state agency action report on application for certificate...

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Punta Gorda HMA, LLC

d/b/a Charlotte Regional Medical Center/CON #10186 809 East Marion Avenue Punta Gorda, Florida 33950

Authorized Representative: Mr. Jose Morillo Chief Executive Officer

(941) 637-3128

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Blvd./CON #10187 8300 Collier Boulevard

Naples, Florida 34114 Authorized Representative: Mr. Scott Campbell

Chief Executive Officer (239) 354-6601

Venice HMA, LLC d/b/a Venice Regional Medical Center/CON #10188

540 The Rialto Venice, Florida 34285

Authorized Representative: Mr. Peter Wozniak Chief Executive Officer

(941) 483-7773 2. Service District

District 8 (Charlotte, Collier, Desoto, Glades, Hendry, Lee, and Sarasota

Counties)

CON Action Numbers: 10186, 10187 & 10188

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B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposed

projects. Letters of Support

Punta Gorda HMA, LLC, d/b/a Charlotte Regional Medical Center

(CON #10186), (CRMC), submitted 17 letters of support signed and dated during January 21 through April 1, 2013. One letter was undated.

William F. Albers, Mayor of the city of Punta Gorda, states that “Charlotte County has the second highest number of residents over the

age of 65 in the state of Florida” many of whom require CMR services or care for someone who does. Mayor Albers states that “the closest facility providing these (CMR) services is Fawcett Hospital in Port Charlotte,

which can be a significant burden on the elderly” because of travel and the patients’ physicians not being on staff at Fawcett.

Richard H. Satcher, Charlotte Market Chief Executive Officer at Peace River Regional Medical Center, states “the Fawcett unit is not an

alternative as our patients and physicians would prefer to support a unit in one of our campuses”.

Denise Barnett-Stuckey, CPHQ, LHRM, CPHRM, and Director of Case Management over Charlotte Regional and affiliate HMA hospital Peace River Regional Medical Center, states that “daily we experience the

difficulty in placing patients with rehabilitation needs into the appropriate setting within our community boundaries”. Ms. Barnett-

Stuckey emphasized that “many patients awaiting placement due to the lack of rehabilitation beds/services within the community are forced to transfer out of the area leaving many senior citizens with a long drive to

visit their loved one” and “without the addition of in hospital acute rehabilitation beds we cannot provide timely therapeutic treatment

services to those difficult to place patients due to bed availability”.

Thomas W. Noone, MD, Chairman of CRMC’s Utilization Committee and

Physician Advisor to the Case Management Department, writes that “in my Physician Advisor role I am acutely aware of the difficult process steps to ensure a safe discharge for all patients…the addition of

in-hospital acute rehabilitation beds will allow those difficult to place patients a place to begin their therapeutic treatment”.


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The local physicians listed below signed variations of a form letter1:

Mark Davis, MD, Chief of Staff and Joint Academy Medical Director,

Charlotte Regional Medical Center*

Joseph Ravid, MD*, Chief/Chairman Department of Medicine,

Charlotte Regional Medical Center

Amy Mellor, MD, Neurology Associates of Charlotte County

Robert T. Getter, MD, orthopedic spine surgeon, MIDISC Spine Care*

Saeed Shahzad, MD, Neurology Center of Southwest Florida*

Jose I. Cabrera, MD, Neurosurgeon, Peace River Neurosurgery*

Elias Quintos, MD, Cardio/Thoracic Surgeon, Charlotte Harbor

Cardiac Surgical Associates*

S. Cary Huber, MD, Charlotte Harbor Cardiac Surgical Associates*

Jeffrey G. Bentson, MD, PLLC, Orthopedic surgeon, Associates in

Orthopedics.

This letter contends that need for a CMR unit at CRMC is supported by the following reasons:

There is a gap in service for comprehensive medical rehabilitation beds in the Charlotte County area.

The federal directive for managing patients throughout the clinical process necessitates CMR beds as part of comprehensive medical

care.

The nearest CMR facility, Fawcett Memorial Hospital, is not an option

for CRMC patients because it isn’t within the HMA hospital system.

Stephen P. Schroering, M.D*., Gulf Pointe Surgery Center, an orthopedic

surgeon, expresses concern for the present situation requiring post-operative patients to be discharged to a diversity of facilities because “it

is impossible to see my patients in multiple facilities…an in-patient rehabilitation center at Charlotte Regional removes and addresses these concerns…(the project) would allow me to see my post-operative patients

while making rounds on in-patients”.

Janet Burbank, R.N., RPT, a 21 year employee in the rehabilitation department of CRMC, submitted a handwritten letter in which she states that “through the years we have had very skilled, talented, and caring

therapists and I have felt that patients could and would benefit from, and improve their physical capabilities, if we could offer them post critical care right here”. An HMA physical therapist assistant submitted a

1 The reviewer notes that physicians marked with an “*” have privileges at Fawcett Memorial Hospital

(see http://fawcetthospital.com/physicians/), which has a 20-bed CMR inpatient unit.

http://fawcetthospital.com/physicians/


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handwritten letter stating “inpatient rehab would contribute to

therapists, and other associates, to better use our knowledge and skills (to the) benefit of our patients which builds a strong community”.

A. Jill C. McCrory, attorney with the McCrory Law Firm in Punta Gorda, states “CRMC is the only hospital in Punta Gorda, Florida, one of the oldest median population areas in the country”. Ms. McCrory cites the

challenges facing an elderly patient population “having no option but to seek rehabilitation services often in other counties and cities and often

from doctors and nurses who do not know the patient history is a significant detriment to our community and the level of health care provided”.

Naples HMA, LLC, d/b/a Physicians Regional Medical Center -

Collier Boulevard (CON #10187), (PRCB), provided 14 letters of support signed and dated during March 20 through April 4, 2013. Two letters were undated and one was unsigned.

Representative Matt Hudson, Florida House of Representatives District 80, states that “he would like to Strongly Advocate” for an inpatient

rehabilitation unit at Physicians Regional Medical Center and notes that Physicians Regional has a Comprehensive Stroke Program.

Representative Hudson states that “patients in my community will experience improved outcomes and more rapid recovery in the (CMR) unit” and that it is important “for patients to have ready access to this

level of care close to home”.

Donna Fiala, Collier County Commissioner for District 1, states need for

CMR beds at PRMC due to “the Comprehensive Stroke Program, the only such program that exists between Sarasota and Miami-Dade County”.

Joan Colfer, MD, MPH, states she serves as the Florida Department of Health Director in Collier County. She states that “Collier’s population

was 324,422 in 2011 (and that) 87,144 or 27 (percent) were people over the age of 65”. Dr. Colfer supports the applicant’s CMR unit because she

wants “to be sure we have sufficient facilities to serve our ever increasing number of older residents”.

Dennis Hidlebaugh, MD, Chief of Staff, Physicians Regional Healthcare System, states that “with the current federal directive for managing patients throughout the clinical process, it is important for our patients

to have ready access to a CMR level of care. The NCH unit is not an alternative. Our patients need this service in one of the two local HMA

hospitals”. These sentiments were shared by Frederick Buechel Jr., MD, and Director, Robotic Joint Replacement Center of Naples; and Mark A. Liberman, MD, surgeon at Liberman Advanced Surgical in Naples.


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Michael Finkel, MD, FAAN, states he has been practicing neurology in

Collier County for more than 13 years and “if Physicians Regional establishes an inpatient CMR, my patients’ outcomes would improve and functionality would be restored to a greater level in a more rapid time

frame.” Sandy Zsuppon, RN, BSN, CCM, and System Director of Case

Management at Physicians Regional Healthcare System, states “there is one existing comprehensive medical rehabilitation provider in Collier

County…and the four providers in Lee, Charlotte and Sarasota Counties have no relationship to services, referral patterns, physicians or patients/families of Collier County (and)… referring (patients) to facilities

that distant is not even considered, when it is a challenge to have the elderly patient and family consider going to a hospital on the other side

of Collier County when their physician doesn’t go with them”. In reference to Collier County’s CMR provider, she notes that it is owned by NCH Healthcare System and states that “while some physicians may

have staff privileges at both systems, the reality is that physicians in this community either practice at NCH or Physicians Regional, not both”. Ms. Zsuppon further states that the NCH North Naples is generally not a

resource for Physicians Regional patients and “even when it (CMR unit) was at the downtown NCH hospital, it was very rare to refer a patient for

services”. This is largely due to the patient-physician relationship and physician discharge instructions and alternatives presented”.

Ms. Zsuppon indicates that an error in discharge coding by the Physician Regional hospitals resulted in inaccurate rehabilitation discharge data during the 12 months ending June 30, 2012. She notes that the

Agency’s hospital discharge database “indicates there were a total of 81 discharges to a rehabilitation facility… six from PRCB and 75 from

Physicians Regional Medical Center-Pine Ridge”. She indicates that she reviewed each of these 81 patient records and found that only two Collier Blvd. and 27 PRMC–Pine Ridge patients were discharged to a rehab

facility. She contends PRMC has a significant need to establish a CMR unit “when we consider the fact that we discharge about two patients per

month to rehab yet have hundreds and hundreds of stroke, hip fractures, joint replacements and other orthopedic and neurological admissions each year.” She also states that with PRMC Pine Ridge’s

“comprehensive stroke center designation, it is even more incumbent on our hospital system to provide CMR services”.

Donna Hierta, RN, Director of Nursing for medical surgical areas at PRCB, also cites PRMC’s Comprehensive Stroke Center as an important

factor demonstrating need for CMR services.


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Five physical therapists practicing in the Physicians Regional Medical

System—Lisa Ceto, MPT, Director of Rehabilitation at PRMC, Jared Cornegia, DPT; Chelsea Winslow, OTR, Occupational Therapist; Anthony Valente, P.T.; and John Salka, PT contend that CMR services are needed

because:

The continuity of care for PRMC patients would enhance their

recovery process.

PRMC’s role as an established Comprehensive Stroke Program.

Increasing caseload of patients in need of rehabilitation services.

Current federal directive for managing patients throughout the clinical process makes additional CMR beds necessary.

Venice HMA, LLC, d/b/a Venice Regional Medical Center

(CON #10188), (VRMC), submitted 12 letters of support dated during February 14 through March 19, 2013. One letter was undated and three were unsigned.

Bob Daniels, Vice Mayor, City Vice-Mayor praises Venice Regional’s quality of care, cites the Venice area’s Medicare population and states

that the project would “fill a need…that is not currently being met”.

Jeanette F. Gates, Venice city Councilmember, states that due to an aging population, “a CMR unit at Venice Regional Medical Center would provide our community with a quality, convenient service for those who

desperately require it”. Emilio Carlesimo, Venice City Councilman, states that the aging

community of Venice is “prime population for orthopedic procedures as well as stroke care and other neurological conditions” and that due to

their health care needs, “a CMR Unit at VRMC would provide a solution for these challenges while giving patients the best opportunity for good outcomes and better quality of life”.

Juliette E. Coleman, MD, Stroke Director, Gulf Coast Neurology

Associates, which has four neurologists in the group, states she and her colleagues treat an average of 30-40 or more acute stroke patients at Venice Regional Medical Center per month and about 40-50 percent of

these patients require inpatient rehab. She states that a CMR unit at VRMC “would allow patients to begin their aggressive rehab program sooner, enhance their recovery, and decrease overall length of stay”.

Jeffrey R. Blood, MD, Physical Medicine and Rehabilitation specialist

(physiatrist) at Gulf Coast Medical Group, and Joseph Noah, MD (orthopedic surgeon) submitted letters which indicate the project is needed for the following reasons:


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A large elderly population in Venice; “according to the U.S. Census Bureau, over 57 (percent) of the population of Venice is over the age of

65” and “hip fractures, replacements and neurological conditions such as stroke are prevalent in this population”.

Patients “often” choose to “forego rehabilitation at HealthSouth or

Sarasota Memorial after an acute inpatient hospitalization, utilizing alternative treatment such as Home Health Therapy or Skilled

Nursing that will not optimize recovery”

Patients choose these options due to accessibility, limited travel by

their spouse or family support members, and the desire to maintain continuity of care with their primary physician.

Rosanne DiBello, RN, CCM, and Director of Resource Management at VRMC, states “…during calendar year 2012, we referred 228 patients to

HealthSouth…we had more than 450 stroke discharges last year; we had more than 300 hip fractures; we had nearly 100 joint replacements for elderly 85 years of age and older; and nearly 1,200 rehab appropriate

discharges…even if one half of these patients were admitted to rehabilitation that would equate to 600 admissions not the limited

referral number of 228. Our ability to admit patients to rehabilitation is limited by distance to beds and the availability of beds on a regular basis”.

Melissa Reifschneider, PTA, and Rosalie Pyra, OTR/L, therapists cite their first-hand experience working with patients at VRMC and indicate

that the patients and the facility would greatly benefit from having a CMR unit. They contend the project will improve quality of care, and

benefit all patients who want to remain close to family and familiar medical staff.

William E. Patton, DDS, a volunteer at VRMC, states that “Venice Regional is willing to convert available space in the facility to a

Comprehensive Rehab Unit, eliminating need for travel by the patient and their families and providing access by their treating physicians and therapists”.

Stephen K. Boone, a practicing attorney in Venice, cites the excellent reputation of VRMC providing quality care, which he states could be

enhanced with the addition of CMR beds.

Two letters submitted by Venice residents indicate that CMR beds are needed at VRMC due to limited availability requiring residents to either forgo much needed rehabilitation or travel to facilities far from home,

family, and familiar physician support.


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Letters of Opposition R. Terry Rigsby, an attorney, submitted a letter on behalf of Naples

Community Hospital, Inc. d/b/a NCH North Naples Hospital Campus, in opposition to the proposed 15-bed CMR unit at Physician’s Regional Medical Center - Collier Blvd. (CON #10187). Mr. Rigsby cites eight

reasons for opposing the project. These reasons are listed below:

CMR is a “tertiary” health service and with respect to access and availability for the criterion in rule, the two-hour drive time standard

establishes that the proposal is without merit. Granting additional CMR beds in close proximity (17.4 miles and 19 minutes ground travel under normal circumstances) to Naples Community Hospital

(NCH) North’s existing (54-bed) program would result in a dilution of service and CMR is a resource intensive patient group. The Centers

for Medicare and Medicaid requires a minimum of 60 percent of admissions to any CMR program to fall within 13 specific conditions. NCH North’s existing program may be threatened with financial

penalties that reduce reimbursement to MS-DRG payment if dilution of the existing patient pool threatens NCHs ability to comply with the CMR 60 percent rule.

Results from fixed need pool-District 8 occupancy rates of licensed CMR beds was 63.45 percent (61,264 patient days) for the 12-month

period ending June 30, 2012. This is below the 85 percent standard in rule. NCH North also cites the three year decline in CMR

occupancy from the 12-month period ending June 30, 2010 of 66.61 percent and 62,198 patient days compared to the 12 months ending June 30, 2012 cited above.

Relationship with other acute hospitals for CMR referrals-the location of PRCB is the farthest south of all hospitals in Health

Planning District 8, and Physician’s Regional Collier Blvd. is remote from other acute care hospitals that could serve as a referral base.

PRCB is not within a population base of sufficient size to support a CMR program, and PRCB is proximate to NCH North’s 54 CMR beds.

Fallacy of the HMA model for Forecasting Demand for CMR-HMA

hospitals applying for CMR services have stated 3.5 percent of acute care admissions are appropriate for CMR services. However, only .08

percent of acute care patients from two District 8 PRCB hospitals were discharged to rehabilitation facilities during the 12-month period ending June 30, 2012. NCH North indicates that a review of CY 2010

Hospital Financial Data for acute care hospital discharges to CMR indicates that HMA’s 3.5 percent is well above the state’s average of

1.1 to 1.6 percent.


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Lack of Sufficient Demand Within PRMC-for the 12-month period

ending June 30, 2012 the two PRCB District 8 Hospitals discharged 81 adults to CMR services, only six of which came from the

applicant’s facility.

Direct Adverse Impact on Naples Community Hospital-NCH’s

internal records indicate that during the 12 months ending June 30, 2012, Physicians Regional Hospital referred 87 patients to NCH’s CMR service and 54 were admitted. Twenty two percent of these patients

were unfunded or lacked a payer source to cover the admission, estimated at $19,259 each. NCH North contends that if the applicant’s program is more about Physicians Regional Hospital

Systems increasing utilization and revenues, unfunded and underfunded referrals to NCH would negatively impact Naples

Community Hospital.

Negative Impacts on Over Supply of Health Care Resources-these

can include compromised physician coverage, difficulty meeting financial requirements of federal mandates by small CMR facilities, duplications of staffing and medical equipment, shortages of

specialists, as well as concerns regarding a surge in HMA applications during the same batching cycle which, if approved, may flood the

market.

Other Health Planning Factors Yield No Benefit to the Proposal-

the applicants proposal will not benefit patients through competition of payer choice or patient choice, will not reduce cost of care due to redundancy of services within the same coverage area, insufficient

patient pool to support the program, and does not resolve access issues as coverage exists already within the service area.

R. Terry Rigsby, an attorney, submitted a letter on behalf of HealthSouth Rehabilitation Hospital of Sarasota in opposition to the proposed 22-bed

CMR unit at Venice Regional Medical Center (CON #10188). Mr. Rigsby cites nine reasons for opposing the project. These reasons are listed below:

CMR is a “tertiary” health service and should be provided in a limited

number of facilities in a given medical market. There are currently two providers of CMR services in Sarasota County, and there is no

valid health planning reason to add a third at this time.

HealthSouth meets the needs of the medical market for CMR services

as demonstrated by high discharge ratios, patient outcomes, quality of staffing and services.

The Agency’s need formula does not show a numeric need whether

applied at the district or county level. The addition of CMR beds would be an unnecessary duplication of services already available in

the county and throughout the district.


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There are no special circumstances such as geographic access,

financial access, or special services that justify approval of this application.

Venice Regional Medical Center is less than 18 miles driving distance from the two existing providers in Sarasota County.

