided (frequency), and how long it will continue to be provided (duration). Services provided beyond the frequency and duration indicated on the care plan are not allowable. If the type, duration or frequency need to be changed, the case manager must approve the new schedule and update to the plan of care. Medicaid reimbursement is limited to necessary services. Service Authorization: 11.13 Case managers authorize only services which are on the written plan of care. Chapter 12 of the Florida Medicaid Aged and Disabled Waiver Provider Handbook contained the following discussion on "[r]estrictions on [b]illing": You are required to bill your usual and customary fee. Medicaid will pay the maximum fee, or your usual and customary fee, whichever is lower. All services must be authorized by an enrolled Medicaid aged/disabled waiver case manager and must be on the recipient's written plan of care. Petitioner is now, and has been at all times material to the instant case, licensed by AHCA to operate an adult day care center (North Pointe) in Miami-Dade County. Nadine Proctor is now, and has been at all times material to the instant case, the owner and administrator of North Pointe. Ms. Proctor is college educated. She has taken at least one graduate-level course (in public administration at Florida International University). In or around 1997, Ms. Proctor contacted the Alliance for Aging, Inc. (Alliance), by telephone and spoke with Lynn Pollack, one of the Alliance's Medicaid Waiver Specialists, about Petitioner becoming enrolled as a Medicaid provider. Ms. Proctor indicated to Ms. Pollack that she wanted Petitioner enrolled as a provider of adult day health care services to recipients in the state's ADA "waiver" program. Petitioner was "qualified" to provide these services by virtue of its being licensed to operate North Pointe as an adult day care center. Ms. Pollack explained, accurately, to Ms. Proctor "how the [ADA] 'waiver' [program] worked," including its assessment, plan of care development, and referral features (that are described above).3 She emphasized to Ms. Proctor that, to participate in the program as an adult day health care service provider, Petitioner needed, not only to enroll as a Medicaid provider and obtain (from AHCA, through its fiscal intermediary) a Medicaid provider number, but also to enter into a referral agreement with United or Miami-Dade Elderly Services. Following her telephone conversation with Ms. Proctor, Ms. Pollack mailed Ms. Proctor a Florida Medicaid Provider Enrollment Application, along with written "instructions on how to complete the application." There were directions on the application that, upon completion, it be returned to the Alliance for approval (before the completed application was sent to AHCA's fiscal intermediary). Ms. Proctor completed the application and mailed it back to the Alliance. "[T]here were errors on the application," however. Ms. Pollack informed Ms. Proctor of these errors. Ms. Proctor made several unsuccessful attempts to submit an error-free application. Finally, in June of 1997, she paid a visit to the Alliance's offices and met with Ms. Pollack in person. Ms. Pollack "explained [to Ms. Proctor] step-by-step exactly how to do the application." Ms. Pollack also "went over . . . again" with Ms. Proctor the requirements of the state's ADA "waiver" program. In so doing, she reminded Ms. Proctor that having a referral agreement with United or Miami-Dade Elderly Services was an absolute condition precedent to Petitioner's participation in the program as an adult day health care service provider. With Ms. Pollack's help, Ms. Proctor correctly filled out the Florida Medicaid Provider Enrollment Application. Ms. Proctor indicated on the application that Petitioner was seeking to become an adult day health care service provider as part of the state's ADA "waiver" program. Ms. Pollack approved the completed application on June 13, 1997. She then sent it to AHCA's fiscal intermediary, Unisys Corporation (Unisys). Unisys sent Petitioner the following letter dated August 16, 1997: Welcome to the Florida Medicaid Program. Your Florida Medicaid provider number is 6754961 00. Please use you number whenever you bill Medicaid for the following services and invoice type beginning 06/11/97. Service: HOME AND COMM BASED SVCS Invoice Type: FMMIS Non-Institutional Claim Form. The enclosed handbooks explain how to bill Medicaid and how to order additional invoices (billing) forms. We supply invoices that are unique to Medicaid at a nominal charge. An initial supply is enclosed for your convenience. If you have any questions or problems about billing matters or claims, please telephone: Unisys Corporation Fiscal Agent Contractor Toll Free 1-800-289-7799 If Unisys cannot resolve your problems, call your AHCA area Medicaid office. A list of area offices and their telephone numbers is included in your reimbursement handbook. Thank you for participating in Medicaid. AHCA also sent Petitioner a letter dated August 16, 1997. It read as follows: We are pleased that you have chosen to join the Florida Medicaid program and serve the needs of our Medicaid eligible recipients. We are dedicated to making your participation in the program straightforward and productive. Enclosed are handbooks that explain how the Medicaid program operates and how to bill for services that you have agreed to provide. We feel that your enrollment in the Florida Medicaid program is a statement that you want to make a difference in the availability and quality of health care for every Florida citizen who qualifies for Medicaid and we will always try to meet your commitment with a willingness to serve your needs. Enclosed is a sheet that contains you unique Medicaid number. Please remember to always use your number when billing Medicaid. If you encounter a problem or have a question, call Unisys Provider services at 1-800-289- 7799 or if out-of-state 1-800-955-7799. For provider enrollment questions, call 1-800- 377-8216. The Unisys phone lines are staffed especially to assist you, but after contacting them if you still have a problem, call your Medicaid area office. The telephone numbers for area Medicaid offices are listed in Appendix C of your Medicaid Provider Reimbursement Handbook. The area offices are primary sources of information concerning Medicaid policy and covered services. The success of the Florida Medicaid program is dependent primarily on providers like you who furnish services directly to recipients. Thank you for your participation and your efforts to maintain and improve the health of Florida Medicaid recipients. Ms. Proctor "never received" the handbooks referenced in Unisys' and AHCA's August 16, 1997, letters to Petitioner. A few months after her June 1997 meeting with Ms. Pollack, Ms. Proctor telephoned Ms. Pollack and angrily complained that "nobody [was] giving her any referrals" and that she was being "discriminat[ed] against."4 Ms. Pollack asked Ms. Proctor if she had, on behalf of Petitioner, executed a referral agreement. Ms. Proctor responded that she had not because "the process took too long and [United and Miami-Dade Elderly Services] were giving her the runaround." Ms. Pollack told Ms. Proctor, as she had done previously, that Petitioner was "not going to get any referrals" unless it had a referral agreement with United or Miami-Dade Elderly Services. John Saxon, who was "working