on application for certificate of need a. project … · 2008. 2. 22. · on application for...

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Adventa Hospice Services of Florida, Inc./CON #9999

400 East Bay Street, Suite 406 Jacksonville, Florida 32202 Authorized Representative: Roger A. Cochran, Ph.D. (904) 634-0276

Compassionate Care Hospice of Florida, Inc./CON #10000

3051 Highland Oaks Terrace, Suite D Tallahassee, Florida 32301 Authorized Representative: Ms. Judith Grey (201) 919-4905 Crown Hospice, Inc./CON #10001 103 Marsh Edge Lane

Savannah, Georgia 31419 Authorized Representative: Mr. Newell D. Yarborough Jr.

(912) 925-5896 HCR Manor Care Services of Florida, Inc./CON #10002

333 North Summit Street Toledo, Ohio 43604 Authorized Representative: Mr. Bruce Schroeder (419) 252-5668

CON Action Numbers: 9999-10002 & 10004

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North Central Florida Hospice Inc./CON #10004

175 Salem Court Tallahassee, Florida 32301 Authorized Representative Mr. Gene Nelson (850) 222-7110

2. Service Area/Subdistrict

District 4, Hospice Service Area 4B, Volusia and Flagler Counties B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area 4B. However, letters of support were submitted, as discussed below.

Adventa Hospice Services of Florida, Inc. (CON #9999) included four letters of support with its application. These were from Joanne D. Saxour, M.D., Halifax Family Medicine, Port Orange, Florida; Jason R. Mercer, M.D., Signature Healthcare of Volusia, Ormond Beach, Florida; and LPN’s from Grand Villa Assisted Living Residence, and Alterra Sterling House Assisted Living Facility. Dr. Saxour and Dr. Mercer state they are familiar with the applicant’s sister agency, Amedisys Home Health Care/House Call Home Health, have been pleased with the quality of services and believe that the applicant would provide similar quality services for its hospice patients. Representatives of Grand Villa and Alterra Sterling House state that they would be willing to discuss a contract with the applicant to provide inpatient care for its hospice patients. Compassionate Care Hospice of Florida, Inc. (CON #10000) included 42 letters of support from out of state programs, providers, patients, and referrers with its application. In addition, the applicant submitted nine letters of support from the service area. These were from: Steven T. Thompson, City Manager, City of Deltona, Florida; Lynda Linke, Community Services Director, Flagler County Board of County Commissioners, Palm Coast, Florida; Paul Mitchell, Administrator, Indigo Palms Assisted Living Facility, Daytona Beach, Florida; Nanci Villani, Executive Director, Alterra Sterling House Assisted Living Facility, DeLand, Florida; Deborah Tolan, BSN, Administrator, Rose Manor, Inc., DeLand Florida; Isabelle Berber, Administrator, Herald’s Retirement Home, Daytona Beach Florida; Kim Broke, Administrator, Home Sweet Home Assisted Living, DeLand Florida; Jack S. Murphy, Georgia State

CON Action Number: 9999-10002 & 10004

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Senator, Daytona Beach Florida (apparently his vacation residence); and William Jenkins, Nursing Home Administrator (NHA), The Terrace of Daytona Beach, Daytona Beach Florida. These letters generally stated the need for an additional hospice program to meet the needs of the indigent and underserved in Volusia and Flagler Counties. The applicant’s letter of support in Appendix L from William Jenkins, NHA, The Terrace of Daytona Beach, indicated this facility would be willing to contract with Compassionate Care Hospice for hospices services. Crown Hospice, Inc. (CON #10001) submitted 16 letters of support with its application. Eleven letters were from Crown Hospice, Inc./Seasons Hospice supporters in other states. Five letters were from the service area of Volusia and Flagler Counties. Steven P. Schrunk, M.B.A., Administrator, CountrySide Lakes, Port Orange Florida; Paul M. Cohen, Owner & Managing Director, Comfort Keepers non-medical in home health services, Port Orange Florida; Chadwick Hagan, Associate, Sterling Healthcare, Inc.; Paula Shoemaker, Regional Vice President of Operations, Gentiva home health services; and Perry J. Weiker, MSHA, LNHA, Director of Business Development, Indigo Manor Nursing & Rehabilitation Center state there is an unmet need for a faith-based hospice to join the health care community. Comfort Keepers, in-home care; Gentiva, home health services; Sterling Healthcare, Inc. (Sandalwood Nursing Center); and Indigo Manor Nursing & Rehabilitation Center have stated their willingness to establish a referral arrangement with Crown Hospice, Inc. should the CON be approved. HCR Manor Care Services of Florida, Inc. (CON #10002) submitted 111 letters of support with its application. The letters of support were from area doctor’s offices, assisted living facilities directors and owners, community businesses, Hispanic residents and business owners, Veterans and Veteran’s advocates. Many of the letters were of a form letter variety. Forty-six letters were from ALF staff, owners, and administrators, 15 letters were from doctor’s offices and the general medical community, 15 letters were from Hispanic business owners and residents, 15 letters were from community businesses, 13 letters were from Veterans and Veteran advocates, and six letters were from area residents.


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According to the letters of support, the Hispanic community feels that a hospice that is willing to focus on their community’s specific needs and concerns is missing from the current hospice providers in Volusia and Flagler Counties. The Veterans and Veteran’s advocate letters of support state that hospice patients and their families need a continuum of care for emotional, physical, and bereavement support. They also state that services for terminally ill veterans are not always available and when they are, they do not always take into account the particular needs of the population. These supporters agree with the need for another hospice provider in Subdistrict 4B and express that the applicant will be able to fill the void in Veterans hospice services. Paul Malley, President of Aging With Dignity, a non-profit organization formed to protect the rights of the sick, aging or dying, also provided a letter of support. This letter states that Heartland was one of seven organizations receiving the “National Innovators” award. This award is given to recognize organizations that made exceptional progress in promoting dignified care at the end-of-life, and encouraging decision making ahead of a health crisis through advance planning. He concludes that based on “my six years working with Heartland…communities served by (Heartland) benefit greatly”.

North Central Florida Hospice, Inc. (CON #10004) submitted 76 letters of support with its application. Four of the 76 were submitted directly to the Agency. Sixty-two of the letters of support were from service area doctor’s offices, home health agencies, skilled nursing facilities, assisted living facilities, area businesses, and residents. Thirty-one letters were from ALF staff, owners, and administrators; 15 letters were from area physicians; eight were from skilled nursing facilities; 11 were from businesses; three letters were from home health agencies; four letters from area residents, two letters from service area hospitals. The support letters basically state that they look forward to working with a new hospice service provider and offer their full support. Fourteen of the 76 letters of support were from neighboring counties where the applicant has existing hospice programs. Robert C. Davis, with the Alachua County Health Department, cites Haven Hospice’s work with AIDS patients in his letter of support. Many of the supporters note that “The 2007 Circle of Life Award was presented to Haven Hospice by the American Hospital Association singling them out as one of three Hospices nationwide which exemplify the level of regard Haven has been able to achieve within their industry.”


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However, at the American Hospital Association’s annual summit, the 2007 Circle of Life Award Honorees were: Covenant Hospice in Pensacola, Florida; University of California San Francisco Palliative Care Program; and Woodwell: A Program of Presbyterian SeniorCare and Family Hospice and Palliative Care in Oakmont, PA. Haven Hospice, Gainesville, Florida was one of five hospices to receive a Citation of Honor from the American Hospital Association in 2007. The applicant’s letters of support from Florida Hospital Fish Memorial, Orange City and from Bert Fish Medical Center, New Smyrna Beach state their intent to contract for inpatient care with Haven. Letters of Opposition Halifax Hospice, Inc. d/b/a Hospice of Volusia-Flagler and VITAS Healthcare Corporation of Central Florida submitted letters in opposition to the approval of a new hospice program in Subdistrict 4B, Volusia and Flagler Counties, Florida. Halifax states that if residents of Service Area 4B wish to choose a hospice, based on whether the hospice is for profit for not-for–profit, ample choice is available among the hospices currently serving the area. Halifax also states that the decline in death rates and the leveling of the absolute number of deaths in Service Area 4B have important health planning implications. Halifax contends that review of the death rates in the service area suggest that growth in the volume of deaths will not occur at a rate sufficient to support a new provider, plus the two newer existing providers should be given the opportunity to be able to reach a minimum threshold of 350 annual admissions. Halifax also states that penetration rates achieved by the four existing providers exceed the state average therefore eliminating any concern regarding under-service. VITAS reiterates many of the points presented by Halifax. VITAS states that hospice services are readily available throughout Volusia and Flagler Counties. VITAS also contends that AHCA’s use of the Bureau of Economic & Business Research (BEBR) population estimates in the most recent batching cycle publication which relied upon the July 1, 2005 population statistics and 2005 resident deaths, rather than 2006 is flawed. VITAS notes that this most likely occurred because of the delay in publishing 2006 deaths by the Office of Vital Statistics VITAS states that from 2004 to 2006 there was only an increase of 0.3 percent in resident deaths. The 0.3 percent increase combined with the increasing number of hospice admissions has led VITAS to question the validity of BEBR population estimates. VITAS concludes that should AHCA approve a fifth hospice to serve Service Area 4B, it would be duplicating


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services already available, foster unhealthy competition and ultimately challenge the viability of the four existing programs as well as the fifth provider. Regardless, the Agency’s need formula calculation resulted in the projected hospice need of one program based on the criteria in administrative rule.

C. PROJECT SUMMARY

Adventa Hospice Services of Florida, Inc. (CON #9999) proposes to establish a new hospice program in Hospice Service Area 4B, Volusia and Flagler Counties. Adventa, a for-profit corporation, is owned by Adventa Hospice, LLC (AH). Adventa does not currently offer any hospice services in Florida. However, Adventa’s parent company, Adventa Hospice, LLC, does provide licensed and accredited hospice care in 30 separate hospices in 14 states: Alabama, Alaska, Colorado, Georgia, Idaho, Indiana, Kansas, Louisiana, New Hampshire, Oregon, Tennessee, Texas, Virginia, and Wyoming. The applicant has agreed to condition award of the CON upon providing the following: 1. Special outreach program to homeless patients.

• Designation of an outreach coordinator for the homeless

community by Adventa as certified by a letter to AHCA. • Identification of a representative of homeless patients or

homeless organizations to serve as an advisor and liaison to Adventa as certified by a letter to AHCA.

• Identification of a medical clinician or other practitioner who works with homeless patients and who expresses direct willingness to refer those of their patients in need of end-of-life care to Adventa Hospice.

• Provision of an annual report by the director of operations to the governing body of Adventa and by a copy of the report to AHCA. Such report to provide the number of homeless patients that were served and the types of services provided.

2. Special program to assist patients without a caregiver living at

home. • Adventa will establish a special program for training volunteers

to work in the homes of those who live alone. The content of this training program will be developed in the first three to six months of operations. The volunteer coordinator will manage


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this program. The clinical manager will identify those patients without a caregiver living with them as who are most in need of assistance and work in conjunction with the volunteer coordinator to match them with volunteers willing to commit to an ongoing relationship with a single patient in need of care.

• The director of operations will make an annual report to the governing body of Adventa and Adventa will forward a copy of that report to AHCA. Such report to provide the number of patients without caregivers that were served and the types of services provided.

3. Special community education and outreach program to Hispanic

patients. • Designation of an outreach coordinator for the Hispanic

community by Adventa as certified by a letter to AHCA. To the extent possible, such coordinator shall be bilingual in Spanish and English.

• Identification of a representative of Hispanic patients or Hispanic organizations to serve as an advisor and liaison to Adventa as certified by a letter to AHCA.

• Identification of a medical clinician or other practitioner who works with Hispanic patients and expresses a willingness to refer Hispanic patients in need of end-of-life care to Adventa.

• Provision of an annual report by the director of operations to the governing body of Adventa and by a copy of the report to AHCA. Such report to provide the number of Hispanic patients that were served and the types of services provided.

4. Special community education and outreach program to Black or

African-American patients. • Designation of an outreach coordinator for the black or African-

American community by Adventa as certified by a letter to AHCA.

• Identification of a representative of black or African-American patients or black or African-American organizations to serve as an advisor and liaison to Adventa as certified by a letter to AHCA.

• Identification of a medical clinician or other practitioner who works with black or African-American patients and who expresses a willingness to refer those of their patients in need of end-of-life care to Adventa.

• Provision of an annual report by the director of operations to the governing body of Adventa and by a copy the report to


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AHCA. Such report to provide the number of black or African-American patients that were served, and the types of services provided.

5. Establish Offices in Palm Coast and in Port Orange to assure that

the needs of the residents of Flagler County are not overshadowed by the substantially greater population of Volusia County. • The initial office will be established in Port Orange as the initial

site of service. The Palm Coast office will be established by the 13th month of operations and will be documented by licensure by AHCA.

6. Establish bereavement support groups in at least one outlying area

in Flagler County and one outlying area in Volusia County. • The director of operations will provide a letter of notice to AHCA

upon establishment of the first bereavement meeting in each county.

7. A Quality of Life Program will be established to offer supportive

therapies to end-of-life patients. • The volunteer coordinator will establish one or more supportive

therapy programs (subject to the availability of qualified volunteers) which may include such things as pet therapy, aromatherapy, or other similar therapies.

• At least one supportive therapy program will be established by the end of the first full year of operation and the director of operations will provide a letter of notice to AHCA as confirmation.

Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy and care to the indigent and charity patients. Should the project be approved, the applicant’s proposed conditions that require reports would be reported in the annual condition compliance report as required by Rule 59C-1.013 (4) Florida Administrative Code. The applicant is proposing total project costs to be approximately $274,700 with year one operating costs of $1,299,926 and year two costs of $3,067,776.


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Compassionate Care Hospice of Florida, Inc. (CON #10000) (CCHF) proposes the establishment of a new hospice program in Hospice Service Area 4B, Volusia and Flagler Counties. Compassionate Care Hospice was founded in 1993. Over the past 14 years Compassionate Care Hospice has developed 12 start-up hospice programs in the nine states of Pennsylvania, New Jersey, Delaware, New York, Massachusetts, Georgia, Texas, South Dakota, and Minnesota. Compassionate Care Hospice does not currently offer services in Florida. The applicant is proposing total project costs of $222,077 with year one operating cost of $1,015,584 and year two costs of $1,905,868. The applicant has agreed to condition award of the CON upon providing the following: 1. CCHF will develop a pediatric program with specially trained staff. 2. CCHF will locate its initial office in the Daytona Beach area and

open a second office in the year two in the Deltona area. 3. CCHF will provide extended bereavement services for up to 15

months as necessary. 4. CCHF will offer outreach programs for targeted populations

identified by CCHF as underserved including cancer population under the age of 65 years old, pediatric, Hispanic populations, uninsured populations, and end-stage dementia patients.

5. CCHF will offer a Transitions program: Transitions is a community

service program, designed to enhance the quality of life for individuals and their families facing life-threatening illnesses. Services include emotional support, education, and practical assistance such as running errands, doing chores, and food preparation. Transitions is a free service provided to eligible residents and is funded by Compassionate Care Hospice and community donations. Transitions is an approach to providing a bridge program for families of pediatric patients not yet ready to accept a hospice program. This program could be offered by a home health agency and is not considered to be appropriate for hospice programs.

6. CCHF will provide Spanish language materials.


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7. CCHF will apply to become a State of Florida Partners in Care provider when expansion is announced by Florida Children’s Medical Services.

Crown Hospice, Inc. (CON #10001) proposes the establishment of a new hospice program in Hospice Service Area 4B, Volusia and Flagler Counties. Crown Hospice Inc. is a newly formed not-for-profit Florida corporation. The applicant has four additional hospice programs in Okalahoma, Missouri, and Texas; two of which are for-profit. Crown Hospice Inc. is a faith-based, independent, community supported hospice. The proposed total project cost is $404,912 with year one operating costs of $1,146,068 and year two costs of $3,272,888. The applicant has agreed to condition the CON upon providing a minimum of two percent of patient days per year to charity patients. However, hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services to the indigent and charity patients. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice of Volusia/Flagler and HCR Manor Care of Volusia/Flagler) proposes the establishment of a new hospice program in Hospice Service Area 4B, Volusia and Flagler Counties. HCR Manor Care Services of Florida, Inc. is a Florida for-profit corporation that is affiliated with Manor Care, Inc. a publicly traded company and a provider of nursing home, assisted living, home health and hospice services throughout the United States. Through its operating group Heartland Home Health and Hospice, Manor Care operates over 100 hospice and home health agencies in 23 states, including six home health care agencies in Florida. Also through the HCR Manor Care operating group, Manor Care operates over 300 nursing home and assisted living facilities in 30 states, including 48 in Florida. The proposed total project cost is $378,237 with year one operating costs of $2,328,251 and year two costs of $3,614,750. The applicant agrees to condition award of the CON upon providing:


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1. The commitment of 1.0 FTE for the development and implementation of programs focused on improving access to hospice service in Service Area 4B. This condition will include the development and provision of programs for the rapidly growing Hispanic population that will include support from or involvement of bilingual staff, translated literature, training on cultural differences and competencies and flexible programming to meet their unique needs. These programs will include special community education efforts, clinical care protocols, and bereavement services for families in order to increase participation in hospice for groups traditionally underrepresented. Programs for other cultural groups will be developed as the needs are identified in the community.

2. The commitment of a total of $75,000 for the first two years of

operation for education of hospice patients and their families regarding end-of-life care. These efforts may include, but are not limited to, physician education programs, special teleconferences on grief and bereavement, and informing patients and their families about community care giving resources. Heartland Hospice of Volusia/Flagler will serve as a clearinghouse for information regarding programs offering respite care, extra care giver services, care during weekends and holidays, and related services when there is an absence of caregivers in the home or the caregiver is too frail or elderly to provide the necessary care. In addition, the applicant will provide access to a listing of educational materials regarding end-of-life issues through the internet and telephone.

3. Commitment of $10,000 for the first year of operation of the

Service Area 4B hospice specifically designated as seed money for programs and services outside of the Medicare hospice benefit. Such programs may include, but are not limited to services to the homeless, military veterans, and other special needs populations based on community input.

4. For at least the first five years of operation of Heartland Hospice of

Volusia/Flagler, a minimum budget of $15,000 per year for the provision of special wish funds for hospice patients and families in Service Area 4B.


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5. Contracting for 1.0 FTE physician specializing in palliative care to offer such consults for patients served by Heartland Hospice in hospitals, nursing homes, and other care settings in the community once the Heartland Hospice reaches an average daily census of at least 100 patients in the preceding fiscal year.

6. Commitment to provide 24-hour availability of care coordination

and intake of patients including holidays and weekends.

7. Development in year one of children’s and family retreat programs to the residents of Service Area 4B. These retreats will augment traditional bereavement services especially for children experiencing problematic grief.

8. A commitment of $10,000 annually for tuition reimbursement for

employees to continue education in hospice or end-of-life care.