CMR hospital units in general are more costly and less effective than HealthSouth CMR hospitals, as measured by cost per discharge and

change in FIM scores.

Small general hospital units cannot provide the same quality of staff,

equipment and facilities as a specialty hospital.

The most recent CON applications filed by HMA to establish new CMR

units proposed spending under $2 million in total project costs, an indication that their proposed units would lack the necessary state-of-the-art equipment crucial for achieving superior outcomes.

VRMC does not meet the comparative review criteria of Florida Administrative Code Rule 59C-1.039(3)(f), (5)(f) and (g) Florida

Administrative Code. VRMC is not a low income pool participating hospital or a disproportionate share hospital. Nor is VRMC a certified

trauma center.

C. PROJECT SUMMARY Punta Gorda HMA, LLC, d/b/a Charlotte Regional Medical Center

(CRMC) (CON #10186), a 208-bed Class I general hospital, proposes to develop a 15-bed comprehensive medical rehabilitation unit (CMR) within

its existing infrastructure in Punta Gorda, Florida, located in Charlotte County. CRMC has a total licensed bed complement of 156 acute care and 52 adult inpatient psychiatric beds. If approved, the project would

increase the total facility bed count to 223 beds. CRMC states that the hospital specializes in neurological, spine, and joint care. Charlotte

Regional Medical Center is a primary stroke center. The project involves 8,918 GSF of renovation. The construction cost is

$1,293,110. Total project cost is $1,836,379. Project cost includes building, equipment, project development and start-up costs.

The applicant proposes the following conditions to CON approval on CON application #10186’s Schedule C:

CRMC will provide seven percent of its CMR patient days to a

combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients. This will be measured by submittal of CMR utilization data by payor to the Agency.


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CRMC will offer a comprehensive outpatient rehabilitation program for

all patients discharged from the CMR unit at the hospital. This will be measured via a signed affidavit by the applicant and submitted to

the Agency.

CRMC will maintain its Joint Commission accreditation. This will be

measured by submitting its Joint Commission accreditation certificate to the Agency.

CRMC will seek Joint Commission accreditation as a designated

stroke rehabilitation provider. This will be measured by submitting its Joint Commission accreditation certificate to the Agency.

The medical director of the CMR until will be a board-certified or board-eligible physiatrist with at least two years of experience in the

medical management of all inpatients requiring rehabilitation services. This will be measured by submitting a copy of the medical

director’s board certification and/or credentials indicating eligibility.

Therapy services will be readily available to all CMR patients seven

days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency.

Patients will be evaluated and admitted to the CMR unit seven days a

week. This will be measured via a signed affidavit by the applicant and submitted to the Agency.

The CMR program at CRMC will have an activities of daily living (ADL) suite for occupational therapy. This will be measured by submittal of

schematic drawings to the Agency and via a signed affidavit by the applicant and submitted to the Agency.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (PRCB) (CON #10187) proposes to establish a 17-bed CMR

unit at Physicians Regional Medical Center-Collier Boulevard in Naples, (Collier County) Florida. PRCB has a total licensed bed complement of 100 acute care beds. If approved, the project will increase the bed count

to 117 beds.

The applicant indicates that Physicians Regional Medical Center - Collier Blvd. offers a “women’s center with obstetrics, orthopedic hand surgery and an inpatient hospice unit” whereas, Physicians Regional Medical

Center – Pine Ridge (10.3 miles north of PRMC - Collier Blvd.) “has a joint replacement program and is certified by the Agency” as a comprehensive stroke center2. Together, these facilities are referred to in this report as

Physicians Regional Medical Center (PRMC).

2 Agency records confirm that Physician’s Regional Medical Center – Pine Ridge, the applicant’s sister facility, received comprehensive stroke center designation effective 11/19/12 and is the only hospital

in Collier County so designated.


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The project involves 5,800 GSF of new construction and 6,005 GSF of

renovation. The construction cost is $2,376,000. Total project cost is $4,093,736. Project cost includes building, equipment, project development and start-up costs.

The applicant proposes the following conditions to CON approval on CON application #10187’s Schedule C:

PRCB will provide six percent of its CMR patient days to a

combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients. This will be measured by submittal of CMR

utilization data by payor to the Agency.

PRCB will offer a comprehensive outpatient rehabilitation program for

all patients discharged from the CMR unit at the hospital. This will be measured via a signed affidavit by the applicant and submitted to the Agency.

PRCB will maintain its Joint Commission accreditation. This will be measured by submitting its Joint Commission accreditation certificate

to the Agency.

PRCB will seek Joint Commission accreditation as a designated stroke

rehabilitation provider. This will be measured by submitting its Joint Commission accreditation certificate to the Agency.

The medical director of the CMR until will be a board-certified or board-eligible physiatrist with at least two years of experience in the

medical management of all inpatients requiring rehabilitation services. This will be measured by submitting a copy of the medical director’s board certification and/or credentials indicating eligibility.

Therapy services will be readily available to all CMR patients seven days a week. This will be measured via a signed affidavit by the

applicant and submitted to the Agency.

Patients will be evaluated and admitted to the CMR unit seven days a

week. This will be measured via a signed affidavit by the applicant and submitted to the Agency.

The CMR program at PRCB will have an activities of daily living (ADL) suite for occupational therapy. This will be measured by submittal of

schematic drawings to the Agency and via a signed affidavit by the applicant and submitted to the Agency.

Venice HMA, LLC, d/b/a Venice Regional Medical Center (VRMC) (CON #10188), located in the city of Venice, Florida, in Sarasota County, proposes to establish a 22-bed CMR unit through the conversion of 22

existing acute care beds. VRMC has a total licensed bed complement of 312 acute care beds, provides Level II Adult Cardiovascular Services and

is a primary stroke center.


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The project involves 17,569 GSF of renovation. The construction cost is

$2,970,000. Total project cost is $4,564,819. Project cost includes building, equipment, project development and start-up costs. The applicant proposes the following conditions to CON approval on

CON application #10188’s Schedule C:

VRMC will provide four percent of its CMR patient days to a

combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients. This will be measured by submittal of CMR utilization data by payor to the Agency.

VMRC will offer a comprehensive outpatient rehabilitation program for all patients discharged from the CMR unit at the hospital. This will

be measured via a signed affidavit by the applicant and submitted to the Agency.

VMRC will continue to operate Easy Street® as a benefit for all of its patients, including the patients who will be admitted to the CMR

program. This will be measured via a signed affidavit by the applicant and submitted to the Agency.

VRMC will maintain its Joint Commission accreditation. This will be

measured by submitting its Joint Commission accreditation certificate to the Agency.

VRMC will seek Joint Commission accreditation as a designated stroke rehabilitation provider. This will be measured by submitting

its Joint Commission accreditation certificate to the Agency.

The medical director of the CMR until will be a board-certified or

board-eligible physiatrist with at least two years of experience in the medical management of all inpatients requiring rehabilitation

services. This will be measured by submitting a copy of the medical director’s board certification and/or credentials indicating eligibility.

Therapy services will be readily available to all CMR patients seven

days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency.

Patients will be evaluated and admitted to the CMR unit seven days a week. This will be measured via a signed affidavit by the applicant

and submitted to the Agency.

The CMR program at VRMC will have an activities of daily living (ADL)

suite for occupational therapy. This will be measured by submittal of schematic drawings to the Agency and via a signed affidavit by the applicant and submitted to the Agency.


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Specific to the applicants’ proposed conditions—Section 408.043 (4), Florida Statutes prohibits accreditation by any private organization as a requirement for the issuance or maintenance of a certificate of need, so Joint Commission and accreditation will not be cited as conditions to approval. The CMR medical director is required by administrative rule and as such does not require a report. Should a project be approved, the applicant’s conditions would be reported in the annual condition compliance report as required by Rule 59C-1.013 (3) Florida Administrative Code.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review

criteria found in Section 408.035, Florida Statutes; and applicable rules of the State of Florida, 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 and data provided in the application, and independent information gathered by the

reviewer. Applications are analyzed to identify strengths and weaknesses in each

proposal. If more than one application is submitted for the same type of project in the same district, applications are comparatively reviewed to determine which applicant(s) best meets the review criteria.

Rule 59C-1.010 (3) (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, Jessica Hand analyzed the

application with consultation from the financial analyst, Derron Hillman, Bureau of Central Services, who reviewed the financial data and Said Baniahmad of the Office of Plans and Construction, who reviewed the

application for conformance with the architectural criteria.


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E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicate the level of conformity of the proposed project with

the criteria and application content requirements found in Florida Statutes, Sections 408.035, and 408.037 and 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? ss. 408.035(1) (a), Florida Statutes. Rule 59C-1.008(2),

Florida Administrative Code and Rule 59C-1.039(5), Florida Administrative Code.

In Volume 39, Number 13, dated January 18, 2013 of the Florida Administrative Register, a fixed need pool of zero beds was published for

CMR beds in District 8 for the January 2018 planning horizon. District 8 has 264 licensed and zero approved CMR beds. During the

12-month period ending June 30, 2012, the district’s licensed CMR beds experienced 63.45 percent utilization.3

b. According to Rule 59C-1.039 (5)(d) of the Florida Administrative

Code, need for new comprehensive medical rehabilitation inpatient

services shall not normally be made unless a bed need exists according to the numeric need methodology in paragraph (5)(c) of this rule. Regardless of whether bed need is shown under the need

formula in paragraph (5)(c), no additional comprehensive medical rehabilitation inpatient beds shall normally be approved for a

district unless the average annual occupancy rate of the licensed comprehensive medical rehabilitation inpatient beds in the district was at least 80 percent for the 12-month period ending six months

prior to the beginning date of the quarter of the publication of the fixed bed need pool.

As shown in the table below, District 8’s licensed CMR beds experienced 63.45 percent occupancy during the 12-month period ending June 30,

2012.

3 Florida Hospital Bed Need Projections & Service Utilization by District, January 2013 Batching Cycle.


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Comprehensive Medical Rehabilitation Bed Utilization

District 8 July 1, 2011 – June 30, 2012

Facility Beds Total Occupancy %

Naples Community Hospital* -- 20.40%

NCH Healthcare System North Naples Hospital Campus** 54 56.83%

Fawcett Memorial Hospital 20 36.17%

Lee Memorial Hospital 60 61.33%

HealthSouth Rehab Hospital of Sarasota 96 81.51%

Sarasota Memorial Hospital 34 68.92%

District 8 Total 264 63.45% Source: Florida Hospital Bed Need Projections & Service Utilization by District, January 2013 Batching Cycle. Note: * Naples Community Hospital delicensed 60-bed CMR unit & NCH Healthcare System North Naples Hospital Campus licensed 54-bed CMR unit effective 11/15/11.

District 8’s last five years of utilization for these facilities are illustrated below.

District 8 CMR Providers

Utilization for the 12-Month Periods Ending June 30, 2008 - 2012

Facility Beds 2008 2009 2010 2011 2012

Naples Community Hospital 60* 65.51% 71.36% 61.73% 50.47% 20.40%

NCH Healthcare System North Naples Hospital Campus

54*

56.83%

Fawcett Memorial Hospital 20 36.68% 45.40% 39.47% 29.67% 36.17%

Lee Memorial Hospital 60 53.15% 55.87% 52.50% 53.43% 61.33%

HealthSouth Rehab Hospital of Sarasota 96** 90.84% 91.21% 85.75% 85.88% 81.51%

Sarasota Memorial Hospital 34 69.65% 67.31% 70.06% 68.38% 68.92%

District 8 Total 264 68.52% 71.05% 66.61% 63.61% 63.45% Source: Florida Hospital Bed Need Projections & Service Utilization by District, January (2009-2013) Batching Cycles. Notes: *Naples Community Hospital delicensed 60-bed CMR unit & NCH Healthcare System North Naples Hospital Campus licensed its 54-bed CMR unit effective 11/15/11.

**HealthSouth Rehab Hospital of Sarasota added 10 CMR beds in CY 2009 and an additional 10 CMR beds in CY 2011, both times by exemption.

The map below shows District 8’s licensed CMR providers and the locations of

the applicants.


17

District 8 Comprehensive Medical Rehabilitation Providers

and CON application #s 10186, 10187 and 10188

Source: Microsoft MapPoint 2012.


18

The table below shows driving distance and travel times for the co-batched applicants and the five nearest existing CMR facilities.

Driving Distance Miles and Travel Times

Existing CMR Facilities and Proposed Sites

Facility

Charlotte Regional Medical

Center CON#10186

Physicians Regional-Collier

Boulevard CON #10187

Venice Regional Medical

Center CON #10188

Fawcett

Memorial Hospital

Lee Memorial Hospital

HealthSouth Rehab

Hospital of Sarasota

NCH Healthcare System North

Naples Campus

Sarasota

Memorial Hospital

CRMC (CON #10186)

68.2 miles

1.6 hrs

29.4 miles

42 min

5.6 miles

9 min

25.4 miles

33 min

48 miles

51 min

56.9 miles

54 min

52.5 miles

58 min

PRCB (CON 10187)

68.2 miles 1.6 hrs

101 miles 1.39 hrs

73.8 miles 1.15 hrs

45.2 miles 50 min

113 miles 1.47 hrs

17.2 miles 24 min

117 miles 1.54 hrs

VRMC (CON #10188)

29.4 miles 42 min

101 miles 1.39 hrs

24.3 miles 36 min

60.6 miles 1.6 hrs

18.3 miles 27 min

90.7 miles 1.27 hrs

17.6 miles 30 min

Fawcett Memorial Hospital

5.6 miles 9 min

73.8 miles 1.15 hrs

24.3 miles 36 min

29.6 miles 38 min

45.1 miles 52 min

64.1 miles 1.4 hrs

41.7 miles 1 hr

Lee Memorial Hospital

25.4 miles 33 min

45.2 miles 50 min

60.6 miles 1.6 hrs

29.6 miles 38 min

71.7 miles 1.15 hrs

26.8 miles 39 min

76 miles 1.22 hrs

HealthSouth Rehab

Hospital of Sarasota

48 miles

51 min

113 miles

1.47 hrs

18.3 miles

27 min

45.1 miles

52 min

71.7 miles

1.15 hrs

102 miles

1.36 hrs

11 miles

24 min

NCH Healthcare System North Naples

Campus

56.9 miles

54 min

17.2 miles

24 min

90.7 miles

1.27 hrs

64.1 miles

1.4 hrs

26.8 miles

39 min

102 miles

1.36 hrs

106 miles

1.45 hrs

Sarasota Memorial Hospital

52.5 miles 58 min

117 miles 1.54 hrs

17.6 miles 30 min

41.7 miles 1 hr

76 miles 1.22 hrs

11 miles 24 min

106 miles 1.45hrs

Source: Google Maps NOTE: Drive times shown above as “hour –decimal- minutes”

The reviewer notes the two closest existing CMR facilities for each of the co-batched applicants as follows:

CRMC, CON #10186, is 5.6 miles (nine minute drive) from Fawcett Memorial Hospital and 25.4 miles (33 minutes) from Lee Memorial

Hospital.

PRCB, CON #10187, is 17.2 miles (24 minutes) from NCH Healthcare

System North Naples Campus and 45.2 (50 minutes) miles from Lee Memorial Hospital.

VRMC, CON #10188, is 17.6 miles (30 minutes) from Sarasota Memorial Hospital and 18.3 miles (27 minutes) from HealthSouth

Rehab Hospital of Sarasota; and 24.3 miles (36 minutes) from Fawcett Memorial Hospital.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) data is shown below, beginning with the total number of Charlotte County residents discharged or transferred to an inpatient

rehabilitation provider (regardless of whether CMR freestanding or an in-hospital CMR distinct unit) by CRMC during the 12-month period ending

June 30, 2012.


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Discharges to a CMR Provider

12-Month Period Ending June 30, 2012 Total

Charlotte County

Resident Discharges

Total All Other

County Resident

Discharges

Total Discharges

Total Charlotte County

Resident Discharge Percent

Total All Other County


Total Discharge Percent

57 22 79 72.15% 27.85% 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, 2011 - June 30, 2012 database.

CRMC includes DeSoto County in its need argument, and it is noted that

CRMC discharged four DeSoto County residents to CMR during the 12-month period ending June 30, 2012.

The table below shows the total number of Charlotte County adult residents discharged from a Florida CMR provider (CMR freestanding or an in-hospital CMR distinct unit) during the12-month period ending

June 30, 2012.

Total Charlotte County Adult Residents

Discharged from CMR Providers 12-Month Period Ending June 30, 2012

Facility Name

Facility County

District

Total Discharges

Percent Total

Discharges

Total

Patient Days

Percent Total

Patient Days

Fawcett Memorial Hospital Charlotte 8 102 40.80% 1,243 38.19%

HealthSouth Rehab. Hospital of Sarasota Sarasota 8 99 39.60% 1,393 42.80%

Sarasota Memorial Hospital Sarasota 8 17 6.80% 206 6.33%

Lee Memorial Hospital Lee 8 17 6.80% 207 6.36%

All Other Florida CMR Providers 15 6.0% 206 6.33%

Total 250 100.0% 3,255 100.01% Source: Florida Center for Health Information and Policy Analysis, June 30, 2012. MS-DRGs 945 and 946. Note: Two of the “All Other Florida CMR Providers” discharges were from NCH Healthcare Systems’ CMR units in Collier

County.

The following table shows Desoto County adult residents discharged from

a CMR facility during the 12-month period ending June 30, 2012.

Desoto County Adult Residents

Discharged from CMR Providers

12-Month Period Ending June 30, 2012

Facility Name

Facility County

District

Total Discharges

Percent

Total

Patient Days

Percent

HealthSouth Rehab. Hospital of Sarasota Sarasota 8 20 44.44% 242 44.90%

Fawcett Memorial Hospital Charlotte 8 12 26.67% 139 25.79%


All Other Florida CMR Providers -- -- 9 20.0% 105 19.48%

Total 45 100.0% 539 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, 2011 - June 30, 2012, MS-DRGs 945 and 946

discharges.