for" a Florida state senator, subsequently telephoned Ms. Pollack and indicated that the senator "wanted to find out what was going on" with Ms. Proctor. Ms. Pollack "explained the situation to [Mr. Saxon]" and "how the [ADA} 'waiver' program worked," pointing out, among other things, that Petitioner "need[ed] to have [referral] agreements [with United and Miami-Dade Elderly Services] in order to get referrals" from them. Mr. Saxon advised Ms. Pollack that "he would make sure that [Ms. Proctor] underst[ood] [this]." Thereafter, Mr. Saxon telephoned Ms. Pollack again and "assured [her] that [Ms. Proctor] understood." On or about December 17, 1997, Ms. Proctor sent Unisys a check in the amount of $30.00 to obtain the handbooks referenced in Unisys' and AHCA's August 16, 1997, letters to Petitioner. The check was received and cashed. In or around April of 1998, Ms. Proctor asked for and was granted a meeting with the Alliance's executive director, John Stokesberry. Ms. Proctor's pastor and Mr. Saxon accompanied Ms. Proctor to the meeting. Linda Levin, one of Mr. Stokesberry's subordinates, was also in attendance at the meeting. As she had done during her last telephone conversation with Ms. Pollack, Ms. Proctor complained to Mr. Stokesberry at the meeting that "no one was referring clients to her" and therefore "she wasn't receiving any [Medicaid] money." She wanted to know why there had been no referrals made. Mr. Stokesberry told Ms. Proctor, in response to her inquiry, that the Alliance was not involved in the referral process and that any questions she had regarding lack of referrals should be addressed to United and Miami-Dade Elderly Services. Mr. Stokesberry, during the meeting, "made it very clear" that Ms. Proctor "could not bill [Medicaid] if she did not have referrals" from United or Miami-Dade Elderly Services, an advisement Ms. Levin echoed. Ms. Levin added that Ms. Proctor could not receive any referrals if she did not have a referral agreement with one of these case management agencies. What Ms. Proctor had told Mr. Stokesberry at the meeting about her situation was only partially true. Petitioner indeed had not received any referrals from United or Miami-Dade Elderly Services; however, notwithstanding the absence of such referrals, Petitioner had been submitting Medicaid claims and receiving "[Medicaid] money." Petitioner continued to bill Medicaid and be reimbursed following the meeting. Petitioner received payments totaling $673,754.50 for Medicaid claims it had submitted for ADA "waiver" services assertedly rendered from June 12, 1997, to August 28, 1998 (Paid Claims). These Paid Claims were processed by Unisys. At the request of DOEA, an Alliance staff member reviewed one of these Paid Claims (that was randomly selected) and determined that it was not "an appropriate billing." A more extensive post-payment review of the Paid Claims was then conducted. By letter dated September 11, 1998, DOEA's Inspector General, Lisa Milton, advised the Chief of AHCA's Bureau of Medicaid Program Integrity, Edward Turner, of the results of this post-payment review. By memorandum dated September 16, 1998, Mr. Turner requested the Chief of AHCA's Bureau of Medicaid Contract Management to "have Unisys pend [Petitioner's] claims for prepayment review." By letter dated September 17, 1998, AHCA's Bureau of Medicaid Contract Management asked Unisys, until further notice, to "pend for prepayment review any claim" Petitioner submitted, a request with which Unisys complied. On September 22, 1998, Costas Miskis, Esquire, an attorney with AHCA, sent the following letter to Ms. Proctor: The Florida Department of Elder Affairs has advised the Office of Medicaid Program Integrity ("MPI") that certain claims totaling $673,754.50 were improperly submitted under your Medicaid Provider number 6754961-00 for the time period beginning January 1, 1998, though and including September 16, 1998. The information received indicates that the services were not provided pursuant to a written plan of care developed by a case management agency which meets certain standards, and the recipients were not pre- screened as meeting disability criteria as required by the Social Security Act, Federal Regulations, and Aged/Disabled Medicaid Waiver Program. Given this information, the agency is compelled to seek a resolution of this matter. In an effort to expedite and simplify this process, we will extend to you the opportunity to settle this matter. Any settlement at this juncture will save both you and this office the burden and expense of litigation, as well as minimize the public airing with regard to any improper claims. The final terms of any settlement will be incorporated into a written agreement, and will effectively bring this matter to a close. Please be advised however, that in resolving situations involving false Medicaid claims, this agency may seek interest, investigative costs, or penalties as part of any negotiated settlement. Finally, please be advised that should we be unable to settle this matter, this office will consider proceeding under the False Claims Act (section 68.081, Florida Statutes, et seq.). Successful prosecution of such a case for any false claims submitted on or after July 1, 1994, would result in full restitution of the moneys in question plus the award of treble damages (triple the amount paid) together with a mandatory minimum $5,000 penalty per false claim- the maximum penalty per false claim is $10,000. If an agreement is reached between the appropriate parties, however, this agency would forego filing an action. Should you wish to discuss settlement of this matter, please call me at . . . by October 4, 1998. If I do not hear from you, I will assume that you are not interested in discussing this matter and will pursue any and all remedies available. A settlement was not reached. Petitioner continued to bill Medicaid, but was not reimbursed. Petitioner submitted Medicaid claims totaling $1,135,932.96 for ADA "waiver" services assertedly rendered from June 12, 1998, to February 29, 2000, which have not been paid (Pended Claims). The record evidence is insufficient to establish that any AHCA employee or agent, including Mr. Miskis, ever guaranteed Ms. Proctor that these Pended Claims would be paid. None of the Paid or Pended Claims was for any service for which Petitioner was entitled to be reimbursed by Medicaid, as Ms. Proctor knew or should have known. At all times material to the instant case, each of the individuals identified as recipients in the Paid and Pended Claims was Medicaid-eligible, but none of them had undergone a CARES assessment and been deemed eligible for ADA "waiver" services5; none of them had a plan of care; and none of them had been referred to Petitioner by United or Miami-Dade Elderly Services to receive the services billed for. Indeed, Petitioner did not even have a referral agreement with either of these case management agencies. Furthermore, a substantial number of the Paid and Pending Claims were for ADA "waiver" services other than adult day health care (including case management, counseling, respite care, and risk reduction) that Petitioner, as an adult day health care provider, was not authorized to bill for. Ms. Proctor used the FaxBack service offered by Unisys before billing Medicaid. The record evidence is insufficient to establish that Unisys, in responding to Ms. Proctor's inquiries via the FaxBack service, ever advised her that any of the individuals she inquired about were eligible to receive ADA "waiver" services from Petitioner.6 In any event, even if Unisys had provided Ms. Proctor with such an advisement, given what she had been told during her dealings with Alliance staff concerning the requirements of the ADA "waiver" program, it would have been unreasonable for her to have blindly relied on this information without making any further inquiry. On July 18, 2001, AHCA issued its Final Agency Audit Report,7 finding that the monies totaling $673,754.50 Petitioner received for the Paid Claims constituted overpayments Petitioner had to return to AHCA and that the Pended Claims were for services "not covered by Medicaid" and thus should not be paid.