9. Within three years of opening, HCR Manor Care of Volusia/Flagler commits to operate service offices in both Volusia and Flagler Counties.

10. A commitment to seek CON approval for an inpatient hospice unit

in Service Area 4B once the Heartland Hospice reaches an average daily census of at least 100 patients in the preceding fiscal year.

11. A commitment to provide charity care of at least one percent of the

patient days of Heartland Hospice of Volusia/Flagler per year to increase access to patients without the means to pay for care.

Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy and care to the indigent and charity patients.

North Central Florida Hospice, Inc. (CON #10004) d/b/a Haven Hospice proposes the establishment of a new hospice program in Hospice Service Area 4B, Volusia and Flagler Counties. Haven Hospice is a 501 (c) 3 community-based, not-for-profit organization, founded in 1979. It is accredited by the Community Health Accreditation Program (CHAP), licensed by the Agency for Health Care Administration (AHCA), and is accredited as a Jewish Hospice by the National Institute of Jewish Hospice.


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The proposed total project cost is $320,803 with year one operating costs of $1,953,818 and year two costs of $3,467,071. The applicant states that it is willing to condition award of the CON upon the following: 1. Establish and fully staff a home office in DeLand, Volusia County

by January 1, 2009, or within six months of the receipt of a certificate of need for Service Area 4B. By the end of the third year of operation Haven Hospice will establish two additional offices: one in Bunnell and one in New Smyrna Beach. Haven Hospice will apply for initial licensure prior to January 1, 2009, listing its office in DeLand, Florida. Prior to January 1, 2012, Haven Hospice will apply for a renewal or amended license adding Bunnell and New Smyrna Beach as branch office locations.

2. Respond to referrals within two hours of receipt of the referral.

Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

3. From the initiation of services, employ two FT professional liaisons

and one FT customer service specialist in 4B.

4. A Haven Hospice staff member will contact all patients admitted at home, not in a facility, within 48 hours of admission and then again after seven days to ensure patient/family needs are being met. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

5. A pain assessment will be completed on all patients at time of

admissions. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

6. After hours phone calls to Haven Hospice by patients and families

will be answered by Haven Hospice staff, not by a contracted answering service or a computerized attendant. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will neither contract out nor automate this function.


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7. Massage Therapy services will be offered to every patient admitted by Haven Hospice. Massage therapists will be employed by Haven Hospice to provide this therapy. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

8. RN case managers, social workers and chaplains will use laptop

computers in the field to collect and input clinical information into the patient database system in order to maximize available clinical information and response to patient/family needs. Haven Hospice will establish written policies in 4B to this effect. All RN case managers, social workers, and Chaplains will be trained in the use of laptop computers in the field, and in methods of recording and transmitting key information back to the patient database system. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

9. Haven Hospice will provide patient’s hospice medications through

a regional or national pharmacy benefit management system, which will allow patients/families access to an extensive network of pharmacies inside and outside of Service Area 4B maximizing patient/family responsiveness, access and choice. Haven Hospice will establish a regional or national pharmacy benefit management system in 4B prior to January 1, 2009.

10. Haven Hospice will directly provide routine home medical

equipment/durable medical equipment (HME/DME) as a part of the scope of services provided by Haven Hospice staff. Contracted medical equipment companies will provide only liquid oxygen, unusual or specialty HME/DME. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will contract out only liquid oxygen, unusual or specialty HME/DME, and will maintain written contracts to this effect.

11. Conduct semi-annual meetings with all contracted hospitals and

long-term care facilities to review quality of service and responsiveness. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.


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12. By the end of the first year of operation, establish the Haven Hospice Transitions Program in 4B. Prior to January 1, 2010 Haven Hospice will establish the Haven Hospice Transitions Program in 4B.

13. By the end of the first year of operation, provided Haven Hospice

workplace counseling and support program to employers in 4B service area prior to January 1, 2010.

14. By the end of the second year of operation, distribute at least

10,000 advance directives/five wishes throughout 4B through educational presentations, community presentations and targeted direct mailings. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

15. Haven Hospice will target diversity and cultural outreach activities

to Hispanics and African Americans. Haven Hospice will advertise in Hispanic Language papers, provide the advance directive “Five Wishes” in Spanish, as well as providing other culturally relevant material in Spanish. Haven Hospice will establish written policies to this effect.

16. Haven Hospice will target the recruitment and retention of

bilingual staff, English/Spanish. Haven Hospice will commit to at least 10 percent of its 4B staff will be bilingual, English/Spanish. Haven Hospice will establish written policies in 4B to this effect. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

17. Establish the patient/family “Special Needs Fund” of $2,500 per

interdisciplinary team per year, not less than $ 20,000 per year, to be used by the clinical team members to meet unusual and uncovered patient and family needs. Haven Hospice will establish written policies in 4B to this effect. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.


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It is noted that recent changes to the Florida Statutes require hospice programs to meet their CON conditions or the Agency may deny their license unless good cause is demonstrated.1

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review criteria found in Section 408.035, Florida Statutes, rules of the State of Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by evaluating the responses provided in the application, and independent information gathered by the reviewer. Applications are analyzed to identify various strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district (subdistrict or service planning area), applications are comparatively reviewed to determine which applicant best meets the review criteria. Section 59C-1.010(2) b, Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the certification of the applicant. As part of the fact-finding, the consultant, Cheslyn Green, analyzed the application in its entirety with consultation from financial analysts, Melody Miller and Everett Broussard, who evaluated the financial data.

1 s. 400.606(7), Florida Statutes. The Agency may deny a license to an applicant that fails to meet any condition for the provision of hospice care or services imposed by the Agency on a certificate of need by final Agency action, unless the applicant can demonstrate that good cause exists for the applicant's failure to meet such condition.


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E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed projects with the criteria found in Florida Statutes, Sections 408.035 and 408.037; applicable rules of the State of Florida, Chapter 59C-1 and 59C-2, Florida Administrative Code.

1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C-1.0355, Florida Administrative Code.

In Volume 33, Number 40 of the Florida Administrative Weekly, dated October 5, 2007, the Agency for Health Care Administration published a need for one hospice program in AHCA Hospice Service Area 4B for the January 2009 Hospice Planning Horizon. Hospice Service Area 4B is currently served by Hospice of Volusia-Flagler, Florida Hospital HospiceCare, Odyssey Healthcare, and Vitas Healthcare Corporation of Central Florida. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 4B, Volusia and Flagler Counties.

2. Agency Rule Criteria and Preferences a. Rule 59C-1.0355(4)(e) Preferences for a New Hospice Program. The

agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs:

(1) Preference shall be given to an applicant who has a

commitment to serve populations with unmet needs.

None of the co-batched applicant clearly demonstrated that any population in the service area had unmet needs. Each applicant is responding to published need for an additional hospice program for the January, 2009 planning horizon.

Although none of the applicants receive preference for this criterion because they have not clearly demonstrated there are populations of unmet need, each applicant has discussed serving populations they believe to be underserved.


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Adventa Hospice Services of Florida, Inc. (CON #9999) identified four segments of the population it contends have unmet needs; the homeless, non-Hispanic blacks, Hispanics, and persons without caregivers. The applicant presented research that identified these subgroups as “marginalized” populations. The research presented also examined the reasons why these populations are not utilizing hospice care. The applicant states that one study found that Hispanics and African Americans reported low hospice utilization arose because of a lack of awareness of hospice and because of the prohibitive cost of health care. Further the study showed that Latinos were more likely to report language barriers, while African Americans were more likely to report mistrust of the system. The research concluded that both groups “were highly receptive to end-of-life care that would provide relief for patients and caregivers and emphasize spirituality and family consensus.”2 The applicant states that when they combine the epidemiologically predicted deaths of the homeless in Service Area 4B with the estimated deaths for non-Hispanic blacks and Hispanics there could be as many as 863 deaths in 2010 in these groups. They estimate that number to be the minimum number to be expected in 2008 and 2009, its first two years of operation. The applicant states that these groups will be informed about the availability of hospice care by the specific programs they have outlined in the conditions (Schedule C) of the application.

Compassionate Care Hospice of Florida, Inc. (CON #10000) commits to serve populations with unmet hospice needs and to specifically target the areas of highest unmet hospice need. According to the applicant, areas of highest unmet need as identified in its market assessment of the service area include: • hospice care for the population under the age of 65, • hospice care for the non-cancer population over 65 years of age

is projected to rapidly expand in Subdistrict 4B by 2009, and

2 Wendi Born, K. Allen Greiner, Eldonnia Sylvia, James Butler, Jasjit S. Ahluwalia. 2004. Knowledge, Attitudes, and Beliefs about End-of-Life Care among Inner-City African Americans and Latinos. Journal of Palliative Medicine 7:247-256. doi:10.1089/109662104773709369.


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• improved access to hospice services to the lower income population, African-American population, in rural areas, and the transient population. The applicant also provided Solucient, Market Planner Plus Data projections for CY 2012 which demonstrate Deltona will have the largest minority population in the service area and lower per capita income ($20,914) than the service area average ($26,615).

The applicant states that the hospice penetration rate of cancer patients under 65 years of age in Subdistrict 4B has consistently been below the state average. The applicant also states that the pediatric population is underserved in all categories of hospice. Strong population growth in the elderly and over all increased penetration of hospice results in an expected demand for almost 250 new hospice cases in the non-cancer 65 and older population, according to the applicant. The applicant states that community providers identified unmet and growing need for hospice care within the end-stage dementia population. The applicant indicates that it has significant experience in meeting the needs of these populations in its existing programs elsewhere in the United States. The applicant also discusses pre-hospice eligible individuals and a program called Transitions. Transitions is a national organization which enables hospice agencies to provide services to people with life-limiting illnesses while they are still receiving curative care. The applicant states that it is a member of Transitions and will offer this program in Florida.

Section 400.6005, Florida Statutes provides the legislative findings and intent regarding hospice regulation as: The Legislature finds that terminally ill individuals and their families,

who are no longer pursuing curative medical treatment,

should have the opportunity to select a support system that permits

the patient to exercise maximum independence and dignity during

the final days of life. The Legislature finds that hospice care

provides a cost-effective and less intrusive form of medical care while

meeting the social, psychological, and spiritual needs of terminally ill

patients and their families. The intent of this part is to provide for the

development, establishment, and enforcement of basic standards to

ensure the safe and adequate care of persons receiving hospice

services. (bold underline added for emphasis).


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The Florida Legislature has clearly intended hospice care to be received by patients not seeking curative treatment. Hospice is defined in the Florida Statutes as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family. Palliative care is defined as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering.3

Crown Hospice, Inc. (CON #10001) states that it plans to address this unmet need by establishing a “Community Linkage” program designed to all potential referral sources aware of Crown’s willingness to accept all hospice patients in need regardless of their medical condition, ability to pay, sex, race, gender, disability, mental health status, or religious affiliation. The applicant states that after making personal visits to the area to obtain letters of support and to determine local opinion as to what populations had unmet needs, area residents expressed a specific need for a faith-based hospice program. The applicant also states that since Florida Hospital is the only existing hospice program reporting services to charity patients, by conditioning to serve this population it will meet another unmet need. Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy and care to the indigent and charity patients. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) states that through its analysis there are significant unmet needs in hospice Service Area 4B with particular need demonstrated for Hispanic patients and chronically ill patient populations with Alzheimer’s disease. The applicant notes that while the number of deaths in the service area has been increasing at a modest rate over the past years, in examining the causes of death, there have been some notable trends. One such trend is the increase in the numbers of deaths in which Alzheimer’s disease was listed as the cause of death4.

3 Section 400.601, Florida Statutes 4 Trends in Alzheimer’s Disease Deaths in Volusia and Flagler County chart on page 29 CON #10002.


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The applicant states that Alzheimer’s disease patients present a particular challenge for hospice providers since their cognitive deficits require specialized approaches to care during the final stages of the disease. Heartland Hospice has developed care strategies for Alzheimer’s patients that integrate contemporary therapies such as massage and music therapy with traditional palliative care. The applicant states that under-service to these populations is identified through the proportionately low numbers of hospice patients in Area 4B compared to the state rate of hospice patients to deaths, or the penetration rate by disease state. Heartland Hospice makes a commitment to serve these populations with unmet needs and will ensure all populations; including minorities are educated about the benefits of hospice care through community educational seminars, distribution of multi-lingual educational materials, and direct counseling utilizing trained staff and volunteers. North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states that primary unmet need for hospice care within Service Area 4B is for cancer patients under the age of 65. The applicant states that this population has been consistently underserved for a number of years despite the introduction of two new hospice providers into the area. That applicant also states that during the 12 months ending in June 2007, hospice admissions in this category lagged behind expected admissions by 31 percent. The applicant goes on to state that under-service to this group of hospice patients is consistent with a pattern of out-migration form the area to Gainesville, Jacksonville, and Orlando for oncology care; and while existing hospice providers within the 4B area posses referral ties to the Orlando area no strong ties exist to providers in the Gainesville and Jacksonville areas. The applicant attempts to distinguish itself from its co-batched applicants by stating that among the applicants in the current batching cycle only Haven Hospice possesses similar referral ties to oncology providers in Gainesville and Jacksonville. Moreover, the applicant states that it has a strong historic record of service to this patient diagnosis/age group.


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(2) Preference shall be given to an applicant who proposes to provide the inpatient care component of the hospice program through contractual arrangements with existing health care facilities, unless the applicant demonstrates a more cost-efficient alternative.

Adventa Hospice Services of Florida, Inc. (CON #9999) proposes to provide inpatient care thought a contractual arrangement with an existing inpatient hospice, hospital, or nursing home. Adventa Hospice will identify appropriate institutions and will enter a contractual agreement with one of the existing facilities to provide the inpatient component of hospice care. Grand Villa, Assisted Living Residence and Alterra Sterling House, Assisted Living Facility stated in their letters of support that they would be willing to discuss a contract with the applicant to provide inpatient care for its hospice patients. Compassionate Care Hospice of Florida, Inc. (CON #10000) states it will contract with existing hospitals and skilled nursing facilities in Subdistrict 4B to provide inpatient beds. The applicant states it has received a letter of willingness to contract for inpatient beds from Terrace of Daytona Beach Skilled Nursing Facility and anticipates receiving additional letters of interest. If approved, the applicant states that it will continue to contact existing health care facilities to obtain a balance of locations to provide the hospice patients with the most convenient options. Crown Hospice, Inc. (CON #10001) states that Comfort Keepers, in-home care and hospice related services; Gentiva, home health services; Sterling Healthcare, Inc. (Sandalwood Nursing Center); and Indigo Manor Nursing & Rehabilitation Center have stated their willingness to establish a referral arrangement with Crown Hospice, Inc. should the CON be approved. The applicant has demonstrated its ability to contract for inpatient beds. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) proposes to provide the inpatient care component of its hospice program through contractual arrangements with existing health care facilities, including the acute care hospitals in the service area, and skilled nursing facilities. A letter of intent to contract for beds is provided by Indigo Manor Nursing & Rehabilitation Center. Country Cottage Assisted Living, LLC states it would be willing to negotiate with the applicant on contract options for inpatient care as well. The applicant states that building on its experience in establishing


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relationships with nursing homes and assisted living facilities, it will quickly create mutual partnerships to better serve hospice patients. It is noted that HCR Manor Care intends to establish an inpatient hospice facility when stabilized occupancy in the proposed hospice program (pending approval) is attained. It is understood that HCR Manor Care Services of Florida, Inc. would need to be awarded a second CON for a freestanding inpatient facility in order to establish this facility. The applicant has demonstrated its ability to contract for inpatient beds.

North Central Florida Hospice, Inc. (CON #10004) expects to provide approximately two percent of its total patient days to inpatients during the first two years of operation in Service Area 4B, consistent with its experience in Service Area 4A. The applicant is confident in its ability to establish appropriate relationships with providers in a timely manner to meet all of patients’ needs. Haven Hospice now has agreements with nine hospitals for inpatient care and 42 skilled nursing facilities for inpatient and/or residential care in Service Area 4A. The applicant expects to have the same kind of success in Service Area 4B. Currently, the applicant has a letter of support and willingness to contract for inpatient care in Service Area 4B from Florida Hospital Fish Memorial, Orange City and from Bert Fish Medical Center, New Smyrna Beach. Haven Hospice states it will establish all necessary agreements with hospitals and nursing homes prior to initiation of services in Service Area 4B and expects to provide virtually all of its Flagler and Volusia inpatient hospice care through such agreements. The possible exception to this would be in the instance of a homeless patient or one without an appropriate caregiver at home. In these instances, the applicant states it would offer inpatient placement at one of its inpatient facilities in Service Area 3A, most likely at Roberts Hospice Care Center in Palatka, Florida, which is located adjacent to Flagler County, and close to northwest Volusia County.

(3) Preference shall be given to an applicant who has a commitment to serve patients who do not have primary caregivers at home; the homeless; and patients with AIDS.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that it does not discriminate based upon a patient’s status as having or not having a primary caregiver at home. Adventa will


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work with the patient to devise a plan of care that meets their needs for the safe delivery of hospice care. Adventa does not discriminate in admission based upon a person’s status as being homeless, nor does Adventa use HIV/AIDS status as a basis for denying admission to hospice care. Adventa has a specific commitment to serving these populations as demonstrated by the experience of our hospices in other communities where patients who do not have a primary caregiver at home are treated. In addition, Adventa hospices provide care to homeless patients and AIDS patients. Adventa states that by the end of year two of operations it will serve a minimum of 25 persons who are in one of the three groups identified, those without a caregiver, those who are homeless, and those with AIDS. In taking care of patients without caregivers, the applicant states that if the person does not have a caregiver then they will educate the patient on identifying someone who could come to assist, such as a family member of friend. If not, the next step would be to determine if there is a family member they could go to. If that is not an option, then Adventa will attempt to help the patient locate a community resource such as a nursing facility placement or ALF placement to support them. The applicant states that it uses the same strategies with the homeless as it does with patients without caregivers. The applicant assesses the patients’ needs as they are evaluated for hospice and certainly as they are admitted and a plan of care to help them is developed. Adventa states that it works with the homeless patient to help them get into a shelter or get into services that they need such as nursing facility placement, through state assistance or whatever. The applicant further states that it has a commitment to serving AIDS patients which is evidenced by one of the disease management plans provided for specific guidance for physicians with AIDS patients5. Compassionate Care Hospice of Florida, Inc. (CON #10000) states that they are committed to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS.