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Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier

Blvd. (CON #10187) data is shown below, beginning with the total number of Collier County adult residents discharged or transferred to an inpatient rehabilitation provider (CMR freestanding or an in-hospital

CMR distinct unit) by PRPR during the 12-month period ending June 30, 2012.

Physicians Regional Medical Center-Pine Ridge

Discharged to a CMR Provider – 12-Month Period Ending June 30, 2012 Total

Collier County

Resident Discharges

Total All Other

County Resident Discharges

Total Discharges

Total Collier County




Total Discharge Percent


MS-DRGs 945 & 946.

The reviewer notes that Physicians Regional Pine Ridge discharged 24

Lee County residents to CMR providers during the reporting period. The applicant’s facility, Physicians Regional Medical Center- Collier Blvd. discharged four Collier County residents to CMR providers during the

reporting period. The applicant indicates that Collier Blvd. discharged a total of six patients to CMR during the 12-months ending June 30, 2012.

The table below shows the total number of Collier County adult residents discharged from a Florida CMR provider (CMR freestanding or an in-

hospital CMR distinct unit) during the 12-month period ending June 30, 2012.

Total Collier County Adult Residents

Discharged from CMR Providers – 12-Month Period Ending June 30, 2012

Facility Name

Facility County

District

Total

Discharges

Percent

Discharges

Total Patient Days

PercentPatient Days

NCH Healthcare System North Naples Collier 8 442 76.74% 5167 74.08%

Naples Community Hospital Collier 8 113 19.62% 1,466 21.02%



Total 576 100.0% 6,975 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, 2011 - June 30, 2012. MS-DRGs 945 and 946. Note: One of the “All Other Florida CMR Providers” patients was treated at HealthSouth Rehabilitation Hospital of Sarasota

(District 8).

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) data is shown below, beginning with the total number of

Sarasota County adult residents discharged or transferred to an inpatient rehabilitation provider (CMR freestanding or an in-hospital CMR distinct unit) by VRMC for the 12-month period ending June 30,

2012.


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Venice Regional Medical Center

Discharges to a CMR Provider – 12-Month Period Ending June 30, 2012

Total

Sarasota County

Resident Discharges


Resident Discharges

Total Discharges

Total Sarasota

County Resident Discharge Percent

Total All Other

County Resident Discharge Percent

Total

Discharge Percent


Per the database, the applicant also discharged 27 Charlotte County

residents, two Lee County, one Desoto, one Hillsborough and eight residents from unknown counties during the reporting period.

The following table shows the total number of Sarasota County adult residents discharged from a Florida CMR provider (CMR freestanding or

an in-hospital CMR distinct unit) during the 12-month period ending June 30, 2012.

Total Sarasota County Adult Residents Discharged from CMR Providers

12-Month Period Ending June 30, 2012

Facility Name

Facility County

District

Total Discharges

Percent

Total Patient Days

Percent

HealthSouth Rehabilitation Hospital of Sarasota

Sarasota

8 1,229 68.97% 16,676

70.55%

Sarasota Memorial Hospital Sarasota 8 496 27.83% 6,084 25.74%

Fawcett Memorial Hospital Charlotte 8 21 1.18% 296 1.25%


Total 1782 100.0% 23,638 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, 2011- June 30, 2012 database. MS-DRGs 945 & 946. Note: Four patients in the “All Other Florida CMR Providers” were discharged from Lee Memorial Hospital (District 8).

c. Other Special or Not Normal Circumstances

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) states nine “not normal” circumstances that justify need,

as follows:

Charlotte and Desoto Counties have the lowest CMR discharge use rate per 1,000 population age 65 and older compared to the other

District 8 counties and 11 health planning districts in the state.

The Charlotte and Desoto resident to rehab bed ratio far exceeds the

statewide and District 8 resident to rehab bed ratios and is one of the highest in the state with just one rehab bed for every 8,276 residents.

CMR beds are geographically and programmatically inaccessible to

residents of the CMRC service area. This is evidenced by the CRMC and Peace River Regional Medical Center (PRRMC) Case Management

Department’s internal review of medical records which supports the argument that patients do not get transferred to any of the district’s

rehab hospitals.


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Hospital-based CMR units are primarily supported by referrals that

come directly from within the acute care hospital or system. This is the case with the existing 20-bed unit at Fawcett Memorial as will be

the case with the proposed 15-bed unit at CRMC.

Clinical continuity between acute care providers and programming,

and post-acute providers and programming is imperative but is, unfortunately, not the case for many service area residents. As the case mix index (severity rating) of patients admitted to CMR programs

continues to increase, rehab appropriate patients at CRMC always experience a break in continuity of care as this level of care is not currently available for the service area population. Evidence of a

break in continuity is supported by the Case Management Department’s analysis of sample medical records for those acute care

patients who would have been appropriate for admission to a CMR bed.

As a designated primary stroke center by the Agency and a Joint

Commission accredited Stroke Program, CRMC is committed to fulfilling the continuum of care for its stroke patients in a post-acute

setting of a CMR program, and being accredited as a stroke rehabilitation program.

There is a large percentage of elderly population in the CRMC service area compared to the state average.

There is a gap in CRMC’s continuum of care; the missing component is inpatient rehabilitation. In light of the Affordable Healthcare Act,

and its initial selection for the CMS Bundled Payment pilot, the Applicant must position itself for the future where CRMC will be able to offer a full array of services to compete effectively in providing

quality services.

The applicant is able to fully support a CMR program based on the

CRMC and PRRMC internal volume of rehab appropriate patients who reside within its distinct service area.

Service Area Characteristics

CRMC and its sister facility, 254-bed Peace River Regional Medical Center, six miles to the north of the applicant, report serving primarily Charlotte and Desoto Counties as a two acute care hospital system, with

shared medical staff. Agency discharge data for the 12-month period ending June 30, 2012, indicates that there was one DeSoto County zip

code (34269) with 142 discharges or 2.27 percent of the facility’s total, in Charlotte Regional’s primary service area4. The reviewer notes that a Sarasota County zip code accounted for 198 discharges (3.17 percent)

4 The primary service area consists of 75 percent of the facility’s total discharges. Taking the zip code

review to 81.67 percent of the facility total, there were two more Sarasota and no other DeSoto County zip codes. The applicant’s remaining zip codes had less than 50 discharges (or approximately 0.8

percent) of the facility’s total.


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and there were no DeSoto County zip codes with more than 50

discharges in Charlotte Regional’s remaining zip code service area. The reviewer notes PRRMC is located 0.3 miles (2 minutes) from Fawcett Memorial Hospital. Per the applicant, the populations of these two

counties (166,831) comprise 12.6 percent of District 8’s total population (166,831/1,322,746). The applicant concludes that 38.7 percent (64,483/166,831) of the adult service area is age 65 years and older, the

age group most likely to utilize CMR services.

Below are three tables the applicant provides to account for service area population, age cohort, and growth changes.

District 8 Population

Ages 18 and Older

As of January 2013 County Ages 18-64 Ages 65+ Ages 18+

Charlotte 81,807 58,018 139,825

Collier 176,844 92,474 269,318

Desoto 20,541 6,465 27,006

Glades 7,396 2,833 10,229

Hendry 23,675 4,670 28,345

Lee 360,502 159,427 519,929

Sarasota 201,408 126,686 328,094

District 8 872,173 450,573 1,322,746

Charlotte/Desoto 102,348 64,483 166,831 Source: CON application #10186, page #14.

CRMC Service Area Population Growth

Ages 18 and Older

2013 to 2016 County 2013, Ages 18+ 2016, Ages 18+ Incremental Growth

Charlotte 139,825 142,941 3,116

Desoto 27,006 27,082 76

Service Area 166,831 170,022 3,191 Source: CON application #10186, page #15.

CRMC Service Area Percent Growth

Ages 18 and Older 2013 to 2016

County Ages 18-64 Ages 65+ Ages 18+

Charlotte (1.4%) 7.3% 2.2%

Desoto (0.6%) 3.2% 0.3%

Service Area (1.2%) 6.9% 1.9% Source: CON application #10186, page #16.

Per the applicant, the forecasted growth in the service area will be primarily in Charlotte County, the location of the proposed CMR facility,

with a combined service area percentage increase in population of more than two percent annually during years 2013 to 2016.


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District 8 CMR Providers The applicant states 264 licensed CMR beds in District 8 had an average

occupancy rate of 63.5 percent (63.45 percent per Hospital Bed Need Projections - January 2013) for the 12-month period ending June 30, 2012. However, due to seasonal population changes, a nine to 10 point

upswing occurs during the busy season (first quarter of each year). The applicant notes this population increase results in an occupancy rate of

up to 90 percent (89.90 percent per Hospital Bed Need Projections -January 2013) in District 8’s largest acute rehab program, HealthSouth Rehabilitation Hospital of Sarasota.

District 8

CMR Utilization 12-Month Period Ending June 30, 2012

Hospital

Bed Days

Patient Days

Annual

Occupancy Rate

Q-1-2012 Average

Occupancy Rate

Fawcett Memorial Hospital 7,320 2,648 36.2% 45.7%

North Naples Hospital 12,258 6,966 56.8% 60.4%

Lee Memorial Hospital 21,960 13,467 61.3% 63.6%

HealthSouth Rehab Hospital of Sarasota 34,236 27,905 81.5% 89.9%

Sarasota Memorial Hospital 12,444 8,577 68.9% 76.5%

District 8 96,558 61,264 63.5% 72.8% Source: CON application #10186, page 17, NHA Analysis from Florida Hospital Bed Need Projections & Service Utilization by District, January 18, 2013.

To demonstrate internal volume to justify need for a CMR program, the applicant provides the following table demonstrating stroke discharges.

CRMC states that many of these patients “would certainly” benefit from CMR services. MedPac data indicates that stroke patients make up the largest rehab volume5. The applicant has stated intent to seek Joint

Commission accreditation as a designated stroke rehabilitation provider, which it contends will ensure continued patient volume requiring

comprehensive rehab services.

Charlotte Regional Medical Center & Peace River Regional Medical Center Stroke Discharges

Hospital

12 Months Ending

June 30, 2010

12 Months Ending

June 30, 2011

12 Months Ending

June 30, 2012

CRMC 224 215 208

PRRMC 159 138 177

Total 383 353 385 Source: CON application #10186, page 37 from “Agency Data Tapes and NHA Analysis”.

5 The Medicare Payment Advisory Commission (MedPAC) is an independent US federal body

established by the Balanced Budget Act of 1997 whose primary role is to advise the US Congress on

issues affecting the administration of the Medicare program. Specifically the commission's mandate is to advise the US Congress on payments to private health plans participating in Medicare and health

providers serving Medicare beneficiaries.

http://en.wikipedia.org/wiki/United_States_Congress

http://en.wikipedia.org/wiki/Medicare_(United_States)


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Case Management Study of Attempted Rehab Appropriate Placements The applicant states that the Case Management Department of CRMC

and its sister facility, PRRMC, compiled a random sample of patients admitted during a 90-day period ending January 2013. CRMC states that based on this review, “many patients appropriate for admission to a

rehab facility opt for skilled nursing facilities instead, due to existing barriers impeding placement of patients in a CMR program”. Of 21

patients deemed appropriate for rehab, the applicant reports only two patients were sent to an acute rehab facility, as a result of programmatic barriers (physicians prefer to refer within their own healthcare system) or

geographic barriers. The applicant provides documentation demonstrating the method and outcome of this study (CON #10186,

pages 19-23). The applicant does not provide documentation of problems that have resulted from the current CMR referral arrangement in Charlotte County.

CRMC’s CMR unit will have no impact on existing providers

The applicant maintains that the five existing CMR programs in District 8 are geographically and programmatically inaccessible to CRMC

patients. Further, CRMC and PRRMC have sufficient patient volume to support a 15-bed CMR unit program. The applicant’s programmatic access problems appear to be systematic in that the project is designed

to serve patients in the HMA system.

Alternatives are inappropriate for CMR patients

The applicant discusses disadvantages and suboptimal outcomes when

rehabilitation services are provided outside a licensed CMR facility, such as at a skilled nursing facility or long term acute care (LTAC) facility. The applicant states that in summary, CMR facilities and nursing homes

provide different levels of service, with nursing homes not staffed or equipped to provide intensive rehabilitation services that hospital-based

CMR can provide. The applicant does not attempt to document sub-optimal outcomes among residents of its proposed service area due to inappropriate placements among the various alternatives to CMR

services.

CMR bed need analysis

The applicant offers two methodologies to prove that sufficient demand

exists for the project. Methodology number one is described as an average statewide resident use rate of hospital-based CMR discharges compared to the applicant’s service area population. Methodology


26

number two is described as the applicant’s historical rehab appropriate

cases compared to total rehab cases discharged to hospital-based CMRs statewide. Both methodologies result in a stated bed need count of 20 to 22 beds by CY 2016. Because these bed need count estimates are

approximately the same, for brevity, methodology number two is summarized below.

Methodology #2: Hospital-Based Need Methodology

The applicant states that in each of the last three years, CRMC has discharged in excess of 520 patients that meet CMS primary diagnoses requirements (referenced as CMS-13), sufficient in severity to qualify as

inpatient rehabilitation candidates. Additionally, PRRMC discharged in excess of 469 patients meeting these criteria. Below is the applicant’s

summary table to account for this discharge count, during the 12-month period ending June 30, 2012.

Charlotte Regional Medical Center & Peace River Regional Medical Center

CMS-13 (Rehab Appropriate) Discharges by Category 12 Months Ending June 30, 2012

CMS Category

Hospital Discharges

CRMC PRRMC

Amputation 2 8

Brain Injury 69 76

Burn 1 0

Hip Fracture 136 152

Joint Replacement, Age 85+ 16 49

Neuro 70 52

Rheumatoid Arthritis 0 3

Spinal Cord 32 22

Stroke 208 177

Trauma 1 1

CMS-13 Total 535 540

Hospital Total 6,092 7,499

Rehabilitation Admissions at CRMC NONE-NO CMR UNIT

Rehabilitation Admissions as a Percent of Total Hospital Admissions NOT APPLICABLE Source: CON application #10186, page 48, from AHCA Inpatient Data Tapes and NHA Analysis, all discharges exclude obstetrics/gynecology, newborns, psychiatry, substance abuse and ages 0-17.

The applicant states that of the combined 13,591 total discharges, 7.9 percent (1,075/13,591) met the requirements set forth by CMS defining medical conditions that qualify patients for inpatient rehabilitation

services. For comparison, the applicant identified a total of 31 hospitals in Florida

with inpatient rehabilitation units, with 469,101 total patient discharges, of which 40,806 had rehab appropriate diagnoses; 16,284 of these were

admitted for inpatient rehabilitation elsewhere. All three applicants used the following chart to calculate the percentage of rehab appropriate admissions in hospitals with CMR units.


27

Hospital-Based CMR Units

CMS-13 (Rehab Appropriate) Discharges by Category (*)

12 Months Ending June 30, 2012 CMS Category Hospital Discharges

Amputation 484

Brain Injury 9,186

Burn 294

Hip Fracture 8,075

Joint Replacement, Age 85+ 1,427

Neuro 3,744

Rheumatoid Arthritis 232

Spinal Cord 3,399

Stroke 13,845

Trauma 120

CMS-13 Total 40,806

Hospital Total 469,101

Rehabilitation Admissions to the Above Hospitals 16,284

Rehabilitation Admissions as a Percent of Total Hospital Admissions 3.5% Source: CON application #10186, page 49, CON application #10187, page 51, CON application #10188, page 46, from AHCA Inpatient Data Tapes and NHA Analysis. Note: (*) The applicants state that only 10 of the CMS 13 categories are included herein for conservatism.

All discharges exclude obstetrics/gynecology, newborns, psychiatry, substance abuse and ages 0-17.

The applicant concludes that 3.5 percent (16,284/469,101) of total

admissions to hospitals with CMR units are rehab admissions, whether their own rehab unit or elsewhere in the state.

The applicant applied the same 3.5 percent to CRMC and PRRMC total admissions resulting in 432 estimated possible CMR admissions (see the chart below).

CRMC, PRRMC & Florida Hospitals with CMR Units

Potential/Estimated Rehab Admissions 12 Months Ending June 30, 2012

Hospitals with CMR Units:

Hospital Discharges


Actual Rehab Admissions 16,284

Rehab as Percent of Hospital Admissions 3.5%

Applicant CMR Unit CRMC PRRMC


Rehab as Percent of Hospital Admissions (Hospital-Based Units) 3.5% 3.5%

Rehab Admissions 211 260

Capture Rate 100% 85%

Potential/Estimated Rehab Admissions 211 221

Total Potential/Estimated Rehab Admissions 432 Source: CON application #10186, page 50, from AHCA Inpatient Data Tapes and NHA Analysis.

The applicant concludes that the 432 admissions result in a need projection as shown below:


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CMR Bed Need

2012 and 2016 2012 2016

Forecasted Admissions 432 464

Average Length of Stay 13.3

Total Patient Days 5,755 6,171

Average Daily Census 15.8 16.9

Bed Need at 85% Occupancy 19 20 Source: CON application #10186, page 50 from AHCA Inpatient Data Tapes and NHA Analysis.

Utilization forecast Below is the applicant’s summary table to account for admissions,

patient days, average daily census (ADC) and occupancy rates for year one (CY 2015) and for year two (CY 2016). The applicant includes a

“ramp up” period for year one as well.

CRMC 15-bed CMR Unit Forecasted Utilization

Years One and Two

Admissions by Quarter

Year One Based on Need and

Before Ramp Up Adjustment

Year One (2015) With Ramp Up

Adjustment

Year Two (2016) with Unit Size Adjustment

Quarter 1 140 46 86

Quarter 2 122 81 85

Quarter 3 108 83 86

Quarter 4 116 87 88

Total Admissions 486 298 344

Patient Days N/A 3,971 4,582

Average Daily Census N/A 10.9 12.5

Occupancy Rate N/A 72.5% 83.5% Source: CON application #10186, page 52.