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that AHCA enter a final order finding that the monies, totaling $673,754.50, Petitioner received for the Paid Claims constituted overpayments that Petitioner must return to AHCA and that the Pended Claims were for services "not covered by Medicaid" and should therefore be denied. DONE AND ENTERED this 22nd day of July, 2004, in Tallahassee, Leon County, Florida. STUART M. LERNER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 22nd day of July, 2004.
Conclusions Fraes Nos. 2008013980 2008013874 2009004203 2009003498 RENDITION NO.: AHCA-09- \ c:o2.. -5-OLC Having reviewed Administrative Complaint for Case No. 2008013980, dated April 10, 2009 (Ex. 1); Administrative Complaint for Case No. 2008013874, dated April 10, 2009 (Ex. 2); Administrative Complaint for Case No. 2009004203, dated July 16, 2009 (Ex. 3); and Notice of Intent to Deny for Case No. 2009003498, dated March 20, 2009 (Ex. 4); attached hereto and incorporated herein, and all other matters of record, the Agency for Health Care Administration ("Agency") has entered into a Settlement Agreement (Ex. 5) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows: ORDERED: The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. The Respondent shall pay an administrative fine in the amount of ten thousand, five hundred dollars ($10,500.00) and a survey fee in the amount of five hundred dollars ($500.00) for a total of eleven thousand dollars ($11,000.00). The fine and the survey fee are due and payable within sixty (60) days of the rendition of this order. 1 Filed October 13, 2009 4:37 PM Division of Administrative Hearings. If the Petitioner is cited for a Class I or Class II deficiency within one year of the date of the final order executing this settlement agreement, then the full amount of the fines sought in the aforementioned administrative complaints will become due. The Agency agrees that it will not impose any further penalty against Petitioner as a result of the surveys conducted on August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008. However, no agreement made herein shall preclude the Agency from imposing a penalty against Petitioner for any deficiency/violation of a statute or rule identified in a future survey of Petitioner, which constitutes a cumulative fine or uncorrected deficiency from the surveys conducted on August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008. The deficiencies from the August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008 surveys will be deemed proved for such future actions. Furthermore, no agreement made herein shall preclude the Agency from using the deficiencies from the August 21, 2008, October 1, 2008, November 3, 2008, December 18, 2008, and March 9, 2008 surveys in any decision regarding an application(s) for an assisted living facility license, an extended congregate care license, a limited nursing services license, or a limited mental health license. The Notice of Intent to Deny is deemed superseded and the Agency shall begin processing the Petitioner's application. Checks should be made payable to the "Agency for Health Care Administration." The check, along with a reference to this case number, should be sent directly to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, MS# 14 Tallahassee, Florida 32308 Unpaid fines pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available. The petitions for formal administrative proceedings are hereby dismissed. Each party shall bear its own costs and attorney's fees. The above-styled cases are hereby closed. DONE and ORDERED this _i!!_ day of all,p/.{,< , 2009, in Tallahassee, Leon County, Florida. Holly Benson, Secretary Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF 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. Copies furnished to: Jan Mills Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS #3 Tallahassee, Florida 32308 (Interoffice Mail) Jonathan S. Grout, Esquire Counsel for Petitioner 2160 Park Avenue North Winter Park, Florida 32789 (U.S. Mail) Finance & Accounting Agency for Health Care Administration Revenue Management Unit 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Interoffice Mail) Vikram Mohan, Senior Attorney Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MS # 3 Tallahassee, Florida 32308 (Interoffice Mail) Bernard Hudson, Unit Manager Division of Administrative Hearings Assisted Living Unit The Desoto Building Agency for Health Care Administration 1230 Apalachee Parkway 2727 Mahan Drive, MS #30 Tallahassee, Florida 32301-3060 Tallahassee, Florida 32308 (Electronic Mail) (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this f f:y of Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA
Findings Of Fact CON APPLICATIONS HCR-CON No.7530 HCR is a publicly owned, for-profit corporation which operates approximately 25 nursing homes in Florida. HCR filed an application, CON No. 7530, to construct a 98-bed freestanding nursing home. HCR proposes to locate the nursing home in the northwest part of Orange County, Florida. HCR proposes that the entire 98-bed facility will be dedicated to the care of patients with Alzheimer's Disease and related dementias. The total cost of the HCR project is $7,132,000 for 47,750 square feet, or $472,776 per bed. The HCR proposal is modeled after an HCR 120-bed nursing home facility in Boynton Beach, Florida. The Boynton Beach facility is entirely dedicated to the treatment of patients with Alzheimer's Disease or related dementias. The proposed HCR facility in Orange County would be identical to the Boynton Beach facility less one patient wing. HCR's Boynton Beach facility, as well as HCR's existing Orange County nursing home facility, have superior licensure ratings. HCR's Boynton Beach facility received accreditation with commendation from the Joint Commission on the Accreditation of Health Care Organizations (JCAHCO), a national accreditation body which has established standards to measure the quality of care in dementia care units. Dementia is a complex of symptoms that can be caused by many different underlying diseases. Alzheimer's disease is one cause of dementia. Alzheimer's disease is the most common cause of dementia. Significant research is being conducted into the cause and treatment of Alzheimer's disease. Dementia is defined as a decline in intellectual function; global cognitive impairment, that is memory impairment and at least one of the following: impairment of abstract thinking; impairment of judgment; impairment of other complex capabilities such as language use, ability to perform complex physical tasks, ability to recognize