5 A copy of the prognostic indicators provided to physicians is provided in Appendix E, CON #9999.


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The applicant states that it does not require that a patient have a caregiver in the home to be part of their program. In addition, the applicant asserts that it provides care to individuals who are in boarding homes, homeless shelters, psychiatric centers and correctional facilities. Compassionate Care also states it serves patients all patients including those who live alone, are transient, have AIDS, or are homeless. Compassionate Care Hospice states that if a homeless patient is discharged from the hospital needing hospice care with no where to go, it will place them in an inpatient unit and apply for Medicaid. Once the patient qualifies and receives Medicaid, they will be placed into a long-term care environment in which hospice care can still be provided as long as the patient requires it. However, the process of qualifying the homeless for Medicaid can be difficult. One way in which the homeless can receive Medicaid is by qualifying for SSI (Supplemental Security Income) benefits through Social Security. Once becoming eligible for SSI, Medicaid coverage is a benefit of the program. In most cases, the hospital will initiate the process of applying for SSI and Medicaid in order to receive payment for services. The homeless can receive SSI for six months out of every nine months they stay in a public (government run) emergency shelter. There is no time limit on getting SSI in a private shelter. Crown Hospice Inc. (CON #10001) states it is committed to serve those patients without a primary caregiver at home, the homeless, and patients with AIDS. The applicant does not provide further information regarding how it plans to serve these populations. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) states that it is committed to serving patients who do not have primary caregivers at home; the homeless; and patients with AIDS, by having a longstanding policy that states the company’s commitment to such patients. When a hospice patient can no longer care for him or herself, the Hospice’s Plan of Care works with the individual to assure that a primary caregiver can be designated. With the relationship among nursing homes and assisted living facilities each person can be placed so that the patient benefits from hospice care. A lack of a home or a primary caregiver will not result in a person foregoing the hospice benefit.


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The applicant states that in order to ensure continuity of care, the hospice RN will contact the primary care physician to discuss the need to admit to respite, inpatient, or outpatient, and obtain the order6. Heartland Hospice commits to provide hospice services to all, without discrimination: “Heartland Hospice will not discriminate on the basis of ability to

pay, race, ethnic origin, sex, sexual orientation, handicap status, age,

or other category that may classify a person as medically

underserved. The proposed hospice services will be provided to all

hospice appropriate patients based on physician orders and the

hospice plan of care. Hospice services will be available 24 hours per

day/7 days per week.

HCR Manor Care Hospice will admit and treat all persons without

regard to race, color, creed, national origin, ancestry, religion, six,

age, handicap, marital status, or sexual preference. There is no

distinction in the manner of providing palliative care to terminally ill

persons and their families.

Admissions will not be refused nor services discontinued or

diminished due to the inability of the patient/caregiver to pay for

care. Just as all others, patients with a terminal illness and family

needs of personalized care who are not fully covered by Medicare or

Medicaid will be admitted in accordance with NHO criteria.

A Medical Social Worker will assist patient/family in completing a

financial assessment to determine need. If there is no insurance or

funds, hospice will provide services. The hospice RN will contact the

primary care physician to discuss the need to admit to respite,

inpatient or outpatient and obtain the order.

6Appendix K for the plan for primary care giving and intake form CON #10002.


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Medically indigent individuals are defined as persons who do not

qualify for Medicare, Medicaid, Private Insurance, or other identified

healthcare benefits payments program and who do not have the

resources and ability to pay for their care. Medically indigent

persons typically include the working poor and elderly that live out or

near poverty levels of income. As stated before, HCR Manor Care

will not discriminate against the ability to pay for services being

rendered.7” North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states its longstanding history of and commitment to exceeding federal and state licensure requirements and to extended care to non-traditional elements of the service area population. The applicant specifically addresses this in its non-discrimination in services provided policy, which specifies that Haven’s network staff and volunteers: “Shall not discriminate in providing services to patients because of race, creed, color, gender, sexual orientation, national origin, age,

qualified individual with a disability, military status, pregnancy, or

other protected status. Haven shall not discriminate in providing

services to patients because of diagnosis or caregiver status. Haven

services shall seek to find placement, when possible for homeless

patients.”

The applicant states that its open access approach to hospice care delivery attempts to prevent denial or delays of admission to hospice caused by restrictive admission criteria, caregiver status, diagnosis, type and nature of palliative treatments, preferences for resuscitation, complexity of care, site of care, reimbursement source or cost of care. Haven believes this approach to care promoted high quality care outcomes for people with limited life expectancies in the key areas of comfort, safety, choice, and support. Unlike its co-batched applicants, Haven Hospice is currently in year two of a five-year rural area demonstration grant project authorized by section 409 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2004. The demonstration is designed to test whether provision of hospice services provided by a demonstration hospice program (Haven Hospice in this instance) to Medicare beneficiaries who lack an appropriate caregiver and who reside in rural areas result in wider access,

7 A copy of Heartland Hospice patient handbook is included in Appendix L CON #10002.


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improved hospice services, benefits to the community, and a sustainable pattern of care. The authorizing language allowed for awards to up to three hospices nationwide. Haven Hospice states it was chosen on the strength of its long history of service to a wide geographic area comprised primarily of rural counties, its strategically located high-quality inpatient facilities within the area, and its management and reporting capabilities. The applicant states that even though Flagler and Volusia are metropolitan statistical areas and do not qualify as a rural area, the residents will be served through the model developed and utilized for that project. Haven Hospice states that it has a continuing commitment to serve the homeless, persons without caregivers, and persons with AIDS, as well as all others for whom hospice and palliative care is appropriate and beneficial.

(4) In the case of proposals for a hospice service area comprised of three or more counties; preference shall be given to an applicant who has a commitment to establish a physical presence in an underserved county or counties.

Hospice Service Area 4B consists of two counties, Volusia and Flagler. This criterion is not applicable to this review.

(5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private insurance, Medicaid, or Medicare.

Adventa Hospice Services of Florida, Inc. (CON #9999) proposes to provide a number of services which are not covered by private insurance, Medicaid, or Medicare. These include: 13 months of bereavement care; volunteer recruitment, training, and supervision; community education including culturally competent presentations of the availability of hospice care to Hispanic and African-American groups; charity and indigent care; and through the Christen Foundation, assistance with household necessities. Compassionate Care Hospice of Florida, Inc. (CON #10000) states that it currently provides those services needed by the community to patients regardless of their payer status and in many cases regarding of their legal status. The applicant further states that a significant portion of services that are not specifically covered by private insurance, Medicaid, or Medicare are provided


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by its programs. On a combined basis in 2006 the applicant states its programs provided 2.8 percent of all days of care to patients that were identified as being unable to pay. Brochures and marketing materials for these programs and other services offered by Compassionate Care Hospice are provided in Appendix D. The following non-covered services proposed to be offered include: • Bereavement - Bereavement support and grief counseling are

essential services and should be part of any comprehensive palliative care program. Compassionate Care Hospice also provides age-specific grief group counseling, such as the Rainbow Program, a pediatric bereavement program as well as individualized one-on-one counseling.

• Transitions - A community service program, designed to

enhance the quality of life for individuals and their families facing life-threatening illnesses who are still seeking curative treatment. (As noted earlier, the applicant’s commitment to offer services to patients who want to receive curative treatment

suggests that it intends to operate outside of the statutory

definition of a hospice program.8)

• CCH Foundation - Compassionate Care Hospice Foundation, Inc. is a non-profit organization headquartered in Newark, Delaware which provides financial assistance to terminally ill patients and families in need. Additionally, it supports public programs to provide the general public with information about the end-of-life choice so that individuals can determine their wishes and help their families prepare for future events.

8 Florida Statutes Chapter 400.6005 Legislative findings and intent.--The Legislature finds that terminally ill individuals and their families, who are no longer pursuing curative medical treatment (emphasis added), should have the opportunity to select a support system that permits the patient to exercise maximum independence and dignity during the final days of life. The Legislature finds that hospice care provides a cost-effective and less intrusive form of medical care while meeting the social, psychological, and spiritual needs of terminally ill patients and their families. The intent of this part is to provide for the development, establishment, and enforcement of basic standards to ensure the safe and adequate care of persons receiving hospice services. Section 400.601(3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. Section 400.601(3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering.


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• Compassionate Courage - Compassionate Courage offers a safe place for children to express their feelings and share with others who have also experienced a loss. Compassionate Courage programs provide bereavement support groups for elementary and middle school children who are dealing with a significant loss.

• Complementary Therapies - Complementary therapies are

offered at no charge to hospice patients to ease pain and discomfort and to bring joy to their lives by living life to its fullest. Some of the complementary therapies include: songs for the soul, music therapists provide unique, relaxing tunes to alleviate stress, pain and discomfort, and to provide peace, tranquility, and relaxation; looking great, a licensed beautician provides haircuts and styles, along with beauty tips and techniques, to help patients look and feel their very best; and therapeutic touch, a licensed massage therapist provides massage to reduce stress and improve circulation in order to promote comfort and an increased sense of well being.

• Comfort Corners - A program is which Compassionate Care

Hospice sponsors physical areas of long-term care facilities to provide a warm, home-like environment for hospice patients and their families.

Crown Hospice, Inc. (CON #10001) states it will provide chaplains to local Veterans Administration (VA) hospitals and VA long-term care facilities at no cost or obligation to these facilities. The applicant also states that it accepts invitations to provide chaplain care from facilities that do not have adequate chaplain coverage at no cost or obligation to the facilities. The applicant also intends to establish a ministry program similar to the LINC program it sponsors and it managed by Baptist Retirement Village Centers. This program helps to link local churches to specific nursing facilities in order to have the church volunteers to minister to the people in the facility and provide support, training, and encouragement through out the year. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) has agreed to condition this application with a commitment of $10,000 for the first year of operation of the Subdistrict 4B hospice specifically designated as seek money for programs and services outside of Medicare hospice benefit. Such programs may include services to the homeless, military veterans, and other special needs populations based on community input.


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The applicant states that in addition to the core hospice services, including continuous care during periods of crisis and bereavement services, Heartland Hospice has established a program of Caring Promises that is currently employed by the hospices in Subdistrict 4A. The Heartland Caring Promises are as follows: • We promise to care for the mind, body, and spirit. • We promise to provide care that is comforting and

compassionate. • We promise to respect patient and family choices. • We promise to unite with community partners in care. • We promise to be accepting and supportive of patients wherever

they are in life’s journey.

Unlike the co-batched applicants, Heartland Hospice offers Children’s Grief Camp, “Camp Heartland” to provide an outlet for children of ages three to 15 to express themselves and ease their grief. Activities include horseback riding, pet therapy, basketball, beadwork, swimming, hayrides, camp fires and dancing. The children also make “memory boxes” in memory of their loved one, and participate in a balloon release memorial service. The applicant states that it has also implemented several bereavement programs throughout the nation with grant funding from the Hospice Memorial Fund, including: • Bereavement support groups for teens works in conjunction

with the local school system to help teens verbalize their feelings and to discover healthy support systems. Teens participate in retreat weekends and activities, giveaways and a caring environment, helping them through the grieving process and assisting them in identifying ways to make important lifestyle decisions that will affect their future in a positive way.

• Community educational events and seminars, on topics such as “Palliative Chronic Disease Management: A Strategic Advantage” for health care providers and clinicians; and Alzheimer’s seminar for health care professionals and caregivers.


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• Hospice educational materials are distributed to schools and community agencies. A training program is conducted in schools for guidance counselors and social workers.

• Workshops for volunteers to explore a fresh, innovative approach to art as a healing medium.

North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states that it provides a broad range of services that are not covered by private insurance, Medicaid, or Medicare, and will continue to do so in the program proposed herein for Service Area 4B. The applicant further states that working together with community service organizations and accessing donated funds; Haven Hospice provides care to those people who are not served by traditional medical entities. During calendar year 2006, approximately 3.7 percent of total Haven Hospice care was uncompensated, according to the applicant. The following are specific non-covered services offered by Haven Hospice: • Bereavement and grief support programs (available to all serve

area residents regardless of any relationship to Haven Hospice). Programs include: Individual and Family Grief Support; Anticipatory Grief Support for Children and Teens; Telephone Grief Support; Grief Support Groups; School Support Groups; Coping with the Holidays Programs; Community Outreach; Messages of Caring; SHARE (pregnancy and child loss) and Pet loss.

• Integrative and expressive therapies, such as music therapy, art therapy, massage therapy, and pet visitor program.

• Supportive counseling or consultation with patients or families addressing issues of serious illness even if they do not qualify for hospice benefit (Transitions Program).

• Non-health care related services such as homemaker services

and errands, as well as minor purchases to foster quality of life and maintenance at home, such as telephone installation and service or wheel chair ramp installation.

• Recruitment, training, and use of volunteers to augment Haven’s capabilities.


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• Educational and support services for Veterans.

• Services to citizens of other countries residing in Haven’s service area even if they have no hospice coverage.

b. Chapter 59C-1.0355, Florida Administrative Code contains the

following general provisions and review criteria to be considered in reviewing hospice programs. (1) Required Program Description (Rule 59C-1.0355(6), Florida

Administrative Code): An applicant for a new hospice program shall provide a detailed program description in its certificate of need application, including:

(a) Proposed staffing, including use of volunteers.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that Amydisys, Inc. Human Resources Department will coordinate the recruitment efforts its hospice here in Florida. The applicant goes on to outline the process by stating a needs assessment is conducted by position based on current volume of business affecting the particular agency. After the need of needed staff for each position is determined, the recruiting process begins. The applicant states that there are only a total of 6.31 FTEs needed for initial staffing. Some of these FTEs will be recruited from existing Amedisys Home Health Care staff. The applicant has included resumes of current staff who have expressed interest in working the proposed hospice.9 If additional persons are needed the applicant states it will use the following methods to recruit: Classified advertising in local newspapers, trade journals or industry-specific publications; relationships with local nursing schools, especially LPN to RN bridge programs; use of outdoor/billboard advertising; internal employee referrals’ company web-site (www.amedisys.com) and link with www.monster.com; and direct mail pieces to professional licensure groups (nurses, therapists, other). The applicant goes on to state that orientation and training programs ensure that personnel are highly qualified and committed to provide quality services. The individual agency offers an intensive orientation program for all new staff. This

9 Resumes are included in Appendix N.3. CON #9999.


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training orients the staff to general operating procedures and provides customized clinical training depending on the experience of the individual. Staff members receiving ongoing in-service education and have the opportunity to attend other workshops and seminars on new techniques and procedures. Staff members also receive compliance training at orientation and annually thereafter. The applicant states that retention of staff is insured through offering of benefits to full-time employees as well as through the company’s core beliefs. Staff At Start–up End Year One End Year Two

Clinical Manager 0.00 FTE 0.00 FTE 2.00 FTE

Director of Operations 1.00 FTE 1.00 FTE 1.00 FTE

Business Office Manager 1.00 FTE 1.00 FTE 1.00 FTE

Business Office Support 0.00 FTE 1.00 FTE 2.00 FTE

Account Executive 1.00 FTE 1.00 FTE 1.00 FTE

Community Education 1.00 FTE 1.00 FTE 1.00 FTE

Nursing (RN & LPN) 0.45 FTE 4.75 FTE 8.95 FTE

MSW 0.18 FTE 1.90 FTE 3.58 FTE

HHA 0.45 FTE 4.75 FTE 8.95 FTE

Chaplain 0.11 FTE 1.19 FTE 2.24 FTE

Bereavement Coordinator 0.50 FTE 0.50 FTE 1.00 FTE

Volunteer Coordinator 0.50 FTE 0.50 FTE 1.00 FTE

Medical Director 0.12 FTE 0.12 FTE 0.12 FTE

Volunteers 0.50 FTE 1.50 FTE 2.80 FTE

Total 6.81 FTE 20.21 FTE 37.64 FTE Source: CON #9999 page 46.

Compassionate Care Hospice of Florida, Inc. (CON

#10000) states it will provide sufficient staff to equal or exceed state and Medicaid guidelines. Compassionate Care’s staffing schedule indicates 13.1 FTEs in year one and 24.6 FTEs in year two10. CCHF states it will utilize an interdisciplinary team model to ensure a holistic approach to patient care. The applicant states that by including a wide range of personnel skills and experience and input from the family, Compassionate Care Hospice believes that the patient and the family are the primary unit of care. Other members of the care team include: patient’s primary hospice physician, hospice medical director, registered nurse, social worker, certified home health aides/nursing assistants, therapists (to be utilized on a contractual basis), dieticians (to be utilized on a contractual basis), bereavement counselors, chaplains, and trained volunteers. Additional staff will be added as needed.

10 Staffing Schedule provided in Schedule 6A, CON #10000.


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Crown Hospice, Inc. (CON #10001) states that it will recruit staff by using local health care publications and magazines, local career centers, and newspaper advertisements. The applicant also plans to offer clinical training programs to nursing students at the local nursing school, Bethune-Cookman University School of Nursing as well as the other two nursing schools located in DeLand, Angley College, and Central Florida Career Institute. The applicant states it utilizes a number of recruitment strategies to secure volunteers and offer an extensive volunteer training program as well as quarterly meetings, in-services and support. The applicant expects to have 10.3 FTEs in year one and 33.6 FTEs in year two. The applicant did not provide any contractual agreement with the area nursing schools regarding clinical training programs. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) states that the initial office will be fully staffed with an office manager, clerical support, director of professional services/patient care coordinator, and appropriate field staff. This proposed hospice program will follow the same staffing patterns that have served patients well in numerous other communities. The applicant listed the following as its standards of staffing: 1.0 FTE registered nurse and home health aid per 12 census, 60-70 percent of RN, HHA staffing should be full-time employees, 1.0 FTE admissions nurse to do a minimum of 10-12 admissions per week, 1.0 FTE medical social worker per 25-30 census, 1.0 FTE administrator, 1.0 FTE office manager, 1.0 FTE clerical staff per 25 census (includes office manager, team coordinator, and receptionist, etc.) 1.0 FTE director of professional services, patient care coordinator per 50 census, 1.0 FTE Chaplain per 50 census, 1.0 FTE volunteer coordinator per 100 census, and 1.0 FTE bereavement coordinator per 80 census. The applicant states that through the company’s existing network and initial public awareness campaign’s, Heartland Hospice expects no difficulty in recruiting the volunteers needed for the new hospice based on its successes in


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numerous other communities. HCR Manor Care states it will provide volunteer orientation and ongoing training to ensure that volunteers have the skills needed to assist patients and their families.

North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states that year one staffing calls for hiring 18 FTEs to fully staff one new office and care team, as well as to account for the staffing from the existing Palatka office and the planned St. Augustine office expected to serve parts of Flagler County and northwest Volusia County. Year two staff will increase by 8.55 FTEs, primarily in direct categories. Haven Hospice states it will vigorously recruit, train, and use volunteer staff in the proposed Flagler/Volusia program. It has extensive expertise and capability in doing so. As of December 2007 Haven Hospice has approximately 850 active volunteers throughout its existing 16-county service area. About 40 percent of those work directly with patients or families in various capacities. The remaining 60 percent provide a wide variety of other essential services, including office support, assisting in the resale store (The Attic), fundraising activities, and community outreach. Haven anticipates a similar level of volunteer activity in Flagler and Volusia Counties relative to Haven’s expected level of admissions11.