The applicant’s estimates indicate an ADC of 10.9 and 72.5 percent occupancy in year one and an ADC of 12.5 and 83.5 percent occupancy in year two.


Boulevard (CON #10187) states seven “not normal” circumstances that justify need, as follows:

Physicians Regional Health System has the only certified comprehensive stroke center in southwest Florida, in the middle of a

200+ mile stretch, and therefore needs an acute rehab unit to appropriately provide the full continuum of acute services to its stroke patients.

Collier County’s CMR discharge use rates per 1,000 population are lower than both District 8 and State of Florida use rates, indicating

underutilization of this needed level of care.


29

CMR beds are programmatically inaccessible to residents of the

defined service area and evidenced by NCH Health System discharge data and from the PRMC Case Management Department’s internal

review of medical records which supports the argument that patients do not get transferred to any of the district’s rehab hospitals. The reviewer notes there is no evidence that Collier County residents in

need of rehabilitation services are not being discharged to the appropriate setting. It is noted that four of the five rehabilitation providers are located in acute care hospitals (two of which are much

closer) to Collier residents than HealthSouth Hospital of Sarasota.

CMR beds are geographically inaccessible to residents of the PRCB

service area. This is evidenced by the location of the only existing beds in the county located at the Collier/Lee County line.

Clinical continuity between acute care providers and programming, and post-acute providers and programming is imperative but is,

unfortunately, not the case for many service area residents. As the case mix index (severity rating) of patients admitted to CMR programs continues to increase, rehab appropriate patients at PRCB and PRPR

always experience a break in continuity of care as this level of care is not currently available.

There is a large percentage of elderly population in the PRCB service area compared to the state average.

The applicant is able to fully support a CMR program based on the PRCB and Physicians Regional Pine Ridge (PRPR) internal volumes of

rehab appropriate patients who reside within its distinct service area. The applicant’s facility’s discharged six and Pine Ridge 75 patients to CMR facilities during the 12 months ending June 30, 2012.

Service area

The applicant defines the service area of PRCB as all of Collier County. The applicant’s sister facility, Physicians Regional Pine Ridge (PRPR), a

101-bed hospital, is located 10 miles north of PRCB and provides complementary programs (including the comprehensive stroke center) within a shared service area to the applicant.

As an acute care hospital, PRCB provides care to an aging population,

with one in three adults aged 65 and older. Per the applicant, Collier County has 269,318 residents, but this does not reflect a “huge seasonal population which maintains primary residence outside the State of

Florida and is not counted in population estimates”. The applicant anticipates continued population growth, particularly among residents aged 65 and older, who benefit most from comprehensive rehab services.


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Defined Service Area Population Ages 18 and Older

Calendar Year 2015 and 1016 Collier County

Calendar Year 2015 Calendar Year 2016

Ages 18-64 Ages 65+ Ages 18+ Ages 18-64 Ages 65+ Ages 18+

Population 178,908 97,088 275,997 179,639 99,700 279,338

2013-2016 Growth __ __ __ 1.6% 7.8% 3.7% Source: CON application #10186 page 14.

District 8 CMR providers

The applicant identifies North Naples Hospital (NCH) as the only hospital or CMR competition in Collier County. Due to a recent relocation of the NCH main campus, patient volume declined at NCH, but the applicant

expects volume will soon increase and quickly exceed previous occupancy levels of 73 percent during the busy season. Per the

applicant, NCH owns 76 percent of all licensed acute care beds in Collier County, and due to competition between these facilities, few patients are discharged from PRCB to NCH programs. It is noted that NCH’s

opposition letter indicated it had 87 referrals from the two Physicians Regional facilities.

Case management study of attempted rehab appropriate placements

The applicant states that an internal audit of Physicians Regional Healthcare System patient records for the 12-month period ending June 30, 2012, indicates only 29 patients were discharged to acute

rehabilitation. Per the applicant, HMA erroneously coded some discharges to skilled nursing rehab programs as “discharges to

rehabilitation facility”, resulting in an inaccurately high count of 81 reported discharges from PRMC to acute care rehab facilities.

Physicians Regional contends that due to existing programmatic and geographic barriers, the applicant has discharged only 29 of the

“hundreds and hundreds at PRMC who have diagnosis codes appropriate for rehabilitation”. The applicant contends that this demonstrates need for inpatient CMR services at PRCB. The applicant’s programmatic

access problems appear to be systematic in that the project is designed to serve patients in the HMA system.

PRCB’S CMR unit will have no impact on existing providers

The applicant maintains that the five existing CMR programs in District 8 are geographically and programmatically inaccessible to PRCB, and few PRCB patients currently utilize CMR programs elsewhere.


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Alternatives are inappropriate for CMR patients

The applicant discusses disadvantages and suboptimal outcomes when rehabilitation services are provided outside a licensed CMR facility, such

as at a skilled nursing facility or long-term acute care (LTAC) facility. The applicant states that in summary, CMR facilities and nursing homes provide different levels of service, with nursing homes not staffed or

equipped to provide intensive rehabilitation services that hospital-based CMR can provide. The applicant does not attempt to document sub-

optimal outcomes among residents of its proposed service area due to inappropriate placements among the various alternatives to CMR services.

CMR bed need analysis

The applicant offers two methodologies to prove that sufficient demand exists for the project. Methodology number one is described as an

average statewide resident use rate of hospital-based CMR discharges compared to the applicant’s service area population. Methodology number two is described as the applicant’s historical rehab appropriate

cases compared to total rehab cases discharged to hospital-based CMRs statewide. Both methodologies result in a stated bed need count of 20 to

22 beds by CY 2016. Because these bed need count estimates are approximately the same, for brevity, methodology number two is summarized below.

Methodology #2: Hospital-Based Need Methodology

The applicant states that in each of the last three years, PRCB discharged in excess of 116 patients that meet CMS primary diagnoses

requirements (referenced as CMS-13), sufficient in severity, to qualify as inpatient rehabilitation candidates. Additionally, the applicant’s sister facility, PRPR, discharged in excess of 268 patients who met these

criteria.

Physician’s Regional also states that in each of the last three years, PRCB discharged in excess of 38 stroke cases, and the applicant’s sister facility PRPR discharged between 51 and 151 stroke cases. Because

stroke cases typically benefit from CMR services, the applicant proposes to establish its program at the facility with lower stroke volume (28.1 percent of the two hospital system’s total—see chart below) located

approximately 10 miles from the system’s certified Comprehensive Stroke center, as part of a commitment to provide quality care.


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The applicant provides the following chart to demonstrate rehab

appropriate discharges at Physician Regional’s two facilities:

PRCB & PRPR

CMS-13 (Rehab Appropriate) Discharges by Category

12 Months Ending June 30, 2012 CMS Category

Hospital Discharges

PRCB PRPR

Amputation 0 3

Brain Injury 15 84

Burn 0 0

Hip Fracture 75 116

Joint Replacement, Age 85+ 5 45

Neuro 13 25

Rheumatoid Arthritis 1 3

Spinal Cord 4 53

Stroke 59 151

Trauma 0 1

CMS-13 Total 172 481


Rehabilitation Admissions at CRMC NONE-NO CMR UNIT

Rehabilitation Admissions as a Percent of Total Hospital Admissions NOT APPLICABLE Source: CON application #10187, page 50 from AHCA Inpatient Data Tapes and NHA Analysis.

Note: Discharges exclude obstetrics/gynecology, newborns, psychiatry, substance abuse and ages 0-17.

The applicant applies the 3.5 percent rate shown in the “Hospital Based

CMR Units CMS-13 (Rehab Appropriate) Discharges by Category for the 12 Months Ending June 30, 2012” table on page 27 of this report, to PRCB and PRPR total admissions (8,894), resulting in 389 rehab

appropriate patients, or 360 after adjusting for a lower, 90 percent capture rate at the Pine Ridge facility.

Per the applicant, 360 rehab appropriate admissions results in a need of 16 beds, an ADC of 13.1, and 4,788 patient days based on a 13.3 day

average length of stay. The projected bed need for years one and two are show below:

PRCB & PRPR’s CMR Bed Need

Calendar Years 2015 and 2016 2011 2015





Bed Need at 85% Occupancy 17 17 Source: CON application #10187 page 53.

Utilization forecast

Below is the applicant’s summary table to account for admissions,

patient days, average daily census (ADC) and occupancy rates for year one (CY 2015) and for year two (CY 2016). The applicant includes a

“ramp up” period for year one.


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PRCB 17-bed CMR Unit

Forecasted Utilization Years One and Two

Admissions by Quarter

Year One Based on Need and

Before Ramp Up Adjustment

Year One (2015) With Ramp Up

Adjustment

Year Two (2016) with Unit Size Adjustment

Quarter 1 116 39 109

Quarter 2 101 68 103

Quarter 3 74 74 76

Quarter 4 95 95 98



Average Daily Census N/A 10.0% 14.0%

Occupancy Rate N/A 59.0% 82.5% Source: CON application #10187 page 54.

As shown above, Physicians Regional projects an ADC of 10.0 and 59.0 percent occupancy in year one and an ADC of 14.0 and 82.5 percent

occupancy in year two. Venice HMA, LLC d/b/a Venice Regional Medical Center

(CON #10188), states nine “not normal” circumstances that justify need, as follows:

There is a disproportionately large percentage of elderly population in

the VRMC service area compared to both the Sarasota County and State averages; 50.4 percent of all adult residents are 65 and older compared to 38.6 in Sarasota County and 23.2 statewide.

The median age in the city of Venice is 67.7 years, 14.2 years older than Sarasota County’s overall population.

There are significantly more acute care patients admitted to VRMC who would qualify for admission to an inpatient rehabilitation

hospital as a post-acute option than there are, on average, in other hospitals across the State of Florida, even in those hospitals with

licensed CMR beds.


residents of the VRMC service area. Geographic inaccessibility is evidenced by excessive drive times compounded by a disproportionate elderly and seasonal population. Programmatic inaccessibility is

evidenced by the high occupancy in the county and district’s only freestanding CMR hospital and little vacancy in the county’s only hospital-based CMR unit.


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Even though Sarasota is home to 50 percent of the district’s 264

licensed CMR bed inventory, all 130 beds are clustered in the northern region of the county leading to lower accessibility for VRMC

service area residents. This is evidenced by the huge disparity in discharge use rates amongst those 65 and older, 1,635 rehab discharges per 1,000 population in the county excluding the VRMC

service area, compared to just 8.22 discharges per 1,000 population in the VRMC service area. The county’s overall discharge use rate in this age cohort is 12.65 discharges per 1,000 populations, brought

down nearly four points by VRMC’s service area.


come directly from within the acute care hospital or system. This is the case with the existing 34-bed unit at Sarasota Memorial as will be

the case with the proposed 22-bed unit at VRMC.


and post-acute providers and programming is imperative but is, unfortunately, not the case for many service area residents. As the case mix index (severity rating) of patients admitted to CMR programs

continues to increase, rehab appropriate patients at VFRMC experience a break in continuity of care as this level of care is not

currently available at VRMC or within southern Sarasota County.

In the past three years, VRMC’s stroke cases have increased 51.3

percent, from 300 cases up to 454 per year. Post discharge, these patients require intense inpatient rehabilitation to achieve greatest functional improvements.

VRMC is able to fully support a CMR program based on its own internal volume of rehab appropriate patients who reside within its

distinct service area.

Service area characteristics VRMC reports serving primarily six zip codes including Venice, Nokomis

and the northernmost zip code of Englewood. Per the applicant, half of the adults (as much as 65 percent in parts of Venice) in VRMC’s service area are aged 65 and older, the age group most likely to utilize CMR

services. Below are two tables the applicant provided to account for service area population, by age cohort, and growth changes.


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VRMC Service Area Population

Ages 18 and Older January 2013

Zip Code Area Ages 18-64 Ages 65+ Ages 18+ Percent of Adults 65+

34293 Venice 16,085 12,931 29,016 44.6%

34285 Venice 5,994 10,951 16,945 64.6%

34292 Venice 5,593 7,972 13,565 58.8%

34275 Nokomis 8,263 6,432 14,695 43.8%

34223 Englewood 7,388 7,917 15,305 51.7%

34287 North Port 11,609 9,516 21,125 45.0%

Service Area 54,932 55,719 110,651 50.4%

Source: CON application #10188, page #16.

The applicant indicates that 38.7 percent (64,483/166,831) of the adult service area is age 65 years and over. Per the applicant, the forecasted growth in the service area will be primarily in Charlotte County, with a

combined service area percentage increase in population of more than two percent annually during years 2013 to 2016.

CRMC Service Area Population Growth

Ages 18 and Older

2013 to 2016 County 2013, Ages 18+ 2016, Ages 18+ Incremental Growth

Charlotte 139,825 142,941 3,116

Desoto 27,006 27,082 76

Service Area 166,831 170,022 3,191 Source: CON application #10186, page #15.

CRMC Service Area Percent Growth

Ages 18 and Older

2013 to 2016 County Ages 18-64 Ages 65+ Ages 18+

Charlotte (1.4%) 7.3% 2.2%

Desoto (0.6%) 3.2% 0.3%

Service Area (1.2%) 6.9% 1.9% Source: CON application #10186, page #16.

District 8 CMR providers

Per the applicant, the 264 licensed CMR beds in District 8 had an

average occupancy rate of 63.5 percent for the 12-month period ending June 30, 2012. However, due to seasonal population changes, a nine to 10 point upswing occurs during the busy season, resulting in an

approximate occupancy rate of 90 percent in the district’s largest acute rehab program, HealthSouth Rehab Hospital of Sarasota.

VRMC’S CMR unit will have limited impact on existing providers

The applicant states that only one facility will be impacted by the proposed project; HealthSouth Rehab Hospital in Sarasota, which the applicant maintains is already operating at 80-90 percent capacity.


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Because the applicant will retain a board certified physiatrist already on

staff, there is no threat of loss of this position from other facilities.

Per the applicant, geographic barriers and mutually exclusive medical

staffs between VRMC and District 8 CMR providers ensure the proposed project will have no impact on existing providers. Venice Regional Medical Center does not document that the existing hospitals have

mutually exclusive physicians and that residents have geographic barriers to accessing rehab services. The applicant notes that it referred

228 patients to HealthSouth for CMR services during the 12 months ending June 30, 2012. The applicant’s programmatic access problems appear to be systematic in that the project is designed to serve patients

in the HMA system.

Alternatives are inappropriate for CMR patients The applicant discusses disadvantages and suboptimal outcomes when

rehabilitation services are provided outside a licensed CMR facility, such as at a skilled nursing facility or long-term acute care (LTAC) facility. Venice Regional Medical Center states that in summary, CMR facilities

and nursing homes provide different levels of service, with nursing homes not staffed or equipped to provide intensive rehabilitation services

that hospital-based CMR can provide. The applicant does not attempt to document sub-optimal outcomes among residents of its proposed service area due to inappropriate placements among the various alternatives to

CMR services. CMR bed need analysis

Venice Regional Medical Center offers two methodologies to prove that

sufficient demand exists for the project. Methodology number one is described as a population based need methodology applying two use rates—1) the Sarasota County rehabilitation use rate per thousand

population and 2) the Sarasota County rehabilitation use rate, excluding the VRMC service area population. The applicant provides two tables to

summarize forecasted CMR utilization.


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VRMC Service Area Forecasted CMR Utilization

Based on Sarasota County Use Rate Years One and Two

Year One Year Two

Ages 18-64

Ages 65+

Total 18+

Ages 18-64

Ages 65+

Total 18+

Service Area Population 54,143 58,646 112,789 53,749 60,110 113,859

Sarasota, County Use Rate 1.26 12.65 -- 1.26 12.65 --

Forecasted Rehab Cases 68 742 810 68 760 828

Average Length of Stay 13.3 13.3



Bed Need at 85% Occupancy 35 36 Source: CON application 10188, page 42.

Venice Regional Medical Center notes that applying the Sarasota County use rates to forecasted VRMC service area population results in 810 expected cases in 2015 increasing to 828 in 2016. Based on a 13.3

ALOS, identical to hospital-based CMR units throughout the state, VRMC forecasts 6,564 and 6,708 patient days in 2015 and 2016. With

an ADC of 29.5 in year one and 30.2 in year two, the result is a need for 36 beds by 2016 based on 85 percent occupancy.

VRMC next provides projections excluding its service area patients in the use rate to increase its projected need.

VRMC Service Area Forecasted CMR Utilization

Based on Sarasota County Use Rate, Excluding VRMC Service Area

Years One and Two Year One Year Two

Ages 18-64

Ages 65+

Total 18+

Ages 18-64

Ages 65+

Total 18+

Service Area Population 54,143 58,646 112,789 53,749 60,110 113,859

Sarasota, Excluding VRMC Service Area Use Rate

1.28

16.35

--

1.28

16.35

--

Forecasted Rehab Cases 69 959 1,028 69 983 1,052

Average Length of Stay 13.3 13.3



Bed Need at 85% Occupancy 44 45 Source: CON application 10188, page 43.

As shown above, the projected bed need is 44 to 45 beds in years one

and two, respectively. VRMC notes that removing the 228 patients it referred to HealthSouth reduces the bed need to 26 beds in the first population based need projection and to 35 in the second population

based methodology. The applicant’s population based projections appear to be somewhat optimistic. It is noted that VRMC proposes a 22-bed

CMR unit to meet the need.


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Methodology number two is described as based on the applicant’s

internal demand. This methodology results in a stated bed need count of 22 in CY 2015 and to 23 beds in CY 2016 at 85 percent occupancy. Methodology number two is summarized below.

The applicant states that during the 12-month period ending June 30, 2012, VRMC discharged 1,180 patients that met CMS primary diagnoses

requirements (referenced as CMS-13), sufficient in severity, to qualify as inpatient rehabilitation candidates. Four hundred and fifty four of these

were stroke cases. Because stroke cases typically benefit from CMR services, the applicant, a primary stroke care center, seeks to establish an inpatient CMR program as part of a commitment to provide quality

care.