objects or people, or to construct objects; and, personality change. The Reisberg Cognitive Rating Scale (RCS) classifies the stages of Alzheimer's disease from 1 to 7, with a rating of 7 being most severe. The rating scale is based on 10 axes: concentration, recent memory, past memory, orientation, functioning and self-care, speech, motor functioning, mood and behavior, practice of an art or skill, and calculation ability. The Global Deterioration Scale (GDS) for Age-Associated Cognitive decline and Alzheimer's Disease also defines seven stages of deterioration ranging from no cognitive decline to very severe cognitive decline. Persons suffering from Alzheimer's disease generally cannot survive without assistance upon reaching early dementia or level five on both the RCS and GDS. Approximately 50-58 percent of persons currently residing in community nursing homes suffer from some form of dementia. There is a need for community nursing home beds for persons suffering from the latter stages (levels 5-7) of Alzheimer's disease in Orange County. It is particularly difficult to place in nursing homes in Orange County, persons suffering from the latter stages of Alzheimer's disease (levels 5-7) who also have displayed a history of disruptive behavior patterns. Persons suffering from the latter stages of Alzheimer's disease have specific needs for care and treatment in nursing homes. Alzheimer's victims tend to wander and should have areas set aside for secured walking. The movement of Alzheimer's victims should also be carefully monitored. HCR's Boynton Beach facility, which is the prototype for HCR's proposed Orange County facility, has specific design features to accommodate the needs of patients suffering from the latter stages (levels 5-7) of Alzheimer's disease. HCR proposes a pod design of five residential pod units each with a central living area, also called the atrium area. The resident rooms open to the central living area. Each pod has an enclosed courtyard. Access to the courtyards is controlled. The two nursing stations are centrally located in each wing of the facility. Each central living area, or atrium, is visible from one or the other of the nursing stations. HCR provides specific staff training in the care and treatment of Alzheimer's disease and related dementias. A unit or a facility dedicated to the treatment of dementia patients may reduce the need for psychotropic medication of the patients. On a long-term basis, there may be some staff burnout in a facility or unit dedicated solely to the care and treatment of victims of Alzheimer's disease or related dementias. HCR proposes that its CON be conditioned upon locating in northwest Orange County, providing at least 30 percent of its patient days to Medicaid eligible persons, providing respite care, and dedicating all 98 beds to the care and treatment of persons suffering from Alzheimer's disease and related dementias. HCR currently meets its Medicaid commitment in the Boynton Beach facility. LIFE CARE CON Nos. 7534 and 7534P LIFE CARE is a for-profit corporation which owns and operates two nursing homes in Florida. LIFE CARE also operates three other nursing homes in Florida. As of September 1993, LIFE CARE had a net worth of approximately $50 million. LIFE CARE proposes to construct a freestanding 98-bed nursing home (CON No. 7534) in southwest Orange County, at a total cost of $5,988,000. The LIFE CARE 98-bed facility proposal includes a 20-bed unit dedicated to the care and treatment of persons suffering from Alzheimer's disease, a 20-bed subacute unit, an adult day care center, mental health services, and services to persons suffering from AIDS/HIV. LIFE CARE also made a partial request (CON No. 7534P) for a 60-bed facility which would be constructed at the same site and would include the same features. For economic reasons, patients are being released from acute care hospital settings at earlier stages of recovery and there is a need for subacute nursing home services in Orange County. The incidence of AIDS/HIV is increasing and there is a need for nursing home services for persons suffering from AIDS/HIV in Orange County. The 20-bed unit proposed by LIFE CARE for the care and treatment of Alzheimer's patients will be a distinct part of the facility, separate from other residents. The Alzheimer's unit has its own dining area and activity area, a centrally located bathing facility, and a secured courtyard for wandering space. The 20-bed LIFE CARE subacute unit will also be separate. The subacute unit will have two ventilator areas and be contiguous to a therapy area. The LIFE CARE design includes outdoor courtyards, a library, gift shop, and ice cream parlor. Pursuant to Sections 408.037(2)(a) and (b), Florida Statutes, one of the required elements of a CON application is the listing of capital projects, which is presented in Schedule 2 of the CON application. The Schedule 2 filed by LIFE CARE in these proceedings is identical to the Schedule 2 filed by LIFE CARE in the December 1993 batching cycle for LIFE CARE'S proposed Clay County Project, CON No. 7501. It has been held that Schedule 2 of the LIFE CARE Clay County Project CON application No. 7501 met minimum CON application content requirements. Life Care Centers of America, Inc. v. State of Florida, Agency for Health Care Administration, 20 F.L.W. 1435 (Fla. 1st DCA June 12, 1995). During November of 1993, a LIFE CARE nursing home located in Altamonte Springs was downgraded from a superior to a conditional licensure rating due to a deficiency related to outdated medication. The conditional rating given to the facility was in effect for approximately fifty days. The facility was then given a standard rating, and upon the annual survey in the fall of 1994, the facility has been recommended for a superior rating. All other LIFE CARE facilities have superior ratings. LIFE CARE proposes to condition its CON application upon providing Medicaid participation of 65 percent in the 98-bed facility, and 43 percent in the 60-bed facility. ADVENTIST CON No. 7528 ADVENTIST is a not-for-profit corporation that owns and operates nursing homes, hospitals, and other health care related enterprises. ADVENTIST is a wholly owned subsidiary of Adventist Health System/Sunbelt Health Care Corporation, which owns and operates hospitals and health care facilities throughout the United States. ADVENTIST has operated health care facilities in Orange County since the early 1900s when Florida Hospital was founded. ADVENTIST is the largest hospital system in Orange County, with more than 1,400 beds located on five campuses. ADVENTIST proposes to add 38 beds to an existing freestanding 80-bed community nursing home, Sunbelt Living Center-East Orlando (SLC), which is directly adjacent to Florida Hospital's East Orlando campus. The ADVENTIST proposal would include a 20-bed subacute unit and also an 18-bed skilled nursing unit. This addition to SLC would be accomplished by constructing two new wings to the existing facility. The projected cost of the ADVENTIST addition is $1,386,500, or approximately $36,000 per bed. SLC is an 80-bed skilled nursing facility which opened in January of 1993. SLC has a superior licensure rating. SLC provides nursing home service to a variety of residents, including persons with AIDS/HIV, as well as persons with a primary diagnosis of Alzheimer's disease and related dementia. SLC does not have a distinct