(b) Expected sources of patient referrals.

Adventa Hospice Services of Florida, Inc. (CON #9999) provides the following as expected sources of patient referrals:

Projected Referrals to Adventa Hospice Services of Florida, Inc. Service Area 4B

Referral Source Percentage

Hospitals 30%

Physicians 30%

Skilled Nursing Homes 30%

Individuals and other 10%

Total Referrals 100% Source: CON #9999, page 47.

11 Appendix 6 gives information regarding Staffing and Volunteers including Interdisciplinary Team Members, Recruitment and Retention, and Volunteer Services Strategic Plan, CON #10004.


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#10000) states that patient referrals are expected to come from numerous sources, including physicians, hospital social workers and case managers, long-term care facilities, other community-based agencies, and family members and others. The applicant states that it has started to develop relationships with area health care providers and social services organizations in Subdistrict 4B and will continue to develop these relationships once approved. The applicant intends to educate the existing providers about the types of services it can provide to their patients and the availability to refer patients to them.

Crown Hospice, Inc. (CON #10001) states that it is confident that it will be able to develop a successful hospice program in Service Area 4B. The applicant states it has been well received by local providers and key referral sources and, based on its past experiences, fully anticipates that type of reception to develop into a productive network of community support. Similar to its co-batched applicants, excluding Haven Hospice, Crown was able to secure letters of support from service area providers of which three agreed to contract services. The applicant also states that it will make personal visits to potential referral sources such as hospital, nursing homes, and physicians describing how the company’s unique faith-based programs could benefit their terminally ill patients. The applicant also provided a “Community Linkage” list in Appendix 4. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) states that it will target a variety of sources for hospice referrals such as physicians, hospital discharge planners, social workers, nursing facilities, assisted living facilities, home health agencies, community social service agencies, churches, and veterans groups. The applicant received several letters of support for the project from local physicians and hospital staffs that expect to refer patients to Heartland Hospice. Patients and families may also refer themselves with the support and direction of


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an attending physician. HCR Manor Care also plans to conduct a variety of marketing activities to let the community know of its presence as a hospice provider in the service area and has reserved a considerable portion of the funding for this project for community outreach initiatives.

North Central Florida Hospice, Inc. (CON #10004) states that referral source is not a data element that is readily retrievable from their electronic data base. The applicant examined patient records from the first six months of 2006 to determine overall referral patterns. Those referrals were as follows: physicians 30 percent; patient, family or friend 15 percent; long-term care facilities 25 percent; and hospitals 30 percent.

(c) Projected number of admissions, by payer type, including Medicare, Medicaid, private insurance, self-pay, and indigent care patients for the first two years of operation.

The table below is provided, to illustrate projected admissions for years one and two for each applicant.

Total Projected Admissions By Applicant for Years One and Two

CON # Applicant Year One Year Two

9999 Adventa 152 370

10000 Compassionate Care 136 240

10001 Crown 149 431

10002 Heartland 217 319

10004 Haven 140 250 Source: CONs 9999-10002 and 10004.

Adventa Hospice Services of Florida, Inc. (CON #9999) expects Medicare to comprise about 84.48 percent of the admissions during the first two years of operation and provided the following table for illustration.


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Expected Admissions by Payer Type

For Adventa Hospice Services for Florida, Inc. Service Area 4B

Payer Type Year One Year Two

Medicare 127 314

Medicaid 10 24

Private-Insurance 10 20

Self-Pay 1 2

Indigent 4 10 Total 152 370

Source: CON #9999, page 48.

As shown in the table above, the applicant intends to serve 152 and 370 patients in its first and second year of operation respectively. It is noted that the applicant’s provision of charity care is referenced in this table and will comprise 2.68 percent of admissions during the first two years of operations. Compassionate Care Hospice of Florida, Inc. (CON

#10000) states its commitment to providing hospice services to all appropriate patients regardless of their ability to pay. The following table delineates the number of admissions by payer type for the first two years of operation.

Expected Admissions by Payer Type For Compassionate Care Hospice of Florida, Inc.

Service Area 4B Payer Type Year One Year Two

Medicare 78 184

Medicaid 7 12

Commercial Other 21 32

Self-Pay/Uncompensated 30 12 Total 136 240


As shown in the table above, the applicant intends to serve 136 and 240 patients in its first and second year of operation respectively. It is noted that the applicant’s provision of Medicare will comprise 69.68 percent of admissions during the first two years of operations.

Crown Hospice, Inc. (CON #10001) referenced Schedule 7A regarding the projected number of admissions by payer type, including Medicare, Medicaid, private insurance, self-pay, and indigent care patients for the first two years of operation.


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Schedule 7A contains information regarding projected revenues and does not provide a break down of projected number of admissions by payer type. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.

Projected Number of Admissions by Payer Type For Haven Hospice


Medicare 197 290

Medicaid 8 11

3rd Party Insurance 8 11

Self-Pay 2 3

Charity/Other 2 3

Total 217 319 Source: CON #10002, page 70.

As shown in the table above, the applicant intends to serve 197 and 290 patients in its first and second year of operation respectively. It is noted that the applicant’s provision of Medicare will comprise 90.85 percent of admissions during the first two years of operations and charity care/other will comprise 0.93 percent. North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.

Projected Number of Admissions By Payer Type For North Central Florida Hospice, Inc.


Medicare 110 195

Medicaid 8 15

Private Insurance 10 18

Indigent/Self-Pay 12 22 Total 140 250


As shown in the table above, the applicant intends to serve 140 and 250 patients in its first and second year of operations respectively. It is noted that the applicant’s provision of Medicare will comprise 78.80 percent of admissions during the first two years of operations and indigent/self-pay will comprise 8.71 percent.


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(d) Projected number of admissions, by type of terminal

illness, for the first two years of operation.

Adventa Hospice Services of Florida, Inc. (CON #9999) provided the following number of admissions by type of terminal illness:

Projected number of Admissions by Diagnosis For Adventa Hospice Services of Florida, Inc.

Service Area 4B Disease Year One Year Two

Cancer 55 134

Non-Cancer 97 236


According to the information provided the applicant projects to serve 152 patients by year one and 370 by the end of year two of operation, 333 of which will be non-cancer patients (years one and two combined). Compassionate Care Hospice of Florida, Inc. (CON

#10000) provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For Compassionate Care Hospice Service Area 4B

Disease Year One Year Two

Malignant Neoplasms 32 58

Debility 41 72

Neurological/Sense Organs 19 33

CV Disorders 16 28

Respiratory Disorders 10 17

Failure to Thrive 3 5

Psychiatric Disorders 6 10

Other 11 17 Total 138 240


The applicant projects to serve 138 patients in year one and 240 patients in year two.

Crown Hospice, Inc. (CON #10001) refers to the “Detailed Pro Forma and Assumptions” contained in Appendix 2. However, this section does not detail by illness but only provides total year one (149) and two (431) admissions.


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HCR Manor Care Services of Florida, Inc. (CON #10002) provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For HCR Manor Care Services of Florida, Inc.


Cancer 79 116

Non-Cancer 138 203


The applicant projects to serve 217 patients in year one and 319 patients in year two. North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) provided the following number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For North Central Florida Hospice, Inc.


Cancer 56 101

Non-Cancer 84 149


According to the information provided the applicant projects to serve 140 patients by the end of year one, and 250 patients by the end of year two.

(e) Projected number of admissions, by two age groups, under 65 and 65 or older, for the first two years of operation.

Adventa Hospice Services of Florida, Inc. (CON #9999) projects the following admissions by age cohorts.

Projected Admissions by Age Group for Adventa Hospice Service of Florida, Inc.

Service Area 4B Under 65 Over 65 Total

Year One 23 129 152

Year Two 55 315 370 Source: CON #9999, page 49.


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The applicant expects most of its patients in Hospice Service Area 4B to be over 65. In year one and year two, 85.05 percent of patients will be over 65. Compassionate Care Hospice of Florida, Inc. (CON

#10000) projects 136 admissions in its first year of operations and 240 in the second year. The projected number of admissions by age groups under 65 and over 65 appears in the following table.

Projected Admissions by Age Group for Compassionate Care Hospice of Florida, Inc.


Year One 31 105 136

Year Two 55 185 240 Source: CON #10000, page 89. Crown Hospice, Inc. (CON #10001) refers to the “Detailed Pro Forma and Assumptions” contained in Appendix 2. This section does not provide detail by age as it only provides total year one admissions of 149 and year two 431.

HCR Manor Care Services of Florida, Inc. (CON #10002) provides the following table for the projected number of admissions by age cohort.

Projected Admissions by Age Group for HCR Manor Care Services of Florida, Inc.


Year One 31 186 217


North Central Florida Hospice, Inc. (CON #10004) provided the following table regarding the projected number of admissions by two age cohorts, under 65 and 65 or older, for the first two years of operation.

Projected Admissions by Age Group for North Central Florida Hospice, Inc.


Year One 31 109 140



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(f) Identification of the services that will be provided directly by hospice staff and volunteers and those that will be provided through contractual arrangements.

The hospice care team shall directly provide the following core services: nursing services, social work services, pastoral or counseling services, dietary counseling, and bereavement counseling services. Physician services may be provided by the hospice directly or through contract. A hospice may also use contracted staff if necessary to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. Adventa Hospice Services of Florida, Inc. (CON #9999) states it will hire staff that provides the following services: physician services – responsible for the overall medical direction of hospice program; nursing services – responsible for the supervision, management, coordination and provision of quality patient care; home health aide services – provides support services, under the supervision of the appropriate professional staff in accordance with state regulations; social work services, and counseling services- social workers and counselors assist and counsel hospice patients and families with health related financial, social and emotion concerns; Chaplain services; bereavement services – responsible for the provision of spiritual care services to patients/families/ caregivers; volunteers - will provide assistance to families and caregivers or direct care volunteers, assistance in administration and support services, and special projects which include fundraising. The applicant states that it will contract for physical therapy, speech therapy, occupational therapy, inpatient hospice care, and dietary counselors. Dietary is a core service and cannot be provided for through contract services. The applicant does not have an FTE for dietary services on Schedule 6A. Compassionate Care Hospice of Florida, Inc. (CON

#10000) asserts that it will provide the core services (physician services, nursing services, social work services, bereavement and chaplain service, etc.) directly through hospice staff and volunteers. Compassionate Care states it intends to also offer non-core services and some of these will be provided directly by hospice staff and volunteers. The


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applicant states it will provide the following services through contractual arrangements: inpatient and respite services, therapists, and dietician/nutritionist. It is noted that dietary is a core service and cannot be provided for through contract services. The applicant’s Schedule 6A does not have an FTE for dietary services.

Crown Hospice, Inc. (CON #10001): According to Schedule 6A the applicant provides FTEs for all core services. The applicant also includes FTEs for ancillary services as well. HCR Manor Care Services of Florida, Inc. (CON #10002) asserts that with the exception of physicians, hospice core services will be provided by the hospice care team, including volunteers. When needed, contract services are determined on an individualized basis by attending physician. The applicant indicates that contract services are authorized in advance and provided with the ongoing awareness and input of multidisciplinary team. The multidisciplinary team consists of: • RNs and LPNs (hospice staff) • Social workers (hospice staff) • Home health aide (hospice staff) • Physical therapists/assistants (contract) • Occupational therapists/assistants (contract) • Speech and language pathologists (contract) • Paraprofessionals (homemakers, companions, aides)

(hospice staff) • Spiritual counselors (hospice staff) • Pharmacist (contract) • Registered dietitians (hospice staff) • Durable medical equipment (contract) North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states that it will provide all its core services directly by hospice staff and volunteers: • Nursing services • Social work services • Pastoral & counseling services • Dietary counseling • Bereavement counseling services • Home health aides


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• Pharmacy services • Supplies and durable medical equipment • Homemaker & chore services • Physician services Unlike its co-batched applicants, the applicant states that it will also directly provide routine home medical equipment/ durable medical equipment as part of the scope of services provided by Haven Hospice staff. To accomplish this, Haven operates its own licensed HME company that provides only internal hospice patient services. The applicant notes that contracted medial equipment companies will provide only liquid oxygen, unusual or specialty HME/DME equipment. The following additional services will be provided through contractual arrangement: • Physical, occupational, & speech therapy • Patient transportation services • Infusion therapy • Liquid oxygen and specialty HME/DME equipment

It is noted that three of the five applicants have included allowable contracted services: Crown Hospice, HCR Manor Care, and North Central Florida. The other two applicants, Adventa and Compassionate Care have indicated that they plan to contract for dietary services and dietary counseling cannot be contracted.12

(g) Proposed arrangements for providing inpatient care.

Adventa Hospice Services of Florida, Inc. (CON #9999) states it will contract with area hospitals or nursing homes in Subdistrict 4B to provide inpatient hospice care. The application includes a sample of a hospital contract used by Adventa in Appendix I. The applicant provided evidence of local support for the project and its ability to secure contacts for services.

12 Section 400.609(1), Florida Statutes


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Compassionate Care Hospice, Inc. (CON #10000) states it will provide inpatient care services through contractual arrangements with existing skilled nursing facilities and hospitals within Subdistrict 4B. The applicant provided evidence of local support for the project and its ability to secure contracts for services in Appendix L of the application.

Crown Hospice, Inc. (CON #10001) states it will arrange for inpatient care through contractual arrangements with hospitals, nursing homes, assisted living facilities and other settings in District 4B. The applicant states it has made personal visits to the service area in an attempt to obtain formal agreements for inpatient hospice care. The applicant provided evidence of local support for the project and its ability to secure contracts for services. Appendix 10 contains sample inpatient hospice care agreements.

It is noted that inpatient care may not be provided in assisted living facilities in Florida. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) will initially arrange for providing inpatient care through contractual arrangements with hospitals and nursing homes. Heartland Hospice has received on letter of intent from Indigo Manor to contract for the provision of inpatient beds. The applicant does not propose to construct a freestanding inpatient hospice facility at this time, but has conditioned this application on seeking approval for its inpatient unit once its average daily census of hospice patients is Subdistrict 4B exceeds 100. The applicant states that hospice care will be under the direct administration of the hospice, whether the inpatient facility is located in a nursing home or a hospital. The applicant provided evidence of local support for the project and its ability to secure contracts for services.


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North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states it expects to provide less than two percent of its total patient days to inpatients during the first two years of operation consistent with its experience in Service Area 4A, and further states is substantially above that of the two most recent licensees in Service Area 4B for 2006. Haven Hospice asserts it is experienced in providing inpatient care directly, through its own inpatient units in Service Area 3A, and in leased space in Service Area 4A, as well as through contractual arrangements with existing nursing homes and hospitals throughout its existing 16-county service area. Haven Hospice included letters of support and willingness to contract for inpatient care from two Service Area 4B providers, Florida Hospital Fish Memorial and Bert Fish Medical Center.

(h) Proposed number of inpatient beds that will be located in a freestanding inpatient facility, in hospitals, and in nursing homes.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that based upon Adventa Hospice, LLC’s experience in providing contracted inpatient hospice care in other hospices, they anticipate that in year one about 184 patient days and in year two about 537 patient days will be needed to provide inpatient care. The applicant goes on to state that approximately one inpatient bed would be needed over the course of year one and two beds over the course of year two would be needed. Compassionate Care Hospice of Florida, Inc. (CON

#10000) did not provide a number of expected inpatient beds but rather states that it intends to enter into contractual agreements with nursing homes and hospitals in Subdistrict 4B to provide inpatient care to hospice patients when needed. The applicant further states that it is not proposing to construct a freestanding inpatient hospice facility but instead will utilize existing beds in the subdistrict.


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Crown Hospice, Inc. (CON #10001) did not provide the number of expected inpatient beds that will be located in a freestanding inpatient facility, in hospitals, and in nursing homes. HCR Manor Care Services of Florida, Inc. (CON #10002) did not provide a number of expected inpatient beds but rather proposes to contract for inpatient beds with existing providers.

North Central Florida Hospice, Inc. (CON #10004) states it has no expectation of locating any beds in a freestanding inpatient facility to provide inpatient care. The applicant states that the expected two percent of total patient days anticipated to be devoted to inpatient care will result in a very low average daily inpatient census of about 0.5 during year one, and still less than one in year two. Haven Hospice states it currently provides inpatient care in contractual beds in hospitals, and in dedicated and contractual beds in nursing home SNF units. Haven expects to meet its anticipated inpatient care delivery in Flagler and Volusia Counties through contractual agreements with hospitals and nursing homes. The applicant anticipates being able to execute agreements with several hospitals and nursing homes in different locations throughout the service area to ensure that inpatient services will be available. But according to the applicant, these beds will not be dedicated or reserved beds, but will be available on an “as needed” basis under the terms of its agreements.

(i) Circumstances under which a patient would be admitted to an inpatient bed.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that two types of events would require admission to an inpatient bed. One is to provide relief to patient caregivers. This type of inpatient care is reimbursed for up to five days for a given stay. The second event is for pain control or management of acute or chronic medical problems requiring inpatient hospital, nursing home, or hospice facility management. This care is provided when no other venue for symptom control is effective.


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#10000) states that patients may require admission to an inpatient bed to control acute or chronic symptoms which cannot be managed in an alternate setting. The interdisciplinary team is responsible for identifying and recommending patients who meet general inpatient hospice criteria and admission decisions are made on an individual case by case basis after evaluation by the Hospice interdisciplinary team and in consultation with the patient’s attending physician. The applicant further states that in order to be placed in inpatient care for hospice one must meet the following general admission criteria: the prognosis for life expectancy is six months or less and a decision has been made to provide only palliative care. Compassionate Care states that it will also provide respite care for when the patient’s family/caregiver needs a short period of relief. This will be offered on an “as needed” basis for a maximum of five days per respite admission for a Medicare/Medicaid patient. For patients covered by other insurers, the duration may be approved for a longer period of time.

Crown Hospice, Inc. (CON #10001) states that general inpatient care will be provided as specified under the Medicare or Medicaid and specific private insurance hospice benefits. Inpatient care may be recommended in other circumstances but will not be the financial responsibility of Crown Hospice. The applicant goes on to state one or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care: pain, psychosocial pathology, and other symptoms. The applicant states that inpatient respite care will be provided by arrangement to patients whose care is covered under the Medicare or Medicaid hospice benefit and specific private insurance hospice benefits. Inpatient respite care will be provided at times when the patient’s/family/ caregiver needs a short period of relief. This is offered on an “as needed” basis for a maximum of five days per respite admission.


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HCR Manor Care Services of Florida, Inc. (CON #10002) states that inpatient care is dictated by a patient’s medical need. If possible, symptoms are addressed in the patient’s home environment. Occasionally this is not possible due to the nature of the symptoms, the level of caregiving support available, or patient or family wishes. The applicant states that at that point, hospice patients are encouraged to seek the level of care with which they are most comfortable, up to and including inpatient hospice care. Based on their need, inpatient, residential or an alternative mode of care is provided.