Venice Regional Medical Center provides the following chart to demonstrate discharge patterns and rehab appropriate percentages:


CMS-13 (Rehab Appropriate) Discharges by Category 12 Months Ending June 30, 2012

CMS Category VRMC

Amputation 9

Brain Injury 173

Burn 2

Hip Fracture 322

Joint Replacement, Age 85+ 94

Neuro 79

Rheumatoid Arthritis 5

Spinal Cord 42

Stroke 454

Trauma 0

CMS-13 Total 1,180


Rehabilitation Admissions to the Above Hospitals NONE-NO CMR UNIT

Rehabilitation Admissions as a Percent of Total Hospital Admissions NOT APPLICABLE Source: CON application #10188, page 45, from AHCA Inpatient Data Tapes and NHA Analysis, Note: Discharges exclude obstetrics/gynecology, newborns, psychiatry, substance abuse and ages 0-17.

The applicant notes the 3.5 percent rate shown in the “Hospital Based

CMR Units CMS-13 (Rehab Appropriate) Discharges by Category for the 12 Months Ending June 30, 2012” table on page 27 of this report.

However, VRMC contends that since the rehab admissions as a percentage of CMS-13 discharges are nearly 40 percent (16,284/40,806), it is important to consider this statistic in light of VRMC’s patient

population and case volume. The applicant states that applying the 39.9 percent factor to VRMC’s total CMS-13 admissions results in 471 rehab appropriate patients (see the table below).


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VRMC & Florida Hospitals with CMR Units

Potential/Estimated Rehab Admissions 12 Months Ending June 30, 2012

Hospitals with CMR Units:

Hospital Discharges

CMS-13 40,806

Actual Rehab Admissions 16,284

Rehab as Percent of Hospital CMS-13 39.9%

VRMC:

CMS-13 1,180

Rehab as Percent of Hospital CMS-13 (Hospital-Based Units) 39.9%

Total Potential/Estimated Rehab Admissions 471 Source: CON application #10188, page 47, from AHCA Inpatient Data Tapes and NHA Analysis. Note: Discharges exclude obstetrics/gynecology, newborns, psychiatry, substance abuse and ages 0-17.

Per the applicant these 471 rehab appropriate admissions during the 12 months ending June 30, 2012, result in a need of 20 beds, an ADC of

17.2 patients, and 6,264 patient days based on a 13.3 day average length of stay.

Venice Regional states its population projections indicate that the 65 and older population will increase nearly eight percent or 2.7 percent per year

which will yield 507 admissions in year one. The projected bed need for years one and two are show below:

VRMC’s CMR Bed Need

Year One and Two Year One Year Two





Bed Need at 85% Occupancy 22 23 Source: CON Application #10188, page 47.

Utilization forecast

Below is the applicant’s summary table to account for admissions,

patient days, average daily census (ADC) and occupancy rates for year one (CY 2015) and for year two (CY 2016). The applicant includes a “ramp up” period for year one.


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VRMC 22-bed CMR Unit

Forecasted Utilization Years One and Two

Admissions by

Quarter

Year One Before Ramp Up

Adjustment

Year Two With Adjustments

Year Two

Quarter 1 98 32 102

Quarter 2 115 77 118

Quarter 3 142 142 143

Quarter 4 125 125 128



Average Daily Census N/A 13.7 17.9

Occupancy Rate N/A 62.3% 81.4% Source: CON application #10188, page 49.

2. Agency Rule Criteria:

Please indicate how each applicable preference for the type of service proposed is met. Refer to Chapter 59C-1.039, Florida

Administrative Code, for applicable preferences. a. General Provisions:

(1) Service Location. The CMR inpatient services regulated under

this rule may be provided in a hospital licensed as a general hospital or licensed as a specialty hospital.

The applicants all propose to add CMR units to licensed general hospitals.

(2) Separately Organized Units. CMR inpatient services shall be

provided in one or more separately organized unit within a

general hospital or specialty hospital.

ALL three co-batched applicants state the CMR unit will be

organized as a separate dedicated unit for CMR services.

(3) Minimum Number of Beds. A general hospital providing

comprehensive medical rehabilitation inpatient services should normally have a minimum of 20 comprehensive rehabilitation inpatient beds. A specialty hospital providing

CMR inpatient services shall have a minimum of 60 CMR inpatient beds.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) states the minimum size provision is


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outdated and does not take into consideration CMS regulations

and the “60 percent rule”. The applicant states its 15-bed CMR unit is appropriately sized to meet the rehab demands of the population within its service area.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) states the minimum size

provision is outdated and does not take into consideration CMS regulations and the “60 percent rule”. The applicant states its 17-

bed CMR unit is appropriately sized to meet the rehab demands of patients cared for by the applicant and the fresidents within its service area.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188)’s 22-bed CMR project is in compliance with this

standard.

(4) Conformance with Criteria for Approval. A CON for the

addition of new comprehensive medical rehabilitation beds shall not normally be approved unless the applicant meets the applicable review criteria in Section 408.035, Florida Statutes

and the standards of need determination criteria set forth in this rule.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical

Center (CON #10186) states that the establishment of a 15-bed unit meets the demand for CMR services in the applicant’s service

area. Naples HMA, LLC d/b/a Physicians Regional Medical Center-

Collier Boulevard (CON #10187) states the establishment of a 17-bed unit meets the demand for CMR services in the applicant’s

service area. Venice HMA, LLC d/b/a Venice Regional Medical Center

(CON #10188) states that the establishment of a 22-bed unit meets the demand for CMR services in the applicant’s service area.

(5) Medicare and Medicaid Participation. Applicants proposing to

establish a new comprehensive medical rehabilitation service shall state in their application that they will participate in the Medicare and Medicaid programs.


Center (CON #10186) states intent to participate in the Medicare and Medicaid programs. The applicant maintains that it will ensure the provision of care to underserved/underprivileged


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persons by conditioning project approval on a combined seven

percent of CMR patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) states intent to participate in the Medicare and Medicaid programs. The applicant maintains that it

will ensure the provision of care to underserved/underprivileged persons by conditioning project approval on a combined six

percent of CMR patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) states intent to ensure the provision of care to

underserved/underprivileged persons by conditioning project approval on a combined four percent of CMR patient days to a combination of Medicaid, Medicaid HMO and charity care

(including self-pay) patients.

b. Required Staffing and Services

(1) Director of Rehabilitation. CMR inpatient services must be

provided under the medical director of rehabilitation who is a board-certified or board-eligible physiatrist and has had at least two years of experience in the medical management of

inpatients requiring rehabilitation services.


Center (CON #10186) states the CMR program will be supervised by a board-certified or board-eligible physiatrist who will serve as

the medical director. The applicant anticipates recruiting a physician for this position and refers to Volume 2, Tab 11 of the application, which includes the “Inpatient Rehabilitation Seven

Rivers Regional Medical Center Policies and Procedures” adopted by CRMC that address the requirements of a medical director of

rehabilitation. Naples HMA, LLC d/b/a Physicians Regional Medical Center-

Collier Boulevard (CON #10187) states the CMR program will be supervised by a board-certified or board-eligible physiatrist with at least two years’ experience, who will serve as the medical director.

The applicant anticipates recruiting a physician for this position and will consider the four existing physiatrists on staff if desired.


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The applicant refers to Volume 2, Tab 11 of the application, which

includes the “Inpatient Rehabilitation Seven Rivers Regional Medical Center Policies and Procedures” adopted by CRMC that address the requirements of a medical director of rehabilitation.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) states Dr. Jeffrey R. Blood will be appointed

medical director of the proposed CMR unit. Dr. Blood is certified by the American Board of Physical Medicine and Rehabilitation,

and certified in Electro-diagnostic Medicine and Evaluation of Disability and Impairment Rating (CEDIR). Dr. Blood currently oversees the outpatient rehabilitation program at VRMC and is a

member of Gulf Coast Medical Group. The applicant refers to

Volume 2, Tab 10 of the application, which includes the “Inpatient Rehabilitation Seven Rivers Regional Medical Center Policies and Procedures” adopted by CRMC that address the requirements of a

medical director of rehabilitation.

(2) Other Required Services. In addition to the physician

services, CMR inpatients services shall include at least the following services provided by qualified personnel:

1. Rehabilitation nursing 2. Physical therapy

3. Occupational therapy 4. Speech therapy 5. Social services

6. Psychological services 7. Orthotic and prosthetic services

ALL three co-batched applicants state intent to provide all the services listed in 1-7 above, and therapeutic recreation and respiratory therapy.

A brief description of each CMR inpatient service is provided on

pages 65-69 of CON application #10186, pages 67-71 of CON application #10187, and pages 62-66 of CON application #10188.

(c) Criteria for Determination of Need:

(1) Bed Need. A favorable need determination for proposed new or

expanded comprehensive medical rehabilitation inpatient

services shall not normally be made unless a bed need exists according to the numeric need methodology in Rule 59C-1.039

(5) (c), Florida Administrative Code.


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All applicants note that the fixed need pool is zero. Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical

Center (CON #10186) states the proposal is outside the fixed need pool in response to nine special, not normal circumstances related to the lack of available and accessible CMR services in the service

area. Per the applicant, specific arguments that warrant approval are listed in item E, 1. c. above.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) states the proposal is outside

the fixed need pool in response to seven special, not normal circumstances related to the lack of available and accessible CMR

services in the service area. Per the applicant, specific arguments that warrant approval of the project are listed in item E, 1. c. above.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) states the proposal is outside the fixed need pool in

response to nine special, not normal circumstances related to the lack of available and accessible CMR services in the service area.

These arguments are listed in item E, 1. c. above.

(2) Most Recent Average Annual District Occupancy Rate.

Regardless of whether bed need is shown under the need formula in Rule 59C-1.039 (5) (c), no additional comprehensive medical rehabilitation inpatient beds shall normally be

approved for a district unless the average annual occupancy rate of the licensed comprehensive medical rehabilitation

inpatient beds in the district was at least 80 percent for the 12-month period ending six months prior to the beginning date of the quarter of the publication of the fixed bed need

pool.

The most recent average annual District 8 occupancy rate for beds was 63.45 percent. ALL applicants state their projects are based on not normal circumstances. Venice Regional Medical Center also

reiterates its contention about the geographic inaccessibility of CMR beds in the service area.


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(3) Priority Consideration for Comprehensive Medical Rehabilitation Inpatient Services Applicants. In weighing and balancing statutory and rule review criteria, the Agency will

give priority consideration to: (a) An applicant that is a disproportionate share hospital as

determined consistent with the provisions of section 409.911, Florida Statutes.

NONE of the applicants are low-income pool participating hospitals or disproportionate share hospitals. However, all

state their hospital maintains a charity care policy and provide services to patients who are financially unable to pay

for their care. Their policy and practice is to write off a patient’s entire account balance for charity and indigent care, and this policy will extend to patients admitted to the

CMR unit.

(b) An applicant proposing to serve Medicaid-eligible

persons.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) states intent to serve indigent/charity care and Medicaid patients in its CMR unit. Per the

applicant’s Schedule 7B, in year one and year two, the applicant will provide 5.46 and 6.14 percent of its total CMR patient days to Medicaid patients. The applicant conditions

the project to provide six percent of its patient days to a combination of Medicaid, Medicaid HMO and charity care

(including self-pay) patients. Naples HMA, LLC d/b/a Physicians Regional Medical

Center-Collier Boulevard (CON #10187) states intent to serve indigent/charity care and Medicaid patients in its CMR

unit. Per the applicant’s Schedule 7B, in year one and year two, the applicant will provide 6.90 and 6.91 percent of its total CMR patient days to Medicaid patients. The applicant

conditions the project to provide seven percent of its patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients.

Venice HMA, LLC d/b/a Venice Regional Medical Center

(CON #10188) states intent to serve indigent/charity care and Medicaid patients in its CMR unit. Per the applicant’s Schedule 7B, in year one and year two, the applicant will


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provide 4.99 and 5.01 percent of its total CMR patient days

to Medicaid patients. The applicant conditions the project to provide four percent of its patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-

pay) patients. (c) An applicant that is a designated trauma center, as

defined in Rule 64J-2.011, Florida Administrative Code.

Charlotte Regional Medical Center (CON #10186), Physicians Regional Medical Center-Collier Boulevard (CON #10187) and Venice Regional Medical Center

(CON #10188) are not designated trauma centers.

d. Access Standard. Comprehensive medical rehabilitation inpatient services should be available within a maximum ground travel time of two hours, under average travel conditions, for at least 90 percent

of the district’s total population.

The reviewer notes that the access standard is already currently met for

District 8 CMR services. The applicants reiterate the following:

Existing CMR facilities in District 8 are geographically and/or programmatically inaccessible (based on hospital competition) to residents of the applicant’s service area. The elderly will often forego

inpatient CMR, even when clinically appropriate, for suboptimal but more accessible modalities, such as SNF care, home health or outpatient therapy. Suboptimal care option impacts their ultimate outcome, often

resulting in suboptimal recovery, longer treatment times, lower functional independence, greater chance of future debilities, need for

additional care in the future and increased health care costs. The applicant’s project location would be geographically accessible to the residents within the service area.

e. Quality of Care

(1) Compliance with Agency Standards. Comprehensive medical

Rehabilitation inpatient services shall comply with the Agency

standards for program licensure described in section 59A-3, Florida Administrative Code. Applicants who submit an application that is consistent with the Agency licensure

standards are deemed to be in compliance with this provision.

All three applicants state intent for the project to comply with all Agency standards for licensure.


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f. Services Description. An applicant for comprehensive medical

rehabilitation inpatient services shall provide a detailed program description in its certificate of need application including:

(1) Age group to be served Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical

Center (CON #10186) states CMR services will be predominantly to patients in the 65 and older age cohort with all patients at least

18 years of age. The applicant will serve all patients regardless of race, creed, color, sex, age or national origin, as long as they meet the admission criteria.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-

Collier Boulevard (CON #10187) states CMR services will be to adults age 18 or older. The applicant expects a majority of patients will be age 65 and older.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) states CMR services will be predominantly to

patients in the 65 and older age cohort with all patients at least 18 years of age.

(2) Specialty inpatient rehabilitation services to be provided, if

any (e.g. spinal cord injury; brain injury)

ALL applicants state intent to:

provide a CMR program focused on the CMS 13 diagnoses

have programs designed to assure patients receive appropriate treatment, optimal outcomes and functional improvement in the

shortest time, and

seek specialty certification by The Joint Commission for its

stroke rehabilitation program.

(3) Proposed staffing, including qualifications of the medical

director, a description of staffing appropriate for any specialty program and a discussion of the training and experience requirements for all staff who will provide comprehensive

medical rehabilitation inpatient services.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) provides the following staffing pattern for year one and two of its CMR program.


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Staffing Pattern For CON Application #10186

Year One Ending 12/31/2015 Total FTEs added for

this project

Year Two Ending 12/31/2016

Total FTEs added for this project

ADMINISTRATION

Nursing Administration 1.0 1.0

NURSING (12 HR Shifts)

RNs 10.0 12.0

LPNs 1.0 1.0

Nurses’ Aides/Unit Secretary 7.0 8.0

ANCILLARY

Physical Therapist 4.0 6.0

Other: Lab/Rad/Pharmacy/RT/Other 4.0 5.0

Speech Therapy 1.5 1.5

Occupational Therapist 2.5 2.5

DIETARY

Dietary Aides 1.0 1.0

SOCIAL SERVICES

Resource Manager 1.0 1.0

GRAND TOTAL 33.0 39.0

Source: CON application #10186, Schedule 6A for year one and two.


Collier Boulevard (CON #10187) provides this staffing pattern for year one and two of its CMR program:

Staffing Pattern For CON Application #10187 Year One

Ending CY 2015 Total FTEs added for

this project

Year Two Ending CY 2016

Total FTEs added for this

project

ADMINISTRATION

Director of Nursing 1.0 1.0

Bookkeeper 1.0 1.0


RNs 15.0 20.0

Nurses’ Aides 8.0 8.0

ANCILLARY

Physical Therapist 6.0 7.5

Speech Therapist 2.0 3.0


Other 5.0 5.0

SOCIAL SERVICES

Other: Resource Manager 1.0 1.0

PLANT MAINTENANCE

Maintenance Assistant 1.0 1.0



Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) provides the following staffing pattern for year one

and two of its CMR program. It is noted that the applicant’s Schedules 7, 8 and 10 indicate the project’s years one and two end June 2015 and June 2016. The applicant’s Schedule 6A states

years one and two end is as in the table below.


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Staffing Pattern For CON Application #10188

Year One Ending 12/31/2014 Total FTEs added for

project

Year Two Ending 12/31/2015 Total FTEs added for

project

ADMINISTRATION

Nursing Administration 1.0 1.0

Accounting/Business Office/IS 1.0


RNs 10.0 12.0

LPNs 1.0 2.0

Nurses’ Aides/Unit Secretary 8.0 9.0

ANCILLARY

Speech Therapist 1.5 2.5

Physical Therapist/ Assistant 5.5 6.0


Other: Lab/Radiology/Pharmacy/RT 4.0 5.0

DIETARY

Cooks/Dietary Aides 1.0 1.0

SOCIAL SERVICES

Resource Managers 1.0 1.0

PLANT MAINTENANCE

Maintenance Assistant 1.0



(4) A plan for recruiting staff, showing expected sources of staff. ALL applicants state numerous recruitment and retention methods

to staff the CMR unit, including:

in-house job postings

HMA corporate recruiting and other HMA hospitals around the

country

professional recruitment firms

advertisement in local newspapers/specialty newsletters

medical and dental insurance

paid holidays and sick leave

retirement savings plan (401k), and life insurance

leadership development opportunities.

(5) Expected sources of patient referrals

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) expects its CMR unit patients to come

“primarily” from both CRMC’s and PRRMC’s medical/surgical patients being discharged from other units within the hospital.

Some are expected from nursing homes as well.


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Collier Boulevard (CON #10187) expects its CMR unit patients to come “primarily” from both Physician Regional hospitals’ medical/surgical patients being discharged from other units within

the hospital. Some are expected from nursing homes as well. Venice HMA, LLC d/b/a Venice Regional Medical Center

(CON #10188) expects its CMR unit patients to come “primarily” from the hospital’s own units (discharge from within the hospital).