Alzheimer's unit, but is equipped with security features to accommodate Alzheimer's patients. SLC staff is trained in the care and treatment of all its residents, including those with dementia. SLC reached an occupancy rate of 96 percent-97 percent capacity in its first ten months of operation. The SLC design is based on a residential model. The intent of the design is to create a residential community, and to encourage the interaction among the residents, and also between the residents and staff. The residential wings contain twelve rooms with private and semiprivate accommodations. Each room has its own toilet facilities. The support facilities, food service, therapy areas, administrative offices, visitor and welcoming areas, are located in the center of the facility. The residential wings are clustered on each side of the facility. The facility also features outdoor courtyards and walkways adjacent to the residential wings. ADVENTIST proposes to condition its CON application on providing a Medicaid commitment of 65 percent of total patient days in the non-subacute wing of the 38-bed expansion. The ADVENTIST proposal also features an AIDS program and respite care. ADVENTIST currently meets it Medicaid commitment at SLC. As indicated above, there is a need for subacute nursing home beds in Orange County. There is a need for nursing home beds for persons suffering from AIDS/HIV in Orange County. In the 20-bed subacute unit ADVENTIST proposes that each room will include wall-mounted suction and gases to accommodate ventilator dependent patients, which will enable ADVENTIST to provide more intensive subacute care. RHA/PRINCETON CON No.7538 RHA is the owner and operator of Princeton Hospital, located on the west side of Orlando. Princeton Hospital is situated on 32 acres bordering Lake Lawne. Princeton Hospital has 150 beds, including 24 psychiatric beds, a multipurpose intensive care unit, a 13-bed progressive care unit, a nursery, pediatric services, women's services, an obstetrical unit and an inpatient cardiac catheterization lab. The psychiatric unit at Princeton Hospital treats a wide range of mental disorders, including those afflicting the elderly population. The hospital also operates a senior psychiatric partial hospitalization program which serves geriatric patients, including persons suffering from Alzheimer's disease and related dementias. Princeton Hospital currently provides care and treatment to persons suffering from AIDS/HIV. Princeton Hospital is accredited by the Joint Commission on Accreditation of Health Care Organizations. On August 1, 1994, subsequent to the filing of CON application No. 7538, Princeton Hospital entered into a wide-ranging affiliation agreement with the University of Florida, College of Medicine and Shands Hospital. The agreement provides for extensive reciprocal training and educational programs between Princeton Hospital and the College of Medicine, as well as Shands Hospital. The agreement also provides for priority transfer of patients between Princeton and Shands hospitals. RHA proposes to include its nursing home facility within the scope of the affiliation agreement. The nursing home staff would benefit from the training and educational opportunities, and the nursing home patients would have access to priority reciprocity with the College of Medicine and Shands Hospital as provided for in the agreement. During fiscal years 1993 and 1994 Princeton Hospital had a Medicaid patient ratio of approximately 40 percent. Princeton Hospital also provides indigent care. RHA proposes to construct a freestanding 60-bed Medicaid certified skilled nursing facility on the campus of Princeton Hospital at a cost of $4,991,961 for 43,741 square feet, or $83,199 per bed. The services that are proposed include subacute care, a 15-bed unit for persons suffering from Alzheimer's disease and related dementias, long term care, and two pediatric beds. Respite care will also be provided. RHA proposes that its subacute care unit would provide step-down care for patients referred from acute care hospital settings. RHA also proposes to provide rehabilitative therapies to serve patients suffering from fractured hips and joint replacements as well as other patients needing more intensive physical therapy. Cardiac and respiratory patients will also be served in the subacute unit. As indicated above, there is a need for subacute nursing home beds in Orange County. RHA's proposed 15-bed Alzheimer's unit will be a distinct and secured part of the facility. The unit will have its own enclosed courtyard and activities area. As indicated above, there is a need for nursing home beds for persons suffering from Alzheimer's disease and related dementias in Orange County. RHA also proposes a program dedicated to the care and treatment of persons suffering from AIDS/HIV. This program will provide long-term care, and will include psychiatric, as well as subacute services. As indicated above, there is a need for nursing home beds for persons suffering from AIDS/HIV in Orange County. The RHA proposal includes two pediatric nursing home beds. It is not uncommon to provide pediatric nursing home beds in a small unit within a nursing home facility. These beds will provide subacute care to pediatric patients referred from acute care hospital settings. It is anticipated that the pediatric unit will serve patients with respiratory problems and other multiple system failures. RHA has experienced difficulty in placing pediatric patients discharged from Princeton Hospital. The RHA facility is designed in a series of modules. There are four patient wings located around a single nursing station. The Alzheimer's wing is distinct and secured. The pediatric beds are located in a single semiprivate room close to the nursing station. The subacute unit includes six beds with wall-mounted medical gases and vacuums. Each residential room has approximately 272 net square feet, and features its own handicapped toilet and bathing facilities. The facility includes a chapel, convenience store, laundry, ice cream shop, and beauty shop, designed in a mall concept. The corridors are ten feet in width instead of the standard eight feet. The intent of the design concept is to encourage social interaction. As designed, the location of the soiled utility room in the facility does not comply with applicable Florida code regulations; however, a proposed minor change in the design will move the soiled utility room approximately twenty feet to bring the facility into compliance with Florida code regulations. ALLOCATION FACTORS Relationship to District and State Health Plans Section 408.035(1)(a), Florida Statutes District Health Plan Allocation Factor 1 of the District Health Plan provides a priority for an applicant proposing to locate in the northwest Orange County population center. This preference will continue to be given applicants until a total of 120 beds is obtained. HCR is the only applicant proposing to locate in the northwest Orange County population center; however, in January of 1993, Sunbelt Living Center, a 120-bed community nursing home opened in Apopka, Florida, which is located in the northwest Orange County population center. Accordingly, the total bed number for this preference has been obtained, and this district allocation factor is inapplicable to these proceedings. Allocation Factor 2 of the District Health Plan provides a