North Central Florida Hospice, Inc. (CON #10004) states that patients are admitted to an inpatient bed according to the guidelines set forth in the federal Medicare guidelines for hospice inpatient care. At the patients’ request and with their physician’s order, patients are admitted for management of severe symptom control, end-stage dying process, or medical crisis. The applicant goes on to state that the inpatient component of care is a short-term adjunct to hospice home care. The total number of inpatient days for all hospice patients in a 12-month period may not exceed 20 percent of the total number of hospice days. Haven Hospice states that it is well below this proportion, providing just over seven percent of total patient days to inpatient care in 2006. Haven Hospice proposes that in addition to general admission criteria, admission by hospice to an inpatient bed will be based on one or more of the following acute care admission criteria: • Pain control • Symptom control • Imminent death with symptoms necessitating frequent

physician and nursing intervention • Medical/surgical procedures or therapies aimed at

palliation of symptoms • Family educational needs necessary in order to follow the

established plan of care at home


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• Provision of a safe supportive environment to the terminally ill individual during periods of acute psychosocial and/or spiritual breakdown of primary caregiver(s)

• Primary caregiver incapable of continuing daily care in home setting

Evidence to support the applicant’s contracting for inpatient beds was provided.

(j) Provisions for serving persons without primary caregivers at home.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that it accepts patients without regard to their caregiver status. If the patient doesn’t have a caregiver then the patient is educated on how to identify someone who could come to assist at that point, such as a family member or friend. If that is not an option, then Adventa states it will attempt to locate a community resource such as nursing facility placement or ALF placement to support them. The applicant states that hospice is an intermittent care and they look for all the resources and opportunities to serve that patient’s needs and then write the plan of care around those resources. The applicant states it has never turned away a patient due to lack of caregiver. Compassionate Care Hospice of Florida, Inc. (CON

#10000) states it is committed to serving patients who do not have primary caregivers at home. Compassionate Care Hospice does not require that a patient have a caregiver in the home to be part of their program. According to the applicant, in 2007 it served 549 patients that lived alone which totaled about 8.7 percent of its total patients. In addition to serving patients who live alone, with no caregiver, CCH group states it served 140 patients during 2006 that lived with a compromised caregiver. In cases where there is no caregiver in the home, the applicant states that it will work with community agencies and the patient’s physicians to determine the appropriate response to care.


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Compassionate Care states it will also inquire about the availability of other caregivers such as fellow church members, neighbors, volunteers or friends who might assist in the care of the patient. The applicant states it will train its staff on how to care for patients who live alone. Crown Hospice, Inc. (CON #10001) states that it does not provide primary families/caregivers or 24-hour coverage for the patient through its hospice program of services. Patients who do not have a primary family/caregiver member will develop a plan with the hospice social worker to provide for his/her care in the event their condition dictates the need for additional care. The applicant states that such care can be arranged through friends, volunteers and/or private pay attendant services13. HCR Manor Care Services of Florida, Inc. (CON #10002) states that when a hospice patient can no longer care for himself, the plan of care requires a primary caregiver at the home or admission to a contracted long-term care facility or an alternate place where the patient’s safety can be secured.

North Central Florida Hospice, Inc. (CON #10004) states that for patients without a suitable primary caregiver at home, an appropriate caregiver network will be sought from among neighbors, nearby relatives and friends who are capable of providing the necessary amount of supervision and assistance to the patient within the patient’s or caregiver’s home. If there are too few qualified caregivers available to guarantee the safety of the patient, or if 24-hour caregiving is required, qualified sitter services may be recommended to the patient/family in order to keep the patient in the home. Alternately, the applicant states that placement in an assisted living environment or nursing home may be appropriate in some cases, and would be arranged by Haven Hospice through its relationships with ALFs and nursing home in the area, or with the patient and/or family agreement, through placement in one of its existing Hospice House Care Centers.

(k) Arrangements for the provision of bereavement services.

13 Refer to policy 4-019.1 Appendix 7, Tab D. CON #10001.


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Adventa Hospice Services of Florida, Inc. (CON #9999) states that it provides for up to 13 months of bereavement support. Adventa states that system wide it provides the following levels of bereavement care: bereavement care for family and loved ones; bereavement and grief in the community; and bereavement and community memorial services. In addition to memorial services, the applicant states it provides very specific grief in-services for facility partners, for example during the holidays, on coping with grief during those times while also providing education to the community for very specific grief issues. Compassionate Care Hospice of Florida, Inc. (CON

#10000) states that it will provide bereavement services to the surviving family members, for up to 15 months as needed after the patient’s death. Bereavement services will begin with an initial bereavement risk assessment to be completed by the social worker, bereavement coordinator or designee within three days of admission or at the earliest convenience of the patient/family/caregiver. The applicant states that the bereavement coordinator may also provide supportive counseling prior to the death of the patient but within two weeks after the death of the patient a sympathy card will be sent to the bereaved. Bereavement counselors work with patients and families to assist with coping, grief work, and bereavement care and teach grieving families how to find healthy paths to healing. The applicant states it also provides bereavement support for children. Types of activities that the children participate in during the support group include art activities, age appropriate reading, poetry, writing exercises, group discussions, drawings, memory collages and books. The applicant distinguishes itself from the co-batched applicants in that it offers up to 15 months of bereavement services. Crown Hospice, Inc. (CON #10001) states it will provide bereavement services for up to 13 months after the patient’s death to surviving family/caregiver members. The applicant outlines the bereavement procedure as follows14:

14 Refer to Policy 3-009.1, Appendix 7, Tab C, CON #10001.


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• Within seven calendar days, the Chaplain/bereavement coordinator will complete a bereavement risk assessment.

• Bereavement coordinator will review the bereavement risk assessment to determine potential needs of the survivors.

• After the death occurs, the bereavement coordinator in consultation with the interdisciplinary team will complete the bereavement follow-up risk assessment.

• Based on the finding of the bereavement follow-up risk assessment, the bereavement coordinator will develop the bereavement plan of care.

• The bereavement coordinator will document the interventions on the bereavement contact form and the bereavement plan of care.

• All bereavement documentation will be submitted for filing in the bereavement file.

HCR Manor Care Services of Florida, Inc. (CON #10002) indicates that it has a strong commitment to providing bereavement services both to its surviving family members and the community at large. HCR Manor Care plans to employ a full-time bereavement coordinator (one per 80 census) in order to establish the types of bereavement programs that are provided throughout its national network of hospices. The applicant also proposes a children’s and family retreat program to be developed to augment traditional bereavement services, especially for children experiencing problematic grief.

North Central Florida Hospice, Inc. (CON #10004) states that bereavement support beings at the time of admission and continues through at least 13 months post-death for the family members and friends of Haven Hospice patients. The patient’s social worker has primary responsibility for assessing bereavement issues and providing support for this aspect of care. The applicant states that social workers, Chaplains and counselors provide individual and family counseling as needed during a patient’s time with Haven Hospice. Grief support services range from individual and group counseling and support, to telephonic support, and bibliotherapy (printed materials designed to help with the grieving process). The applicant further states that at 30 days after the death, the bereavement coordinator sends the family a letter reiterating the scope of grief support available


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to them. This begins the process of providing to them various invitations throughout the year to support groups, memorials, camps and receiving Haven Hospice’s ‘Journey Toward Healing’ supportive pamphlets. The applicant states that all of its offerings are available to the community as well as other hospice families residing in the area regardless of whether the patient was served by Haven Hospice.

(l) Proposed community education activities concerning hospice programs.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that it provides a wide range of community education in areas which it serves. The applicant anticipates providing a substantial number of community education programs through the activities of the designated full-time community educator. Adventa states it will also provide grief groups which are open to all members of the communities which it serves. Compassionate Care Hospice of Florida, Inc. (CON

#10000) states that it tailors its services and program offerings to the unique needs of the communities in which it serves. Compassionate Care asserts that it is committed to providing community education activities concerning hospice programs to residents of Subdistrict 4B. The applicant states that through a community assessment it found there was a need for education on the provision of hospice services for pediatric patients. Therefore, Compassionate Care will provide education on pediatric hospice as well as education of general hospice programs. Some of the community education activities will be included, but not limited to: • Community education programs on overview of hospice,

pediatric hospice, how to cope with dying, and other outreach programs to the underserved.

• Educational seminars presented to long-term care facilities on the care of hospice patients.

• Support groups for caregivers and family member of terminally ill patients.


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Crown Hospice, Inc. (CON #10001) states that hospice personnel as well as patients/families/caregivers will have access to community resources in the provision of patient education appropriate to patient/family/caregiver. The applicant also states that it will maintain a list of community resources and appropriate contacts which have patient education materials available for use in the home setting15. HCR Manor Care Services of Florida, Inc. (CON #10002) states that its community education activities include meeting one-on-one with physicians and other health care professionals as well as formal educational programs. Formal programs include: frequent programs for the community address living with the loss of a loved one; presentation to Alzheimer’s support groups; guest lecturing at schools, churches, and professional organization; distribution of educational materials to schools, churches, and professional organizations; distribution of educational materials to school and community organizations; and publication of articles of interest and of education in local community newspapers. The applicant is proposing a considerable marketing campaign to launch its hospice into the service area and foster community support through regular and frequent educational seminars. By educating the public about the benefits of hospice care, utilization is expected to increase for all hospice providers in the area. North Central Florida Hospice, Inc. (CON #10004) indicates it has a very active and effective community outreach and education program organized under the Transitions program, in its 16-county service area located adjacent to northwest areas of Service Area 4B.

Haven Hospice states it has participated in a number of community education and outreach activities throughout 200616. Additionally Haven states it offers presentations to the general public free of charge on topics such as: alternative care - what is it? who needs it? who qualifies?; seasons of grief – preparing for the holidays; companionship

15 Refer to Policy 5-010.1, Appendix 7 Tab E. CON #10001 16 Copies of sample brochures, informational flyers, and community outreach activities in Haven’s existing service areas provided in Tab 4 & 10 CON #10004.


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in dying; wills and trusts; wise use of over-the-counter medications. Haven also offers a training class, An Introduction to Hospice, that is offered to and open to the public. For the proposed service area, Haven states it will initially have two professional liaison representatives and one customer service specialist dedicated to activities in the new service area, beginning upon initiation of services.

(m) Fundraising activities. Adventa Hospice Services of Florida, Inc. (CON #9999) states that it has established a charitable foundation which provides certain non-reimbursable services to hospice patients and to home health patients among others. The Hospice Fund, administered by Amedisys’ Christen Foundation (parent company of Adventa Hospice, LLC), was founded to ensure support and financial assistance to terminally ill patients and their families. The applicant states that the fund can lend a helping hand to those patients and/or family members who may not have the financial resources to pay for basic needs such as food and utilities, or for medications and supplies to those who are not covered by Medicare, Medicaid, or other insurance hospice plans. In addition, the fund provides special grants for patients and/or family members to support last wishes, such as transportation to bring families together. Grants from the fund are also used for community activities, end-of-life care education, and bereavement services. The applicant asserts that the Christen Foundation relies on contributions. All donations and in-kind gifts are tax deductible under section 501 (c)(3) of the IRS Code and help support hospice care for those who otherwise could not pay. Compassionate Care Hospice of Florida, Inc. (CON

#10000) states that it participates in fundraising activities through their Compassionate Care Hospice Foundation. Compassionate Care Hospice Foundation, Inc. is a non-profit organization located in Newark Delaware which provides financial assistance to terminally ill patients and families in need. Additionally, it supports public programs to provide the general public with information about the end-of-life


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choice so that individuals can determine their wishes and help their families prepare for future events17. According to the applicant, some of the fund raising activities that the foundation has participated in include: Sunflower fest annually held at Union Hill Farms in Denville, New Jersey in which participants can buy sunflowers and enjoy the outdoors all while supporting The Compassionate Care Hospice Foundation. All proceeds from the purchase of the sunflowers goes to the foundation; the foundation also receives donations from community members, patients, and families and through memorial gifts made in respect of loved ones. Compassionate Care Hospice Foundation does not use contributions to provide direct hospice care; but rather, it is there to help when financial difficulty is overwhelming and places an added stress on terminally ill patients and their families. The applicant states that the foundation provides services that are generally not covered or reimbursed by insurance. The following are examples of how Compassionate Care Hospice Foundation has helped patients and families: • Rent, mortgage, and utility payments are made for

individuals and families - this provides a familiar place to live and helps the family remain intact as long as possible.

• Summer camp for an 11-year old child whose single mother is terminally ill.

• Provides an annual grant of $10,000 to Compassionate Courage, a program for school-aged children who has a family member undergoing cancer treatments, terminal illness, or children who have experienced loss due to death or changes in family structure.

The applicant states it will have access to the foundation to provide services to financially needy patients and families.

17 Compassionate Care Hospice Foundation Brochure and Newsletter are provided in Appendix H, CON #10000.


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Crown Hospice, Inc. (CON #10001) provides information regarding the use of protected health information in fundraising activities. Unlike its co-batched applicants, the applicant does not provide information regarding its fundraising activities. HCR Manor Care Services of Florida, Inc. (CON #10002) states that it established The Hospice Memorial Fund on October 1, 2001, a not-for-profit fund that distributes donations for community support and patient and family needs. Since some community and family needs are urgent in nature, the fund has a very fast turnaround time. Examples of services provided in the past include providing handicap accessible accommodations, transportation costs to visit a hospice patient and funds for local hospice and palliative serves and education. According to the applicant, total grants made from the fund totaled $761,752 between June 2006 and May 2007. The applicant also states that since the foundation was established, approximately two million dollars in grants have been made to diverse research, public education and community-based service programs in various stages of development throughout the country.

North Central Florida Hospice, Inc. (CON #10004) states that it is an effective fundraising organization, and is prepared to extend its knowledge and expertise into the proposed Area 4B program. Some hospice services are not covered by insurance benefits, or, in the case of some hospice patients, these benefits are exhausted before or during the patient’s hospice care. The applicant indicates that under no circumstances will hospice care be denied, limited or discontinued for any qualified patient or family. Therefore, alternative funding sources will be necessary to supplement Medicare, Medicaid, private and other reimbursement resources, and like most hospice programs, Haven will continue to rely upon these alternative sources of funds to help subsidize its operations.


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3. Statutory Review Criteria

a. Is need for the project evidenced by the availability, quality of care,

efficiency, accessibility and extent of utilization of existing health care facilities and health services in the applicant’s service area? ss. 408.035(2), 408.035(7), Florida Statutes.

Need for an additional hospice program is evidenced by the availability, accessibility and extent to utilization of existing health care facilities and health services in this service area. The co-batched applicants are responding to published need of one hospice program in Hospice Service Area 4B.

The following chart illustrates the increase in hospice admissions for the past five years. As shown below, admissions have increased from 2,813 in year ending June 30, 2002 to 4,045 in year ending June 30, 2007.

Hospice Admissions for Service Area 4B Fiscal Years 2002 - 2007

Fiscal Year Admissions

07/06 – 06/07 07/05 – 06/06 07/04 – 06/05 07/03 – 06/04 07/02 – 06/03 07/01 – 06/02

4,045 3,832 3,413 3,170 2,873 2,813

Source: AHCA Florida Need Projections for Hospice Programs, 2002-2007

Adventa Hospice Services of Florida, Inc. (CON #9999) states that the availability of hospice care would be increased by the addition of another hospice program to serve Subdistrict 4B. Adventa is part of the national hospice care provider Adventa Hospice, LLC which provides care in 14 states in 30 existing hospice programs. The applicant states that it has an extensive quality improvement program and includes a copy of this in Appendix L. Adventa also states it will benefit from the operational experience of the management teams of the 30 hospice programs run by Adventa Hospice, LLC and from the operation experience of Amedisys, Inc. management which owns and manages over 275 home health agencies. The applicant states that the four hospices currently serving Flagler and Volusia Counties all list offices in Volusia County, but it will establish a local office in Flagler County in addition to a main office in Volusia County. However, Hospice of Volusia-Flagler and Odyssey Healthcare (formerly Hospice of the Palm Coast) both have branch offices in Flagler County with their main offices located in Volusia County.


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Adventa states it has reviewed the levels of service needed in the subdistrict and finds that non-cancer patients of all ages are the most underserved patients in the area without access to hospice services. Adventa will focus many of its community education services on the needs of these non-cancer patients with end-of-life prognoses.

Adventa has provided evidence that it can obtain local support needed to provide the hospice services it proposes in this planning area.

Compassionate Care Hospice of Florida, Inc. (CON #10000) proposes to serve Subdistrict 4B by locating its initial office in Daytona Beach to best serve residents of both Volusia and Flagler Counties. In order to address geographic and underserved minority and low income populations in the southwest portion of Volusia County, the applicant will open a second office in the Deltona area in the second year of the program. Additionally, the applicant proposes to establish a third office in Flagler County in year three provided patient census make such an office economically and programmatically reasonable. The applicant asserts that it is committed to providing the highest quality care possible to terminally ill patients and their families. The applicant states that examples of its standard of high quality care are demonstrated through its accreditation and certifications18, performance improvement plan19, compliance with data reporting, patient/family satisfaction surveys, staff membership in quality associations, staff continuing education, letters of support, and the standard of every hospice patient being seen in the home by the hospice’s medical director.

Compassionate Care asserts that it strives to be accessible to all patients who require hospice services. The offering of many specific programs such as pediatrics, bereavement groups, and specific ethnicity services allows CCH to be accessible to a large number of diverse people. The applicant states that it does not have “cookie-cutter” programs but designs each hospice program around the needs of that particular community. The applicant has provided evidence that it can obtain local support needed to provide the hospice services it proposes in this planning area.

18 Accreditation for all CCH programs is provided in Appendix M, CON #10000. 19 A copy of the performance improvement plan is provided in Appendix N, CON #10000.