Some are expected from nursing homes as well.

(6) Projected number of comprehensive medical rehabilitation

inpatient services patient days by payer type, including Medicare, Medicaid, private insurance, self-pay and charity

care patient days for the first two years of operation after completion of the proposed project.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) expects 3,883 total patient days in year one and 4,486 patient days in year two. The expected payer mix for

the first two years is shown below. The applicant’s Schedule 7A indicates zero Medicare HMO and zero Medicaid HMO patient days.

Charlotte Regional Medical Center (CON application #10186)

Projected CMR Payer Mix for Calendar Years 2015 & 2016 CY 2015 CY 2016

Patient Days Patient Days

Medicare 2,706 3,126

Other Managed Care 767 886

Medicaid 268 310

Self-Pay/Charity 142 164

Total 3,883 4,486 Source: CON application #10186, Page 82.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) presents the following

information showing payer type in years one and two of the proposed project. The applicant’s Schedule 7A indicates zero

Medicaid HMO and Medicare HMO patient days.

Physicians Regional Medical Center (CON application #10187)

Projected CMR Payer Mix for Calendar Years 2015 & 2016 CY 2015 CY 2016

Patient Days Percent Patient Days Percent

Medicare 2,300 62.81% 3,169 61.73%

Other Managed Care 712 19.44% 1,000 19.48%

Commercial Insurance HMO/PPO 250 6.83% 350 6.82%

Medicaid 200 5.46% 315 6.14%

Self-Pay/Charity 200 5.46% 300 5.84%

Total 3,662 100.00% 5,134 100.00% Source: CON application #10187, Schedule 7A.


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Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) includes the following information showing payer type in years one and two of the proposed project. The applicant’s

Schedule 7B indicates zero Medicaid HMO and Medicare HMO patient days.

Venice Regional Medical Center (CON application #10188)

Projected CMR Payer Mix for Years Ending June 30, 2015 & 2016 Ending 6/30/2015 Ending 6/30/2016

Patient Days Percent Patient Days Percent

Medicare 3,754 74.99% 4,898 75.00%

Other Managed Care 501 10.01% 653 10.00%

Commercial Insurance HMO/PPO 300 5.99% 392 6.00%

Medicaid 250 4.99% 327 5.01%

Self-Pay/Charity 200 4.00% 261 4.00%

Total 5,006 99.98% 6,530 100.01% Source: CON application #10188, Schedule 7B.

(7) Admission policies of the facility with regard to charity care

patients.


Center (CON #10186) states it provides services to patients financially unable to pay for their care and maintains a charity care policy. The applicant conditions its project to provide seven

percent of its annual CMR patient days to the combination of Medicaid, Medicaid HMO and charity (including self-pay) patients.


Collier Boulevard (CON #10187) states it currently maintains a charity care policy and will extend charity care to CMR patients.

The applicant conditions its project to provide six percent of its annual CMR patient days to the combination of Medicaid, Medicaid HMO and charity (including self-pay) patients.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) states it maintains a charity care policy and provides services to patients financially unable to pay for their

care. The applicant conditions its project to provide four percent of its annual CMR patient days to the combination of Medicaid,

Medicaid HMO and charity (including self-pay) patients.


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(g) Utilization Reports. Facilities providing licensed comprehensive

medical rehabilitation inpatient services shall provide utilization reports to the Agency or its designee, as follows:

(1) Within 45 days after the end of each calendar quarter, facilities shall provide a report of the number of comprehensive medical rehabilitation inpatient services

discharges and patient days which occurred during the quarter.

(2) Within 45 days after the end of each calendar year, facilities

shall provide a report of the number of comprehensive medical

rehabilitation days which occurred during the year, by principal diagnosis coded consistent with the International

Classification of Diseases (ICD-9). ALL applicants state they comply with reporting requirements of

the Agency and the local health council and will timely report relevant CMR program data, in addition to sufficient data to demonstrate compliance with its stated conditions for the project.

3. Statutory Review Criteria a. Is need for the project evidenced by the availability, quality of care,

accessibility and extent of utilization of existing health care facilities and health services in the applicant’s service area? ss. 408.035(1)(a) and (b), Florida Statutes.

As of June 30, 2012, District 8 had 264 licensed CMR beds. During the

12-month period ending June 30, 2012, District 8’s licensed CMR beds experienced 63.45 percent utilization. There are no approved CMR beds pending licensure. The three co-batched applicants are applying outside

of the fixed need pool. Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center

(CON #10186):

Availability and Extent of Utilization

CRMC indicates that although District 8 has 264 licensed CMR beds, only one CMR provider (Fawcett Memorial Hospital in Port Charlotte) exists between Charlotte and Desoto Counties. Per the applicant, CMR

beds are utilized primarily by the elderly, aged 65 and older, who may forgo inpatient rehabilitation level of care for suboptimal modalities due

to limited access to CMR programs.


53

The applicant indicates that discharge rates among residents age 65 and older provides insight into the underutilization of CMR beds in Charlotte and Desoto Counties. Per the applicant, these two counties have lower

discharge use rates per 1000 population compared to District 8 counties and the 11 state health planning districts. The table below is used by two applicants, CRMC and PRCB, and presents rehab discharge use

rates for the districts and state.

State of Florida by District

Rehabilitation Discharge Use Rate per 1,000 Population 12 Months Ending June 30, 2012

District Ages 18-64 Ages 65+

District 1 0.60 4.87

District 2 1.26 18.94








District 10 1.24 12.95

District 11 1.00 11.49

Florida Total 0.84 7.62 Source: CON application #10186, page 43, CON application #10187, page 43, from Florida Population Estimates, February 2012, Agency Inpatient Data Tapes and NHA Analysis.

The applicant states that when use rates are compared at the county level, it becomes clear that District 8 use rates are driven up by residents

in two existing CMR programs in Sarasota County. The chart below is used by two applicants, CRMC and PRCB, to demonstrate District 8 CMR

Discharge Use Rate per 1,000 Population for the 12 month period ending June 30, 2012.

District 8

CMR Discharge Use Rate per 1,000 Population

12-Month Period Ending June 30, 2012 County Ages 18-64 Ages 65+

Charlotte 0.75 3.3

Collier 0.72 5.1

Desoto 0.53 5.3

Glades 0.26 1.4

Hendry 0.43 3.5

Lee 0.70 4.2

Sarasota 1.26 12.6

District 8 0.82 6.7

District 8 Less Sarasota 0.69 4.3

Florida 0.84 7.62 Source: CON application #10186, page 44, CON application #10187, page 45, from Florida Population

Estimates, February 2012, Agency Inpatient Data Tapes and NHA Analysis.


54

The applicant states that the statewide adult use rate is considerably

higher than that of Charlotte and Desoto Counties, suggesting evidence of an underserved market.

In order to demonstrate the actual bed to resident ratio in the service area, the applicant provides the chart below, isolating Charlotte and Desoto Counties from the rest of District 8.

Resident Population per Licensed & Approved CMR Beds

January 2012 District Ages 18+

District 2 3,831

District 10 4,486

District 9 4,643

District 8 4,932

District 5 5,381

District 11 5,436

District 4 5,586

District 1 6,951

District 7 7,638

Charlotte/Desoto 8,276

District 3 8,372

District 6 10,296

Florida Average 5,850 Source: CON Application #10186, page 89, from Florida Population Estimates, February 2012, Agency Inpatient Data Tapes and NHA Analysis.

This chart demonstrates the rehab bed to resident population ratio is 1:8,276, “one of the worst in the state”.

CRMC states that if approved, the 15-bed CMR unit at CRMC would equalize the bed to resident ratio closer to the District 8 overall ratio,

improving the Charlotte/Desoto bed to resident ratio from 1:8,276 to 1:4,729. The District 8 ratio will improve from 1:4,932 to 1:4,667.

Quality of Care

The applicant indicates that a new CMR program at CRMC will improve quality of care for patients in this service area, improving patient

outcomes as a result of participation in a program currently inaccessible to many residents.

Efficiency CRMC states it will be an efficient/cost-effective provider of CMR services

at a reasonable price. Additionally, the backing of the parent, HMA, an experienced provider of cost-effective care, will benefit the efficiency of

the program.


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Accessibility

CRMC reiterates its contention that CMR beds are geographically and programmatically inaccessible to residents of the CMRC and PRRMC

service area. Although a 20-bed CMR unit exists at Fawcett Memorial, “virtually across the street” from PRRMC, it is an HCA facility. The applicant states that residents are “loyal to either the HMA hospitals or

Fawcett Memorial; the same holds true for the respective medical staffs”, with medical staffs of CRMC and PRRMC mutually exclusive from

Fawcett Memorial. This presents a disruption in continuity of care for patients transferred from CRMC to the CMR unit at Fawcett Memorial.

The applicant maintains that the remaining CMR programs in District 8 are geographically inaccessible and/or programmatically inaccessible to

the CRMC/PRRMC service area. CRMC fails to provide documentation of problems that have resulted from the current CMR referral arrangement in Charlotte County.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187):


The applicant indicates that although District 8 has 264 licensed CMR beds, only one CMR provider exists in Collier County, the 54-bed CMR

unit at North Naples Hospital, part of the NCH Healthcare System, the largest and only hospital competition to PRCB. Per the applicant, CMR beds are utilized primarily by the elderly, aged 65 and older, who may

forgo inpatient rehabilitation level of care for suboptimal modalities due to limited access to CMR programs.

Physicians Regional Medical Center-Collier Blvd. indicates that discharge rates among residents age 65 and older provides insight into the

underutilization of CMR beds in Collier County. Per the applicant, Collier County experiences lower discharge use rates per 1000

population compared to District 8 counties and the 11 state health planning districts.

The applicant provides the chart “District 8 CMR Discharge Use Rates

per 1,000 Population During the 12 Month Period Ending June 30, 2012” on page 53 of this report, to show that when viewed at a county level, the use rates of those ages 65 and older are “nearly 50 percent

lower in Collier County than the statewide rate and 31 percent lower than use rates for District 8”. The reviewer notes that the CMR

discharge use rates per 1,000 population during this period in Collier


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County is shown in the chart as 5.1 per 1,000 population, District 8 as

6.7 per 1,000 population, and the state of Florida as 7.62 per 1,000 population ages 65 and over.

Quality of Care Physicians Regional Medical Center-Collier Blvd. indicates that a new

CMR program at PRCB will improve quality of care for patients in this service area, improving patient outcomes as a result of participation in a

program currently inaccessible to many residents. Efficiency

The applicant states it will be an efficient/cost-effective provider of CMR

services at a reasonable price. Additionally, the backing of the parent, HMA, an experienced provider of cost-effective care, will benefit the efficiency of the program.

Accessibility

PRMC states the only Collier County CMR unit, North Naples Hospital, is intended to meet the needs of its own acute care patients, with “virtually

no overlap of physicians between the two health systems”, and thus negatively impacts continuity of care for patients of PRCB.

Per the applicant, the remaining CMR programs in District 8 are programmatically and/or geographically inaccessible to Collier County residents. To demonstrate this impact, the applicant has provided the

following chart, showing only 10 Collier County residents were treated in a CMR program “outside Collier County but inside District 8, proving

these programs are not accessible to Collier County residents despite an arbitrary drive time standard.” Additionally, the applicant maintains that only 26 patients within PRMC hospitals in Collier County were

admitted to NCH’s rehab program, suggesting patients from two of the four Collier County hospitals lack access to a District 8 CMR program.

District VIII CMR Providers Outside Collier County

Discharges by County of Residence

12 Months Ending June 30, 2012 Hospital

Collier County Resident

Discharges

Total

Discharges

Percent Collier County

Discharges

Fawcett Memorial Hospital 0 144 0.0%

Lee Memorial Hospital 9 888 1.0%

HealthSouth Rehab Hospital of Sarasota 1 2,017 0.0

Sarasota Memorial Hospital 0 688 0.0%

Total 10 3,737 0.3% Source: CON application #10187 page 35, from Agency Data Tapes and NHA Analysis.


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Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188):


The applicant states that two CMR providers with 130 aggregated

licensed beds exist in Sarasota County, and operate on a combined basis above 80 percent occupancy. Demand for CMR beds at VRMC is “tremendous”, and the proposed 22-bed CMR unit is “absolutely

necessary” in order to provide quality care to VRMC patients.

Per the applicant, the population of the service area of VRMC is unique, with the city of Venice average age being 13-14 years older than the average resident age of Sarasota County, with an anticipated median age

of 69 in the city of Venice by year 2018. Because CMR services are most often utilized by those ages 65 and older, the need for this project is high.

VRMC indicates that the discharge use rate for CMR services in the

VRMC service area is just 8.22 per 1,000 populations, compared to 12.65 per 1,000 populations in Sarasota County.

Accessibility

Per the applicant, CMR beds are geographically and programmatically inaccessible to VRMC acute care patients in need of inpatient rehabilitation. Although these programs are within the two-hour

standard drive time indicated for service area residents, this poses a burden to elderly populations, particularly during winter months when traffic patterns are congested. The applicant does not document that

Sarasota residents in need of CMR services were unable to access them.

Quality of Care The applicant indicates that a new CMR program at VRMC will improve

quality of care for patients in this service area, improving patient outcomes as a result of participation in a program currently inaccessible to many residents.

Efficiency

VRMC states it will be an efficient/cost-effective provider of CMR services at a reasonable price. Additionally, the backing of the parent, HMA, an

experienced provider of cost-effective care, will benefit the efficiency of the program.


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b. Does the applicant have a history of providing quality of care? Has

the applicant demonstrated the ability to provide quality care? ss. 408.035(1)(c), Florida Statutes.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) provides Joint Commission hospital accreditation and is an Agency accredited designated primary stroke center, a program that

holds the Joint Commission’s Gold Seal of Approval. CRMC was awarded the Silver Plus Designation from the American Heart

Association’s “Get with the Guidelines” Program. The Joint Commission recognized CRMC as one of 41 HMA Top Performers on Key Quality Measures™ hospitals for quality and safety; only the top 18 percent of

Joint Commission-accredited hospitals achieve this recognition. The applicant provided documentation of awards with the application

(CON #10186, Volume 2, Tab 5). CRMC indicates that it will use the Uniform Data System (UDS), the

“most widely used system in the world” for documenting severity of patient disability and outcomes for medical rehabilitation for the proposed project. The applicant indicates patient improvement will be

measured by a functional independence measure score, with a FIM score upon program discharge minus a FIM score upon admission being the

“FIM gain” or patient progress. CRMC also discusses that activities of daily living (ADL) training will be coordinated through occupational therapy services. All these measures and programs are stated to result

in optimum outcomes. The parent, HMA, has 24 licensed hospitals in Florida with a total of

3,516 beds. Agency data indicates that HMA affiliated hospitals had 87 substantiated complaints for the three-year period ending April 10, 2013.

A single complaint can encompass multiple complaint categories. The table below has these listed by complaint categories.


59

HMA Substantiated Complaint Categories in the Past 36 Months Complaint Category Number Substantiated

Quality of Care/Treatment 40

Nursing Services 17

Resident/Patient/Client Assessment 16

Admission, Transfer & Discharge Rights 12

Administration/Personnel 8

Resident/Patient/Client Rights 6

Emergency Access 6

Physician Services 3

Infection Control 3

EMTALA 3

Resident/Patient/Client Abuse 2

State Licensure 2

Physical Environment 2

Falsification of Records/Reports 2

Restraints/Seclusion General 2

Dietary Services 1 Source: Agency for Health Care Administration complaint records.

Charlotte Regional Medical Center had six substantiated complaints during the three-year period ending April 10, 2013. These substantiated

complaints are identified in the table below.


Substantiated Complaint Categories in the Past 36 Months Complaint Category Number Substantiated

Quality of Care/Treatment 1

Physical Environment 1

Admission, Transfer & Discharge Rights 1

Resident/Patient/Client Assessment 1

Resident/Patient/Client Rights 1

State Licensure 1 Source: Agency for Health Care Administration complaint records.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) provides Joint Commission hospital

accreditation and is an Agency accredited certified comprehensive stroke center, a program that has received the Joint Commission’s Top Performers on Key Quality Measures Award for the past two years. The

Joint Commission recognized PRCB as one of 41 HMA Top Performers on Key Quality Measures™ hospitals for quality and safety. Only the top 18

percent of Joint Commission-accredited hospitals achieve this recognition. The applicant states plans to seek Joint Commission disease-specific certification of its stroke rehabilitation program which it

will initiate immediately upon licensure. Naples HMA, LLC provided documentation of awards with the application (CON #10187, Volume 2, Tab 8).

Per Naples HMA, LLC, the Uniform Data System (UDS) is the “most

widely used system in the world” for documenting severity of patient disability and outcomes for medical rehabilitation. Again, per the


60

applicant, the UDS will be used for the proposed project. The applicant

indicates patient improvement will be measured by a functional independence measure score, with a FIM score upon program discharge minus a FIM score upon admission being the “FIM gain” or patient

progress. The applicant also discusses that activities of daily living (ADL) training will be coordinated through occupational therapy services. All these measures and programs are stated to result in optimum outcomes.

During the three-year period ending April 10, 2013, PRCB had no

substantiated complaints. Venice HMA, LLC d/b/a Venice Regional Medical Center

(CON #10188) provides Joint Commission hospital accreditation, with Joint Commission certification for its Heart Failure Program, and is an

Agency accredited designated primary stroke center. Additionally, VRMC was awarded the Joint Commissions’ Top Performer on Key Quality Measures ™ and a “Get with the Gold Guidelines-Stroke” Silver Plus

Achievement Award (CON application #10188, Volume 2, Tab 5). The applicant states plans to seek Joint Commission disease-specific certification of its stroke rehabilitation program which it will initiate

immediately upon licensure. Venice HMA, LLC provides a copy of its 2012 Performance Improvement Plan, which it states assures delivery of

the highest possible patient care (CON application #10188, Volume 2, Tab 7). Per the applicant, the UDS will be used for the proposed project. Venice HMA, LLC indicates patient improvement will be measured by a

functional independence measure score, with a FIM score upon program discharge minus a FIM score upon admission being the “FIM gain” or patient progress. The applicant also discusses that activities of daily

living (ADL) training will be coordinated through occupational therapy services. All these measures and programs are stated to result in

optimum outcomes. During the three-year period ending April 10, 2013, VRMC had four

substantiated complaints, one in each of the following categories: quality of care/treatment, infection control, resident/patient/client rights, and

resident/patient/client abuse.