preference for applicants developing specific services for newborn and/or pediatric patients. RHA is the only applicant proposing specific services which include a unit for the care and treatment of pediatric patients. Accordingly, RHA is the only applicant which meets this allocation factor. Allocation Factor 3 of the District Health Plan provides a preference for an applicant proposing to develop a specific specialty service (or services), such as a unit for medically complex patients, a unit dealing with psychiatric disorders as a primary diagnosis, or services for persons suffering from AIDS/HIV. This preference is also provided to an applicant which commits to working with, or in conjunction with, an existing provider of a specialty service, such as hospices, or mental health providers. RHA is the applicant which best meets this allocation factor. The RHA proposal provides for specialty services for medically complex patients, provides for services to persons suffering from AIDS/HIV, and RHA specifically commits to working with mental health providers, including working with the psychiatric unit at Princeton Hospital. ADVENTIST and LIFE CARE also propose to provide specialty services to medically complex patients in subacute units; however, the ADVENTIST facility is better equipped in this regard and is designed with piped in medical gases, vacuum, and expanded electrical capacity will have the capability to provide more extensive services. LIFE CARE also proposes to treat persons suffering from AIDS/HIV and persons with mental disorders. The LIFE CARE proposal, however, is not as specific in this regard as that of RHA. HCR proposes to provide specialty services to persons suffering from Alzheimer's disease and related dementias, and is in general compliance with this allocation factor. State Health Plan Allocation Factors Each applicant meets the first State Health Plan allocation factor which provides a preference for an applicant proposing to locate in areas within the subdistrict with occupancy rates exceeding 90 percent. The occupancy rate in Orange County exceeds 90 percent. RHA and LIFE CARE meet the second State Health Plan allocation factor which provides a preference for an applicant proposing to serve Medicaid patients in proportion to the average subdistrict-wide percentage of nursing homes. In Orange County the average is 65 percent for Medicaid service. ADVENTIST meets this preference with regard to its non-subacute unit. HCR which proposes a 30 percent Medicaid service does not meet this preference. The third State Health Plan allocation factor provides a preference to an applicant proposing specialized services to special care residents, including AIDS residents, Alzheimer's residents, and the mentally ill. Each applicant generally complies with this allocation factor and offers specialty services; however, RHA with its broader spectrum of specialty services, including services to AIDS/HIV residents, Alzheimer's residents, and its specific commitment to working with residents suffering from psychiatric disorders best meets this preference. The fourth State Health Plan allocation factor provides a preference to an applicant proposing to provide a continuum of services to community residents including, but not limited to, respite care and adult day care. RHA and ADVENTIST best meet this preference. RHA and ADVENTIST have a history of providing quality health care service to the community. RHA and ADVENTIST have extensive ongoing relationships with acute care hospitals. HCR and LIFE CARE have also established relationships which will address providing a continuum of care, but not to the extent proposed by RHA and ADVENTIST. The fifth State Health Plan allocation factor provides a preference to an applicant proposing to construct facilities which provide maximum resident comfort and quality of care. Each applicant proposes facilities designed to provide resident comfort and quality care. Each design has comfortable resident rooms, spacious activities areas, recreation areas, courtyards, landscaping, therapy rooms, and staff lounge areas. Each applicant meets this preference. The sixth State Health Plan allocation factor provides a preference for an applicant proposing innovative therapeutic programs which have proven effective in enhancing the residents' physical and mental functioning level and which emphasize restorative care. Each of the applicants' proposals feature specific elements of innovative therapeutic programs. HCR has received an award for its innovative design of the Boynton Beach Alzheimer's unit. RHA offers a multi-discipline approach with a psychiatric program. ADVENTIST offers an intensive subacute care unit, and LIFE CARE offer a well-balanced approach with intensive staff training. The seventh State Health Plan allocation factor provides a preference for an applicant proposing charges which do not exceed the highest Medicaid per diem rate in the subdistrict. In this respect, HCR projects Medicaid charges of $96.20 per patient day in Year 1, and $93.32 in Year 2. LIFE CARE projects Medicaid charges of $104.74 per patient day in Year 1, and $106.20 in Year 2. ADVENTIST projects Medicaid charges of $106.00 per patient day in Year 1, and $111.30 in Year 2. RHA projects Medicaid charges of $107.02 per patient day in Year 1, and $109.24 in Year 2. While HCR projects the lowest Medicaid per diem charges and appears to best meet this allocation factor, all applicants have agreed to a specified Medicaid utilization rate, and will accept the appropriate Medicaid reimbursement levels. The eighth State Health Plan allocation factor provides a preference for an applicant with a history of providing superior resident care in Florida or other states. HCR has maintained superior licensure ratings, and its prototype Boynton Beach facility currently is rated superior. LIFE CARE in 1993 experienced a conditional rating for its Altamonte Springs facility; however, the facility, upon evaluation in the fall of 1994, is now recommended for a superior licensure rating. RHA does not currently operate nursing homes; however, RHA has a history of providing quality care in its Princeton Hospital. ADVENTIST is the only applicant proposing to add nursing home beds to an existing facility that currently has a superior licensure rating, and in this respect, ADVENTIST best meets this allocation factor. The ninth State Health Plan allocation factor provides a preference to an applicant proposing staff levels which exceed minimum staffing standards contained in licensure administrative rules. Applicants proposing higher ratios of RNs- and LPNs-to-residents shall be given preference. All applicants meet this factor; however a comparison of the nursing staffing patterns of the applicants reflects that HCR (45.40 nursing FTE) and LIFE CARE (45.30 nursing FTE) have a higher than the minimum required ratio of nursing staff to residents for their proposed 98-bed facilities. RHA has proposed 35.30 nursing FTE for its 60-bed facility. ADVENTIST proposes a total 62.40 nursing FTE for its facility after the proposed 38-bed addition. The tenth State Health Plan allocation factor provides a preference for an applicant who will use professionals from a variety of disciplines to meet the residents' needs for social services, specialized therapies, nutrition, recreational activities, and spiritual guidance. These professionals shall