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Crown Hospice, Inc. (CON #10001) has provided evidence that it can obtain local support needed to provide the hospice services it proposes in this planning area. Crown states it will provide the services 24 hours a day, seven days per week to all patients in need without regard to age, race, sex, disability, medical condition, or ability to pay. Crown will provide the following services 24 hours a day: regular visits by registered hospice nurses with specialized training and expertise in pain and symptom management; visits by hospice home health aides to provide additional personal care, time, and attention; psychosocial support for patients and families, as well as for the long-term staff and care givers; spiritual support, as requested, for patients and families; trained volunteers who provide companionship, assistance, and support; bereavement counseling for up to 13 months; consultation and emergency care; coordination of medical equipment for comfort and symptom management; and physical, occupational, speech, music, and other therapies as indicated by plan of care. HCR Manor Care Services of Florida, Inc. (CON #10002) (Heartland Hospice) states that the proposed project will enhance the availability, quality of care, efficiency, and accessibility of hospice services within Subdistrict 4B. The applicant asserts that hospice services should be promoted to such a degree that the average person is aware of hospice service and has access to them when needed. Targeted efforts will be implemented for other special needs populations to ensure that they are aware of the benefits of hospice care and have ready access. In particular, military veterans and homeless individuals will be sought out with special outreach efforts. By establishing a hospice program in the area, Heartland will be able to work with families of appropriate long-term patients in nursing centers and assisted living facilities to help them better understand the value of hospice care versus curative care, thereby improving availability and access. Heartland states its primary focus is on the continuous improvement of organizational performance. Essential activities include the design, measurement, assessment, and improvement of systems and processes to increase value and positively impact patient/family outcomes. The Heartland parent corporation is also a member of the National Hospice and Palliative Care Organization and adheres to its quality standards, as will Heartland Hospice. The applicant states it is not a stand alone provider but is supported by an established network of quality health care resources, both nationally and in the State of Florida. Relationships with area hospitals, physicians, discharge planners and others, along with


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local and regional Heartland Hospice staff, will assure that the hospice benefit will be maximized within the subdistrict, resulting in improved quality and better coordination of care throughout the continuum of health care services. The applicant asserts that it is committed to serving the underserved groups in the subdistrict, including the homeless, military veterans, and Hispanics. The applicant also states that there is an opportunity to increase penetration rates in the subdistrict and that it is the appropriate applicant to lead this effort. North Central Florida Hospice, Inc. (CON #10004) states that the extent of utilization in the service area by cancer patients under age 65 is substantially below statewide norms. While this is a relatively small proportion of the overall hospice-appropriate population, it is widely recognized and important on that is consistently underserved. The applicant states that at least one cause of this level of under-service is that members of this group disproportionately seek hospital and physician cancer care outside of the service area in Gainesville, Jacksonville, Orlando, or other areas, and thus are not captured by the typical Flagler/Volusia hospice referral patterns. The applicant states that it is well positioned to address this identified need because of its service to this age/diagnosis group in its existing service areas; and because of its established relationships with components of the acute cancer care delivery system in Gainesville and Jacksonville, where Haven currently operates.

According to the applicant, the greatest indication of need for improved availability and accessibility was the recurrent theme expressed that the existing hospices are predominately located in the coastal communities, and that they tend to focus their attention and operational activities in those areas as well. Haven Hospice intends to locate its initial office in DeLand.

b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? Is the applicant a Gold Seal Program nursing facility that is proposing to add beds to an existing nursing home? ss. 408.035(3), 408.035(10), Florida Statutes.

Adventa Hospice Services of Florida, Inc. (CON #9999) was formed in November 2007 and therefore has no operating history. But Adventa Hospice is wholly owned by Adventa Hospice, LLC which is in turn wholly owned by Amedysis, Inc.


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According to the applicant, Adventa Hospice, LLC operates hospice programs in 14 states including Alabama, Alaska, Colorado, Georgia, Idaho, Indiana, Kansas, Louisiana, New Hampshire, Oregon, Tennessee, Texas, Virginia, and Wyoming. Amedysis, Inc. operates over 250 home health agencies in over 20 states in addition to the above listed hospice programs of its subsidiary, Adventa Hospice, LLC. The applicant states that Adventa hospices have no unmet licensure deficiencies. The applicant asserts that it has the ability to build upon the successful management of both Adventa Hospice, LLC and Amedisys, Inc. in preparing a strong platform on which to provide high quality care to the residents of Subdistrict 4B who need hospice care. The applicant states that the 45 separate home health services in Florida that are owned by Amedisys are all in regulatory compliance. The applicant provides a list of the home health offices in Appendix M. The applicant indicates that it holds national membership in the National Hospice and Palliative Care Organization and the National Association for Home Care and Hospice. The applicant also states that it is accredited by the Joint Commission. Compassionate Care Hospice of Florida, Inc. (CON #10000) states it is committed to providing the highest quality care possible to terminally ill patients and their families. Founded in 1993, the applicant states it has developed 12 start-up hospice programs in the nine states of Pennsylvania, New Jersey, Delaware, New York, Massachusetts, Georgia, Texas, South Dakota, and Minnesota. The applicant asserts that it is committed to providing the highest quality care possible to terminally ill patients and their families. The applicant states that examples of its standard of high quality care are demonstrated through its accreditation and certifications20, performance improvement plan21, compliance with data reporting, patient/family satisfaction surveys, staff membership in quality associations, staff continuing education, letters of support, and the standard of every hospice patient being seen in the home by the hospice’s medical director.

20 Accreditation for all CCH programs is provided in Appendix M, CON #10000. 21 A copy of the performance improvement plan is provided in Appendix N, CON #10000.


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Crown Hospice, Inc. (CON #10001) is a newly formed non-profit Florida corporation and, as such, does not have a hospice licensure history. The applicant does however state that Crown Hospice (the operational entity) is accredited by Community Health Accreditation Program, Inc. (CHAP) and if approved it will seek CHAP accreditation in Florida22.

HCR Manor Care Services of Florida, Inc. (CON #10002) is a newly formed non-profit Florida corporation. The applicant has a brief hospice licensure history, with its hospice in Service Area 4A being licensed effective September 6, 2007. There have been no confirmed complaints as of February 5, 2008. HCR Manor Care Services of Florida, Inc. is affiliated with Manor Care, Inc., providers of nursing home, assisted living, home health and hospice services. Through its operating group Heartland Home Health and Hospice, the applicant states that Manor Care operates over 100 licensed hospice and home health agencies in 23 states, including six home health care agencies in Florida. Through the HCR Manor Care operating group, Manor Care operates approximately 340 nursing homes and assisted living facilities in 30 states, including 37 nursing homes and 11 assisted living facilities that are located in Florida. The applicant states that Heartland Home Health Care and Hospice is a member of the National Association for Home Care and Hospice (NAHC) and adopts its policies and procedures in the conduct of operations. Heartland Home Health Care and Hospice programs are also accredited by the Community Health Accreditation Program, Inc. (CHAP), an independent, non-profit accrediting body, first established in 1965. North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states it has a long exemplary history of providing quality of care. Haven Hospice is a 501 (c) (3) community-based, not-for-profit organization, and is accredited by the Community Health Accreditation Program (CHAP), and is accredited as a Jewish hospice by the National Institute for Jewish Hospice (NIJH)23. The applicant also asserts its status as a provider of Medicare and Medicaid benefits, and is a member of Florida Hospices and Palliative Care, Inc., as well as a member of, and a quality partner with, the National Hospice and Palliative Care Organization.

22 CHAP accreditation documentation, Appendix 14, CON #10001. 23 NIJH is a non-profit organization established in 1985 to alleviate suffering in serious & terminal illness which recently established an accreditation program providing on site training for care of the Jewish terminally ill in hospice, geriatric centers and hospitals in the U.S. Forty of these providers have been accredited per the NIJH website at www.nijh.org/.


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Haven Hospice states that it has an approved quality improvement plan in place, and a complete and thorough set of policies and procedures to guide care delivery. The applicant states that it conducts extensive monitoring of its care to ensure ongoing quality assessment and improvement. Its quality improvement department consists of five full-time individuals, including an infection control nurse24. Agency records indicate that for the past 36 months the applicant’s two affiliate programs in Florida had no confirmed complaints.

c. What resources, including health manpower, management personnel, and funds for capital and operating expenditures, are available for project accomplishment and operation ss. 408.035(4), Florida Statutes.

Adventa Hospice Services of Florida, Inc. (CON #9999): The audited financial statements of the applicant were reviewed to assess the financial position as of the balance sheet date and the financial strength of its operations for the period presented. The applicant is a development stage company with net assets of $10,000 and no liabilities for the period ended November 30, 2007.

The applicant’s parent corporation, Amedisys, Inc. (Amedisys), will provide funding for the project. Amedisys provided a letter of commitment with the application stating it would fund the estimated capital expenditures of $274,700 for the project. To support its ability to provide the necessary funding for the project, Amedisys included a copy of its Securities and Exchange Commission filing Form 10-K for the period ending December 31, 2006. Staff analyzed the audited financial statements included in the filing for the purpose of evaluating Amedisys’ ability to provide the capital and operational funding necessary to implement the project. Short-Term Position:

The parent’s current ratio of 2.2, which is about average and indicates current assets are slightly more than two times current liabilities, an adequate position. The ratio of cash flows to current liabilities of 0.53 is below average and a moderately weak position. The working capital (current assets less current liabilities) of $97.3 million is a measure of excess liquidity that could be used to fund capital projects. Overall, the parent has an adequate short-term position. (See Table below).

24 Quality improvement plan and samples of Haven’s policies and procedures are in Tab 5, CON #10004.


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Long-Term Position:

The long-term debt to equity ratio of 0.05 indicates that the parent has a low proportion of long-term debt, a strong position. The cash flow to assets ratio of 9.3 percent is about average and an adequate position. For the period ended December 31, 2006, the company had excess revenues over expenses of $61.9 million, which resulted in a margin of 7.1 percent. Overall, the parent has an adequate long-term operating position.

CON #9999 - Adventa Hospice

Analysis of Amedisys, Inc. (Parent Company) Audited Financial Statement

12/31/2006 12/31/2005

Current Assets $179,205,000 $92,340,000

Cash and Current Investment $84,221,000 $17,231,000

Assets Restricted for Capital Projects $0 $0

Total Assets $463,756,000 $339,997,000

Current Liabilities $81,978,000 $96,738,000

Total Liabilities $99,749,000 $147,398,000

Net Assets $364,007,000 $192,599,000

Total Revenues $541,148,000 $381,558,000

Interest Expense $4,907,000 $2,932,000

Operating Income (OI) $61,897,000 $48,740,000

Cash Flow from Operations $43,080,000 $43,540,000

Working Capital $97,227,000 ($4,398,000)

FINANCIAL RATIOS

12/31/2006 12/31/2005

Current Ratio (CA/CL) 2.2 1.0

Cash Flow to Current Liabilities (CFO/CL) 0.53 0.45

Long-Term Debt to Net Assets (TL-CL/NA) 0.05 0.26

Times Interest Earned (NPO+Int/Int) 13.6 17.6

Net Assets to Total Assets (TE/TA) 78.5% 56.6%

Operating Margin (ER/TR) 11.4% 12.8%

Return on Assets (ER/TA) 13.3% 14.3%

Operating Cash Flow to Assets (CFO/TA) 9.3% 12.8%

Capital Requirements:

The company indicated on Schedule 2 of the application that the only project planned is the initiation of a hospice program in Volusia County, Subdistrict 4B. In addition to the total cost projected for the project of $274,700, the applicant anticipates a first-year operating loss of $90,534 for the project. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2.


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Staffing:

Schedule 6A indicates for year one ending June 2009, the applicant forecasts 18.71 FTE’s as follows: director of operations 1.0 FTE, Business office manager 1.0 FTE, business office support 1.0 FTE, account executive 1.0 FTE, community education 1.0 FTE, nursing 4.75 FTE’s, MSW 1.9 FTE’s, HHA 4.75 FTE’s, Chaplain 1.19 FTE’s, bereavement coordinator 0.50 FTE, volunteer coordinator 0.50 FTE, and medical director 0.12 FTE. In the second year ending June 2010, the applicant forecasts 34.84 FTE’s as follows: clinical manager 2.0 FTE’s, director of operations 1.0 FTE, business office manager 1.0 FTE, business office support 2.0 FTE’s, account executive 1.0 FTE, community education 1.0 FTE, nursing 8.95 FTE’s, MSW 3.58 FTE’s, HHA 8.95 FTE’s, Chaplain 2.24 FTE’s, bereavement coordinator 1.0 FTE, volunteer coordinator 1.0 FTE, and medical director 0.12 FTE. The applicant does not provide FTE staff for dietary services, which are required by statute25. Adventa states that staff will be available through local Amedisys HHA, local colleges, recruitment, and Amedisys advertising. Three Amedisys home health care staff in Port Orange and Palm Coast with prior experience in hospice care have indicated interest in hospice opportunities upon award of CON26. Conclusion: Based on the liquidity of the parent company, funding for this project should be available as needed. Compassionate Care Hospice of Florida, Inc. (CON #10000): Compassionate Care Hospice of Florida, Inc. was formed as a for-profit corporation in Florida on September 19, 2007. An audit of the development stage company as of October 31, 2007 revealed total liabilities of $49,900 due to the parent, Compassionate Care Hospice Group. Because this applicant is a development stage company and the applicant did not provide audited financial statements for the parent, the applicant’s financial position cannot be determined. The applicant included a copy of the parent’s $3.5 million letter of credit dated December 18, 2007 from Robert A. Schultz, Senior Vice President of LaSalle Bank, N.A., indicating the entire credit line is available for use. The parent Compassionate Care Hospice Group, has provided a commitment letter to provide any and all funding or financial resources from the Chief Executive Officer, Milton Heching. The letter also

25 Section 400.609, Florida Statutes 26 Resumes of key staff are provided in Appendix N2 and N3, CON #9999.


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indicates that the funding commitment includes but is not limited to funding the project costs and cash flow requirements, through operations and if needed the unencumbered line of credit of $3.5 million with LaSalle Bank.

Schedule 3, Summary of Significant Assumptions also indicates that the project will be funded by the parent, and that the entire line of credit of $3.5 million would be made available to the applicant, if needed.

Capital Requirements: Schedule 2 indicates that the only project planned is the initiation of a hospice program in Volusia County, Subdistrict 4B, which is the subject of this application. The total cost of this project is $222,077. It should be noted that the applicant is projecting a year one operating loss of $173,235, and anticipates becoming profitable in year two projecting net income of $122,822. The applicant will have to fund the year one operating loss until profitability can be reached.

Available Capital: The applicant indicated, and it is supported by the audit, that $49,900 has already been acquired from the parent company and spent during the development stage and on the CON application process. As mentioned above, this project will be funded by the parent who has available the entire amount of a $3.5 million line of credit with LaSalle Bank, N.A. Although audited financial statements for the parent were not provided, it appears that the parent’s available line of credit is sufficient to fund this project. Staffing:

Schedule 6A indicates for year one ending June 30, 2009, the applicant forecasts 13.1 FTE’s as follows: administration 4.5 FTE’s, physicians 0.30 FTE, nursing 6.8 FTE’s, and social services 1.5 FTE’s. In the second year ending June 30, 2010, the applicant forecasts 24.6 FTE’s as follows: administration 6.0 FTE’s, physicians 0.6 FTE’s, nursing 15.0 FTE’s, and social services 3.0 FTE’s. The applicant does not provide FTE staff for dietary services, which are required by statute27. The applicant states it does not anticipate any problem with recruitment of the required staff. A number of nursing staff, including a program director, have requested to be considered for employment in the proposed program. Compassionate Care Hospice states it has national contracts

27 Section 400.609(1), Florida Statutes


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with staffing recruiters to assist in filling positions in each of its programs across the country. CCHF intends to utilize these recruiters to find individuals across the U.S. who are qualified for the positions available. Conclusion:

Based on the parent corporation’s line of credit with LaSalle Bank, N.A., and the relatively small size of the project, funding for this project and all capital projects should be available as needed. Crown Hospice, Inc. (CON #10001): This applicant, Crown Hospice, Inc., is a development stage company, formed as a not-for-profit corporation in Florida on October 18, 2007 for the purpose of developing and operating hospice facilities in the State of Florida. An audit of the development stage company as of November 30, 2007 included a cash balance of $180,116. No liabilities were listed on the financial statements. Because the applicant has not begun operations, no operating results were reported in the financial statements (other than a $19,884 expense for general and administrative expenses). The financial statements indicate that a $200,000 revenue contribution was received from Seasons Hospice, an affiliated hospice organization. The president of Crown Hospice, Inc. is also the president of Seasons Hospice. The financial statements further indicate that subsequent to November 30, 2007, Seasons Hospice made additional contributions to the applicant in the amount of $225,000; however, the applicant did not submit evidence that these funds currently exist.


Schedule 2 indicates that the only project planned is the initiation of a hospice program in Volusia County, Subdistrict 4B, which is the subject of this application. The total cost of this project is $404,912. It should be noted that the applicant is projecting year one net income of $13,590, and year two net income of $131,153.

Available Capital:

The applicant received a contribution of $200,000 from Seasons Hospice as evidenced by the audit. The financial statements further indicate that subsequent to November 30, 2007, the applicant received an additional contribution for $225,000 from Seasons Hospice, however there is no current evidence that these funds exist. Staffing:

Schedule 6A indicates for year one, the applicant forecasts 10.3 FTEs as follows: administration 3.0 FTE’s, physicians 0.2 FTE, nursing 4.0 FTE’s ancillary less than 0.3 FTE, dietary 0.1 FTE, and social services 3.0


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FTE’s. For year two the applicant forecasts 33.6 FTE’s as follows: administration 7.0 FTE’s, physicians 0.3 FTE’s, nursing 20.0 FTE’s, ancillary less than .03 FTE, dietary 0.2 FTE, and social services 6.0 FTE’s. The applicant states that it will recruit staff by using local health care publications and magazines, local career centers, and newspaper advertisements. The applicant also plans to offer clinical training programs to nursing students at the local nursing school, Bethune-Cookman University School of Nursing as well as the other two nursing schools located in DeLand, Angley College, and Central Florida Career Institute. The applicant states it utilizes a number of recruitment strategies to secure volunteers and offer an extensive volunteer training program as well as quarterly meetings, in-services and support. The applicant did not provide any contractual agreement with the area nursing schools regarding clinical training programs. Conclusion:

The applicant did not prove that funds were available for this project. Funding for this project is dependent on contributions received from an affiliated hospice organization.

HCR Manor Care Services of Florida, Inc. (CON #10002): The audited financial statements of the applicant were reviewed to assess the financial position as of the balance sheet date and the financial strength of its operations for the period presented. The applicant is a development stage company with net liabilities of $350 and negative equity of $350 for the period ended December 31, 2007.

The applicant’s parent corporation, Manor Care, Inc. (Manor Care/ parent), will provide funding for the project. Staff analyzed the parent’s audited financial statements for the period ended December 31, 2006, for the purpose of evaluating its ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position:

The parent’s current ratio of 1.2 is below average and indicates current assets are only slightly more than current liabilities – a weak position compared to the average; however, with largely predictable revenues a lower current ratio can be acceptable. The ratio of cash flows to current liabilities of 0.53 is below average representing a moderately weak position. The working capital (current assets less current liabilities) of


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$95.6 million is a measure of excess liquidity that could be used to fund capital projects. Overall, the parent has an adequate short-term position. (See Table below).

Long-Term Position:

The long-term debt to equity ratio of 2.3 indicates that the parent has a high proportion of long-term debt, a week position. The cash flow to assets ratio of 11.5 percent is higher than average and an adequate position. For the period ended December 31, 2006, the parent company reported excess revenues over expenses of $266.6 million, which resulted in a margin of 7.4 percent. Overall, the parent has an adequate long-term operating position.

CON #10002 - HCR Manor Care Services of Florida, Inc.