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(1)(d), Florida Statutes.

ALL applicants provided Health Management Associates, Inc. (the

parent’s), audited financial statement, which was reviewed to access the financial position as of the balance sheet date and the financial strength of its operations for the period presented.


61

Short-Term Position - Parent: The parent’s current ratio of 1.5 is below average and indicates current assets are approximately 1.5 times current liabilities, an adequate

position. The working capital (current assets less current liabilities) of $498.8 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.6 is

slightly below average and an adequate position. Overall, the parent has an adequate short-term position (see Table1).

Long-Term Position - Parent: The ratio of long-term debt to net assets of 3.4 is well above average and

indicates that long-term debt is greater than equity, a weak position. The ratio of cash flow to assets of 9.3 percent is average and an adequate

position. The most recent year had revenues in excess of expenses of $301.5 million which resulted in a 5.1 percent operating margin. Overall, the parent has an adequate long-term position (see Table1).

TABLE 1

HMA, Inc. (CON applications 10186-10188)

HMA(Parent)

HMA(Parent)

12/31/12

12/31/11

Current Assets (CA) $1,471,248,000

$1,410,138,000

Cash and Current Investment $180,279,000

$186,420,000

Total Assets (TA) $6,400,789,000

$6,004,189,000

Current Liabilities (CL) $972,423,000

$803,824,000

Goodwill $1,023,456,000

$999,380,000

Total Liabilities (TL) $5,167,806,000

$5,018,430,000

Net Assets (NA) $1,232,983,000

$985,759,000

Total Revenues (TR) $5,878,238,000

$5,087,595,000

Interest Expense (Int) $312,547,000

$222,747,000

Excess of Revenues Over Expenses (ER) $301,481,000

$312,405,000

Cash Flow from Operations (CFO) $597,379,000

$544,022,000

Working Capital $498,825,000

$606,314,000

FINANCIAL RATIOS

12/31/12

12/31/11

Current Ratio (CA/CL) 1.5

1.8

Cash Flow to Current Liabilities (CFO/CL) 0.6

0.7

Long-Term Debt to Net Assets (TL-CL/NA) 3.4

4.3

Times Interest Earned (ER+Int/Int) 2.0

2.4

Net Assets to Total Assets (NA/TA) 19.3%

16.4%

Operating Margin (ER/TR) 5.1%

6.1%

Return on Assets (ER/TA) 4.7%

5.2%

Operating Cash Flow to Assets (CFO/TA) 9.3% 9.1%


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Available Capital:

The applicants indicate on the Schedule 3 of their applications that funding for the project will be provided cash flow from operations and by the parent. A letter from the parent’s chief financial officer in support of

the related company financing was included. The parent’s 2012, audited financial statements shows $498.8 million in working capital and $597.4 million in cash flow from operations.

Staffing: Staffing patterns for the applicants are displayed in their

response to item E. 2. f. (3). Financial Impact and Capital Requirements:

Charlotte Regional Medical Center (CON #10186): Financial impact of

the project will include the project cost of $1,836,379 and year two operating costs of $3,992,492. The applicant indicates on Schedule 2 capital projects totaling $6.8 million which includes this project and

capital expenditures. Physicians Regional Medical Center-Collier Blvd. (CON #10187):

Financial impact of the project will include the project cost of $4,093,736 and year two operating costs of $4,779,936. The applicant indicates on

Schedule 2 capital projects totaling $12.7 million which includes this project and capital expenditures.

Venice Regional Medical Center (CON #10188): Financial impact of the project will include the project cost of $4,564,819 and year two operating costs of $4,860,580. The applicant indicates on Schedule 2

capital projects totaling $29.6 million which includes this project and capital expenditures.

Conclusion—ALL applicants: Funding for the project and the entire capital budget should be available as needed.

d. What is the immediate and long-term financial feasibility of the

proposal? ss. 408.035(1)(f), Florida Statutes. The following applies to ALL applicants.

A comparison of the applicant’s estimates to the control group values provides for an objective evaluation of financial feasibility, (the likelihood

that the services can be provided under the parameters and conditions contained in Schedules 7 and 8), and efficiency, (the degree of economies

achievable through the skill and management of the applicant). In general, projections that approximate the median are the most desirable, and balance the opposing forces of feasibility and efficiency. In other


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words, as estimates approach the highest in the group, it is more likely

that the project is feasible, because fewer economies must be realized to achieve the desired outcome. Conversely, as estimates approach the lowest in the group, it is less likely that the project is feasible, because a

much higher level of economies must be realized to achieve the desired outcome. These relationships hold true for a constant intensity of service through the relevant range of outcomes. As these relationships go

beyond the relevant range of outcomes, revenues and expenses may, either, go beyond what the market will tolerate, or may decrease to levels

where activities are no longer sustainable. Comparative data were derived from hospitals in peer groups that

reported data in 2011; the applicant will be compared to the hospitals in Group 4, Medium Urban Hospital Group. Group 4 has a total of 24

facilities, including the applicant. Per diem rates are projected to increase by an average of 2.6 percent per year. Inflation adjustments were based on the new CMS Market Basket, 4th Quarter, 2012.

Gross revenues, net revenues, and costs were obtained from Schedules 7 and 8 in the financial portion of the application and compared to the

control group as a calculated amount per adjusted patient day.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186): Projected net revenue per adjusted patient day (NRAPD) of $1,400 in year one and $1,433 in year two is lower than the control

group’s lowest value of $1,549 in year one, and $1,589 in year two. With net revenues lower the control group’s lowest value, net revenues appear to be understated (see Tables 2 and 3).

Anticipated cost per adjusted patient day (CAPD) of $1,376 in year one

and $1,405 in year two is lower than the control group’s lowest value of $1,587 in year one, and $1,628 in year two. With CAPD lower the control group’s lowest value, costs appear to be understated (see Tables 2

and 3). The applicant is projecting an increase in CAPD between year one and year two of $29, or 2.1 percent.

The year two projected operating income for the project of $1.8 million computes to an operating margin per adjusted patient day of $29 or 2.0

percent which is between the control group lowest and median values of -$299 and $97. With operating margin between the control group lowest and median values, operating margin appears reasonable (see Table 3).

Conclusion: This project appears to be financially feasible.


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TABLE 2

Charlotte Regional Medical Center CON application #10186 Dec-15 YEAR 1

VALUES ADJUSTED

MEDIUM URBAN HOSPITAL GROUP (TERTIARY) YEAR 1 ACTIVITY

FOR INFLATION

ACTIVITY PER DAY

Highest Median Lowest

ROUTINE SERVICES 435,639,000 7,201

2,230 1,150 303

INPATIENT AMBULATORY 0 0

913 225 71

INPATIENT SURGERY 0 0

0 0 0

INPATIENT ANCILLARY SERVICES 0 0

10,868 6,125 2,088

OUTPATIENT SERVICES 205,950,000 3,404

6,775 4,023 2,718

TOTAL PATIENT SERVICES REV. 641,589,000 10,605

17,995 11,589 6,459

OTHER OPERATING REVENUE 480,000 8

109 23 5

TOTAL REVENUE 642,069,000 10,613

18,003 11,608 6,498

DEDUCTIONS FROM REVENUE 557,392,371 9,213

0 0 0

NET REVENUES 84,676,629 1,400

2,764 2,080 1,549

EXPENSES ROUTINE 18,734,293 310

392 303 184

ANCILLARY 23,372,750 386

1,180 750 595

AMBULATORY 0 0

0 0 0

TOTAL PATIENT CARE COST 42,107,043 696

0 0 0

ADMIN. AND OVERHEAD 28,141,159 465

0 0 0

PROPERTY 8,524,213 141

0 0 0

TOTAL OVERHEAD EXPENSE 36,665,372 606

1,223 873 622

OTHER OPERATING EXPENSE 4,472,708 74

0 0 0

TOTAL EXPENSES 83,245,123 1,376

2,662 2,000 1,587

OPERATING INCOME 1,431,506 24

450 97 -299

1.7%

PATIENT DAYS 41,048 ADJUSTED PATIENT DAYS 60,499 TOTAL BED DAYS AVAILABLE 75,920

VALUES NOT ADJUSTED

ADJ. FACTOR 0.6785

FOR INFLATION

TOTAL NUMBER OF BEDS 208


PERCENT OCCUPANCY 54.07%

77.4% 54.5% 24.1%

PAYER TYPE

PATIENT DAYS % TOTAL

SELF PAY 1,503 3.7% MEDICAID 2,831 6.9%

14.4% 7.2% 0.4%

MEDICAID HMO 0 0.0% MEDICARE 28,606 69.7%

66.1% 52.1% 32.0%

MEDICARE HMO 0 0.0% INSURANCE 0 0.0% HMO/PPO 8,108 19.8%

59.3% 33.6% 15.6%

OTHER 0 0.0% TOTAL 41,048 100%


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TABLE 3

Charlotte Regional Medical Center CON application #10186 Dec-16 YEAR 2

VALUES ADJUSTED


FOR INFLATION

ACTIVITY PER DAY



2,287 1,180 311


936 231 73


0 0 0


11,148 6,283 2,141


6,950 4,127 2,788


18,459 11,887 6,625


112 24 5

TOTAL REVENUE 689,629,750 11,319

18,467 11,907 6,665


0 0 0

NET REVENUES 87,333,136 1,433

2,835 2,133 1,589


402 311 189

ANCILLARY 24,216,511 397

1,211 769 611

AMBULATORY 0 0

0 0 0

TOTAL PATIENT CARE COST 43,546,513 715

0 0 0


0 0 0

PROPERTY 8,744,670 144

0 0 0


1,255 895 638


0 0 0


2,731 2,051 1,628


450 97 -299

2.0%


VALUES NOT ADJUSTED

ADJ. FACTOR 0.6798

FOR INFLATION




77.4% 54.5% 24.1%

PAYER TYPE PATIENT DAYS % TOTAL SELF PAY 1,516 3.7% MEDICAID 2,857 6.9%

14.4% 7.2% 0.4%


66.1% 52.1% 32.0%

MEDICARE HMO 0 0.0% INSURANCE 0 0.0% HMO/PPO 8,181 19.8%

59.3% 33.6% 15.6%

OTHER 0 0.0% TOTAL 41,416 100%


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Boulevard (CON #10187): The applicant failed to provide outpatient revenue on Schedule 7. This omission results in no adjustment to patient days for outpatient services. Therefore, the patient day data

calculated below and on Tables 2 and 3 for the applicant will be overstated.

Projected net revenue per adjusted patient day (NRAPD) of $4,361 in year one and $4,325 in year two is higher than the control group’s highest

value of $2,948 in year one, and $3,024 in year two. With net revenues higher the control group’s highest value, net revenues appear to be overstated (see Tables 2 and 3).


and $3,127 in year two is higher than the control group’s highest value of $2,840 in year one, and $2,913 in year two. With CAPD higher than the control group’s highest value, costs appear to be overstated (see

Tables 2 and 3). The applicant is projecting a decrease in CAPD between year one and year two of $158, or 4.8 percent.

The year two projected operating income for the applicant of $26.1 million computes to an operating margin per adjusted patient day of

$1,198 or 27.7 percent which is higher than the control group’s highest values of $450. With operating margin higher the control group’s highest value, operating margin appears overstated (see Table 3).



67

TABLE 2

Physicians Regional Medical Center CON application #10187 Dec-15 YEAR 1

VALUES ADJUSTED


FOR INFLATION

ACTIVITY PER DAY



2,379 1,227 324


974 240 76


0 0 0


11,594 6,534 2,227

OUTPATIENT SERVICES 0 0

7,228 4,292 2,899


19,198 12,363 6,891

OTHER OPERATING REVENUE 1,100,000 57

116 25 5

TOTAL REVENUE 530,222,000 27,272

19,206 12,383 6,932


0 0 0

NET REVENUES 84,786,250 4,361

2,948 2,219 1,653


418 324 197

ANCILLARY 6,370,000 328

1,259 800 635

AMBULATORY 0 0

0 0 0

TOTAL PATIENT CARE COST 21,794,000 1,121

0 0 0


0 0 0

PROPERTY 12,967,851 667

0 0 0


1,305 931 664

OTHER OPERATING EXPENSE 22,829,580 1,174

0 0 0


2,840 2,133 1,693

OPERATING INCOME 20,926,759 1,076

450 97 -299

24.7%


VALUES NOT ADJUSTED

ADJ. FACTOR 0.9979

FOR INFLATION




77.4% 54.5% 24.1%

PAYER TYPE


SELF PAY 1,050 5.4%

MEDICAID 1,950 10.1%

14.4% 7.2% 0.4%


66.1% 52.1% 32.0%

MEDICARE HMO 0 0.0% INSURANCE 2,440 12.6% HMO/PPO 4,762 24.5%

59.3% 33.6% 15.6%

OTHER 0 0.0% TOTAL 19,402 100%


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TABLE 3

Physicians Regional Medical Center CON application #10187 Dec-16 YEAR 2

VALUES ADJUSTED


FOR INFLATION

ACTIVITY PER DAY



2,440 1,259 332


999 246 78


0 0 0


11,893 6,703 2,284

OUTPATIENT SERVICES 0 0

7,414 4,403 2,974


19,692 12,681 7,068

OTHER OPERATING REVENUE 1,200,000 55

119 25 6

TOTAL REVENUE 566,565,100 26,043

19,701 12,702 7,111


0 0 0

NET REVENUES 94,096,054 4,325

3,024 2,276 1,695


429 332 202

ANCILLARY 7,005,765 322

1,291 821 652

AMBULATORY 0 0

0 0 0


0 0 0


0 0 0

PROPERTY 13,630,360 627

0 0 0


1,339 955 681

OTHER OPERATING EXPENSE 24,110,163 1,108

0 0 0


2,913 2,188 1,737

OPERATING INCOME 26,069,368 1,198

450 97 -299

27.7%


VALUES NOT ADJUSTED

ADJ. FACTOR 0.9979

FOR INFLATION




77.4% 54.5% 24.1%

PAYER TYPE PATIENT DAYS % TOTAL SELF PAY 1,300 6.0% MEDICAID 2,165 10.0%

14.4% 7.2% 0.4%


66.1% 52.1% 32.0%


59.3% 33.6% 15.6%

OTHER 0 0.0% TOTAL 21,709 100%


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(CON #10188): Projected net revenue per adjusted patient day (NRAPD) of $1,975 in year one and $1,975 in year two is between the control group’s lowest and median values of $1,650 and $2,215 in year one, and

$1,693 and $2,272 in year two. With net revenues falling between the control group’s lowest and median values, net revenues appear reasonable (see Tables 2 and 3).


and $1,931 in year two is between the control group’s lowest and median values of $1,691 and $2,130 in year one, and $1,734 and $2,185 in year two. With CAPD falling between the control group’s lowest and median

values, costs appear reasonable (see Tables 2 and 3). The applicant is projecting an increase in CAPD between year one and year two of $1, or

0.05 percent.

The year two projected operating income for the applicant of $3.9 million

computes to an operating margin per adjusted patient day of $44 or 2.2 percent which is between the control group’s lowest and median values of -$299 and $97. With operating margin between the control group’s

lowest and median values, operating margin appears reasonable (see Table 3).



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TABLE 2

Venice Regional Medical Center CON application #10188 Jun-15 YEAR 1

VALUES ADJUSTED


FOR INFLATION

ACTIVITY PER DAY



2,375 1,225 323


972 240 76


0 0 0


11,575 6,524 2,223


7,216 4,285 2,894

TOTAL PATIENT SERVICES REV. 1,150,980,000 13,479

19,166 12,343 6,879


116 25 5

TOTAL REVENUE 1,151,480,000 13,485

19,174 12,363 6,921


0 0 0

NET REVENUES 168,661,915 1,975

2,944 2,215 1,650


417 323 196

ANCILLARY 46,673,727 547

1,257 799 634

AMBULATORY 2,524,940 30

0 0 0


0 0 0


0 0 0

PROPERTY 14,748,679 173

0 0 0


1,303 930 663


0 0 0


2,836 2,130 1,691


450 97 -299

2.3%


VALUES NOT ADJUSTED

ADJ. FACTOR 0.6418

FOR INFLATION




77.4% 54.5% 24.1%

PAYER TYPE


SELF PAY 1,196 2.2%

MEDICAID 1,744 3.2%

14.4% 7.2% 0.4%


66.1% 52.1% 32.0%


59.3% 33.6% 15.6%

OTHER 0 0.0% TOTAL 54,805 100%


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TABLE 3

Venice Regional Medical Center CON application #10188 Jun-16 YEAR 2

VALUES ADJUSTED


FOR INFLATION

ACTIVITY PER DAY



2,436 1,257 331


997 246 78


0 0 0


11,873 6,692 2,281


7,402 4,395 2,969

TOTAL PATIENT SERVICES REV. 1,253,048,000 14,397

19,660 12,660 7,057


119 25 6

TOTAL REVENUE 1,253,568,000 14,403

19,668 12,681 7,099

DEDUCTIONS FROM REVENUE 1,081,660,560 12,428

0 0 0

NET REVENUES 171,907,440 1,975

3,019 2,272 1,693


428 331 201

ANCILLARY 47,836,229 550

1,289 819 650

AMBULATORY 2,562,814 29

0 0 0


0 0 0


0 0 0

PROPERTY 14,756,271 170

0 0 0


1,336 954 680


0 0 0


2,909 2,185 1,734


450 97 -299

2.2%


VALUES NOT ADJUSTED

ADJ. FACTOR 0.6515

FOR INFLATION




77.4% 54.5% 24.1%

PAYER TYPE


SELF PAY 1,265 2.2% MEDICAID 1,832 3.2%

14.4% 7.2% 0.4%


66.1% 52.1% 32.0%


59.3% 33.6% 15.6%

OTHER 0 0.0% TOTAL 56,707 100%


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e. Will the proposed project foster competition to promote quality and cost-effectiveness? ss. 408.035(1)(e) and (g), Florida Statutes.