include physical therapists, mental health nurses, and social workers. All the applicants offer a wide range of social, spiritual, nutritional, and recreational services. RHA, however, also proposes specific utilization of mental health care professionals, and a specific affiliation with the psychiatric care professionals from Princeton Hospital, and best meets this factor. The eleventh State Health Plan allocation factor provides a preference for an applicant who ensures the residents' rights and privacy, and who implements a well-designed quality assurance and discharge planning program. Each applicant has documented specific plans for quality assurance and ensuring the residents' rights and privacy are protected. Accordingly, each applicant meets this factor. The final State Health Plan allocation factor provides for a preference to an applicant proposing lower administrative costs, and higher resident care costs compared to the average nursing home in the district. HCR has the lowest projected administrative and overhead costs ($18.28 per patient day as of Year 2), and best meets this allocation factor. Statutory Review Criteria, Section 408.035(1), F.S. Section 408.035(1)(b): The availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, inadequacy of like and existing health care services and hospices in the service district of the applicant. HCR, LIFE CARE, and RHA each proposes a unit dedicated to the care and treatment of persons suffering from Alzheimer's disease and related dementias (HCR 98-bed facility, LIFE CARE 20-bed unit, and RHA 15-bed unit). ADVENTIST, while currently providing care for Alzheimer's patients at SLC, does not propose a distinct Alzheimer's unit in its 38-bed addition. There are currently at least five nursing homes in the service district, and two others in close proximity, which feature dedicated Alzheimer's units, with a total of at least 345 nursing home beds serving Alzheimer's patients. There is a high utilization rate of Alzheimer's nursing home beds in the district. While there is an established need for more beds to serve Alzheimer's patients, particularly Alzheimer's patients with a history of disruptive behavior, there are additional needs in the service district to provide care and treatment for subacute patients, and for persons suffering from AIDS/HIV. It is difficult to quantify the need for subacute nursing home beds due to the differing professional definitions of what constitutes subacute care; however, acute care hospitals in Orange County are, for cost-effective reasons, now releasing patients on an earlier basis, and there is an established need for nursing home beds to accommodate persons released from acute care hospitals. There is a high utilization rate of subacute beds in the district. There has also been an increase in the incidence of AIDS/HIV patients, and in the need for nursing home beds for persons suffering from AIDS/HIV in the service district. Section 408.035(1)(c): The ability of the applicant to provide quality of care and the applicant's record of providing quality of care. Each applicant has the ability to provide quality of care, and each applicant has a history of providing quality of care. The distinguishing factors in this regard are that LIFE CARE is the only applicant that has experienced a downgrading of a nursing home facility from a superior to a conditional licensure rating, and ADVENTIST is the only applicant that proposes to add nursing home beds to a facility that currently has a superior licensure rating. In comparison, ADVENTIST best meets this factor, and LIFE CARE least meets this factor. Section 408.035(1)(e): Probable economies and improvements in service that may be derived from operation of joint, cooperative, or shared health care resources. ADVENTIST and RHA both have specific proposals to work with, and share services with acute care hospitals. Both are in close proximity to acute care hospitals which will expedite sharing of medical resources. RHA will also share dietary services with Princeton Hospital. The freestanding facilities proposed by HCR and LIFE CARE do not have this advantage. Section 408.035(1)(f): The need in the service district for special equipment and services which are not reasonably and economically accessible in adjoining areas. This factor is inapplicable to the proposals. No specific need was established as to special services and equipment not reasonably and economically accessible in adjoining areas. There are dedicated Alzheimer's units and dementia services for persons in adjoining areas. Section 408.035(1)(g): The need for research and educational facilities, including but not limited to, institutional training programs and community training programs for health care practitioners. RHA has an extensive proposal for the participation and training of health care practitioners in conjunction with Princeton Hospital and best meets this criterion. RHA's affiliation with the University of Florida College of Medicine, Shands Hospital, and the Brain Institute at the University of Florida enhances this proposal. ADVENTIST shares a similar educational and training relationship with Florida Hospital, and with Florida Hospital's registered nurse baccalaureate degree program through Southern College. LIFE CARE proposes to establish relationships with local community colleges and education centers to sponsor nursing programs. Section 408.035(1)(h): The availability of resources, including health manpower, management personnel, and funds for capital and operating expenditures for project accomplishment As stipulated, each applicant meets this criterion. Each applicant also has substantial personnel and management resources available for project accomplishment. Section 408.035(1)(i): The immediate and long- term financial feasibility of the proposal. LIFE CARE, ADVENTIST and RHA meet this criterion, and reasonably project positive cash flows by the second year of operation. RHA a not-for- profit corporation, projects a net loss of $114,000 in Year 1 of operation, and an excess of revenues over expenses of $53,000 in Year 2 of operation. LIFE CARE projects a net loss of $440,496 in Year 1 and a net gain of $145,085 in Year 2 for the 98-bed facility, and a net loss of $259,971 in Year 1 and a net gain of $54,920 in Year 2 for the 60-bed facility. HCR projects an after-tax profit of $25,000 in Year 2; however, in order to attain a level of profitability HCR must meet its projected 65 percent private pay utilization. This is a very high private payor mix, and there is a significant question as to whether this payor mix is attainable in the subdistrict; however, as proposed, HCR meets this factor. Sections 408.035(1)(k)(l) and (m): Impact of the project on cost of health services; cost effective- ness; construction costs. ADVENTIST proposes the most cost-effective project by adding beds to an existing facility (SLC). The addition of 38 beds to SLC will promote and maximize the overall efficiency of the facility which was originally designed with core support features to accommodate 120 residents. The proposed 38-bed addition to SLC will also lower the costs per patient day of the entire facility. The ADVENTIST proposal adds nursing home beds at the lowest per bed cost ($36,000 per bed) of all applicants. Similarly, RHA is located on the campus of an existing acute care hospital owned by the applicant and, unlike HCR and