Analysis of Manor Care, Inc. (Parent Company) Financial Data

12/31/2006 12/31/2005

Current Assets $619,194,000 $531,329,000



Total Assets $2,398,477,000 $2,339,234,000


Total Liabilities $1,825,284,000 $1,565,511,000

Net Assets $573,193,000 $773,723,000

Total Revenues $3,613,185,000 $3,417,290,000

Interest Expense $31,513,000 $41,240,000



Working Capital $95,565,000 $56,158,000

FINANCIAL RATIOS

12/31/2006 12/31/2005










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Schedule 2 indicates that the only project planned is the initiation of a hospice program in Volusia County, Subdistrict 4-B. In addition to the total cost projected for the project of $378,237, the applicant anticipates a first-year operating loss of $50,492 for the project. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2. Staffing:

Schedule 6A indicates for year one ending December 31, 2009, the applicant forecasts 15.91 FTEs as follows: administrator 1.0 FTE, Hispanic community educator 1.0 FTE, director of professional services 1.0 FTE, Chaplain 1.0 FTE, medical social worker 1.47 FTE’s, office manager 1.0 FTE, bereavement coordinator 1.0 FTE, medical director (contract) 0.05 FTE, continuous care staff (RNs & HHAs) 0.25 FTE, team coordinator 1.0 FTE, admissions coordinator (RN) 1.0 FTE, RNs 2.07 FTE’s, HHAs 3.07 FTE’s and volunteer coordinator 1.0 FTE. The applicant forecasts 23.65 FTE’s for year two ending December 31, 2010 with the following additions to year one: patient care coordinator 1.0 FTE, Chaplain 0.5 FTE, medical social worker 1.0 FTE, office manager 1.0 FTE, medical director (contract) 0.1 FTE, continuous care staff 0.2 FTE, RNs 2.0 FTE’s, and HHAs 2.0 FTE’s for a total of 7.74 additional FTE’s. The applicant states that wages and salaries are based on the applicant’s experience and base wage and salary rates have been adjusted for inflation using three percent per annum. Fringe benefits are calculated at 26 percent of salary costs based on the existing benefit level of the applicant. The applicant does not provide FTE staff for dietary services, which are required by statute28.

The applicant states staff recruitment is assisted by corporate Manor Care support services including: use of recruiters as part of Manor Care’s human resources department, corporate partnership with the Job Corps program, scholarships and tuition reimbursement that is provided by Manor Care for job-related education, and support for leadership and management development training.

28 Section 400.609, Florida Statutes


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Conclusion:

Based on the liquidity of the parent company, funding for this project should be available as needed.

North Central Florida Hospice, Inc. (CON #10004): Staff analyzed the applicant’s audited financial statements for the period ended December 31, 2006, for the purpose of evaluating its ability to provide the capital and operational funding necessary to implement the project. Short-Term Position:

The applicant’s current ratio of 2.8 is above average and indicates current assets are more than current liabilities – a strong position. The ratio of cash flows to current liabilities of 0.9 is above average representing a strong position. The working capital (current assets less current liabilities) of $9.2 million is a measure of excess liquidity that could be used to fund capital projects. Overall, the parent has an adequate short-term position. (See Table below). Long-Term Position:

The long-term debt to equity ratio of 0.13 percent indicates that the applicant has a low proportion of long-term debt, a strong position. The cash flow to assets ratio of 13.3 percent is higher than average and an adequate position. For the period ending December 31, 2006, the applicant had excess revenues over expenses of $1.9 million, which resulted in a margin of 4.5 percent. Overall, the parent has an adequate long-term operating position.


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CON #10004 -- North Central Florida Hospice, Inc.

12/31/2006 12/31/2005

Current Assets $14,429,507 $14,990,642



Total Assets $35,207,927 $32,626,885


Total Liabilities $8,586,061 $8,631,797

Net Assets $26,621,866 $23,995,088

Total Revenues $42,102,183 $38,200,186

Interest Expense $271,811 $183,504



Working Capital $9,227,886 $10,140,853

FINANCIAL RATIOS

12/31/2006 12/31/2005










Schedule 2 indicates that the only project planned is the initiation of a hospice program in Volusia County, Subdistrict 4B. In addition to the total cost projected for the project of $320,803, the applicant anticipates a first-year operating loss of $321,773 for the project. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2. Staffing:

Schedule 6A indicates for year one ending December 31, 2009, the applicant forecasts 18.0 FTE’s as follows: administration 8.0 FTE’s, physicians 0.25 FTE, nursing 6.25 FTE’s, ancillary 1.0 FTE, and social services 2.50 FTE’s. For year two, ending December 31, 2010, the applicant forecasts 26.55 FTE’s as follows: administration 9.0 FTE’s, physicians 1.0 FTE, nursing 11.05 FTE’s, ancillary 1.0 FTE, and social services 4.50 FTE’s.


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The applicant does not provide FTE staff for dietary services, which are required by statute29. The applicant states that its fringe benefit package includes group health and life insurance, workman’s compensation and the employer portion of FICA. Fringe benefits have been set at 30 percent of the wage base of each FTE. The applicant states that because of its experience and reputation as a quality health care provider and active participant in the services network in adjacent areas, it does not anticipate any inordinate difficulties in accomplishing its recruitment tasks. Conclusion:

Based on the liquidity of the parent company, funding for this project should be available as needed.

d. What is the immediate and long-term financial feasibility of the proposal? ss. 408.035 (8), Florida Statutes.

Adventa Hospice Services of Florida, Inc. (CON #9999): Schedule 7 of the application indicates that the services to be provided are routine home care, continuous home care, respite and general inpatient care. For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 85.0 percent, Medicaid at 6.5 percent, self-pay/charity at 3.0 percent, and commercial insurance at 5.5 percent. The Department of Health and Human Services sets rates for routine home care, continuous home care, inpatient respite care, and general inpatient care. The federal rates were calculated for the Volusia County, Florida wage index for Medicare Hospice payments of 0.9881 and inflated through June 2010. The average price adjustment factor used was 2.86 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2007 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in the Table below.

29 Section 400.609, Florida Statutes


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The applicant’s projected gross revenue was 11.4 percent ($472,670) less than the calculated gross revenue. Understating revenue is a conservative assumption and therefore, considered reasonable. Operating profits from this project are expected to increase from a loss of $90,534 for year one to a profit of $508,001 for year two. The applicant offered seven conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections. Conclusion:

This project appears to be financially feasible. HOSPICE REVENUE TABLE

CON #9999 Adventa Hospice Services of Florida, Inc.

Wage Index for Volusia County (0.9881)

Wage

Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $92.83 0.9881 $91.73 $42.28 $134.01

Continuous Home Care $541.81 0.9881 $535.36 $246.74 $782.10

Inpatient Respite $75.65 0.9881 $74.75 $64.11 $138.86

General Inpatient $384.71 0.9881 $380.13 $216.31 $596.44

Payment

Rate

Inflation Factor

Year Two

Inflation Adjusted Amount

Patient Days Year Two, Dec 2009

Gross Revenues

Routine Home Care $134.01 1.050 $140.71 26,037 $3,663,551

Continuous Home Care $782.10 1.050 $821.21 135 $110,863

Inpatient Respite $138.86 1.050 $145.80 135 $19,683

General Inpatient $596.44 1.050 $626.26 537 $336,304

Total 26,844 4,130,402

From Schedule 7 3,657,732

Difference (472,670)

Percentage difference -11.4%

Compassionate Care Hospice of Florida, Inc. (CON #10000): Schedule 7 of the application indicates that the services to be provided are: routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are: Medicare at 85.0 percent, Medicaid at 5.0 percent, self-pay/charity at 3.0 percent, and commercial insurance at 7.0 percent.


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The Department of Health and Human Services sets rates for routine home care, continuous home care, inpatient respite care, and general inpatient care. The Federal rates were calculated for the Volusia County, Florida wage index for Medicare Hospice payments of 0.9881 and inflated through June 2010. The average price adjustment factor used was 2.86 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2007 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in the Table below. In year two the applicant’s projected gross revenue was 1.91 percent or $41,428.64 less than the calculated gross revenue. Understating revenue is a conservative assumption and therefore, considered reasonable. Operating profits from this project are expected to increase from a loss of $173,235 for year one to a profit of $122,822 for year two. The applicant offered seven conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections. Conclusion:

This project appears to be financially feasible.


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HOSPICE REVENUE TABLE

CON #10000 Compassionate Care Hospice of Florida, Inc.


Wage


Adjusted Wage

Amount Unadjusted Component Payment Rate





Payment

Rate

Inflation Factor

Year Two


Patient Days. Year Two, June 2010

Calculated Gross

Revenue

Routine Home Care $134.01 1.050 $140.71 13,116 $1,845,494.51

Continuous Home Care $782.10 1.050 $821.21 61 $50,093.66

Inpatient Respite $138.86 1.050 $145.80 75 $10,935.21

General Inpatient $596.44 1.050 $626.26 410 $256,768.26

Total 13,662 $2,163,291.64

From Schedule 7 $2,121,863.00

Difference -$41,428.64


Crown Hospice, Inc. (CON #10001): The applicant did not provide projections for patient days by service type or revenues by service type, therefore we cannot determine if the total revenue projections are reasonable. Further, from the information we have based on the projections of average revenues per patient day in Schedule 7, it appears the applicant will be providing only one service, routine home care. There is no evidence that the applicant intends to provide continuous home care, respite and general inpatient care. The applicant did not provide total revenue or patient days by type of service. The applicant’s projections do not meet the conditions of hospice program participation under section 418.50 of the Code of Federal Regulations 42 CFR 418. The Medicare conditions of participation require that all covered services be available on a continuous basis. The payer types identified in the application as a percentage to total patient days are: Medicare at 86.0 percent, Medicaid at 8.6 percent, self-pay/charity at 1.0 percent, and commercial insurance at 4.4 percent. The applicant has offered one condition to its proposed hospice program, to offer a minimum of two percent of patient days per year to charity patients; however, the applicant’s projections do not appear to meet this condition.


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Conclusion:

This hospice is not financially feasible as described in the applicant’s financial projections. The proposed services do not conform to the requirements contained in the Medicare conditions of participation pursuant to the 42 CFR 418.50 Code of Federal Regulations. Without Medicare certification, the project is not financially feasible. HCR Manor Care Services of Florida, Inc. (CON #10002): Schedule 7 of the application indicates that the services to be provided are routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are Medicare at 90.8 percent, Medicaid at 3.6 percent, self-pay at 2.0 percent, and commercial insurance at 3.6 percent. The Department of Health and Human Services sets rates for routine home care, continuous home care, inpatient respite care, and general inpatient care. The Federal rates were calculated for the Volusia County, Florida wage index for Medicare Hospice payments of 0.9881 and inflated through June 2010. The average price adjustment factor used was 2.8 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2007 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in the Table below. The applicant’s projected gross revenue was 0.9 percent ($29,786) less than the gross revenue calculated by staff. Understatement of the projected revenue appears to be due to steady inflation rate of three percent used by the applicant, compared to staff’s calculation using an average of 2.8 percent for the period; however, staff believes the variance is immaterial considering the level of projected operations. Operating income from this project is expected to increase from a loss of $50,492 for year one to a profit of $332,698 for year two. The applicant offered three conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections.


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Conclusion:

This project appears to be financially feasible. HOSPICE REVENUE TABLE

CON #10002 HCR Manor Care Services of Florida, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate

Inflation Factor

Year Two



Gross Revenues





Total 22,330 3,313,494


Difference (29,786)


North Central Florida Hospice, Inc. (CON #10004): Schedule 7 of the application indicates that the services to be provided are routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are Medicare at 86.3 percent, Medicaid at 7.4 percent, self-pay at 0.9 percent, and commercial insurance at 5.4 percent. The Department of Health and Human Services sets rates for routine home care, continuous home care, inpatient respite care, and general inpatient care. The Federal rates were calculated for the Volusia County, Florida wage index for Medicare Hospice payments of 0.9881 and inflated through June 2010. The average price adjustment factor used was 2.8 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2007 Health Care Cost Review.


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Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in the Table below. The applicant’s projected gross revenue was 10.8 percent ($320,678) more than the gross revenue calculated by staff. Overstatement of the projected revenue appears to be due to higher rates projected by the applicant for each level of care, compared to the rates calculated by staff; however, staff believes the variance is immaterial considering the level of projected operations. Operating income from this project are expected to increase from a loss of $321,773 for year one to a profit of $102,150 for year two. The applicant offered four conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections. Conclusion:

This project appears to be financially feasible.


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HOSPICE REVENUE TABLE

CON #10004 North Central Florida Hospice, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate

Inflation Factor

Year Two



Gross Revenues





Total 18,592 2,963,030


Difference 320,678

Percentage difference 10.82%

e. Will the proposed project foster competition to promote quality and

cost-effectiveness? ss. 408.035(7), Florida Statutes.

Each co-batched applicant is applying for a new hospice program to be located in Hospice Service Area 4B that currently has four existing hospice program. Therefore, each co-batched applicant is offering a new choice of provider in the hospice service area.

The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans.

With the large majority of patient care being provided from fixed price government payer sources, a new hospice provider is not likely to have any discernable positive impact on competition to promote quality assurance or cost-effectiveness. However, with price not considered a


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major factor, competing hospice programs will likely focus on quality of service to remain competitive in the market. Therefore, although a new hospice provider is not likely to have any discernable positive impact on competition to promote cost-effectiveness, it is likely to have a positive impact on quality assurance. Adventa Hospice Services of Florida, Inc. (CON #9999): This application is for a new hospice program to be located in Service Area 4B which currently has four existing hospice programs. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting 5.5 percent of patient days from commercial insurance payers with 91.5 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). Indigent care is projected to account for 2.5 percent of total patient days with self-pay patients accounting for the remaining 0.5 percent. With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the existing hospice providers in the service area. Introducing additional competition within the service area, and, with no direct price-based competition, the emphasis is likely to be placed on quality of care, uncompensated community services, and public awareness/advertising as a means for providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Although this project is not likely to result in price-based competition, if approved, this project will add another competitor to the service area. In general, the introduction of competition to a market results in an environment that promotes quality and cost-effectiveness.


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Compassionate Care Hospice of Florida, Inc. (CON #10000): This application is for a new hospice program to be located in Service Area 4B which currently has four existing hospice programs. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting no patient days from managed care payers with 90.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed-price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the existing hospice providers in the service area. Introducing additional competition within the service area, and, with no direct price-based competition, the emphasis is likely to be placed on quality of care, uncompensated community services, and public awareness/advertising as a means for providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars.

Although this project is not likely to result in price-based competition, if approved, this project will add another competitor to the service area. In general, the introduction of competition to a market results in an environment that promotes quality and cost-effectiveness. Crown Hospice, Inc. (CON #10001): This application is for a new hospice program to be located in Service Area 4B which currently has four existing hospice programs. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price


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competition is limited to the share of patient days that are under managed care plans. The applicant is projecting no patient days from managed care payers with 90.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed-price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. Since the applicant has not projected to offer all the required services of a hospice program, it will be unable to compete with the providers in the service area. This project will likely have no discernable impact on competition.

HCR Manor Care Services of Florida, Inc. (CON #10002): This application is for a new hospice program to be located in Service Area 4B which currently has four existing hospice programs. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting 3.6 percent of patient days from managed care payers with 94.4 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid). Self-pay care is projected to account for 2.0 percent of total patient days. With the large majority of patient care being provided from fixed-price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the existing hospice providers in the service area. Introducing additional competition within the service area, and, with no direct price-based competition, the emphasis is likely to be placed on quality of care, uncompensated community services, and public awareness/advertising as a means for providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality


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measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Although this project is not likely to result in price-based competition, if approved, this project will add another competitor to the service area. In general, the introduction of competition to a market results in an environment that promotes quality and cost-effectiveness. North Central Florida Hospice, Inc. (CON #10004): This application is for a new hospice program to be located in Service Area 4B which currently has four existing hospice programs. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting 5.4 percent of patient days from commercially insured patients and 93.7 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid). Self-pay/indigent days are projected at 0.9 percent of total patient days.

With the large majority of patient care being provided from fixed-price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the existing hospice providers in the service area. Introducing additional competition within the service area, and, with no direct price-based competition, the emphasis is likely to be placed on quality of care, uncompensated community services, and public awareness/advertising as a means for providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars.


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Although this project is not likely to result in price-based competition, if approved, this project will add another competitor to the service area. In general, the introduction of competition to a market results in an environment that promotes quality and cost-effectiveness.

f. Are the proposed costs and methods of construction reasonable? Do they comply with statutory and rule requirements? ss. 408.035(8), Florida Statutes and Ch. 59A-3 or 59A-4, Florida Administrative Code.

Each of the co-batched applicants is requesting approval to establish a new hospice program rather than the development of a freestanding inpatient hospice facility. There are no construction costs and methods associated with the proposals.

g. Does the applicant have a history of providing health services to Medicaid patients and the medically indigent? Does the applicant propose to provide health services to Medicaid patients and the medically indigent? ss. 408.035(11), Florida Statutes.

Adventa Hospice Services of Florida, Inc. (CON #9999) states that it has a history of providing care to Medicaid patients and to charity and indigent patients. Schedule 7A shows $30,143 for charity care in year one, and $81,954 for charity care in year two. Charity care will account for three percent of total patient days for both year one and two. Adventa’s patient day Medicaid percentage is projected at 6.5 percent for years one and two.

Compassionate Care Hospice of Florida, Inc. (CON #10000) states that Compassionate Care Hospice is both Medicare and Medicaid certified. The applicant states that it has a history of providing health services to Medicaid patients and the medically indigent. In 2006, CCH programs collectively provided 292,393 Medicare and 17,377 Medicaid days representing 84.3 percent and five percent of total patient days. Additionally the applicant states that CCH provided over 11,000 days to self-pay and uncollectible patients representing over 3.0 percent of total days. Schedule 7A shows $177,884 for charity care in year one, and 75,349 for charity care year two. Charity care will account for 15 percent of total patient days for year one and three percent of total patient days for year two. Compassionate Care’s patient day Medicaid percentage is projected to be six percent for year one and five percent for year two.


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Crown Hospice, Inc. (CON #10001): Schedule 7A shows 8.6 percent Medicaid patient days for years one and two respectively. Self-pay patients are projected to account for one percent of patient days in both years one and two. The applicant’s proposed two percent charity care days per year is not demonstrated in its financial schedules.