The following applies to ALL applicants. General economic theory indicates that competition ultimately leads to

lower costs and better quality. However, in the health care industry there are several significant barriers to competition:

Price-Based Competition is Limited - Medicare and Medicaid account for 68.5 percent of CMR hospital charges in Florida, while HMO/PPOs

account for approximately 24.8 percent of charges (including a small percentage of commercial insurance). While HMO/PPOs negotiate prices,

fixed price government payers like Medicare and Medicaid do not. Therefore price-based competition is limited to non-government payers. Price-based competition is further restricted as Medicare reimbursement,

in many cases, is seen as the starting point for price negotiation among non-government payers.

The User and Purchaser of Healthcare are Often Different – Roughly 93.3 percent of CMR hospital charges in Florida are from Medicare, Medicaid,

and HMO/PPOs. The individuals covered by these payers pay little to none of the costs for the services received. Since the user is not paying the full cost directly for service, there is no incentive to shop around for

the best deal. This further makes price-based competition irrelevant. Information Gap for Consumers – Price is not the only way to compete for

patients, quality of care is another area in which hospitals can compete. However, there is a lack of information for consumers and a lack of

consensus when it comes to quality measures. In recent years there have been new tools made available to consumers to close this gap. However, transparency alone will not be sufficient to shrink the

information gap. The consumer information must be presented in a manner that the consumer can easily interpret and understand. The

beneficial effects of economic competition are the result of informed choices by consumers.

In addition to the above barriers to competition, a study presented in The Dartmouth Atlas of Health Care 2008 suggests that the primary cost driver in Medicare payments is availability of medical resources. The

study found that excess supply of medical resources (beds, doctors, equipment, specialist, etc.) was highly correlated with higher cost per

patient. Despite the higher costs, the study also found slightly lower quality outcomes. This is contrary to the economic theory of supply and demand in which excess supply leads to lower price in a competitive


73

market. The study illustrates the weakness in the link between supply

and demand and suggests that more choices lead to higher utilization in the health care industry as consumers explore all alternatives without regard to the overall cost per treatment or the quality of outcomes.

Conclusion: Due to the health care industry’s existing barriers in consumer-based competition, this project will not likely foster the type

competition generally expected to promote 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(1)(h), Florida Statutes; Ch. 59A-3 or 59A-4, Florida

Administrative Code.

The architectural reviews of the three co-batched applications should not be construed as an in-depth effort to determine complete compliance with all applicable codes and standards. The final responsibility for

facility compliance ultimately rests with the owner of each of the three co-batched applicants, respectively.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) proposes to create a 15-bed CMR unit by renovating an

existing vacated space on first floor of the hospital. The existing space on the first floor consists of approximately 8,900 square feet that originally included an ICU and medical/surgical rooms that are no longer

in use. In addition to the vacated space, an area currently used for dialysis is proposed to be incorporated into the space required for the rehab unit.

All patient rooms would be private with a connecting toilet/shower room

serving only one patient room. The plans and narrative indicate that all patient rooms and patient toilet/shower rooms would comply with Florida Building Code - Accessibility requirements. The size of the

patient bedrooms exceeds the minimum code requirements.

The architectural plans and narrative propose to provide patient living areas such as day room, group activity within the unit. Physical therapy/occupational therapy rooms are also incorporated in the unit.

All other required support spaces are provided and adequately sized and located. However an area for dining room must be provided to comply with the Guidelines for Design and Construction of Health Care

Facilities.

The architectural narrative indicates that the project will comply with current codes. The current egress corridors and smoke compartments will be maintained.


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The design as presented does not indicate any major impediments that would prevent the design and construction of a code compliant facility.

The estimated construction costs and project completion forecast appear to be reasonable.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) proposes to establish a 17-bed CMR unit by

new construction and renovation on the ground floor of the south wing of the facility. The existing space to be renovated consists of approximately 6,000 square feet; in addition to the renovation approximately 5,800

square feet of new construction will be constructed to match the existing facility. The architectural narrative submitted by the applicant indicates

that the new building is fully sprinklered, and construction type is listed as FBC, type IA. This construction type does meet the requirements for size and occupancy of the current Florida Building Code.

The patient bed rooms occupy two wings of the floor; all 17 patient rooms are private with toilet/shower rooms, and the size of the patient

bedrooms exceeds the minimum requirements of the Guidelines for Design and Construction of Health Care Facilities. Plans and narrative

indicate that all patient bed rooms and patient toilet/shower rooms will comply with the Florida Building Code-Accessibility requirements.

The architectural plans and narrative propose to provide patient living areas such as day room, group activity within the unit. Physical therapy/occupational therapy rooms are also incorporated in the unit.

All other required support spaces are provided and adequately sized and located. However an area for dining room must be provided to comply

with the Guidelines for Design and Construction of Health Care Facilities. It is noted the proposed project does meet the required 55 square feet per patient for patient living (dining, recreation and day

space) areas.

The narrative indicates that the project will comply with current codes. However the project area must be divided into smoke compartments as required by the applicable codes.


The design as presented does not indicate any major impediments that

would prevent the design and construction of a code compliant facility.


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(CON #10188): The new 22-bed CMR unit would be created by renovating a recently vacated area on the fourth floor of the facility and replacing an area currently licensed as a medical/surgical nursing unit.

All patient bedrooms would be private with a connecting toilet/shower room serving only one patient bed room. The plans and narrative indicate that all patient rooms and patient toilet/shower rooms will

comply with the Florida Building Code-Accessibility requirements. However some modifications to the entrance of type 1 and type 2 patient

bedrooms will be needed to meet maneuvering clearance of Florida Accessibility requirements, but the physical constraints of the spaces should accommodate these changes. The sizes of the patient bedrooms

exceed the minimum requirements of the Guidelines for Design and Construction of Health Care Facilities.

The architectural plans and narrative propose to provide patient living areas such as dining room, day space, activity area, and personal

services within the unit. All other required support spaces are provided and adequately sized and located. An existing area on the first floor will serve as additional support including an existing ADL and exercise room

for physical therapy.

The architectural narrative indicates that the project will comply with current codes. The project area is divided into smoke compartments as required by the applicable codes.


The design as presented does not indicate any major impediments that

would prevent the design and construction of a code compliant facility.

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(1)(i), Florida Statutes.

The table below illustrates the Medicaid/Medicaid HMO days and

percentages as well as charity percentages provided by the co-batched applicants’ facilities to fiscal year 2011 data Florida Hospital Uniform Reporting System.


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Medicaid, Medicaid HMO and Charity Data

District 8 and Applicable Facilities Fiscal Year 2011

Applicant

Medicaid and Medicaid HMO

Days

Medicaid and Medicaid HMO

Percent

Percent of Charity Care

Percent Combined Medicaid,

Medicaid HMO and Charity Care

Charlotte Regional Medical Center 3,932 8.06% .06% 8.12%

Physicians Regional Medical Center-Pine Ridge*

3,921

11.39%

.33%

11.73%

Venice Regional Medical Center 2,470 4.82% .06% 4.89%

District 8 Total 136,077 13.74% 2.98% 16.73% Source: Agency for Health Care Administration Florida Hospital Uniform Reporting System (FHURS).

*Physicians Regional Medical Center-Collier Boulevard files FHURS data under 2396-0025 Physicians Regional Medical Center – Pine Ridge.

Each co-batched applicant’s existing and planned service to Medicaid patients and the medical indigent is discussed in greater detail below.

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186): The applicant states intent to provide care to all

admission appropriate persons in need, and conditions the project to provide seven percent of the total CMR patients days to a combination of Medicaid, Medicaid HMO, and charity care (including self-pay) patients.

The applicant provides the following table to demonstrate commitment to serving Medicaid and charity care patients:

CRMC

Medicaid and Charity Deductions from Revenue

Fiscal Year 2011 Medicaid $43,621,754

Medicaid HMO $2,879,198

Charity Care $370,492

Total $46,871,444 Source: CON application #10186, pg. 101.

The applicant’s Schedule 7A indicates CRMC will provide 6.90 percent

Medicaid and 3.66 percent charity care in year one of the project, and 6.91 percent Medicaid and 3.66 percent charity care in year two of the project. The applicant’s Schedule 7A shows zero Medicaid HMO patient

days in years one and two of the project. Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier

Boulevard (CON #10187) conditions the project to provide six percent of the total CMR patient days to a combination of Medicaid, Medicaid HMO,

and charity care (including self-pay) patients. The applicant provides the following table to demonstrate commitment to

providing care to Medicaid and charity patients:


77

Physicians Regional Health System PRHS




Charity Care $3,050,994

Total $80,796,941 Source: CON application #10187, pg. 104.

The applicant’ s Schedule 7A indicates PRCB will provide 5.46 percent

Medicaid and 5.46 percent charity care in year one of the project, and 6.14 percent Medicaid and 5.84 percent charity care in year two of the

project. The applicant’s Schedule 7A shows zero Medicaid HMO patient days in years one and two of the project.


(CON #10188) conditions the project to provide four percent of the total CMR patient days to a combination of Medicaid, Medicaid HMO, and charity care (including self-pay) patients.

The applicant provides the following table to demonstrate commitment to

providing care to Medicaid and charity patients:





Charity Care $556,319

Total $28,981,757 Source: CON Application #10188, pg. 98.

The applicant’s Schedule 7A indicates VRMC will provide 4.99 percent Medicaid and 4.0 percent charity care in year one of the project, and 5.01 percent Medicaid and 4.0 percent charity care in year two of the

project. The applicant’s Schedule 7A shows zero Medicaid HMO patient days in years one and two of the project.

F. SUMMARY

Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186), a 208-bed acute care hospital, proposes to develop a

15-bed comprehensive medical rehabilitation unit (CMR) within its existing infrastructure in Punta Gorda, Florida, located in Charlotte County. CRMC has a total licensed bed complement of 156 acute care

and 52 adult inpatient psychiatric beds. If approved, the project will increase the total facility bed count to 223 beds.


78

The applicant proposes eight conditions to CON approval on the

application’s Schedule C. The project involves 8,918 GSF of renovation. The construction cost is

$1,293,110. Total project cost is $1,836,379. Project cost includes building, equipment, project development and start-up costs.

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) proposes to establish a 17-bed CMR unit at

Physicians Regional Medical Center-Collier Boulevard in Naples, (Collier County) Florida. PRCB has a total licensed bed complement of 100 acute care beds. HMA Naples’ Physician Regional Medical Center – Pine Ridge

is a comprehensive stroke center.

The applicant proposes eight conditions to CON approval on the application’s Schedule C.

The project involves 5,800 GSF of new construction and 6,005 GSF of renovation. The construction cost is $2,376,000. Total project cost is $4,093,736. Project cost includes building, equipment, project

development and start-up costs.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) proposes to establish a 22-bed CMR unit at VRMC, through the conversion of 22 existing acute care beds. VRMC has a total licensed bed

complement of 312 beds. VRMC is a primary stroke center. The applicant proposes nine conditions to CON approval on the

application’s Schedule C.

The project involves 17,569 GSF of renovation. The construction cost is $2,970,000. Total project cost is $4,564,819. Project cost includes building, equipment, project development and start-up costs.

Need:

In Volume 39, Number 13, dated January 18, 2013 of the Florida Administrative Register, a fixed need pool of zero beds was published for

CMR beds in District 8 for the January 2018 planning horizon. During the 12-month period ending June 30, 2012 District 8’s licensed

CMR beds experienced 63.45 percent utilization. There are no CON approved CMR beds in District 8.

All applicants state they are applying under special or not normal circumstances.


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Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) states the following reasons support need for the project:

Charlotte and Desoto Counties have the lowest CMR discharge use rate per 1,000 population age 65 and older compared to the other

District 8 counties and 11 health planning districts in the state.

The Charlotte and Desoto resident to rehab bed ratio far exceeds the

statewide and District 8 resident to rehab bed ratios and is one of the highest in the state with just one rehab bed for every 8,276 residents.


residents of the CMRC service area.


come directly from within the acute care hospital or system. This is

the case with the existing 20-bed unit at Fawcett Memorial as will be the case with the proposed 15-bed unit at CRMC.


and post-acute providers and programming is imperative but is, unfortunately, not the case for many service area residents.

As a designated primary stroke center by the Agency and a Joint Commission accredited stroke program, CRMC is committed to

fulfilling the continuum of care for its stroke patients in a post-acute setting of a CMR program, and being accredited as a stroke rehabilitation program.

There is a large percentage of elderly population in the CRMC service area compared to the state average.

There is a gap in CRMC’s continuum of care; the missing component is inpatient rehabilitation.

The applicant is able to fully support a CMR program based on the

CRMC and PRRMC internal volume of rehab appropriate patients who reside within its distinct service area.


80

Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (CON #10187) states the following reasons support need for the project:

Physicians Regional contends that since PRMC – Pine Ridge has the

only certified comprehensive stroke center in southwest Florida, PRMC – Collier Blvd. needs an acute rehab unit to appropriately provide the full continuum of acute services to its stroke patients.

Collier County’s CMR discharge use rates per 1,000 population are lower than both the District 8 use rates and the State of Florida use

rates indicating underutilization of this much needed level of care.

CMR beds are programmatically inaccessible to residents of the

defined service area

CMR beds are geographically inaccessible to residents of the PRCB

service area.



There is a large percentage of elderly population in the PRCB service area compared to the state average.

The applicant is able to fully support a CMR program based on the PRCB and PRPR internal volume of rehab appropriate patients who

reside within its distinct service area.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) states the following reasons support need for the project:

There is a disproportionately large percentage of elderly population in

the VRMC service area compared to both the Sarasota County and state averages; 50.4 percent of all adult residents are 65 and older

compared to 38.6 in Sarasota County and 23.2 statewide.

The median age in the city of Venice is 67.7 years, 14.2 years older

than Sarasota County’s overall population.

There are significantly more acute care patients admitted to VRMC

who would qualify for admission to an inpatient rehabilitation hospital as a post-acute option than there are, on average, in other hospitals across the State of Florida, even in those hospitals with

licensed CMR beds.


residents of the VRMC service area.

Even though Sarasota is home to 50 percent of the district’s 264

licensed CMR bed inventory, all 130 beds are clustered in the northern region of the county leading to lower accessibility for VRMC

service area residents.


81


come directly from within the acute care hospital or system



In the past three years, VRMC’s stroke cases have increased 51.3 percent, from 300 cases up to 454 per year. Post discharge, these

patients require intense inpatient rehabilitation to achieve greatest functional improvements.

VRMC is able to fully support a CMR program based on its own

internal volume of rehab appropriate patients who reside within its distinct service area.

ALL applicants: The applicants fail to document that current CMR

referral patterns lead to adverse outcomes. There is no documentation of geographic inaccessibility provided. The access problems described do not appear to be programmatic but systematic in that the projects are

designed to specifically serve patients in the HMA hospital system. Quality of Care:

The parent, HMA, has 24 licensed hospitals in Florida with a total of

3,516 beds. Agency data indicates that HMA affiliated hospitals had 87 substantiated complaints for the three-year period ending April 10, 2013.

ALL applicants:

have Joint Commission accreditation and plan to seek Joint

Commission disease-specific accreditation for stroke rehabilitation, if

the project is approved.

include a 2012 Performance Improvement Plan that ensures quality

patient care.

state the uniform data system will be utilized for this project as it is at

HMA’s Seven Rivers Medical Center. Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center

(CON #10186):

is a designated primary stroke center by the Agency, is accredited by the Joint Commission and received their Gold Seal of Approval. The

applicant was recognized as a Joint Commission’s Top Performers on Key Quality Measures.

Charlotte Regional Medical Center had six substantiated complaints

during the same three-year period.


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Boulevard (CON #10187):

Physicians Regional Medical Center-Pine Ridge is a certified

comprehensive stroke center by the Agency.

Physicians Regional for the past two years received the Joint

Commission’s Top Performers on Key Quality Measures Award.

Physicians Regional Collier Boulevard had no substantiated

complaints during the same three-year period.

Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188):

is a designated primary stroke center by the Agency and for the past

two years received the Joint Commission’s Top Performers on Key Quality Measures Award.

The applicant received the Get with the Gold Guidelines-Stroke, Silver

Plus Achievement Award.

Venice Regional Medical Center had four substantiated complaints

during the same three-year period.

Cost/Financial Analysis: ALL applicants:

Funding for this project and the entire capital budget should be

available as needed.

This project appears to be financially feasible.

Due to the health care industry’s existing barriers in consumer based

competition, this project will not likely foster the type competition generally expected to promote quality and cost-effectiveness.

Medicaid/Indigent Care: Charlotte Regional Medical Center (CON #10186) conditions to seven

percent of the total CMR patients days to a combination of Medicaid, Medicaid HMO, and charity care (including self-pay) patients.

Physicians Regional Medical Center-Collier Boulevard (CON #10187) conditions to six percent of the total CMR patients days to a combination

of Medicaid, Medicaid HMO, and charity care (including self-pay) patients.

Venice Regional Medical Center (CON #10188) conditions to four percent of the total CMR patients days to a combination of Medicaid,

Medicaid HMO, and charity care (including self-pay) patients.


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Architectural Analysis: ALL applicants: The architectural narrative indicates that the project

will comply with current codes. The estimated construction costs and project completion forecast appear

to be reasonable.

The design as presented does not indicate any major impediments that would prevent the design and construction of a code compliant project.

G. RECOMMENDATION

Deny CON #’s 10186, 10187 and 10188.


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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, Director

Florida Center for Health Information and Policy Analysis

state agency action report on application for certificate...

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