LIFE CARE, projects no actual cash expenditure for land acquisition. Each applicant has proposed a reasonable design of its proposed facility and reasonable construction costs, and taken into consideration applicable costs and methods of energy provision and conservation. Each applicant meets this criterion. Each applicant has also proposed a very high quality of care facility that will foster competition and promote quality assurance and cost- effectiveness. Each applicant meets this criterion. Section 408.035(1)(n): The applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent. RHA, ADVENTIST and LIFE CARE have proposed providing health care services to Medicaid patients at rates at, or in excess of, the district average. HCR proposes the lowest Medicaid service rate at 30 percent. RHA also has a strong record of providing Medicaid services and service to the medically indigent at Princeton Hospital. All applicants except HCR meet this factor. Section 408.035(1)(o): The applicant's past and proposed provision of services which promote a continuum of care in a multilevel health care system. The RHA and ADVENTIST proposals best meet this criterion. Both the RHA and the ADVENTIST proposals are closely associated with existing hospitals, and emphasize a continuum of care from the acute hospital setting to a nursing home facility. The RHA and ADVENTIST proposals promote the interaction of health care professionals in a multilevel health care system. The HCR and LIFE CARE proposals do not reflect such an extensive interconnection with other aspects of the health care system, and do not promote a continuum of care to the extent proposed by RHA and ADVENTIST. Section 408.035(2)(b): Whether existing inpatient facilities providing inpatient services similar to those being proposed are being used in an appropriate and efficient manner. The evidence reflects that the existing inpatient facilities in, or adjacent to, the district which offer subacute and AIDS services, as well as services dedicated to the care and treatment of persons suffering from Alzheimer's disease and related dementias are operating at, or near, capacity, and are being used in an appropriate and efficient manner.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that: RHA's application for CON No. 7538 be APPROVED. ADVENTIST'S application for CON No. 7528 be APPROVED. HCR's application for CON No. 7530 be DENIED. LIFE CARE'S applications for CON Nos. 7534 and 7534P be DENIED. RECOMMENDED in Tallahassee, Leon County, Florida, this 27th day of July, 1995. RICHARD HIXSON 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 27th day of July, 1995. APPENDIX HCR's Proposed Findings 1-5. Accepted in substance. 6. Rejected, insofar as quantification of need for subacute services, while not readily ascertainable, was demonstrated by other applicants.demonstrated need existed in district 7-8. Accepted in substance. 9. See Number 6. 10-14. Accepted in substance, but disposed of by ruling in Clay County case. 15-27. Accepted in substance. 28-36. Rejected insofar as quantification of need for subacute services is not readily accessible; however, need for such services was established. Accepted, except that need for 120 beds has been met. Accepted, except that RHA proposes specific pediatric services and is entitled to preference. Accepted in substance, except last sentence is rejected. Accepted. Accepted, except that ADVENTIST meets preference as to the non- subacute unit. 42-43. Accepted in substance. 44-45. Rejected. Accepted in substance. Accepted, except that ADVENTIST and RHA also meet this factor, and ADVENTIST is adding beds to an existing superior-rated facility. 48-50. Accepted in part, other applicants meet these factors. 51-65. Accepted in substance; however other services are also needed in the district. 66-67. Rejected. 68-73. Accepted in substance. 74-76. Accepted; however other services are also needed in the district. 77. Rejected. 78-86. Accepted in substance. 87-94. Accepted only to the extent that the HCR proposal meets the minimum requirements to demonstrate financial feasibility. 95-103. Accepted in substance; however each applicant's proposal also meets this factor. 104-112. Accepted in substance. 113. Rejected. 114. Accepted; however RHA proposes a minor change to correct this design. 115-116. Accepted only as to RHA design features. 117-122. Rejected. 123-127. Accepted in substance. 128-131. Rejected. LIFE CARE's Proposed Findings 1-3. Accepted in substance. 4. Accepted, except that district plan includes consideration of pediatric population. 5-7. Accepted; however other applicants also meet these factors. See Finding No. 4. Rejected to the extent that it is not uncommon for pediatric care to be provided in a nursing home setting. 10-38. Accepted in substance. 39-40. Rejected to the extent that RHA and ADVENTIST have competitive staff salaries and have experienced no difficulty in hiring qualified staff. 41-57. Accepted in substance. 58-59. Rejected. Accepted; however RHA proposes a minor change to correct this design. Rejected. 62-65. Accepted in substance. 66-69. Disposed of by Clay County case. Accepted; however ADVENTIST meets this factor in the non-subacute unit. Accepted in substance. ADVENTIST's Proposed Findings 1-4. Accepted in substance. 5. Accepted only to the extent that HCR does not propose a specific subacute care unit. 6-13. Accepted in substance. Rejected to the extent that HCR's proposal meets minimum financial feasibility requirements. Accepted. 16-17. Rejected. Accepted. Accepted to the extent that RHA and ADVENTIST best meet this criterion. 20-21. Accepted in substance. 22-26. Disposed of by Clay County case. 27-29. Accepted in substance 30-31. Rejected. 32-35. Accepted in substance. 36. Rejected; see No. 19. 37-106. Accepted in substance. 107. Accepted; see No. 19. RHA's Proposed Findings 1-21. Accepted in substance. 22. Accepted; however other applicants also meet these factors. 23-54. Accepted in substance. 55. Accepted to the extent that there are at least seven nursing homes with dedicated Alzheimer's units in or near the service area. 56-92. Accepted in substance. 93-96. Accepted; however HCR meets minimum financial feasibility requirements. 97-102. Accepted; however LIFE CARE meets minimum financial feasibility requirements. 103. Rejected. 104-122. Accepted in substance. 123. Rejected. 124-135. Accepted in substance. 136. Rejected to the extent that all applicants have met the design criterion. 137-140. Accepted in substance. 141. Rejected. 142-145. Accepted in substance. 146. Accepted to the extent that RHA and ADVENTIST best meet this criterion. COPIES FURNISHED: Stephen K. Boone, Esquire BOONE, BOONE & BOONE, P.A. Post Office Box 1596 Venice, Florida 34284 Alfred W. Clark, Esquire 117 South Gadsden, Suite 201 Tallahassee, Florida. 32301 R. Bruce McKibben, Jr., Esquire PENNINGTON & HABEN, P.A. 215 South Monroe Street, 2nd Floor Post Office Box 10095 Tallahassee, Florida 32301 Michael J. Glazer, Esquire MACFARLANE, AUSLEY, FERGUSON & MCMULLEN, P.A. Post Office Box 391 Tallahassee, Florida 32301 Samuel Dean Bunton, Esquire Senior Attorney, AHCA Atrium Building, Suite 301 325 John Knox Road Tallahassee, Florida 32303-4131 Steven R. Bechtel, Esquire MATEER, HARBERT & BATES, P.A. Post Office Box 2854 Orlando, Florida 32802 James M. Barclay, Esquire COBB, C0LE & BELL 131 North Gadsden Street Tallahassee, Florida 32301