HCR Manor Care Services of Florida, Inc. (CON #10002) and its parent company, Manor Care, state they have a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. In 2007, the applicant states Heartland hospice provided approximately $2 million in charity care to its hospice patients. The applicant provides the following as its projected payer mix for Heartland for the first two years of operations. Schedule 7A shows that self-pay and charity/other accounts for two percent of patient days while Medicaid accounts for 3.6 percent of total patient days for year one and two respectively. North Central Florida Hospice, Inc. (CON #10004) (Haven Hospice) states it has a history of providing care to all patients in need regardless of payer source or ability to pay for services. Hospice services are available to patients and families, regardless of age, race, religion, sexual preference, diagnosis, financial status or ability to pay. The applicant states that it does not record indigent or charity care by patient days, but rather by admissions, persons served, and proportion of revenues. The applicant states that in 2005 and 2006 it provided approximately 1.4 percent and 1.7 percent of patient days to indigent/charity patients. Schedule 7 shows 1.08 percent patient days to self-pay patients and 7.21 percent patient days to Medicaid patients in year one of operations. Year two projects 0.90 percent self-pay patient days and 7.21 percent of patient days to Medicaid patients.

F. SUMMARY

A fixed need pool was published for a new hospice program in Hospice Service Area 4B, Flagler and Volusia Counties.

Adventa Hospice Services of Florida, Inc. (CON #9999) proposes the establishment of a new hospice program in Hospice Service Area 4B, Flagler and Volusia Counties. The project cost totals $274,700 with year one operating costs of $1,299,926 and year two costs of $3,067,776.


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Adventa proposes to condition award of the CON on the following: special outreach program to homeless patients, special program to assist patients without a caregiver living at home, special community education and outreach program to Hispanic patients, special community education and outreach program to black or African-American patients, establish offices in Palm Coast and in Port Orange to assure that the needs of the residents of Flagler County are not over shadowed by the substantially greater population of Volusia County, Adventa will establish offices in Palm Coast and Port Orange, establish bereavement support groups in at least one outlying area in Flagler County and one outlying area in Volusia County, and a quality of life program will be established to offer supportive therapies to end-of-life patients.

Compassionate Care Hospice of Florida, Inc. (CON #10000) proposes to establish a new hospice program in Hospice Service Area 4B, Flagler and Volusia Counties. The project cost totals $222,077 with year one operating cost of $1,015,584 and year two costs of $1,905,868. Compassionate Care proposes to condition award of the CON on the following: CCHF will develop a pediatric program with specially trained staff; open a second office in year two in the Deltona area; provide extended bereavement services for up to 15 months as necessary; offer outreach programs for targeted populations identified by CCHF as underserved including cancer population under the age of 65 years old, pediatric, Hispanic populations, uninsured populations, and end-stage dementia patients; Transitions program; Spanish language materials; and apply to become a State of Florida Partners in Care provider when expansion is announced by Florida’s Children’s Medical Services. Crown Hospice, Inc. (CON #10001) proposes to establish a new hospice program in Hospice Service Area 4B, Flagler and Volusia County. The project cost totals $404,912 with year one operating costs of $1,146,068 and year two costs of $3,272,888. Crown has agreed to condition the CON upon providing a minimum of two percent of patient days per year to charity patients. It is noted, hospice programs are required by Federal and State law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as care to the indigent and charity patients. The applicant’s financial schedules do not show any charity care.


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HCR Manor Care Services of Florida, Inc. (CON #10002) proposes to establish a new hospice program in Hospice Service Area 4B, Flagler and Volusia Counties. The proposed total project cost is $378,237 with year one operating costs of $2,328,251 and year two costs of $3,614,750. The applicant agrees to condition award of the CON upon providing: 1. The commitment of 1.0 FTE for the development and

implementation of programs focused on improving access to hospice service in Service Area 4B. This condition will include the development and provision of programs for the rapidly growing Hispanic population that will include support from or involvement of bilingual staff, translated literature, training on cultural differences and competencies and flexible programming to meet their unique needs. These programs will include special community education efforts, clinical care protocols, and bereavement services for families in order to increase participation in hospice for groups traditionally underrepresented. Programs for other cultural groups will be developed as the needs are identified in the community.

2. The commitment of a total of $75,000 for the first two years of

operation for education of hospice patients and their families regarding end-of-life care. These efforts may include, but are not limited to, physician education programs, special teleconferences on grief and bereavement, and informing patients and their families about community care giving resources. Heartland Hospice of Volusia/Flagler will serve as a clearinghouse for information regarding programs offering respite care, extra care giver services, care during weekends and holidays, and related services when there is an absence of caregivers in the home or the care giver is too frail or elderly to provide the necessary care. In addition, the applicant will provide access to a listing of educational materials regarding end-of-life issues through the internet and telephone.

3. Commitment of $10,000 for the first year of operation of the

Service Area 4B hospice specifically designated as seed money for programs and services outside of the Medicare hospice benefit. Such programs may include, but are not limited to services to the homeless, military veterans, and other special needs populations based on community input.


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4. For at least the first five years of operation of Heartland Hospice of Volusia/Flagler, a minimum budget of $15,000 per year for the provision of special wish funds for hospice patients and families in Service Area 4B.

5. Contracting for 1.0 FTE physician specializing in palliative care to

offer palliative care consults for patients served by Heartland Hospice in hospitals, nursing homes, and other care settings in the community once the Heartland Hospice reaches an average daily census of at least 100 patients in the preceding fiscal year.

6. Commitment to provide 24-hour availability of care coordination

and intake of patients including holidays and weekends.

7. Development in year one of children’s and family retreat programs to the residents of Service Area 4B. These retreats will augment traditional bereavement services especially for children experiencing problematic grief.

8. A commitment of $10,000 annually for tuition reimbursement for

employees to continue education in hospice or end-of-life care. 9. Within three years of opening, HCR Manor Care of Volusia/Flagler

commits to operate service offices in both Volusia and Flagler Counties.

10. A commitment to seek CON approval for an inpatient hospice unit

in Service Area 4B once the Heartland Hospice reaches an average daily census of at least 100 patients in the preceding fiscal year.

11. A commitment to provide charity care of at least one percent of the

patient days of Heartland Hospice of Volusia/Flagler per year to increase access to patients without the means to pay for care.

North Central Florida Hospice, Inc. (CON #10004) proposes to establish a new hospice program in Hospice Service Area 4B, Flagler and Volusia Counties. The total project cost is $320,803 with year one operating costs of $1,953,818 and year two costs of $3,467,071. The applicant states that it is willing to condition award of the CON upon the following:


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1. Establish and fully staff a home office in DeLand, Volusia County by January 1, 2009, or within six months of the receipt of a certificate of need for Service Area 4B. By the end of the third year of operation Haven Hospice will establish two additional offices: one in Bunnell and one in New Smyrna Beach. Haven Hospice will apply for initial licensure prior to January 1, 2009, listing its office in DeLand, Florida. Prior to January 1, 2012, Haven Hospice will apply for a renewal or amended license adding Bunnell and New Smyrna Beach as branch office locations.

2. Respond to referrals within two hours of receipt of the referral.


3. From the initiation of services, employ two FT professional liaisons

and one FT customer service specialist in 4B. 4. A Haven Hospice staff member will contact all patients admitted at

home, not in a facility, within 48 hours of admission and then again after seven days to ensure patient/family needs are being met. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

5. A pain assessment will be completed on all patients at time of

admissions. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

6. After hours phone calls to Haven Hospice by patients and families

will be answered by Haven Hospice staff, not by a contracted answering service or a computerized attendant. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will neither contract out nor automate this function.

7. Massage therapy services will be offered to every patient admitted

by Haven Hospice. Massage therapists will be employed by Haven Hospice to provide this therapy. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.


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8. RN case managers, social workers and Chaplains will use laptop computers in the field to collect and input clinical information into the patient database system in order to maximize available clinical information and response to patient/family needs. Haven Hospice will establish written policies in 4B to this effect. All RN case managers, social workers, and Chaplains will be trained in the use of laptop computers in the field, and in methods of recording and transmitting key information back to the patient database system. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

9. Haven Hospice will provide patient’s hospice medications through

a regional or national pharmacy benefit management system, which will allow patients/families access to an extensive network of pharmacies inside and outside of Service Area 4B maximizing patient/family responsiveness, access and choice. Haven Hospice will establish a regional or national pharmacy benefit management system in 4B prior to January 1, 2009.

10. Haven Hospice will directly provide routine home medical

equipment/durable medical equipment (HME/DME) as a part of the scope of services provided by Haven Hospice staff. Contracted medical equipment companies will provide only liquid oxygen, unusual or specialty HME/DME. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will contract out only liquid oxygen, unusual or specialty HME/DME, and will maintain written contracts to this effect.

11. Conduct semi-annual meetings with all contracted hospitals and

long-term care facilities to review quality of service and responsiveness. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

12. By the end of the first year of operation, establish the Haven

Hospice Transitions program in 4B. Prior to January 1, 2010, Haven Hospice will establish the Haven Hospice Transitions program in 4B.

13. By the end of the first year of operation, provided Haven Hospice

workplace counseling and support program to employers in 4B service area prior to January 1, 2010.


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14. By the end of the second year of operation, distribute at least 10,000 advance directives/five wishes throughout 4B through educational presentations, community presentations and targeted direct mailings. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

15. Haven Hospice will target diversity and cultural outreach activities

to Hispanics and African Americans. Haven Hospice will advertise in Hispanic Language papers, provide the advance directive “Five Wishes” in Spanish, as well as providing other culturally relevant material in Spanish. Haven Hospice will establish written policies to this effect.

16. Haven Hospice will target the recruitment and retention of

bilingual staff, English/Spanish. Haven Hospice will commit to at least 10 percent of its 4B staff will be bilingual, English/Spanish. Haven Hospice will establish written policies in 4B to this effect. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

17. Establish the patient/family “Special needs Fund” of $2,500 per

interdisciplinary team per year, not less than $ 20,000 per year, to be used by the clinical team members to meet unusual and uncovered patient and family needs. Haven Hospice will establish written policies in 4B to this effect. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

Need/Access:

Each applicant is responding to published need for a new hospice program. Although each applicant states that there is unmet need in Flagler and Volusia Counties, which ranged from undocumented access issues for minority populations including Hispanic and African-Americans, to chronically ill patient populations with Alzheimer’s disease, no access issues or unmet need was demonstrated by any applicant. Compassionate Care indicated that it believes that it has distinguished itself and identified an unmet need in the area. This applicant states that it would like to implement a program for pre-hospice eligible individuals called Transitions. When compared to its co-batched applicants, none were offering curative care or planned to offer curative care. Haven also mentioned a Transitions program, but it is not clear


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that this Transitions program is the same as that mentioned by Compassionate Care. It is noted that hospice is defined in Florida as a provider of palliative care, which is by definition non-curative. ALL five co-batched applicants provided evidence that they have local support for their proposals to enter the service area. Local letters of support, highest to lowest volume: Heartland (111) Haven (60), Compassionate Care (nine), Crown (five), and Adventa (four). These essentially state that they look forward to working with the applicant should the applicant be awarded a CON. Haven Hospice includes letters from Florida Hospital Fish Memorial, Orange City and Bert Fish Medical Center, New Smyrna Beach that indicate a willingness to contract for inpatient care. It is noted that many of Heartland’s letters were of the form letter variety. Adventa, Compassionate Care, Heartland and Haven distinguished themselves by agreeing to measurable conditions, if awarded the CON, to ensure that its proposed program offers improved access to hospice care, improved education regarding available hospice services, and to address any cultural barriers to hospice care in Flagler and Volusia Counties. Crown agreed to condition the CON upon providing a minimum of two percent of patient days per year to charity patients, but did not demonstrate this in their financials. Recent changes in hospice licensing law indicate that hospice programs that fail to meet their CON condition without good cause could lose their license. The Agency’s need methodology that resulted in published need for a new program in Flagler and Volusia Counties showed the projected number of admissions minus the current number of admissions for the January 2009 planning horizon as 417. Crown proposed the largest program to address this published need:

Co-Batched Applicant Proposed Admissions Year Two

Applicant Proposed Admissions

Adventa CON #9999 370 Compassionate Care CON #10000 240 Crown CON #10001 431 Heartland CON #10002 319 Haven CON #10004 250 Source: CONs 9999-10002 and 10004.

Quality of Care:

Each applicant offered evidence of its ability to provide quality care.


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Financial Feasibility/Availability of Funds:

Adventa Hospice Services of Florida, Inc. (CON #9999): Based on the liquidity of the parent company, funding for this project should be available as needed. Overall short-term and long-term positions are adequate.

Compassionate Care Hospice of Florida, Inc. (CON #10000): Based on the parent corporation’s line of credit with LaSalle Bank, N.A., and the relatively small size of the project, funding for this project and all capital projects should be available as needed. Crown Hospice, Inc. (CON #10001): The applicant did not prove that funds were available for this project. Funding for this project is dependent on contributions received from an affiliated hospice organization. HCR Manor Care Services of Florida, Inc. (CON #10002): Based on the liquidity of the parent company, funding for this project should be available as needed. Overall short-term and long-term positions are adequate. North Central Florida Hospice, Inc. (CON #10004): Based on the liquidity of the parent company, funding for this project should be available as needed. Overall short-term and long-term positions are adequate. Medicaid/Charity Care:

Adventa Hospice Services of Florida, Inc. (CON #9999) accepts all patients without regard to gender, national origin, race, creed, sexual orientation, disability, age, and place of residence or ability to pay. Schedule 7A shows $30,143 for charity care in year one, and $81,954 for charity care in year two. Medicaid patient days are projected at 6.5 percent in for years one and two. Charity care will account for three percent of total patient days for both year one and year two.

Compassionate Care Hospice of Florida, Inc. (CON #10000) states it has a history of providing health services to Medicaid patients and the medically indigent. Schedule 7A shows $177,884 for charity care year one, and $75,349 for charity care year two. Charity care will account for 15 percent of total patient days for year one and three percent of total patient days for year two. Medicaid percentage is projected to be six percent for year one and five percent for year two.


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Crown Hospice, Inc. (CON #10001): Schedule 7A shows 8.6 percent Medicaid patient days for years one and two respectively. Self-pay patients are projected to account for one percent of patient days in both years one and two. Yet, the applicant conditioned its award of CON to providing two percent of patient days to charity patients. HCR Manor Care Hospice of Florida, Inc. (CON #10002) (Heartland) and its parent company, Manor Care, state they have a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. Schedule 7A shows that self-pay and charity/other accounts for two percent of patient days while Medicaid accounts for 3.6 percent of total patient days for years one and two respectively. North Central Florida Hospice, Inc. (CON #10004) (Haven) states it has a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. The applicant states it does not record indigent or charity care by patient days, but rather by admissions, persons served, and proportion of revenues. Schedule 7A shows 1.08 percent total patient days provided to self-pay patients and 7.21 percent patient days to Medicaid patients in year one and 0.90 percent self-pay and 7.21 percent Medicaid in year two.

G. RECOMMENDATION

Approve CON #10004 to establish a new hospice program in Hospice Service Area 4B. The total cost of the project is $320,803 with year one operating costs of $19,953,818 and year two costs of $3,467,071. CONDITIONS: (1) Establish and fully staff a home office in DeLand, Volusia County

by January 1, 2009, or within six months of the receipt of a certificate of need for Service Area 4B. By the end of the third year of operation Haven Hospice will establish two additional offices: one in Bunnell and one in New Smyrna Beach. Haven Hospice will apply for initial licensure prior to January 1, 2009, listing its office in DeLand, Florida. Prior to January 1, 2012, Haven Hospice will apply for a renewal or amended license adding Bunnell and New Smyrna Beach as branch office locations.


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(2) Respond to referrals within two hours of receipt of the referral.


(3) From the initiation of services, employ two FT professional liaisons and one FT customer service specialist in 4B.

(4) A Haven Hospice staff member will contact all patients admitted at home, not in a facility, within 48 hours of admission and then again after seven days to ensure patient/family needs are being met. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

(5) A pain assessment will be completed on all patients at time of admissions. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

(6) After hours phone calls to Haven Hospice by patients and families will be answered by Haven Hospice staff, not by a contracted answering service or a computerized attendant. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will neither contract out nor automate this function.

(7) Massage Therapy services will be offered to every patient admitted by Haven Hospice. Massage therapists will be employed by Haven Hospice to provide this therapy. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.


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(8) RN case managers, social workers and chaplains will use laptop computers in the field to collect and input clinical information into the patient database system in order to maximize available clinical information and response to patient/family needs. Haven Hospice will establish written policies in 4B to this effect. All RN case managers, social workers, and Chaplains will be trained in the use of laptop computers in the field, and in methods of recording and transmitting key information back to the patient database system. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

(9) Haven Hospice will provide patient’s hospice medications through a regional or national pharmacy benefit management system, which will allow patients/families access to an extensive network of pharmacies inside and outside of Service Area 4B maximizing patient/family responsiveness, access and choice. Haven Hospice will establish a regional or national pharmacy benefit management system in 4B prior to January 1, 2009.

(10) Haven Hospice will directly provide routine home medical equipment/durable medical equipment (HME/DME) as a part of the scope of services provided by Haven Hospice staff. Contracted medical equipment companies will provide only liquid oxygen, unusual or specialty HME/DME. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will contract out only liquid oxygen, unusual or specialty HME/DME, and will maintain written contracts to this effect.

(11) Conduct semi-annual meetings with all contracted hospitals and long-term care facilities to review quality of service and responsiveness. Haven Hospice will establish a written policy in 4B to this effect. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

(12) By the end of the first year of operation, establish the Haven Hospice Transitions Program in 4B. Prior to January 1, 2010 Haven Hospice will establish the Haven Hospice Transitions Program in 4B.

(13) By the end of the first year of operation, provided Haven Hospice workplace counseling and support program to employers in 4B service area prior to January 1, 2010.


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(14) By the end of the second year of operation, distribute at least 10,000 advance directives/five wishes throughout 4B through educational presentations, community presentations and targeted direct mailings. Haven Hospice will internally collect and record data enabling management to assess conformance with this policy.

(15) Haven Hospice will target diversity and cultural outreach activities to Hispanics and African Americans. Haven Hospice will advertise in Hispanic Language papers, provide the advance directive “Five Wishes” in Spanish, as well as providing other culturally relevant material in Spanish. Haven Hospice will establish written policies to this effect.

(16) Haven Hospice will target the recruitment and retention of bilingual staff, English/Spanish. Haven Hospice will commit to at least 10 percent of its 4B staff will be bilingual, English/Spanish. Haven Hospice will establish written policies in 4B to this effect. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.

(17) Establish the patient/family “Special Needs Fund” of $2,500 per interdisciplinary team per year, not less than $ 20,000 per year, to be used by the clinical team members to meet unusual and uncovered patient and family needs. Haven Hospice will establish written policies in 4B to this effect. Haven Hospice will conduct internal management audits on a periodic basis to assess conformance with these policies and practices.


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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration

adopted the recommendation contained herein and released the State Agency Action Report.

DATE: James B. McLemore Health Services and Facilities Consultant Supervisor Certificate of Need

Jeffrey N. Gregg

Chief, Bureau of Health Facility Regulation

on application for certificate of need a. project … · 2008. 2. 22. · on application for...

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